's Internet Explorer’ A 6-year-old female is brought ta the pediatrician because of severe dysuria, The history is unremarkable excent for the B patient having a sore throat, There is no history of hematuria, fever, use of bubble bath, pinwarms, tight clathing, nylon underwear, or recent medication. Inspection of the perineum reveals an intense erysipelas-like erythema of the vulva, distal vagina, and perianal area. A serosanguinous vaginal discharge is present. Which of the following is the most likely cause? CA Haemophilus influenzae C8, Neisseria gonorhea Cc. Chlamydia trachomatis sf @D, Group AB-hemolytc streptococcus CE, Streptococcus pneumoniae Explanation Nonvenereal infectious vulvovaginitis is not uncammon in prepubertal patients. Bacterial vulvovaginitis due to a primary respiratory or skin pathogen may be found. Group A B-hemolytic, streptococcus may be associated with streptococcal nasopharynattis or scarlet fever, or may occur alone. Vulvovaginal symptoms of group A p-hemoltic streptococcus include severe perineal burning, dysuria, and erythema similar in appearance to erysipelas in the perineal area. Most patients will have a serosanguinous or grayish-white vaginal discharge. Streptococcus pneumoniae (choice E) and Haemophilus influenzae (choice A) may cause a purulent vaginal discharge causing ‘El Tine Remaining: 02:59:08 [ 1) 1) (e@ tere's Internet Explorer’ Cc, Chiamycia trachomatis A \f- @D. Group AB-hemoltic streptococcus. CE, Streptococcus pneumoniae Explanation Nonvenereal infectious vulvovaginitis is not uncammon in prepubertal patients. Bacterial vulvovaginitis due to a primary respiratory or skin pathogen may be found. Group A B-hemolytic, streptococcus may be associated with streptococcal nasopharynattis or scarlet fever, or may occur alone. Vulvovaginal symptoms of group A p-hemoltic streptococcus include severe perineal burning, dysuria, and erythema similar in appearance to erysipelas in the perineal area. Most patients will have a serosanguinous or grayish-white vaginal discharge. Streptococcus pneumoniae (choice E) and Haemophilus influenzae (choice A) may cause a purulent vaginal discharge causing vulvovaginitis following or in conjunction with an upper respiratory infection. Sexual abuse should be suspected when Neisseria gonorrhea (choice B) and Chiamyaia trachomatis (choice C) are found in a prepubertal child. ‘El Tine Remaining: 02:58:59 [ 1) 1) (e@ tere's Internet Explorer’ ‘An 8-year-old child presents with low-grade fever, arthritis, colicky abdominal pain, and a purpuric rash limited to the lower extremities. Laboratory studies reveal a guaiac-positive stool, a urinalysis with red blood cell (RBC) casts and mild proteinuria, and a normal platelet count. Which of the following is the most ikely diagnosis? A, Systemic lupus erythematosus (SLE) CB, Rocky Mountain spotted fever ©.¢, Idiopathic thrombocytopenic purpura (TP) VD, Henach-Schénlein vascultis CE. Poststreptocaceal glomerulonephritis Explanation ‘The symptoms of arthritis, gastrointestinal and renal manifestations, and a purpurie rash on the lower extremities and buttocks are characteristic of Henoch-Schénlein vasculitis. Systemic lupus erythematosus (SLE) [choice Al, although accompanied by arthritis and fever, usually involves a malar rash. The rash of Rocky Mountain spotted fever (choice B) begins peripherally and spreads to the entire body. Idiopathic thrombocytopenic purpura (ITP) [choice C] is associated with a petechial rash, primarily on pressure points (e.g,, where the elastic band of underwear touches the skin). Also, the platelet count is depressed in ITP. Poststreptocaccal glamerulonephiitis (choice E) does not typically invalve a rash, although hematuria is present. ‘Bi tine Remaning: oa5e9's Internet Explorer’ ‘Ayoung lactating mother is found to have mastitis in her right breast and is concemed about breastfeeding. Which of the following is the best advice that the physician can give to the patient? A, Stop breastfeeding immediately because the baby may become infected © .B, Stop breastfeeding immediately because she will be taking an antibiotic Cc, Continue hreast-feeding using the lef breast only ¥-@D___ Continue breastfeeding using both breasts CE Change the infantto a commercially prepared forrnula Explanation Mastitis is not a contraindication to breast-feeding. The infant will not become ill f nursed on the affected breast (choice A). However, the mother should he treated with antibiotic therapy and analgesics that da not put the infant at risk (choice B). Frequent nursing on the affected breast will keep the breast from becoming engorged (choice C). In many cases, this will keep mastitis from progressing to a breast abscess. Because mastitis is not a contraindication to breastfeeding, the infant does notneed to be changed to a commercially prepared formula (choice E). ‘Bi tine Remaning: case's Internet Explorer’ ‘Ayoung mother brings her 4-year-old son to the pediatrician because he is having daily nosebleeds, during which the B nose bleeds slowly but freely, usually ram the lef nosttil. Which of the following is the most cormmon cause of epistaxis inthe pediatric population? CA. Allergic hinitis VB, Nose-picking Cc, Von Willebrand's disease ©D, Idiopathic thrombocytopenic purpura (TTP) Ce, Nasal angioflbroma Explanation Nose-picking is the most common cause of epistaxis in the pediatric population. Trauma and imitation [e.g,, colds, alleraic rhinitis (choice &)] are less common causes of epistaxis in this Population. Bleeding disorders [e.g., von Willebrand's disease (choice C), idiopathic thrombocytopenic purpura (choice D)] are rarely causes of epistaxis and usually have other manifestations. Nasal masses associated with epistaxis may rarely signal a nasal angiofibroma (choice E). ‘El Tine Remaining: 02:68:38 [ 1) 1) (e@ tere's Internet Explorer’ ‘A pediatrician is examining a young infant and notes that the infant symmetrically abducts and extends his extremities B after a loud noise and then begins to cry. This reflexis known as which of the following? A, Asymmetric tonic neck teflex (ATNR) CB. Parachute refex Yo &o, Moro refx CD, Hand-grasp reflex grasping rene) Ce, Protective equilibrium reflex Explanation ‘The Mora reflex is initiated by loud noise or sudden motion. itinvolves abduction of the extremities and extension ofthe elbows and knees, followed by flexion. The Mora reflex appears at birth and disappears at approximately 4 months of age. Ifthe reflexis asymmetric, this suggests extremity fracture or peripheral nerve injury. ‘The asymmetric tonic neck reflex (ATNR) [choice A] appears at approximately 2 weeks of age and disappears at approximately 6 months of age. There is flexion ofthe arm and leg on the occipital side and extension on the chin side, creating a “fencer position." The parachute reflex (choice B) appears at about 8 to 9 months of age and persists voluntarily. The child is placed in the examiner's hands and is permitted to free-fall in ventral suspension. The child extends his extremities ‘El Tine Remaining: 02:68:53 [ 1) 1) (e@ tere's Internet Explorer’ ‘A mother presents ta the emergency department with her 2-month-old daughter. The child appears to be lethargic and dehydrated, The mother reports that the patient has not een feeding well for the past few days. The mother says that she changed the infant's feedings to cow's milk because the infant does not care for the taste of formula. Which nutrient normally in high concentration in cow's milk could cause the symptoms seen in this infant? CA Linolete avia CB, Linolenic acid Co, Calcium Yo 0, Protein CE, B-complexvitamins Explanation Cow's milk is not recommended for children until they are 1 year of age because the high level of protein causes increases in the solute load to the kidneys. Itis this overload that led to the lethargic, dehydrated state ofthe 2-month-old infant, Linaleie acid (choice A), linolenic acid (choice B), calcium (choice C), and B-complex vitamins (choice E) are not present in high concentrations in cow's milk and would not be expected to cause the symptoms noted in this patient. ‘Bi tine Remaning: oas6z7's Internet Explorer’ ‘A3-year-old child presents with recurrent right lower labe pneumonia. His growth parameters are at the 25th percentile, and he is developmentally appropriate for his age. His past medical history is positive for an ear infection at 18 months of age and gastroenteritis at 2 years of age. Which ofthe following conditions is most likely responsible for this patient's disease? A, Primary B- or T-cell immunodeficiency disorder CB. Oystictbrosis Cc, Chédiak-Higashi syndrome ©D, Congenital lung abnormality ¥-@E__ Foreign body aspiration Explanation Foreign body aspiration is the most common cause of recurrent pneumonia in an atherwise healthy S-year-old child. Because of the lung's anatomy, the right side is more common for aspiration. When a child presents with pneumonia, a history of choking can often be elicited. Immunodeficiency disorders (choice A) are characterized by recurrent infections, usually by opportunistic organisms, ‘and failure to thrive. Cystic fibrosis (choice B) similarly results in failure to thrive, and malabsorption and clubbing are offen seen. In cystic firasis, pneumonia is usually caused by Pseticomonas, Chédiak-Higashi syndrome (choice C) is autosomal recessive and is associated with giant granules in neutrophils and recurrent infections ofthe skin, mucous membranes, and the ‘Bi tine Remaning: 02.569's Internet Explorer’ A patient is brought to the pediatrictan's office for a well-child visit. The child is able to transfer an abject from hand-to- hand, maintain a seated position, imitate speech sounds, and has a neat pincer grasp. Which of the following is the most likely age ofthis child? CA 2months CB 4 months Co, Smonths CD. 8months Vo @E, 10 months Explanation Transferring objects from hand-to-hand occurs at 4 1/2 to 7 1/2 months of age. Most infants are able to sit without support between 5 and 7 months of age. Speech sounds can be imitated between 5 1/2 and 11 1/2 months of age. A neat pincer grasp is not seen until approximately 9 1/2 months of age, and maybe seen as late as 15 months of age. Therefore, the child described must be at least, 91/2 months of age. The abilities ofthis child would not all be present in a child at 4 months (choice B), 6 months (choice C), or 8 months (choice D) of age. A 2-month-old child (choice A) smiles responsively, follows to midline, and regards a face but is nat able to imitate speech sounds, cannot transfer an object fram hand-to-hand, does not have a neat pincer grasp, and cannot maintain a seated position, ‘Bi tine Remaning: case's Internet Explorer’ A 2-year-old boy presents to the emergency department with hematemesis, hypotension, and lethargy after ingesting his mother’s prenatal vitamins. Which of the following is the most appropriate fist step in the management of this patient? 4, Measure the patient's iron level and wait forthe results before treating CB, Measure the patient's iron level and total ron-tinding cajacity level and waitfor the results before treating Cc, Administer dimercaprol Cp, Administer evathamil calcium disodium (CaEDTA) Vo @E Abiminister deferoxarine Explanation Prenatal vitamins prescribed during pregnancy contain iron and are especially potent. In potential iron toxicity, symptomatology rather than laboratory data takes priority (choices & and B). Patients with hematemesis, hypotension, and lethargy should receive the antidote deferaxamine after a potential toxic ingestion of iron. In addition, any patient with a serum iron level greater than the total iron-binding capacity, or any patient with a serum iran level greater than 200-360 ug/l, should receive deferoxamine. Dimercaprol (choice C), often in combination with a chelating agent such as edathamil calcium disodium (CaEDTA) [choice D], is used to treat lead poisoning, ‘Bi tine Remaning: 0215608's Internet Explorer’ A 9-month-ald child comes to the pediatric clinic for a well-child visit The mother is certain that her child will soon be walking independently because she uses an infant walker. Which of the following is the best advice the physician can talve to this mother? A, Encourage the mother to continue to use the infant walker ¥- Encourage the mother to stop using the infant walker © 0, Tellthe mother that bearing weight on the infants legs at this young age will make them *howed © °D, Tellthe mother that using an infantwalker will enhance the infant's ability to walk independently Explanation Approximately 1,000,000 infant walkers are sold each year, despite research that indicates that they may actually delay walking (choice D). Infants using infant walkers may experience falls (especially down stairs), tip-overs, and finger amputations. Infant walkers should not be recammended (choice A), However, ifparents insist that their child use an infant walker, it should be equinped with covered, coiled springs and lacking devices that prevent collapse. An infant walker should only be used on flat surfaces; away from thresholds, stairs, and carpets; and under the supervision of an adult. In the absence of rickets, the legs shauld not become bowed by bearing weight (chaice C). ‘Bi tine Remaning: 0215602's Internet Explorer’ A 10-year-old child had an upper respiratory infection 5 days ago and was given aspirin for fever. She now presents with fever, protracted vomiting, and lethargy. Physical examination reveals mild hepatomegaly. Total bilirubin, serurn transaminases, and serurn ammonia are increased. Which of the following is the most likely diagnosis? CA Hepatitis virus (HAY) CB, Druginduced henattis VE. Reye's syndrome ©, Infectious mononucleosis CE Gilbert syndrome Explanation Reye's syndrome shows a very high association with the ingestion of aspirin-containing medicines during influenza-like illnesses or varicella. Reye's syndrome has a biphasic course. It usually presents in a previously healthy child who had an upper respiratory infection (80%) or varicella (5%- 7%). After the child seems to have recovered, the symptoms of vomiting, lethargy, and confusion can appear and progress quickly. Liver enaymes and ammonia are elevated. Treatment requires early recognition and control of increased intracranial pressure. Prognosis depends on duration of disordered cerebral function Hepatitis A virus (HAV) [choice A] is an RNA-containing virus. itis a member ofthe Picarnaviridae ‘Bi tine Remaning: oas7Is6 [@ internet's Internet Explorer’ Parents bring their newly adapted 2-year-old son to the pediatrician’s office because he has a temperature of 40°C (104" F) and a motbilliform rash, which began cephalad and spread caudad to include the palms and soles. The mather reports that prior ta developing the rash the child had cough, coryza, and conjunctivitis. The immunization status is unknown. Which of the following complications is most likely to develop in this child? CA. Acute appendicitis CB. Subacute sclerosing panencephaltis © 0, Interstitial pneumonia Cp. Keratocanjunctivitis Vv Ee, tis media Explanation ‘The symptoms in this patient clearly describe a case of measles. Otitis media is the most common complication, occurring in 8500 to 15,000 per 100,000 cases. Because of mesenteric node involvement, difluse lymphadenopathy can cause abdominal pain mimicking appendicitis (choice A). Subacute sclerosing panencephalits (choice B) is a rare neurologic complication, occurring in 0.5 to 2 per 100,000 cases. Interstitial pneumonia (choice C) is caused by the measles virus itself and is more common in immunacompramised patients. Bronchopneumania is more common than interstitial pneumonia and is usually caused by pneumococcus. The kerataconjunctivitis (choice D) seen in measles is asymptomatic and can persist for up to 4 months. ‘Pitino Remaning: oas77's Internet Explorer’ ‘An 18-year-old woman has been breast-feeding her newborn baby gil; however, her grandmother told her that she should use cow's milk because itis more nutritious, She comes to the office concerned that she is depriving her baby of essential nutrients. Which of the following statements is accurate and should be shared with this patient to alleviate her concern? A, Solute load is significantly higher in hurnan rik ¥— @B__ Vitamin © concentration is significantly higher in hurnan milk Cc, Protein level is significantly higher in hurnan rik ©°D, Vitamin K concentration is significantly higher in hurnan milk CE, tron levels are significantly higher in hurnan milk Explanation Human breast milk contains approximately four times as much vitamin C as does cow's milk Both types of milk contain approximately the same amount of water and solids (choice A). Cow's milk contains approximately twice the amount of protein of human milk (choice C) and four times the ‘amount of vitamin K (choice D). The higher protein concentration may stress the kidneys. Both types of milk contain similar amounts of iron (choice E), butiran in human milkis better absorbed, Pitino Remaningi caer's Internet Explorer’ A 4-day-ald female is brought to the pediatrician hecause she has a bload-tinged discharge coming from her vagina, According ta the mother, the child has been afebrile and is feeding and sleeping well. At this point, the physician should do which ofthe following? CA Drawa hematocrit Het) CB, Notify the Child Protective Services VC, Reassure the mother that this is normal CD, Callthe endocrinologist Ce, Obtain a urinalysis Explanation Vaginal bleeding, or pseudomenses, may occur in a newborn female. In utera, the vaginal epithelium is stimutated by circulating maternal estrogens, which difuse across the placenta. Afler birth, these hormone levels rapidly fall, which results in endometrial sloughing. There may be a thick mucoid discharge from the newborn's vagina, which is sometimes bloody. The discharge will Usually resolve within 10 days after birth. No testing or treatment is necessary (choices A andE), only reassurance. Because the vaginal bleeding is not related to abuse, the Child Protective Services need not be informed (choice B). Itis not necessary o call an endocrinologist (choice D) because this is not an endocrine problern. ‘Bi tine Remaning:oas7e's Internet Explorer’ At 24 hours of ife, a newborn infant is nated to have an eye discharge. The baby was born to a 21-year-old primigravida ‘wha had no prenatal care. Otherwise, the physical examination is unremarkable. Which of the following is the most likely disorder responsible for the conjunctival irtation in this newborn? CA. Gonococcal ophthalmia © 8, Chiarnydial conjunctivitis Cc, Staphylococcus aureus conjunctivitis ©, Chemical conjunctivitis CE, Lacrimal duct obstruction Explanation Chemical iritation (e.g, ABNO,, or siNer nitrate) isthe most common cause of conjunctivitis in the first 24 hours after birth. Gonococcal aphthalmia (chaice A) presents as a purulent conjunctivitis approximately 2 to 3 days after birth—or up to 21 days if prophylaxis is given. Chlamydial conjunctivitis (choice B) is the most common infectious cause of aphthalmia neonatorum (ie., conjunctivitis ofthe newborn) and occurs 5 to 23 days after birth. Staphylococcus aweus conjunctivitis (choice C) is less common. Congenital lacrimal duct obstruction (choice E) appears days to weeks after birth, is usually unilateral, and generally resolves over time with gentle massage of the duct, ‘Bi tine Remaning:caa7ataones A 1-day-old infantis noted to have an asymmetric Moro reflex. The infantis able to extend his forearm, but the biceps B reflex is absent, Physical examination reveals that the right arm is adducted and internally rotated, Which of he following disorders best explains this infant's problem? CA, Klumpke's paralysis Cp Fractured right clavicle Co, Todd's paralysis VD, Etb-Duchenne paralysis CE, Spinal injury with associated hemiparesis Explanation Erb-Duchenne paralysis is due to a brachial plexus injury. it usually occurs during delivery as a consequence oftraction ofthe head. C6 and CB are involved. Insilateral diaphragmatic paralysis occurs with involvement of C4. The characteristic position is with the arm adducted and internally rotated and with the forearm pronated. The position is referred to as the “waiters tip." Kiumpke's paralysis (choice A) involves C7, C8, and T1 and is characterized by a"claw hand." Clavicular fracture (choice B) may also cause an asymmetric Mora reflex. However, when this occurs crepitus is felt over the clavicle, Todd's paralysis (choice C) is a hemiparesis occurring after a focal seizure and resolves within 24 hours. Spinal card injuries (choice E) occur mast commonly in the lower cervical, upper thoracic vertebrae with breech presentations, and atthe fourth cervical vertebra in ‘El Tine Remaining: 02:46:59 [ 1) 1) (e@ tere's Internet Explorer’ Examination of a 6-hour-old infant delivered with difficulty by low forceps reveals an asymmetric Moro reflex involving the Tight arm. The infantis cyanatic and has labored respiration. The abdomen does not bulge with inspiration, and there are decreased breath sounds in the right chest. Which of the following is the most likely diagnosis? A, Respiratory distress syndrome © 8, Meconium aspiration syndrome + @C._Ipsilateral paralysis ofthe diaphragm CD, Tracheoesonhageal fistula CE Choanal atresia Explanation Phrenic nerve injury with ipsilateral diaphragmatic paralysis must be suspected in this infant. The abdomen does nat bulge because the breathing is mostly thoracic. Diagnosis is made by ultrasound or fluoroscopy. Respiratory distress syndrome (choice A) is more common in preterm infants and presents with cyanosis, tachypnea, and grunting respirations. The mother usually has a history of difficult delivery. Chest ray reveals a ground-glass appearance. Meconium aspiration syndrome (choice B) appears at birth, usually n term or post-term infants. There is a history of meconium-stained amniotic uid. When meconium is aspirated into the lungs, respiratory distress may occur within the first hours of Ife. Overdistensian of the chest may be present, Meconiurn aspiration syndrome is nat associated with an asymmetric Moro reflex. Tracheaesophageal fistula ‘Bi tine Remaningr canes's Internet Explorer’ ‘Anewborm examination demonstrates severe hypotonia, generalized weakness, absent tendon stretch reflexes, a fasciculations of the tongue, and preservation of the extraocular muscles. Which of the following is the most likely diagnosis? A Myotonic dystrophy ¥@B__ Werdnig-Hofmann disease Cc, Infant botulism CD, Infantile myasthenia gravis Ce, Duchenne's muscular dystrophy Explanation \Werdnig-Hofmann disease is a spinal muscular atrophy of unknown cause. tis inherited in an autosomal recessive fashion. Infants can be symptomatic at birth. Sparing of the extraocular muscles and sphincters is characteristic. Fasciculations are a sign of denervation of muscle and are best seen in the tongue. Infants assume a flaccid "trag-leg’ posture. Most die by 2 years of age. Aneonatal form of myotonic dystrophy (chaice A) appears in infants born to mothers with myotonic, dystrophy. Clubfoot and contractures are common. Fasciculations are not seen. Infant botulism (choice C) has a peak onset at 2 o 6 months of age. Sources for spores include honey, corn syrup, soil, and dust. Infantile myasthenia gravis (choice D) can be transient—as in thase infants born of mothers with myasthenia gravis—or, very rarely, congenital, Fasciculations are not seen and the ‘El Tine Remaining: 02:46:46 [ 1) 1) (e@ tere's Internet Explorer’ Soon after birth, a term newborn is noted to be cyanotic with feeding. Crying relieves the cyanosis. The delivery was uncomplicated and the mother had good prenatal care. The infant had 1- and §-minute Apgar scores of 8 and 9, respectively. Which of the following is the most likely diagnosis? CA. Atracheoesophageal fistula © 8, Bronchopulmonary dysplasia Cc, Respiratory distress syndrome vo @D, Choanal atresia CE, Apatent ductus arteriosus Explanation Choanal atresia should be suspected in any infant who develops cyanosis that occurs with feedings or at rest, butis relieved by crying. The cyanosis occurs because newborns are obligate nosebreathers. Diagnosis is made by failure to pass a catheter through the nasal passages. Tracheoesophageal fistula (choice &) is characterized by choking with feeding, An orogastric tube curls up and does not pass to the stornach. Bronchopulmonary dysplasia (choice B) is a complication of respiratory distress syndrome (choice C) and appears later in the infant’ life Cyanasis is not relieved by crying in either entity. A patent ductus arteriosus (choice E) is a left-to- Tight shunt and is not associated with cyanosis. ‘Bi tine Remaningi cae's Internet Explorer’ ‘An 8-year-old male presents with multiple patches of alopecia and severe pruritus. A bright blue-green fluorescence is, seen on examination of the scalp with a Wood lamp. Which of the following pathagens is most likely responsible? CA. Epicermophyton floccosum VB, Microsporum canis Coc, Candice aibicans ©D. _Trichophyton tonsurans CE. Aspergillus species Explanation Tinea capitis is a dermatophyte infection of the scalp that may cause multiple patches of alopecia and severe itching. The dermatophytoses are diseases caused by a group of closely related filamentous fungi with a propensity for invading the stratum comeum, hair, and nails. Dermatophyte infections are designated by the word tinea, followed by the Latin name ofthe site. Thus, tinea capitis is a dermatophyte infection of the head. The three genera generally responsible for dermatophyte infections are Trichophyton, ficrosporum, and Epidermophyton, Both Microsporum and Trichophyton species commonly cause tinea capitis. The most common pathogens are Trichophyton tonsurans (choice D) followed by Microsporum canis. These two pathogens are distinguished by the fact that hairs infected with Aficrosporum species fluoresce a bright blue-green color whereas those infected by Trichophyton species usually do not fluoresce. In addition, 7. ‘Bi tine Remaningi canes's Internet Explorer’ ‘A 2-day-old newborn with a normal physical examination passes bloody stools. Which of the following tests would be most indicated in this patient to determine the cause of the bloody stool?” ¥@ A. Apttest on the blood in the stool © 8, Hemoglobin electrophoresis ofthe blood from the stool Cc, Barium enema © °D,Olinitest examination ofthe stool CE, Methylene blue stain ofthe stool Explanation ‘The most common cause of blood in the stool af a newborn is swallowed maternal blood, The Apt test helps distinguish adult hemoglobin (Hab) from fetal Hab. tis easier and less expensive than electrophoresis (choice B). f adult Hgb is detected, the bload is swallowed maternal blood. iffetal Hab is found, a search hegins for the cause of the bleeding. A barium enema (choice C)is bath diagnostic and therapeutic for intussusception, which is rare before 3 months of age. The Clinitest (choice D) is used to quantity the urinary level of reducing sugars. The presence of leukocytes in the stool is determined by the methylene blue stain (choice E). Bi tine Remaningi canes's Internet Explorer’ A low-birthweight infant presents to his pediatrician at 2 months of age. The mother states that the infant has not heen eating well. On physical examination the infantis noted to be pale and tachycardic. The lungs are clearto auscultation and there is no hepatosplenomegaly. & complete blood count (CBC) shows a hemoalobin (Hgb) level of 6 gidl. Which of the following is the mast likely cause of anemia in this infant? CA Megaloblastic anemia © B. Sickle cell anemia 6 @C__ Anernia of prematurity ©. Thalassemia C& Homozygous pt-thalassemia Explanation Anemia of prematurity occurs in low-birthweight infants approximately 1 to 3 months after birth. tis caused by the physiologic effects ofthe transition from fetal to neonatal life, as well as factors such as shortened red blood cell (RBC) survival, rapid growth, and frequent phlebotomy for blood tests. Hemoglobin (Hab) levels in anemia of prematurity are below 7 to 10 gil. Clinical manifestations may include feeding problems, tachypnea, tachycardia, and pallor. Megaloblastic anemia of infancy (choice A) is caused by a deficiency of folic acid and has its peak at 40 7 months of age. Infants with folate deficiency are irritable, have poor weight gain, and have ‘Bi tine Remaning: canes's Internet Explorer’ ‘An 8-year-old boy develops petechial lesions over his entire body 1 week after an upper respiratory infection. A platelet countis 20,000 platelets/ul. The remainder of the complete bload count (CBC) is normal. No hepatosplenameualy is present. Ahone marrow aspirate exhibits normal megakaryocytes, but platelet budding is poor. Which of the following is the most likely diagnosis? A. Thrombotic thrombocytopenic purpura (TTP) sf @ 8 Idiopathic thrombocytopenic purpura (TP) © ¢._ Disseminated intravascular coagulation (DIC) ©. Henoch-Schénlein purpura Ce RockyMountain spotted fever Explanation Part 4: idiopathic (immune) thrombocytopenic purpura (ITP) is the most common thrambocytopenic purpura of childhood. The disease usually fallows a viral infection. The infection seems to trigger an immune mechanism that starts platelet destruction. This destruction is manifested as acute onset of bruising and petechiae. Other than this condition, the patient looks well. Bleeding into tissues can occur. Platelet counts are depressed, and bleeding time is prolonged, but the white blood cell (WBC) count is normal, Platelet antibodies are commonly seen. Bone marrow examination reveals normal megakaryocytes. The disease is self-limited, with resolution ofthe petechiae aver 1 or 2 ‘weeks, although thrombocytopenia may persist longer. ‘Bi tine Remaning: carta's Internet Explorer’ ‘An 8-year-old boy develops petechial lesions over his entire body 1 week after an upper respiratory infection. A platelet countis 20,000 platelets/ul. The remainder of the complete bload count (CBC) is normal. No hepatosplenameualy is present. Ahone marrow aspirate exhibits normal megakaryocytes, but platelet budding is poor. Which ofthe following is the most appropriate approach ta the management of this patient? A. Platelet concentrates should be given prophylactically to prevent bleeding ©B. Whole blood should be administered to prevent bleeding ¥—- @ 6, Gamma globulin andor carcosteroid should be administered © D, Vitamin ¢ should be administered CE, Vitamin K should be administered Explanation Part 4: idiopathic (immune) thrombocytopenic purpura (ITP) is the most common thrambocytopenic purpura of childhood. The disease usually fallows a viral infection. The infection seems to trigger an immune mechanism that starts platelet destruction. This destruction is manifested as acute onset of bruising and petechiae. Other than this condition, the patient looks well. Bleeding into tissues can occur. Platelet counts are depressed, and bleeding time is prolonged, but the white blood cell (WBC) count is normal, Platelet antibodies are commonly seen. Bone marrow examination reveals normal megakaryocytes. The disease is self-limited, with resolution ofthe petechiae aver 1 or 2 ‘weeks, although thrombocytopenia may persist longer. ‘Bi tine Remaning: oai06's Internet Explorer’ ‘A 2-year-old child presents to the physician's office with her mother. The mother states that for the past few days the child B has had a low-grade fever, upper respiratory tract symptoms, and has been tugging at her right ear. An examination of the Tight ear with the pneumatic otoscope reveals a hyperemic, opaque, bulging, tympanic membrane with poor mobility. The physictan makes the diagnosis of right oliis media, Which of he following organisms is the most likely causative pathogen? A, Haemophilus intuenzae CB, Staphylococcus pyogenes Cc, Moraxetia catarmatis Vo @D__ Streptococcus pneumoniae CE, Group B streptococci Explanation ‘The patient has acute otitis media with effusion. The mast common cause of acute otitis media with effusion in all age-groups is Streptococcus pneumoniae. Haemophilus influenzae (choice A), Staphylococcus pyogens (choice B), and Moraxella catarrhaiis (choice C) are less cammon causes of acute otis media with effusion. Group B streptococci (choice E) can cause sepsis and meningitis in neonates. Group 8 streptococci have been isolated in middle ear fuid fram newborns with otitis media ‘El Tine Remaining: 02:45:59 [ 1) 1) (e@ tere's Internet Explorer’ ‘An 8-manth-old infant presents to the pediatrician with a 3-day history of a mild upper respiratory tract infection, with B serous nasal discharge, temperature of 38.5°C (101*F), and decreased appetite. Examination reveals a tachypneic infant ‘with audible wheezing and a respiratory rate of 65 breaths/min. There is flaring of the alae nasi, and use ofthe accessory muscles as well as intercostal and subcostal retractions. Expiratory wheezes are present. Which of the following is the most likely diagnosis? CA. Croup Vo @B, Bronchialts Co, Asthma Cp, Acute epigiotitis Ce, Cystic brosis Explanation Bronchiolitis results from inflammatory obstruction of the smaller airways. The inflammation occurs during the first 2 years of life, with a peak incidence at 6 to 12 months of age. Bronchiolitis starts insidiously as an upper respiratory infection, but develops to include wheezy dyspnea and tachypnea. Physical examination reveals tachypnea, nasal flaring, rales, wheezes, and retractions, Patients begin to show gradual improvement after 72 hours in uncomplicated cases. Asthma (choice C) can easily be confused with bronchiolitis, but asthma usually includes a history of repeated attacks of wheezing and a family history of asthma, Croup (choice &) is characterized by a ‘El Time Remaining: 02:45:52 [ 1) 1) (e@ tere's Internet Explorer’ A child is toilet trained, plays interactive games, gives his first and lastname, pedals a tricycle, and is able to copy a B cross and a circle but not a square or triangle. He is not able to catch a bounced ball or dress withaut supervision. Which of the following is the most ikely age of this child? CA tyearotd Cp, 2years old Vv oe, Byears old Cp, 4years old Ce, Syears old Explanation Most 3-year-old children are toilet trained, play interactive games, give their first and last names, and pedal a tricycle. At age 3, most children should be able to copy a citcle, and some will he able to copy a cross. A 1-year-old child (choice A) would not be able to pedal a tricycle, give his first and last names, or copy a circle or a cross. At age 1, a child should he able ta stand momentatily, say "dad: and "mama," and bang two cubes held in his hands. Although some 2-year-old children (choice B) may he able to accomplish the tasks noted in the scenario, they would not be able ta hop on one foot. Most 4-year-old children (chaice D) are able to dress without supervision, hop an one foot, and catch a bounced ball. A S-year-old child (choice E) would be able to copy a triangle. ‘El Tine Remaining: 02:45:46 [ 1) 1) (e@ tere's Internet Explorer’ A pediatrician plans ta administer the pneumococcal vaccine to a 2-year-old female with sickle cell disease. This vaccine should also he administered to which of the following children? A, Children less than 2 yeats old to prevent otis media YB, Children with nephrotic syndrome Cc, Children receiving radiation therapy ©, Healthy children to prevent upper respiratory tract infection CE, Children less than 2 yeats old to prevent pneurnania Explanation Children 2 years of age and older, at high risk for acquiring systemic pneumococcal infections, or with increased risk of serious disease ifthey become infected, should be vaccinated with pneumococcal vaccine. The high-risk category for pneumococcal disease includes sickle cell disease, functional asplenia, nephrotic syndrome or chronic renal failure, immunosuppression and infection with the human immunodeficiency virus (HIV), and cerebrospinal fluid (CSF) leaks, Vaccination with the current pneumococcal vaccine is not recommended to prevent upper or lower respiratory tract infection in healthy children (choice D). itis not recammended in children less than 2 years of age to prevent otitis media (choice A) or any other pneumococcal infection [e.9., pneumonia (choice E)]. However, the use of pneumococcal vaccine in older children with recurrent otis media is controversial. Vaccination during chemotherapy ar radiation therapy (choice C) ‘Bi tine Remaning: caso's Internet Explorer’ A T-year-old female is referred to the physician by her school nurse, who states that the child often has cessation of B speech in midconversation, a blank stare, and flickering of the eyelids. These symptoms last approximately 10 seconds before she resumes regular activity. The physician suspects that the child has a seizure disorder and asks the child to hyperventilate. During hyperventilation, the above symptoms appear. Which of the following electroencephalogram (EEG) pattems is most characteristic of this disorder? a, Abypsartiythmia CB Aninterictal slow-spike wave Cc, Centrotemparal spikes Vo @D, Atree-nersecond spike-and-wave pattern CE, Asbepersecond spike-and-wave pattern Explanation Petit mal, or absence, seizures cease as quickly as they commence. Motor activity stops abruptly, and patients develop a blank stare with fluttering of the eyelids. The seizures are brief (10-30, seconds), but may occur many times throughout the day. They end abruptly and have no postictal stage. Absence seizures can be triggered by hyperventilation. Electraencephalogram (EEG) shows a typical three-per-second spike-and-wave pattern. Hypsarthythmia (choice &) is seen on EEG in patients with infantile spasms. Interictal slow-spike waves on EEG (choice B) are seen with Lennox. Gastaut syndrome. A centrotemporal spike (choice C) is the EEG finding diagnostic of benign partial ‘El Tine Remaining: 02:45:38 [ 1) 1) (e@ tere's Internet Explorer’ A 2-year-old, symptomatic human immunodeficiency virus (HIV)-infected child presents to his physician because he was exposed to measles. The child is up to date on all immunizations, including his reasles-mumps-rubella (MMR) combination vaccine. The child received immunoglobulin (1G) 6 weeks ago. Which of the following is the most appropriate frst step in the management of this patient? A, Administer monovalent measies vaccine CB, Administer another MMR combination vaccine ¥ &o. Administer 16 CD, Administer vitamin c CE, Donothing, because the child is already immunized for measles Explanation Symptomatic human immunodeficiency virus (HIV)-infected children exposed to measles should receive immunoglobulin (1G) prophylaxis at a recommended dose of 0.50 mirkg (maximum 15 ml) regardless of vaccination status. Asymptomatic HIV-infected children exposed to measles should alsa receive IG ata recommended dose of 0.26 milkg. Ifa child received IG within 3 weeks of exposure, no additional IG is required. Generally, children with symptomatic HIV infection have poor immunologic response to vaccines. Therefore, when these children are exposed to a vaccine- preventable disease (e.9., measles), passive immunoprophylaxis is indicated regardless of the history of vaccination (choices A, B, and E). Low serum concentrations of vitamin A, not vitamin C ‘Bi tine Remaningrcanszs's Internet Explorer’ A 4-year-old swimmer presents to his pediatrician with left ear pain. Physical examination of the left ear reveals edema and erythema ofthe ear canal as well as a greenish otorthea. Pain is increased by manipulation ofthe pinna and pressure on the tragus. Which of the following is the most likely pathogen producing this patient's symptoms? A, Heemophitus infuenzae VB, Pseudomonas aeruginosa Cc, Moraxetta catarthatis CD, Steptococcus agaiactiae CE, Escherichia cov Explanation External otitis, or "swimmer’s ear," is caused by excessive moisture in the ear canal, which causes the loss of protective ceruren and chronic iritation, The patient presents with ear pain that is ‘worsened by manipulation of the pinna, The ear canal is erythematous and edematous. Otorthea may he seen, Pseudomonas aeruginosa is the most commonly isolated bacterium of external otitis, Other organisms include Enterobacter aerogenes, Proteus mirabilis, Kiebsiella pneumoniae, streptococci, Staphylococcus epidermidis, and fungi. Both Haemophilus influenzae (choice A) and Moraxella catarrhalis (choice C) cause otis media, but not as often as P. aeruginosa. Streptococcus agalactiae (choice D) has been isolated from middle ear fluid in neonates with ottis media. However, bath 8. agalactiae and Escherichia cosl (choice E) are leading causes of sepsis and ‘Bi tine Remaning: cas's Internet Explorer’ ‘A 4-year-old female is brought to the pediatric clinic for a well-child visit and immunizations. The child appears to be in B good health and the physical examination is unremarkable, She is developmentally normal for her age. Her past medical history is nat significant, and her immunizations are current. She lives with her mother, a 2-year-old brother who has febrile seizures, and a grandmother who has lymphoma. Which of the following immunization protocals is the most appropriate? Ca, Dinhtheria-tetanus-acellular pertussis (OTaP), aral polio (OPV), and measles-mumps-rubella (MMR) vaccines <6 @ 8 DTaP, inactivated polio (PV), and MMR vaccines © Cc. Dinhtheria-tetanus-pertussis (OTP), OPV, hepatitis 8, and MMR vaccines © D. DTaP, OPV, hepatitis 8, and MMR vaccines Explanation ‘The recommended routine vaccination schedule calls for vaccination with diphtheria-tetanus- acellular pertussis (DTaP), oral polio (OPV), and measles-mumps-rubella (MMR) vaccines (choice A) for the 4 to 6 year old before starting school. In recent years, DTaP has became an accepted substitute for diphtheria-tetanus-pertussis (OTP). Unlike DTP, DTaP is manufactured trom cell-free organisms and, although slightly less potent, produces fewer side effects. The brother's history of febrile seizures does not contraindicate the use of any of these vaccines, including DTP. Therefore, for most children. the hest answer to this question would be choice A, However, the history obtained. zi ‘Bi tine Remaning: casa [@ internet's Internet Explorer’ ‘A mother reports that her infant is able to habe, coo, and form a social smile, When supine, the infantis able to fallow B an object 90 degrees from the midline through an arc of 180 degrees. When prone, the infantis able to lit its head 45, degrees. The infant is also able to roll from the prone to the supine position. Which of the following is the most likely age of this infant? CA Newnor Bt month Co, 2months CD. 3months Vv @ eA months Explanation Babbling and cooing occur by 2 manths of age (choice C). The social smile also is present by this time. Lifting the head and chest occurs by 3 months of age (chalice D). A 2-month-old infant can use the eyes well enough to follow an object through 180 degrees. Rolling over from the prone to supine position usually does not occur until 4 to 6 months of age. From the age ofnewborn (choice A) to 1 ‘month, an infant (choice B) may be able to regard a face, respond to a bell, and have equal movernents. In addition, a 1-manth-ald may fallow ta midline. ‘El Tine Remaining: 02:45:08 [ 1) 1) (e@ tere's Internet Explorer’ A T-year-old boy wakes up in the night with the right side of his face twitching and with speech arrest, He is able to run to his parents' room, where the attack stops within 1 minute, His electroencephalagram (EEG) is completely normal except for a prominent spike focus that emerges aver the left central area during sleep. Which of the following is the most likely explanation for this occurrence? © Childhood absence epilepsy © B, _Lefttemporal lobe tumor 6 @c,_ Benign ralandic epilensy Cp. Sleep terrors Ce, Hypsarhythmia Explanation Benign rolandic epilepsy (benign partial epilepsy of childhood) occurs in the school-age population, and usually emerges during drowsiness or sleep. itis a benign condition that is eventually outgrown. Any anticonvulsant can manage the seizures; or itis legitimate not o treat ifthe events are isolated or rare, because they generally do not interrupt the day's activities. Childhood absence epilepsy (choice A) would nat present with focal manifestations and preserved alertness. although a left temporal lobe tumar (choice B) cannot be excluded, itis less likely given the clinical presentation and would generally show persistent slowing on the left during an electroencephalogram (EEG). Sleep terrors (choice D), a parasomnia, occur during non-rapid eye ‘Bi tine Remaningicans1's Internet Explorer’ ‘Anewbom infant has excessive drooling along with coughing and choking with feeding. Cyanosis is present and is Unrelieved by crying. Bilateral pulmonary rales are present. There is abdominal distention with tympany on percussion. Which of the following is the most likely diagnosis? CA Choanal atresia CB, Respiratory distress syndrome Cc, Zenker's diverticulum VD, Attacheaesophageal fistula CE Duodenal atresia Explanation Choking and cyanosis with feedings are the hallmarks of tracheoesophageal fistula. Rales can be heard and are caused by aspiration, abdorninal distention results fram swallowing ar. A feeding tube fails to pass into the stomach. Choanal atresia (choice A) presents as cyanosis relieved by crying. Cyanosis, grunting, and rales are seen in respiratory distress syndrome (choice B), but they are unrelated to feedings. Zenker’s diverticulum (choice C) does not appear in the newborn period. Duodenal atresia (choice E) is characterized by bilious vomiting without abdominal distention. ‘Bi tine Remaningr case's Internet Explorer’ AS-year-old child has "doll fac hepatomegaly, moderately enlarged kidneys, a tendency for hypoglycemia, and platelet dysfunction, There is an enzyme deficiency in the cytosol rather than the lysosomes. Which of the following is the most likely diagnosis? normal mental development, and stunted growAh. in addition, the patient has CA Tay-Sachs disease CB, Gauchers disease Co, Niemann-Pickdisease ©, Hurler syndrome VE, Von Gierke's disease Explanation Von Gierke's disease is a glycogen storage disease. itis due to a deficiency of glucase-6- phosphatase and results in enlarged kidneys and liver; hypoglycemia is common. Tay-Sachs disease (choice A) involves the central nervous system (CNS). There is a defect in the lysosomal ergyme p-hexosaminidase. Gaucher's disease (choice B) is one ofthe lipidoses, or lysosomal lipid storage diseases, as is Niemann-Pick disease (choice C). The enzyme defect in Gaucher's, disease is R-glucosidase; the enzyme defect in Niemann-Pick disease is sphingomyelin. Tay- Sachs, Gaucher's, and Niemann-Pick diseases are all mare common in Ashkenazi Jews than in other ethnic groups. Hurler’s syndrome (choice D) is the most severe of the mucapalysaccharidoses. A deficiency of a-L-iduronidase leads to mucopolysaccharide-engorged Bi tine Remaningi coast's Internet Explorer’ ‘A 45-year-old woman with polyhydramnios delivers a male infant with Down syndrome. & few hours affer bith, the infant begins to vomit bile-stained fluid. An ray of the chest and abdomen reveals a "double bubbl following is the most likely diagnosis? sign. Which of the CA. Congenital pyloric stenosis VB, Duodenal atresia Cc, Anintussusception CD, Adiaphragmatic hernia CE, Aperforated viscus Explanation Although biliary atresia is more common than duodenal atresia in Down syndrome, duodenal atresia is offen associated with the syndrome and appears in the first day of life as bilious vorniting after feedings. X-ray typically shows the "double bubble" sign; treatment is surgical, Pyloric stenosis (choice A) appears at 2 to 3 weeks of age with nonbilious vomiting. Bile-stained emesis may be seen in the later phase of intussusception (choice C); however, itis rare under 3 months of age. Itis associated with colicky abdominal pain and currant-elly stool. If diaphragmatic hernia (choice D) presents at birth, the infant usually has a scaphoid abdomen and respiratory distress. Bowel sounds can be auscultated in the chest, and x-ray reveals abdominal contents in the thorax. A perforated viscus (choice E) will show free air in the abdomen on xray, ‘Bi tine Remaningr canes's Internet Explorer’ Inwhich of te following situations should a physician inform law enforcement authorities? ¥@ A.A AS-year-old man reveals that he has been sexually abusing his 12-year-old daughter CB. ABS-year-old man reveals that he committed a robhery 26 years ago Cc, A28-yearold wornan reveals that she has never fled an income tax return © p, A 25-year-old woman reveals that she lied about her previous mental prablems on her employment application CE, At T-yearold gil reveals that she regularly steals money ramn the cash register at work Explanation A physician must infarm law enforcement authorities when a patient poses a serious danger to another person (e.9,, a patient who reveals that he has been sexually abusing his 12-year-old daughter). A physician is not ethically or legally required to reportto authorities patients who pose no current danger to others, such as patients wha steal (choices B and), who lie an employment or other applications (choice D), or who fal to file tax returns (choice C). ‘Bi tine Remaning: cas [@ internet's Internet Explorer’ A pediatric intern is called to the nursery to examine an infant who had a cyanotic and chaking episode associated with B feeding. The infant has excessive oral secretions that improve with suctioning of the mouth and pharynx, but recur after a short time, The intern suspects tracheoesophageal fistula. The intemn's suspicion would be supported by which of the following additional findings? CA. Cyanosis that occurs at rest hut is relieved by erying CB, Ahistory of oligohydramnnios during pregnancy Cc, The abiltyto pass a catheter into the stomach YD, Astornach filed with air Ce, An associated renal anomaly Explanation Esophageal atresia is an esophageal malformation causing upper intestinal obstruction. In approximately 86% of the cases, a fistula between the trachea and distal esophagus is present, usually allowing air to enter the abdomen. There is an association with polyhydramnios during pregnancy, not oligahydramnios (choice B). Often, a catheter used at birth for resuscitation cannot be inserted into the stomach (choice C). Anproximately 20% of infants with esophageal atresia have associated anomalies, the most common being heart anomalies (choice E). Cyanosis that occurs, at rest buts relieved by crying (choice A) is characteristic of choanal atresia, which is diagnosed by the inability to pass a catheter through the nose. El Tine Remaining: 02:48:31 [ 1) 1) (e@ tere's Internet Explorer’ ‘Ayoung female with phenylketonuria (PKU) wha wants ta became pregnant asks her physician if any special preparation a is required before conception to ensure that her baby is healthy. Her physician tells her that women with PKU who are nat on low-phenylalanine diets have a higher risk of spontaneous abortion than the general population and often give birth to infants with mental retardation, microcephaly, and congenital anomaly; high levels of phenylalanine seem to be the cause of these problems. Therefore, prospective mothers who have PKU should be placed on a low-phenylalanine diet before conception. In addition, throughout pregnancy the blood phenylalanine levels should be kept below which of the following? Ca Small WB 10 mga Co, 18 maid Op, 20mg CE, 28 maid! Explanation Phenylketonuria (PKU) is caused by a deficiency in phenylalanine hydroxylase. The normal pathway is disrupted, so phenylalanine and other metabolites accumulate and cause brain damage. Clinically, affected infants are blond, with fair skin and blue eyes. A mild eczenatous rash disappears with age. Vorniing can he confused with pyloric stenosis. Mental retardation is usually severe. The infants have a musty, mousey odor of phenylacetic acid. Screening is recommended ‘El Time Remaining: 02:48:28 [ 1) 1) (e@ tere's Internet Explorer’ ‘A 4-year-old child presents with a temperature of 40°C (104*F), which she has had forthe past 4 days. On physical examination, she is noted to have conjunctivitis, an erythematous rash, cervical adenopathy, and swollen hands and feet. Laboratory findings include an absolute neutrophilic leukocytosis, lef shift, normal platelets, and an elevated erythrocyte sedimentation rate (ESR). Which of the following is the most ikely diagnosis? Oa Scarlet ever © B, Acute rheumatic fever Cc, Petiatteritis nodosa © p. _Disseminated lupus erythematosus 6 @E,_ Kawasaki syndrome Explanation Kawasaki syndrome [mucocutaneous lymph nade syndrome (MLNS)| is a febrile vasculltis of large coronary blood vessels of children. Criteria for diagnosis are unexplained fever of § days’ duration and four ofthe following five conditions: bilateral nonpurulent conjunctivitis, changes of the mucosa of the oropharynx (dry, cracked lips; strawberry tongue), changes of the peripheral extremities (edema, erythema), a polymormhaus rash, and cervical lymphadenopathy, Desquamation of the palms and soles is a late finding, usually appearing during the second or third week of the disease, Many experts believe that in the presence of classic features, the diagnosis can be made before § days of fever. Kawasaki syndrome accurs generally in children less than 5 years of age. ‘Bi tine Remaningsoaazo's Internet Explorer’ ‘An 18-year-old female has just graduated from high school and has applied for admittance into a local college, which has implemented the American College Health Association (ACHA) recommendations for prematriculation immunization. Her immunizations are current for mumps, rubella, diphtheria, tetanus, and polio. She must also be immunized against which ofthe following diseases? CA Hepatitis B OB, Pertussis Cc, Haemophilus influenzae type B ©. Influenza CE, Measles Explanation ‘The American College Health Association (ACHA) recammendations for prematriculation immunization require protection from measles, mumps, rubella, diphtheria, tetanus, and polio. As a result of outbreaks of measles on college campuses in recent years, the ACHA recammendations mandate that colleges and universities require two doses of measles vaccine as a condition for matriculation. Hepatitis B (choice A) is recommended, but nat mandated, for all adolescents. Vaccination against influenza (choice D) is nat mandated, although health-care providers should consider administering influenza vaccine to students living in dormitories orto students who are members of athletic teams. Pertussis (choice B) and Haemophilus influenzae type B (choice C) are “ie etoton | net [Hide the explanation to this question ‘El Tine Remaining: 02:43:55 [ 1) 1) (e@ tere's Internet Explorer’ 12-year-old boy has a 5-year history of asthma with episodes of bronchospasm that have resulted in repeated hospitalizations. He has been using a B,selective adrenoceptor agonist drug via inhalation during the day and long- acting theophylline at night, He comes to the emergency depariment with severe respiratory distress, cyanosis, and tachycardia, The examination is consistent with severe bronchaconstriction and shows no other complicating factors. Which of the following statements about the treatment of this patient is accurate? CA. The use ofipratropium via innatation is likely to exacerbate his symptoms © B, Parenteral glucocorticoids should not be given until the bronchospasm is relieved Cc, The present problem is due to excessive use of the inhaler ©, Cromolyn via inhalation should be given until the bronchospasm is relieved ¥—--@E__ Prophylactic corticosteroid therapy after recovery from this episode should be considered Explanation Part 1: Acute episodes of bronchial asthma represent one of the most comman respiratory emergencies. Use of B,selective adrenoceptor agonists via aerosol, plus oxygen and parenteral glucocorticoids (choice B), are appropriate for acute management in this situation. Maximal bronchadilation occurs within 30 minutes after use of albuterol or metaproterenol. Theophylline (or aminophylline) may also be useful in branchospasm and may help to speed resolution. Ipratropium (choice A), a muscarinic blocking agent used via inhalation, will nat exacerbate the bronchaconstriction, but would not ordinarily be used in this situation. Inhalers will not induce an ‘Bi tine Remaning: cae's Internet Explorer’ 12-year-old boy has a 5-year history of asthma with episodes of bronchospasm that have resulted in repeated hospitalizations. He has been using a B,selective adrenoceptor agonist drug via inhalation during the day and long- acting theophylline at night. He comes to the emergency denartment with severe respiratory distress, cyanosis, and tachycardia, The examination is consistent with severe bronchaconstrction and shows no other complicating factors. Which of the following statements about the drugs that could be used to treat this patient's asthma is most accurate? Ca. The Byselective drugs used in asthma have no cardiac actions © 8, Cromolyn blocks the airway smooth muscle contraction that occurs in response to vagal stimulation <6 @C__ Chronic use ofzileuton leads to decreases in branchial reactivity ©. No side effects occurwith the use ofinhalational forms of the glucacorticoids © & The bronchodilating action of methyxanthines is subjectto rapid tolerance Explanation Part 4: Acute episodes of bronchial asthma represent one ofthe most common respiratory emeryencies. Use of f,-selective adrenoceptor agonists via aerosol, plus oxygen and parenteral glucocorticoids (choice B), are appropriate for acute management in this situation. Maximal bronchadilation occurs within 30 minutes after use of albuterol or metaproterenol. Theophylline (or aminophylline) may also be useful in branchospasm and may help to speed resolution. Ipratropium (choice A), a muscarinic blocking agent used via inhalation, will nat exacerbate the bronchaconstriction, but would not ordinarily be used in this situation. Inhalers will not induce an ‘Bi tine Remanngi cane's Internet Explorer’ A pediatric inter is called to the nursery to examine an infant. The intern notes that the infant's torso and upper extremities are pink, but the lower extrernities are blue. Which ofthe following is the most likely diagnosis? CA. Ventricular septal defect © B,_ Infantile coatctation ofthe aorta Vo, Patent ductus arteriosus with coarctation CD, Corrected transposition ofthe great vessels CE, Altial septal defect Explanation This infant has congenital heart disease. The diferential cyanosis seen in this patient (Le,, blue lower extremities and pink upper torso and extremities) occurs when blood shunts fromm right to left across a patent ductus arteriosus in the presence of a coarctation or interrupted aortic arch. Other signs of patent ductus arteriosus include bounding pulses and a to-and-fro machinery murmur. Differential cyanosis would nat he present with a ventricular septal defect (choice A), infantile coarctation of the aorta (choice B), corrected transposition of the great vessels (choice D), or atrial septal defect (choice E) ‘Bi tine Remaning: cae's Internet Explorer’ A 30-year-old mather is breast-feeding her 2-month-old infant. The administration of which of the following drugs ta the mother would he the safest for the nursing infant? CA, Amphetamine—for temporary weight reduction CB. Tetracycline—for a sinus infection due to Mycoplasma pneumoniae Cc, Theophylline—for asthma ©, Methimazole—for hyperthyroidism Vo @E,_Nystatin—fora yeastinfection Explanation Many commonly used drugs (Including nonprescription drugs) should he avoided in the nursing mother because they are detectable in breast milk and may cause effects in the infant. The polyene antifungal agent, nystatin, is used by local administration in candidal infections of the oropharyngeal cavity and the urogenital system (e.g., vaginal yeast infections). By this mode of administration, nystatin is not absorbed into the systemic circulation and is not presentin breast milk. ll ofthe other drugs listed necessitate systemic absorption. Drugs to be avoided in the nursing mather include central nervous system (CNS)-active drugs [e.g,, stimulants and depressants, including benzodiazepines, ethanol, and amphetamine (choice A], certain antibiotics [tetracyclines (choice B), quinolones}, the methylxanthines (caffeine, theophylline (choice C)], the antithyroid drugs [methimazole (choice D), propytthiouracil, and the glucocorticoids. ‘Bi tine Remaning: canez7's Internet Explorer’ ‘An 8-month-old infant presents with a 3-day history of a mild upper respiratory tract infection, with serous nasal discharge, B a temperature of 38.5°C (101"F), and decreased appetite. An examination reveals a tachypneic infant with audible ‘wheezing and a respiratory rate of 85 breaths/min. There is flaring of the alae nasi, use of the accessory muscles, and intercostal and subcostal retractions. Expiratory wheezes are present. Which of the following is the most ikely diagnosis? CA. Croup vo @B, Bronchitis Co, Asthma Cp, Acute epigiotis Ce, Cystic brosis Explanation Bronchiolitis results from inflammatory obstruction of the smaller airways. The inflammation occurs during the first 2 years of life, with a peak incidence at 6 to 12 months of age. Bronchiolitis starts insidiously as an upper respiratory tract infection, but develops to include wheezy dyspnea and tachypnea. Physical examination reveals tachypnea, nasal flaring, rales, wheezes, and retractions, Patients start showing gradual improvernent after 72 hours in uncomplicated cases Asthma (choice C) can easily be confused with branchialiis, but asthma usually includes a history of repeated attacks of wheezing and a family history of asthma. Croup (choice &) is characterized by El Tine Remaining: 02:49:18 [ 1) 1) (e@ tere's Internet Explorer’ A child with cystic fibrosis has pneumonia secondary to Staphylococcus aureus. The child suddenly develops increased respiratory distress, decreased breath sounds in the left chest, and tracheal deviation to the right. Which of he following is the most likely diagnosis? CA Emphysema © B, Apleural ettusion ¥--@¢, Aruptured tension preumnatacyst CD. Adult respiratory distress syndrome (ARDS) Ce, Apulmonary infarction Explanation Sudden deterioration of respiratory status should lead one to suspect pneumothorax. Clinically, decreased breath sounds are heard on the affected side. X-ray shows extrapulmonary air, with deviation ofthe trachea away from the affected side. Staphylococcus aureus frequently causes pneumatocyst, which can rupture and cause a pneumothorax. Emphysema (choice A) and pleural effusions (choice B) are also caused by 8. aureus, but these effusions have a different radiologic, appearance Adult respiratory distress syndrome (ARDS) [choice D] is an acute respiratory fallure associated with impaired oxygenation, increased permeability, pulmonary edema, and normal cardiac function ‘Bi tine Remaning: cae's Internet Explorer’ /Ameasies outbreak at a day-care center has been confirmed in your community, Heating this news, a mother brings her ‘T-month-old child to the pediatrictan’s office for a measles vaccine. The child's immunization record shows that the child's immunizations are up to date far age. The child appears to be very heatthy. All growth parameters are at the 75th percentile, and the physical examination is unremarkable. Which of he following is the mast appropriate next step in the management ofthis patient? Ca, Tellthe mother not to worry hecause the child apnears tobe in good health and his immunizations are already up to date Cg, Tellthe mother not to wary because her child does not attend the day-care center where the outbreak occurred Cg. Tallthe mother that the measles-mumps-rubella (MMR) vaccine is not effective if given before 1 year of age because maternal antibodies interfere with development of immunity Cp, Sive the child manevalent measles vaccine, but de not use the MMR vaccine because itis contraindicated 4/ @_,_ Sie the child the monovalent measles vaccine or MM. vaccine, but tell the mother thatthe child wil need to be revaccinated with MMR vaccine after 12 months of age Explanation Although the child is in good health and immunizations are up to date, the child has nat been immunized against measles, which would normally be administered at 1 year of age (choice A). In children less than 1 year of age, the risk of complication resulting fram measles is high. During an outbreak, monovalent measles vaccine or measles-mumps-rubella (MMR) vaccine (if monovalent q 3 auailab hi ‘0 infant Aimonths nfane fehnines C zi ‘El Tine Remaining: 02:42:47 [ 1) 1) (e@ tere's Internet Explorer’ A premature, small-for-gestational-age infant is born to a 16-year-old primigravida by spontaneous delivery. Eight hours after bith, the infant has a glucose of 20. Which of the following disorders is the most likely cause of this infant's hypoglycemia? A Leucine sensitivity CB, Nesidiotlastosis Vo, Inadequate fat and alycagen stores Cp, Immature pituitary-hypothalamic axis CE Motherwith dianetes Explanation Premature or lovebirth-weight infants have inadequate stores offat and glycogen. Consequently, they are at high risk for hypoglycemia. Early, frequent feedings help avoid this problem. Infants of dlabetic mothers tend to he macrasomic (choice E). Their hypoglycemia is caused by relative hyperinsulinism. Beta cell endocrine turnors are usually seen in the farm of nesidiablastosis, (choice B). Leucine-sensitive hypoulycemia is associated with excessive insulin secretion after leucine administration (choice &). Although the gluconeogenic enzymes may note fully developed in small-for-gestational-age and premature infants, most neonates have functional, normal hormonal systems (choice D). ‘Bi time Remaningr cane's Internet Explorer’ A grammar school teacher who is 2 months" pregnant sees her obstetrician because she is worried about an outbreak of parvovirus 819 in her class. She fears that if she contracts the virus it may harm her fetus. The obstetrician informs her that there is less than a 6% chance that her fetus will contract which ofthe following anomalies? CA Choriretintis ¥@B,_ Hydrops fetalis Coc, Rhagades ©D, Mioravephaty Ce, Hutchinson's teeth Explanation Pregnant women infected by parvovirus may be asymptomatic or have nonspecific symptoms. However, fetal infection may occur via transplacental passage of the virus, which can resuttin, stillbirth and nonimmune hydrops fetalis in less than 5% ofthe cases. The fetus is most sensitive to Infection during the second trimester. Parvovirus is not considered a teratogen and is not associated with a typical syndrame. Chorioretintis (choice A) and micracephaly (choice D) are seen in congenital toxoplasmosis. Rhagades (choice C) and Hutchinson's teeth (choice E) are typical findings of congenital syphilis. ‘Bi tine Remaning: cae's Internet Explorer’ ‘An asymptomatic 3-year-old is brought to the physician because of right cheek swelling. The mother states that the patient had been in his normal state of health until 1 hour ago, when he developed right cheek swelling at a church picnic. ‘The patient is afebrile. Physical examination is unremarkable except for the right cheek, which is erythematous but not ‘warm ta touch. On palpation ofthe right cheek, mildly tender, discrete, indurated masses are appreciated. Which of the following is the most likely cause of this child's problem? CA Ensipelas CB Cellulitis Co, Trauma Yo @p, Pannicuitis Ce, Contact dermatitis Explanation Panniculitis is secondary to cold injury to fat and is characterized hy the development of indurated lesions that resemble buccal cellulitis. Young children who hold popsicles in their mouths may be prone ta panniculitis. Erysipelas (choice A) is an acute, well-demarcated infection of the skin with lymphangittis. The patient with erysipelas usually appears ill with fever, vomiting, and irritability Cellulitis (choice B) usually has distinct margins and is tender, indurated, and warm to touch. There is no history of trauma (choice C), nor is there any evidence of bruising or abrasions. Contact dermatitis (choice E) has an erythematous or papulovesicular rash in the area that was exposed to ‘El Tine Remaining: 02:42:20 [ 1) 1) (e@ tere's Internet Explorer’ Agi in second grade shows the intellectual ability ofa sixth grader. Which ofthe following is the correct intelligence quotient (0) category of this child? CA Lowaverage CB Average Co. High average ©. Superior Vo @E,_ Very superior Explanation A child in second grade is approximately 8 years old. I'she shows the intellectual ability of a 12 year old (sith grader) her intelligence quotient (Q) [using the I formula of mental ageschranalogical age X 100] is approximately 150. Intelligence quotients greater than 130 are in the very superior category. With respect to 1a scores, low average (choice A) is 80-89, average (choice B) is 90-109, high average (choice C) is 110-119, and superior (choice D) is 120-129. ‘Bi tine Remaning: canazn [@ internet's Internet Explorer’ ‘A parent reports that 12 hours after her 6-month-old daughter received the diphtheria-tetanus-pertussis (OTP) vaccine, she developed a seizure that lasted approximately 1 minute. The child has nothad any more seizures since the immunizations and appears to be developmentally appropriate for her age. Which procedure is recommended for future immunizations? Leave out the diphtheria component of the vaccine, and give pertussis and tetanus on the next immunization cp. Leave outthe tetanus component ofthe vaccine, and give diphtheria and pertussis on the next immunization Co, Leave outthe tetanus and pertussis components ofthe vaccine, and give diphtheria toxoid alone on the next immunization 4/ @p, Leave out ne pertussis comnonent ofthe vaccine, and give diphtheria and tetanus toxoids on the next immunization CE, Give DTP again on the next immunization Explanation Most of the reactivity of the diphtheria-tetanus-pertussis (OTP) vaccine is due to the pertussis, component, Serious reactions, such as seizures, contraindicate the further use of the pertussis, vaccine. This reaction, however, does not contraindicate the further use of the tetanus and diphtheria toxoids. Choices A,B, andE all include pertussis as part of future vaccines. Choice C excludes both the tetanus and pertussis components of any future vaccines, which is not necessary; only the pertussis component should be left out ‘Bi tine Remaningi caer's Internet Explorer’ ‘A S-month-old nonimmunized child presents with a 2-week history of paroxysrnal coughing, low-grade fever, posttussive E emesis, and a viscid nasal discharge. Physical examination reveals bilateral alitis media and conjunctival hemorthages. Scattered inspiratory rales are present bilaterally. The complete blood count (CBC) shows a white blood cell (WBC) count of 45,000 cellsirnm®, 96% of which represent lymphocytes. Which of the following is the most likely diagnosis? A, Acute lymphoblastic leukemia © 8, Chlamydial pneumonia Vc, Whooping cough ©D, Bronchialtis CE, Respiratory syncytial viral pneumonitis Explanation Pertussis (whooping cough) is an extremely contagious respiratory disease caused by Bordetella pertussis, From 60% to 70% of cases occur in children less than 1 year of age, and most deaths occur in nonimmunized infants. After a 1-week incubation period, children present with three successive stages ofthe disease. The catarthal stage consists of symptoms of an upper respiratory infection, thick nasal discharge, and conjunctivitis. The paroxysmal stage is characterized by spasms of forceful coughing ending in an inspiratory whoop. The cough is strong enough to force vorniting, and facial redness and cyanosis are often observed. Often, there is no ‘whoop in infants, but apnea may be manifested. In the convalescent stage, the cough and vorniting ‘El Tine Remaining: 02:42:13 [ 1) 1) (e@ tere's Internet Explorer’ A 4-month-old infantis brought to the emergency department with the sudden onset of lethargy, poor feeding, constipation, generalized hypotonia and weakness, and ophthalmoplegia. The child is afebrile. According to the mather, the child does not lke the infant formula unless itis sweetened. Which ofthe following is the most likely diagnosis? CA. Gray syndrome © 8, Hypothyroidism Cc. Werdnig-Hofimann disease ¥ © D._Infant botulism CE. Hypomagnesemia Explanation Infant botulism usually occurs in infants less than 1 year of age, particularly between 2 and 6 months. occurs after the ingestion of Clostridium botulinum spores, which can be found in honey ‘and com syrup, as well as in soll and house dust. The course ofthe disease varies but progresses quickly. Typically, the child is afebrile and has been previously healthy. The infant becomes constipated and feeds poorly. Aweak cry, hypotonia, and loss of head control are then seen. Descending paralysis progresses over hours to days. Ventilatory support may be necessary. Gray syndrome (choice A) is associated with chloramphenicol use. Although hypothyraidism: (choice B) and Werdnig-Hoffmann disease (choice C) present with hypotonia, itis seen earlier in ‘Bi tine Remaning: cates's Internet Explorer’ ‘A 1840-9 (3 lb 6 02) neonate who received 40 days of supplemental oxygen is evaluated by an ophthalmologist for retinopathy of prematurity (ROP). Examination of the infant's eyes shows a thickened, demarcated line and formation of an intraretinal ridge biaterally. This finding is consistent with which of the following stages of ROP? CA Stage! Vv 8, Stage Co, Stage Cp. Stage Ce Stagev Explanation Retinopathy of prematurity (ROP) is a vasoproliferative retinopathy seen primarily in premature infants exposed to oxygen for prolonged periads of time. There is a proliferative and cicatricial phase. ROP is classified according to five distinct stages. Each stage involves specific events that are used in the classification of ROP, as shown in the following table Staging Classification of Retinopathy of Prematurity Stage Classification Demarcation line between vascular and avascular retina ‘Bi tine Remaningi caiExplanation Retinopathy of prematurity (ROP) is a vasoproliferative retinopathy seen primarily in premature infants exposed to oxygen for prolonged periads of time. There is a proliferative and cicatricial phase. ROP is classified according to five distinct stages. Each stage involves specific events that are used in the classification of ROP, as shown in the following table Staging Classification of Retinopathy of Prematurity Stage Classification | Demarcation line between vascular and avascular retina I Thickening of the demarcation line; formation of an intraretinal ridge | EXtaretinal,fibrovascular proliferation forms on ridge, hemormhages may be seen IV ‘Subtotal retinal detachment I¥.A |Detachment is extrafoveal \¥B Detachment involves the fovea Vv ‘Total funnel-shaped retinal detachment ‘Bi tine Remaningi canis Internet's Internet Explorer’ ‘A 13-year-old male basketball player presents to the pediatrician with a limp and knee pain. Running, jumping, or climbing stairs exacerbates the pain. The tibial tuberosity is enlarged, but there is no synovial effusion or thickening of the knee joint. Which of the following is the most ikely diagnosis? A Leug-Canvé-Perthes disease © B, Slipped capital femoral eniphysis Vo @ oe, Osgood- Schlatter disease CD, Septic arthntis ofthe knee CE, Chondromalacia patellae Explanation Osgood-Schlatter disease is an overuse injury that is more cammon in physically active boys ‘around puberty. tis characterized by pain and swelling of the tibial tubercle. The treatments, focused on reduction of the activity. The condition usually resolves within several manths. Legg-Calvé-Perthes (choice A) presents with a gradual limp, stiffness, and pain in the groin, hip, thigh, or knee. tis most common in boys 4 to 8 years of age. itis an avascular necrosis of the femoral head. Slipped capital femoral epiphysis (choice B) typically occurs in overweight adolescent boys. The ‘Bi tine Remaningr cas's Internet Explorer’ ‘A 4-year-old child was playing in afield that had been sprayed with insecticides. The parents come to the emergency + depariment canying the child, who is lethargic, has excessive oral secretions, miosis, tearing, "soiled rousers from Urination and defecation, emesis, and fasciculations. The physician suspects organophosphate poisoning, To treat the nicotinic effects, the physician should use which of the following? CA Atropine 8, British antlewisite (BAL) 6 @C._ Pralidoxime (2-PAM) ©. Naloxone CE, Calcium disodium ethylene-diaminetetraacetate (CaEDTA) Explanation ‘The specific antidote for nicatinic manifestations of organophosphate toxicity is pralidoxime (2-PAM). Itrestores the activity of acetyicholinesterase. Nicotinic effects for organonhasphates include fasciculations, twitching, weakness, areflexia, tachycardia, and hypertension. Atropine (choice A) is an antidote for the muscarinic effects of organophosphate toxicity. Same muscarinic effects include salvation, lacrimation, urination, defecation, and abdorninal cramps. British antilewisite (BAL) [choice B] and calcium disodium ethylene-diaminetetraacetate (Ca-EDTA) [choice E] are used for the treatment of lead toxicity. These therapies are used in symptomatic patients, regardless ofthe lead levels, and in patients with a blood concentration of 70 wgidl ar more. Naloxone (choice D) is El Tine Remaining: 02:41:28 [ 1) 1) (e@ tere