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49 Cards in this Set
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A 15-year-old adolescent female has a 1-month history of urinary frequency without dysuria and recent onset of an itchy rash beneath both breasts. She has been gaining weight over the past year and regularly complains of fatigue. She is afebrile with a weight greater than the 99th percentile and has an erythematous, macular rash beneath both breasts characterized by satellite lesions. Urinalysis is significant for 2+ glucosuria, but no pyuria. Which of the following is the most likely diagnosis?
A. Diabetes mellitus B. Fanconisyndrome C. Human immunodeficiency virus D. Occult malignancy E. Severecombinedimmunodeficiency(SCID) |
A. The obese adolescent in this case has findings of diabetes melli- tus. Her cutaneous candidiasis is likely an indication of secondary immunosuppression related to hyperglycemia. In diabetes, hyper- glycemia promotes neutrophil dysfunction, and circulatory insuffi- ciency contributes to ineffective neutrophil chemotaxis during infection. HIV infection is possible and antibody testing might be reasonable, but this scenario is most consistent with hyperglycemia.
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A mother notes her 6-week-old son’s umbilical cord is still attached. His activity and intake are normal; there has been no illness or fever. Delivery was at term without problems. His examination is notable for a cord without evidence of separation and a shallow, 0.5-cm ulceration at the occiput without discharge or surrounding erythema. Mother declares that the “sore,” caused by a scalp probe, has been slowly heal- ing since birth and was deemed unremarkable at his 2-week checkup. Which of the following is consistent with this child’s likely diagnosis?
A. Defective humoral response B. Functional leukocyte adherence glycoproteins C. Marked neutrophilia D. Normal wound healing E. Purulent abscess formation |
C. You suspect leukocyte adhesion deficiency (LAD) as the etiology of this child’s problem. LAD is an inheritable disorder of leukocyte chemotaxis and adherence characterized by recurring sinopulmonary, oropharyngeal, and cutaneous infections with delayed wound healing. Neutrophilia is common with WBC counts of typically more than 50,000 cells/mm3. Severe, life-threatening infection is possible with Staphylococcus species, Enterobacteriaceae, and Candida species. Good skin and oral hygiene are important; broad-spectrum antimicrobials and surgical debridement are early considerations with infection.
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A 6-month-old girl is seen after an emergency room visit for decreased intake, emesis, and watery diarrhea for the past 3 days. She was diag- nosed yesterday with “stomach flu” and given IV fluids. She is doing better today with improved intake and resolution of her emesis and diarrhea. The father is concerned about her thrush since birth (despite multiple courses of an oral antifungal) and that she has been hospital- ized twice for pneumonia over the past 4 months. Her weight has dropped from the 50th percentile on her 4-month visit to the 5th per- centile today. She has no findings consistent with dehydration, but she does appear to have some extremity muscle wasting. Her exami- nation is remarkable for buccal mucosal exudates and hyperactive bowel sounds. Vital signs and the remainder of her examination are normal. You suspect severe combined immunodeficiency (SCID). Which of the following is consistent with the diagnosis?
A. Autosomal dominant inheritance B. Persistent lymphocytosis C. Defective cellular immunity D. Normal vaccine immune response E. Nocurativetherapy |
C. SCID is an autosomal recessive or X-linked disorder of both humoral and cellular immunity. Serum immunoglobulins and T cells are often markedly diminished or absent. Thymic dysgenesis is also seen. Recurring cutaneous, gastrointestinal, or pulmonary infections occur with opportunistic organisms such as cytomegalovirus (CMV) and PCP. Death typically occurs in the first 12 to 24 months of life unless bone marrow transplantation is performed.
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You are called urgently to examine a term, 2-hour-old newborn who has had temperature instability, difficulty with feeding, and a sus- pected seizure. He has atypical facies (wide-set eyes, a prominent nose, and a small mandible), a cleft palate, and a holosystolic murmur. Stat laboratory tests and chest radiograph reveal marked hypocalcemia, a boot-shaped heart, and no apparent thymus. Which of the following is the most likely diagnosis?
A. Ataxia–telangiectasia B. DiGeorgesyndrome C. Hyper-IgE syndrome D. SCID E. Wiskott-Aldrich syndrome |
B. DiGeorge syndrome is caused by a 22q11 microdeletion. This syn- dromic immunodeficiency is characterized by decreased T-cell pro- duction and recurring infection. Findings include characteristic facies and velocardiofacial defects such as ventricular septal defect and tetralogy of Fallot. Thymic or parathyroid dysgenesis can occur, accompanied by hypocalcemia and seizures. Developmental and speech delay are common in older patients.
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A 14-year-old adolescent female from another state was followed for 7 years for a history of insulin-dependent diabetes mellitus. At your clinic her hemoglobin A1C is 14.9%. This laboratory test indicates which of the following?
A. Her glucose control is poor. B. She does not have insulin-dependent diabetes. C. She has entered the “honeymoon phase” of her diabetes. D. She has an underlying infection. E. She is demonstrating the Somogyi phenomenon. |
A. The patient likely has poor diabetes control. The hemoglobin A1C, commonly used to follow glucose control, measures the average glu- cose levels over the previous 2 or 3 months. The hemoglobin A1C goal for most diabetics is 6% to 9%. Levels greater than 12% suggest poor control, and levels 9% to 12% represent fair control. In the Somogyi phenomenon, a patient has nocturnal hypoglycemic episodes mani- fested as night terrors, headaches, or early morning sweating and then presents a few hours later with hyperglycemia, ketonuria, and gluco- suria. Counter-regulatory hormones, in response to the hypoglycemia, cause the hyperglycemia.
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Six months after being diagnosed with what appears to be insulin- dependent diabetes, the 5-year-old in the case presentation has a significant decrease in his insulin requirement. Which of the following is the most likely explanation?
A. His diagnosis of insulin-dependent diabetes was incorrect. B. He had a chronic infection that is now under control. C. He has followed his diabetes diet so well that he requires less insulin. D. He is demonstrating the Somogyi phenomenon. E. He has entered the “honeymoon phase”of his diabetes. |
E. Up to 75% of newly diagnosed diabetics have a progressive decrease in the daily insulin requirement in the months after their diabetes diagnosis; a few patients temporarily require no insulin. This “honey- moon” period usually lasts a few months, and then an insulin require- ment returns. Patients are told that the “honeymoon” period is not a cure and that they should expect a return to insulin requirement.
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A 15-year-old adolescent female has experienced abdominal pain, vomiting, and lethargy for 3 days. Her chest and throat examinations are clear, but her abdominal examination is significant for right lower quadrant pain. Rectal examination is equivocal for pain, and her pelvic examination is remarkable for pain upon movement of her cervix. Laboratory data include a white blood cell count of 18,000/mm3, serum glucose level of 145 mg/dL, and serum bicarbonate level of 21 mEq/dL. Her urinalysis is remarkable for 1+ white blood cells, 1+ glucose, and 1+ ketones. Which of the following is the most likely diagnosis?
A. Appendicitis B. Diabeticketoacidosis(DKA) C. Gastroenteritis D. Pelvic inflammatory disease (PID) E. Right lower lobe pneumonia |
D. The patient likely has PID; glucosuria is a stress response to the infection and does not represent glucose metabolism problems. All of the options in the question can cause abdominal pain. Although dia- betes mellitus is in the differential, DKA more likely presents with ketoacidosis (significantly decreased serum bicarbonate levels) and high serum glucose levels.
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A 16-year-old obese adolescent female has enuresis, frequent urination, a white vaginal discharge, and a dark rash around her neck. Her serum glu- cose level is 250 mg/dL, and her urinalysis is positive for 2+ glucose but is otherwise negative. Which of the following is the most likely diagnosis?
A. Chemical vaginitis B. Chlamydia cervicitis C. Psoriasis D. Type II diabetes E. Urinary tract infection(UTI) |
D. The description is of an obese adolescent female with candida vaginitis (the vaginal discharge) and acanthosis nigricans (the nuchal dark rash) consistent with type II diabetes. This condition is far more common in overweight children, especially those with a family history of the condition.
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A 6-week-old boy, born by vaginal delivery after an uncomplicated term gestation, has experienced cough and “fast breathing” for 2 days. His mother relates that he has a 1-week history of nasal congestion and watery eye discharge, but no fever or change in appetite. He has a tem- perature of 99.4°F (37.4°C) and a respiratory rate of 44 breaths/min. He has nasal congestion, clear rhinorrhea, erythematous conjunctivae bilaterally, and watery, right eye discharge. His lungs demonstrate scat- tered crackles without wheezes. Which of the following is the most likely pathogen?
A. C trachomatis B. Lmonocytogenes C. Respiratory syncytial virus D. Rhinovirus E. S pneumoniae |
A. Cough and increased respiratory effort in an afebrile infant with eye discharge are consistent with Chlamydia. Transmission typically occurs during vaginal delivery. Approximately 25% of infants born to mothers with Chlamydia develop conjunctivitis; about half of these develop pneumonia. Most infants present with respiratory infection in the second month of life, but symptoms can be seen as early as the second week. Inner eyelid swabs are sent for PCR, and oral erythromycin or sulfisoxazole (latter only in infants older than 2 months of age) is given for 2 weeks for either conjunctivitis or pneumonia.
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A 2-year-old girl has increased work of breathing. Her father notes she has had cough and subjective fever over the past 3 days. She has been complaining that her “belly hurts” and has experienced one episode of posttussive emesis but no diarrhea. Her immunizations are current, and she is otherwise healthy. Her temperature is 102°F (38.9°C). She is somnolent but easily aroused. Respirations are 28 breaths/min, and her examination is remarkable for decreased breath sounds at the left base posteriorly with prominent crackles. Which of the following acute interventions is the next best step in your evaluation?
A. Blood culture B. Chest radiography C. Pulse oximetry D. Sputum culture E. Viral nasal swab |
C. Tachypnea and lethargy are prominent in this patient with clinical pneumonia. Pulse oximetry should urgently be performed to ascer- tain whether oxygen is required. Sputum culturing is reasonable, but an adequate and diagnostically useful specimen can only be obtained from a 2-year-old by endotracheal aspirate or bronchoscopy. In this otherwise healthy toddler for whom concerns for atypical pneumo- nia are high, invasive maneuvers are not indicated. Viruses (RSV and adenovirus) are prominent at this age; one might consider per- forming a nasal swab for viral antigens. Abdominal pain, as noted in this question, can be seen as a presenting symptom in pneumonia, probably as a result of irritation of the diaphragm by pulmonary infection.
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You are evaluating a previously healthy 8-year-old boy with subjective fever, sore throat, and cough over the past week. There has been no rhi- norrhea, emesis or diarrhea, and his appetite is unchanged. According to your clinic records, his immunizations are current and his weight was at the 25th percentile on his examination 6 months ago. Today he is noted at the 10th percentile for weight. He is afebrile, with clear nares and posterior oropharynx, and a normal respiratory effort. He has bilat- eral cervical and right supraclavicular lymphadenopathy. Chest auscul- tation is notable for diminished breath sounds at the left base. Beyond obtaining a chest radiograph, which of the following is the best next step in your evaluation?
A. Rapid strep throat swab B. Viral nasal swab C. PPD placement D. Lymph node biopsy E. Bordetella pertussis direct fluorescent antibody testing |
C. The scenario is typical for pediatric tuberculosis. Neck and peri- hilar or mediastinal lymphadenopathy and pulmonary or extrapul- monary manifestations can occur, with miliary disease and meningitis more common in infants and younger children. Fever, weight loss, and lower respiratory tract signs and symptoms (possible left pleural effusion in this patient) are archetypal tuberculosis (TB) findings. A PPD should be placed, and consideration given to hospi- talizing this patient in negative pressure isolation for further evalua- tion beyond PPD placement (pleurocentesis, bronchoalveolar lavage, gastric aspirates) and possible antituberculous treatment.
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A 13-year-old adolescent female complains of dry cough, slight fever, and fatigue over the past 2 weeks. She noted increased chest conges- tion and coughing yesterday when walking outside in the cold air. She denies nasal congestion, rhinorrhea, emesis, or diarrhea. Her mother declares her daughter is generally healthy with a history of only sum- mertime allergies. Her vital signs, respiratory effort, and chest exami- nation are normal. Which of the following is the most likely pathogen?
A. H influenzae B. M pneumoniae C. Respiratory syncytial virus D. S aureus E. Spneumoniae |
B. All of these findings are consistent with mycoplasmal infection (“walking pneumonia”). The incubation period for mycoplasma is 5 to 7 days, and most symptoms are noted during the second to third week of infection. Hemolysis occurs as antibodies attach to red blood cells, prompting reticulocyte production. If necessary, nasopharyn- geal aspirate for PCR or measurement of cold agglutinins may help aid in the diagnosis. Auscultatory and radiographic findings vary in this infection; a normal CXR or one with an interstitial pattern, effu- sion, or atelectasis could be seen.
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A 14-year-old girl has a 3-day history of swollen “neck nodes” and a dif- fuse salmon-colored rash. On review of systems, she reports a sore throat and a cough with low-grade fever 5 days ago; these symptoms resolved 2 days ago. On examination, she has enlarged posterior auric- ular and suboccipital lymph nodes and tender swelling of multiple large and small joints. Which of the following is the most likely diagnosis?
A. Pauciarticular JRA B. Polyarticular JRA C. Rubella D. Systemic lupus erythematosus E. Systemic-onset JRA |
C. The differential diagnosis for childhood arthritis includes infec- tious and rheumatologic disorders. Her signs and symptoms are typi- cal of rubella. Vaccination is given at age 1 year and again at school entry. The major reason for vaccination is to prevent congenital rubella syndrome, a devastating neonatal condition; the disease usu- ally is mild in non-neonates.
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A 5-year-old girl is referred to a pediatric rheumatologist with a 4-week history of mild swelling and decreased range of motion in the left knee and right elbow. She is afebrile and appears otherwise well. Positive findings on which of the following evaluations will be most helpful in establishing her diagnosis?
A. Arthrocentesis B. Completebloodcount C. Computerized tomographic scan of the involved joints D. Slit-lamp examination of her eyes E. Bone scan |
D. JRA is the most common cause of uveitis in children. Uveitis onset may be insidious, and may be the only initial manifestation of JRA. The disease is more common in young girls. Slit-lamp findings include calcific band keratopathy, posterior synechiae, and cataracts. Children with JRA should have periodic slit-lamp examinations in order to detect eye disease early. Consideration may be given to obtaining the tests suggested in the other answer choices, but posi- tive results on these tests are unlikely to be specific for JRA.
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An obese 12-year-old African-American boy complains of right knee pain. He denies trauma to the right leg. He has a notable limp favoring the right lower extremity. Initial evaluation of his condition should include which of the following?
A. Antinuclear antibody B. Completebloodcount C. Magnetic resonance imaging of both knees D. Range of motion of the right hip E. Rheumatoid factor |
D. Careful attention is paid to the hips when evaluating knee com- plaints; pain from a hip problem can be referred to the knee. Slipped capital femoral epiphysis occurs most commonly in obese African- American boys. JRA rarely affects the hip in the initial disease course.
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A 3-year-old boy with suspected systemic-onset JRA develops tachy- cardia and dyspnea on the fifth hospital day. He complains that his chest hurts. Heart auscultation reveals a “friction rub” sound. Which of the following is the next best step in management?
A. Give him a nebulized albuterol treatment. B. Give him a dose of furosemide. C. Give him some acetaminophen. D. Check his oxygenation status via pulse oxymetry, obtain a stat electrocardiogram, and consult with a pediatric cardiologist. E. Check his oxygenation status via pulse oxymetry, obtain a stat chest x-ray, and initiate intravenous antibiotics. |
D. A friction rub is characteristic of pericarditis, which is a common and serious complication of JRA. The friction rub is a “grating” or “creaking” sound that often is best heard along the left sternal bor- der. Patients typically complain of chest pain that is relieved when the patient is asked to lean forward, and worsened by deep inspira- tion or coughing; pain is not always present, however. Rarely, peri- carditis in JRA may precede the development of arthritis by months or even years. Low voltage QRS complexes and ST-segment elevation may be seen on the electrocardiogram. Treatment consists of salicylates or steroids.
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A 16-year-old adolescent male complains of intermittent cola-colored urine of several years’ duration, usually when he has a “cold.” He is otherwise well and has no medical complaints. When the dark- colored urine is present, he has no dysuria. None of his family mem- bers has similar complaints or renal disease. On physical examination he is normotensive and appears healthy. Which of the following is the most likely cause of his intermittent hematuria?
A. Acute poststreptococcal glomerulonephritis B. Henoch-Schönlein purpura nephritis C. IgA nephropathy D. Recurrent kidney stones E. Rapidly progressive glomerulonephritis |
C. Recurrent painless gross hematuria, frequently associated with an upper respiratory tract infection, is typical of IgA nephropathy. These patients may develop chronic renal disease over decades. If protein- uria, hypertension, or impaired renal function were found, a biopsy would be necessary. The other options are not consistent with the asymptomatic, intermittent nature of this patient’s problem.
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The parents of a healthy 12-year-old girl bring her to you for a physi- cal examination required for summer camp. They have no complaints, and the girl denies any problems. Her last menses was normal 2 weeks prior. The camp requires a urine screen. To your surprise, the clean- catch urine screen has significant hematuria. Red cell casts are noted. You tell the findings to the parents, and they respond that “everyone on dad’s side of the family has blood in their urine and they are all doing well.” The family history is negative for deafness and for renal failure. Microscopy of renal tissue from this patient or from her father will most likely reveal which of the following?
A. Endothelial cell swelling and fibrin in the subendothelial space B. Immune complex deposition in the mesangium C. Large numbers of crescentic glomeruli D. Renal cell carcinoma E. Thinning of the basement membrane |
E. This history is consistent with benign familial hematuria, an auto- somal dominant condition that causes either persistent or intermittent hematuria without progression to chronic renal failure. Biopsy reveals a thin basement membrane; in some cases the biopsy is normal. Immune complex deposition with immunoglobulin (Ig)A in the mesangium is seen in HSP and IgA nephropathy; endothelial cell swelling with fib- rin deposition is seen in hemolytic-uremic syndrome, and crescentic glomeruli are seen in rapidly progressive glomerulonephritis.
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A 17-year-old adolescent female has joint tenderness for 2 months; the pain has affected her summer job as a lifeguard. In the morning, she awakens with bilateral knee pain and swelling and right hand pain. The pain eases during the day but never completely resolves. Nonsteroidal anti-inflammatory drugs help slightly. She also wants a good “face cream” because “her job has worsened her acne.” On physical examina- tion you notice facial erythema on the cheeks and nasolabial folds. She has several oral ulcers that she calls cold sores, bilateral knee effusions, and her right distal interphalangeal joints on her hand are swollen and tender. Her liver is palpable 3 cm below the costal margin. She has microscopic hematuria and proteinuria. Which of the following is the most likely cause of this young woman’s arthritis?
A. Juvenile rheumatoid arthritis B. Lyme disease C. Osteoarthritis D. Postinfectious arthritis E. Systemic lupus erythematosus |
E. Systemic lupus erythematosus affects more women than men, and nephritis is a common presenting feature. Her rash, photosensitivity, oral ulcers, hepatomegaly, arthritis, and nephritis combine to make this a likely diagnosis. A positive antinuclear antibody test and low C3 and C4 levels would help to confirm the diagnosis.
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You are not surprised to see one of your most challenging patients, a 16-year-old adolescent female who has been seen several times per week over the last 2 months complaining of cough, occasional hemop- tysis, malaise, and intermittent low-grade fever. Thus far you have identified a microcytic, hypochromic anemia for which she has been taking iron (without response) and migratory patchy infiltrates on chest radiograph that seem unaffected by antibiotic treatment. She has no tuberculosis (TB) exposure risks, and her TB skin test was neg- ative. Today she also complains of facial edema and tea-colored urine. You suddenly realize her symptoms can be grouped as which of the following syndromes?
A. Alport syndrome B. Denys-Drash syndrome C. Goodpasture syndrome D. Hemolytic-uremic syndrome E. Nephrotic syndrome |
C. Goodpasture syndrome is the clinical diagnosis when patients exhibit nephritis and pulmonary hemorrhage. It can be caused by a number of conditions, including SLE and HSP. Alport syndrome is a genetic defect in collagen synthesis that leads to abnormal basement membrane formation; patients will develop hematuria, proteinuria, and renal failure. Denys-Drash syndrome is a group of findings com- posed of Wilms tumor, gonadal dysgenesis, and nephropathy.
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A 2-year-old boy developed emesis and intermittent abdominal pain yes- terday, with several small partially formed stools. His parents were not overly concerned because he seemed fine between the pain episodes. Today, however, he has persistent bilious emesis and has had several bloody stools. Examination reveals a lethargic child in mild distress; he is tachycardic and febrile. He has a diffusely tender abdomen with a vague tubular mass in the right upper quadrant. Which of the following is the most appropriate next step in managing this condition?
A. Computerized tomography of the abdomen B. Contrast enema C. Intravenous antibiotics for Shigella D. Parental reassurance E. Stool cultures |
B. This child has an intussusception. He has bloody stools, but he also has bilious emesis, colicky abdominal pain, and a right upper quadrant mass. In experienced hands, a contrast enema procedure may be diagnostic and therapeutic. Ensure that a surgeon and a pre- pared operating room are available should the reduction via contrast enema fail or result in intestinal perforation. While a CT may diag- nose intussusception, an enema is preferred as it can be therapeutic as well as diagnostic.
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A previously healthy 2-year-old girl had 3 days of bloody diarrhea last week that spontaneously resolved. Her mother now thinks she looks pale. On examination, you see that she is afebrile, her heart rate is 150 bpm, and her blood pressure is 150/80 mm Hg. She is pale and irritable, has lower-extremity pitting edemas, and has scattered petechiae. After appro- priate laboratory studies, initial management should include which of the following?
A. Careful management of fluid and electrolyte balance B. Contrast upper GI series with small bowel delay films C. Intravenous antibiotics and platelet transfusion D. Intravenous steroids and aggressive fluid resuscitation E. Intubation and mechanical ventilation |
A. Hemolytic-uremic syndrome may be seen after bloody diarrhea, presenting with anemia, thrombocytopenia, and nephropathy. The child in question is hypertensive and has edema, so large amounts of fluids may be counterproductive. Steroids typically are not helpful. The thrombocytopenia is consumptive; unless the patient is actively bleeding, platelet transfusion is not helpful. Most of the care for such patients is supportive, concentrating on fluids and electrolytes. Early dialysis may be needed. Hypertensive patients should have appropri- ate control of their blood pressure.
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A family reunion picnic went awry when the majority of attendees developed emesis and watery diarrhea with streaks of blood. Unaffected attendees did not eat the potato salad. A few ill family members are mildly febrile. They come as a group to your office, seeking medica- tions. Which of the following is the most appropriate management for their condition?
A. Antimotility medication B. Hydration and careful follow-up C. Intramuscular ceftriaxone D. Oral amoxicillin E. Oral metronidazole |
B. This family probably has Salmonella food poisoning. Antibiotics are not indicated for this healthy family, and antimotility agents may prolong the illness. Frequent handwashing should be emphasized.
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You are asked to see a 1-month-old infant to provide a second opinion. During a brief, self-limited, and untreated diarrheal episode last week, his primary physician ordered a stool assay for Clostridium difficile toxin; the result is positive. The infant now is completely asymptomatic, active, smiling, and well hydrated. His physician said treatment was not necessary, but the mother wants treatment. Which of the following is the most appropriate response?
A. Clostridium difficile commonly colonizes the intestine of infants; treatment is not warranted. B. The infant should take a 7-day course of oral metronidazole. C. The infant should take a 10-day course of oral vancomycin. D. The infant should be admitted to the hospital for intravenous metronidazole E. A repeat study to look for the C difficile organism is warranted. |
A. Clostridium difficile colonizes approximately half of normal healthy infants in the first 12 months. In this infant without a history of antibi- otic treatment or current symptoms, treatment is unnecessary. C difficile colitis rarely occurs without a history of recent antibiotic use.
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A 7-year-old has right-sided abdominal pain and fever to 102°F (38.9°C). His mother says that he has had 2 days of poor appetite and cough; he had two loose stools earlier in the day. On examination, his temperature is 101.7°F (38.7°C), his heart rate is 120 bpm, and his res- piratory rate is 50 breaths/min. Breath sounds are diminished, and the abdomen is diffusely tense with hypoactive bowel sounds. Which of the following would likely lead to the diagnosis?
A. Abdominal computerized tomography B. Chest radiograph C. Liver function tests D. Stool leukocytes E. Stool for culture, ova, and parasites |
B. Lower lobe pneumonias can cause abdominal pain, which may be the most distressing symptom in a young patient. Inflammation of the diaphragm can result in an abnormal abdominal examination, which may be mistaken for the source of the child’s illness. This child has cough, fever, tachypnea, and diminished breath sounds, which together make pneumonia the most likely diagnosis.
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A 14-year-old adolescent female with a 3-day history of abdominal pain, anorexia, and vomiting and a 1-day history of fever underwent laparoscopic surgery for suspected appendicitis, which was perforated at the time of surgery. Intravenous ampicillin, gentamicin, and clindamycin were initiated prior to surgery and continued postoperatively. On the seventh postoperative day, she continues to have fevers to 102°F (38.9°C). Which of the following is the next most appropriate step in management?
A. Add metronidazole to the antibiotic regimen. B. Change the antibiotics to amikacin and a cephalosporin. C. Order a computerized tomography scan stat. D. Send a urinalysis and urine culture. E. Perform a pelvic examination. |
C. This adolescent female is at risk for an intra-abdominal abscess despite her appendectomy and intravenous antibiotics. It would be unusual for a urinary tract infection or pelvic inflammatory disease to cause persistent fever despite broad-spectrum intravenous antibiotics.
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A previously healthy 8-year-old boy presents to your office with abdom- inal pain, anorexia, and vomiting that have worsened over the previous 24 hours. The pain is located in the umbilical region. Despite the emesis, he appears well hydrated. A CBC reveals a white blood count of 17,000 cells/mm3 with 50% polymorphonuclear cells. A urine dipstick on a clean-catch specimen shows 2+ leukocytes and 1+ protein but no nitrites. Which of the following is the most appropriate management at this point?
A. Obtain a complete chemistry panel and continue to observe him in the office. B. Send the patient immediately to the hospital for an abdominal ultrasound. C. Give him a prescription for trimethoprim-sulfamethoxazole; schedule a follow-up visit in 2 days to reevaluate the urine. D. Admit him to the hospital for intravenous antibiotics to treat presumed pyelonephritis. E. Schedule a computerized tomography scan of the abdomen for the next morning. |
B. This boy’s symptoms and signs are most consistent with a diagno- sis of acute appendicitis. A urinary tract infection in an otherwise healthy boy would be unusual. His pyuria is most likely the result of bladder wall or ureter irritation caused by an inflamed appendix.
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A 4-year-old girl has a fever of 102.4°F (39.1°C), difficulty swallow- ing, vomiting, and abdominal pain. Which of the following diagnostic tests is most likely to yield the appropriate diagnosis?
A. Streptococcal antigen test (“rapid strep test”) B. Antigen test for Epstein-Barrvirus (“Monospot”) C. Lateral neck radiograph D. Abdominal ultrasound E. Complete blood count |
A. Her symptoms are most consistent with streptococcal pharyngitis. In addition to throat pain and fever, group A Streptococcus infections commonly cause abdominal pain and emesis.
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A 17-year-old adolescent male has left shoulder and left upper quadrant abdominal tenderness and vomiting. He reports having “mono” last month but says he is completely recovered. He was playing flag football with friends when the pain started an hour ago. On examination, his heart rate is 150 bpm and his blood pressure is 80/50 mm Hg. He is pale, weak, and seems disoriented. He has diffuse rebound abdominal tenderness. Emergent management includes which of the following?
A. Laparoscopic appendectomy B. Fluid resuscitation and blood transfusion C. Intravenous antibiotics D. Hospital admission for observation E. Synchronized cardioversion for supraventricular tachycardia |
B. The patient described is in hypovolemic shock and likely has splenic rupture with intraperitoneal bleeding. He will die shortly if not aggressively resuscitated with fluids and blood. Evaluation by a surgeon for potential removal of the ruptured spleen should follow quickly.
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You are asked to see a 2-year-old boy in consultation. His general prac- tice doctor admitted him to the hospital 2 days ago because of 3 days of fever. He has generalized lymphadenopathy but is otherwise well. Results of Monospot, HIV testing, and CMV antigen tests are nega- tive; his liver function test values are mildly elevated. His physician diagnosed the boy’s 7-year-old sibling with “mono” the month prior. You should suggest which of the following?
A. Start intravenous immunoglobulin and obtain an echocardiogram; the patient likely has Kawasaki disease. B. Send an EBV culture for confirmation of the physician’s suspicions. C. Acyclovir treatment because he has an exposure history positive for EBV. D. Obtain EBV-VCA IgG and IgM, EBV-EA, and EBV-NA tests. E. Liver imaging with ultrasonography or computerized tomography. |
D. The Monospot heterophil antibody test, useful in older children, is not so reliable in younger children. Antibodies against specific EBV antigens are more helpful in younger children. No imaging study is diagnostic for EBV; acyclovir is not indicated for EBV expo- sure; EBV culture is not readily available; and while Kawasaki disease must be considered in patients with persistent fever, the exposure history makes EBV more likely.
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The mother of a 15-year-old adolescent female recently diagnosed with infectious mononucleosis calls for more information. She reports that her daughter, although tired, seems comfortable and is recovering nicely. She remembers that her 20-year-old son had “mono” when he was 10 years old, and he received an oral medicine. She requests the same medication for her daughter. Which of the following is the most appropriate course of action?
A. Explain that medications are not routinely used in EBV infection. B. Call the pharmacy and order oral prednisone, 50 mg daily for 5 days (1 mg/kg/d). C. Call the pharmacy and order oral acyclovir 250 mg four times per day (20 mg/kg/d). D. Have her come to the office for a single dose of 50 mg intravenous methylprednisolone (1 mg/kg). E. Call the pharmacy and order oral amoxicillin 250 mg three times per day for 7 days. |
A. Supportive care alone usually is required for a patient with acute EBV infection. Steroids have been used historically; current literature suggests their use only in impending airway compromise due to ton- sillar hypertrophy or other life-threatening complications. Acyclovir suppresses viral shedding acutely but has no long-term benefit and is not routinely recommended. Amoxicillin and ampicillin are ineffec- tive antiviral medications and induce a rash in some EBV-infected patients.
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A teenage boy arrives for a check-up. His friend recently was diagnosed with mononucleosis. He is worried he will contract it. Which of the following is true regarding transmission of EBV?
A. It is common among casual friends. B. It occurs only in immunodeficient individuals. C. It requires close contact with saliva (ie, kissing or drinking from the same cup). D. It is passed only through sexual contact with an infected individual. E. It does not occur after the infected person recovers from the initial infection. |
C. EBV is excreted in saliva and is transmitted through mucosal con- tact with an infected individual (as in kissing) or through a contam- inated object. Virus is shed for a prolonged period after symptoms resolve and is intermittently reactivated and shed for years asympto- matically.
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A mother recently feels a mass in the abdomen of her 4-year-old son during a bath, and brings him to your clinic for evaluation. He has no history of emesis, abnormal stooling, or abdominal pain. Physical examination reveals a resting blood pressure of 130/88 mm Hg, heart rate of 82 beats/minute, pallor, and a firm left-sided abdominal mass that doesn’t cross the midline. Which of the following is the most likely explanation for these findings?
A. Constipation B. Intussusception C. Neuroblastoma D. Wilms tumor E. Volvulus |
D. The scenario presented is typical for Wilms tumor. Beyond abdominal imaging, checking a urinalysis for hematuria, metabolic panel for renal or hepatic dysfunction, and complete blood count for anemia should be considered in the workup of Wilms tumor.
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A 1-week-old infant presents with a right midquadrant abdominal mass and decreased urinary output. There has been no temperature lability, irritability, or abnormal stooling or urine appearance. Which of the following is the most likely diagnosis?
A. Intussusception B. Hydronephrosis C. Neuroblastoma D. Sepsis E. Wilms tumor |
B. Urinary tract obstruction is often silent. In the newborn, a palpa- ble abdominal mass is commonly a hydronephrotic or multicystic dysplastic kidney.
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A father presents his otherwise healthy 15-month-old daughter to the emergency center with cough, post-tussive emesis, and subjective fever over the past 3 days. He also thinks her abdomen has been hurt- ing her. Diarrhea started yesterday, with “regular” stooling prior to this illness. She has been drinking well and recently had a wet diaper. Physical examination reveals a temperature of 98.9°F (37.2°C), con- gested nares, shoddy neck lymphadenopathy, and a mildly distended and apparently tender abdomen without obvious guarding. Which of the following is the most likely etiology for her abdominal pain?
A. Constipation B. Lymphoma C. Neuroblastoma D. Appendicitis E. Mesenteric lymphadenitis |
E. Upper respiratory tract infection symptoms, neck lymphadenopathy, and diarrhea are consistent with viremia; viral-mediated mesenteric lymph node enlargement can occur and cause nonspecific abdominal pain. This otherwise healthy child with classic viremia lacks history or findings consistent with an intra-abdominal tumor, enteritis, or intestinal dysmotility. An abdominal CAT scan may show diffuse, mildly enlarged lymph nodes in mesenteric lymphadenitis, but imag- ing is rarely warranted unless an etiology for abdominal pain remains elusive. Other nonmalignancy-related causes of abdominal pain include enteritis caused by bacteria (salmonella, E. coli, Yersinia sp., and typical or atypical mycobacteria) or viruses (mononucleosis, coxsachie, and adenovirus).
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During a routine preventive health visit for a 3-year-old boy, you inci- dentally note an irregular abdominal mass involving both lower quad- rants. His mother denies having noted this previously and declares her son to be generally healthy. There has been neither gastrointestinal distress nor apparent abdominal pain. Beyond the abdominal mass and pallorous conjunctivae, his vital signs and physical examination are normal. Which of the following tests would be most helpful in determining the etiology of his abdominal mass?
A. Abdominal radiograph B. Chestradiograph C. Urinary catecholamines D. Complete blood count E. Urine myoglobin |
C. This boy’s history and examination are consistent with neurob- lastoma. Given the vast majority of neuroblastoma patients have elevated urinary catecholamines, a 24-hour quantitative assessment of these metabolites should be confirmatory.
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A mother notices a lump on her 5-year-old son’s neck. He complains about pain in the region and difficulty swallowing. Appetite and intake are normal. He had a “chest cold” last week that has since resolved. His past medical history is otherwise unremarkable. On examination, he is afebrile with a 3-cm × 3-cm area of mild erythema, fluctuance, and ten- derness of the central anterior neck. The mass moves superiorly when he opens his mouth. His oropharynx is clear. Which of the following is the most likely explanation for these findings?
A. Contact dermatitis B. Lymphadenopathy C. Salivary gland tumor D. Streptococcal pharyngitis E. Thyroglossal duct cyst |
E. Thyroglossal duct cysts, arising from the embryonic thyroglossal tract, are typically midline, often move on tongue protrusion, and often are noted after a URI. Treatment is usually surgical excision, sometimes after neck CT imaging to ascertain cyst and thyroid anatomy. About half can become infected. Contact dermatitis does not present as a mass, lym- phadenopathy is rarely associated with fluctuance or movement on tongue protrusion, and the oropharyngeal and neck findings make strep- tococcal pharyngitis and salivary gland tumor unlikely.
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A 9-year-old girl complains of sore throat and anterior neck pain of 1-day duration, and nasal congestion and cough over the past 3 days. There has been no nausea or change in appetite. She describes “lumps growing in her neck” over the past day. Her past medical history is unremarkable. She is afebrile with a clear posterior oropharynx and a supple neck. She has four firm, fixed, and minimally tender submandibular masses without overlying skin changes; the largest mass is 1 cm in diameter. Which of the following is the most likely explanation for these findings?
A. Lymphadenopathy B. Peritonsillar abscess C. Retropharyngeal abscess D. Sialadenitis E. Streptococcal pharyngitis |
A. This patient has viral URI symptoms, most likely causing reactive lymphadenopathy. Supportive care such as analgesics would be a rea- sonable treatment recommendation. Rapid streptococcal testing usually is not warranted for classic URI symptoms; streptococcal pharyngitis more commonly presents with sore throat, headache, nausea, and/or fever. Signs of viremia and her neck examination do not suggest sialadenitis or neck abscess.
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A father states that his 7-year-old daughter has a 1-week history of mouth and neck pain. She describes pain on chewing and swallowing. Slight swelling around her right, lower jaw was first noted yesterday. She has been afebrile and exhibits no URI symptoms. Her examina- tion reveals a temperature of 100.2°F (37.9°C) with swelling, tender- ness, and warmth overlying the right, posterior mandible without fluctuance or skin changes. Scattered, bilateral neck lymphadenopa- thy is appreciated. Her posterior oropharynx is minimally erythema- tous, with marked swelling and tenderness of the gum surrounding the posterior molars of the right mandible. Which of the following is the most appropriate next step?
A. Admit her immediately to the hospital for intravenous antibiotics. B. Commence a broad-spectrum antibiotic and advise her to see a dentist as soon as possible. C. Obtain an immediate surgery consult. D. Order a cervical CT and obtain ear, nose, and throat (ENT) consultation today. E. Perform a rapid strep immunoassay in your office. |
B. Tooth abscess is her most likely diagnosis, as evidenced by obvious gingival inflammation and other signs of ongoing infection in the area, despite the absence of frank pus from an evident cavity. Potential causative organisms include Streptococcus mutans and Fusobacterium nucleatum. Therapy includes an antibiotic (amoxicillin or clindamycin) and referral to her dentist within the next 24 hours. Deep neck infection is unlikely; imaging and IV antibiotics are not warranted at this time.
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A previously healthy, 4-year-old boy has been febrile for 1 day. He does not want to drink and vomited this morning. There have been no URI symptoms nor diarrhea. On examination, he is sleepy, but arousable, and has a temperature of 102.8°F (39.3°C). His posterior oropharynx is markedly erythematous with enlarged, symmetrical, and cryptic ton- sils that are laden with exudate. Shoddy cervical lymphadenopathy is noted. He moves his head vigorously in an effort to thwart your exam- ination. Which of the following is the most likely explanation for these findings?
A. Coxsackie pharyngitis B. Lymphadenitis C. Parapharyngeal abscess D. Retropharyngeal abscess E. Streptococcal tonsillitis |
E. This child has a fairly classic examination for streptococcal ton- sillitis. Coxsackievirus is possible, but usually an ulcerative, rather than exudative, pharyngitis is noted. The potential for a retropha- ryngeal or peritonsillar process is diminished by the lack of tonsillar asymmetry, soft palatal changes, and nuchal rigidity. A rapid strepto- coccal immunoassay would be a good initial test; a swab for culture may be sent as well. Standard therapy would include oral or intramus- cular penicillin in the nonallergic patient and an analgesic/antipyretic. If the streptococcal immunoassay is negative, some treat patients whose history and examination are consistent with streptococcal infection while awaiting culture.
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Malrotation with volvulus is most likely to be present in which of the following patients?
A. A healthy 15-month-old with severe paroxysmal abdominal pain and vomiting B. A 15-year-old sexually active girl with lower abdominal pain C. A 3-day-old term infant with bilious emesis, lethargy, and abdominal distension D. A 4-day-old premature baby (33-week gestation) who has recently started nasogastric feeds; he now has abdominal distention, bloody stools, and thrombocytopenia E. A 7-year-old girl with abdominal pain, vomiting, fever, and diarrhea |
C. The 3-day-old term infant with bilious emesis and abdominal dis- tension has classic presenting features of malrotation with volvulus. The 15-month-old child with paroxysmal abdominal pain is most likely to have intussusception. The adolescent female is evaluated for ectopic pregnancy, pelvic inflammatory disease, appendicitis, ovarian torsion, and ruptured ovarian cyst. The premature infant might have necrotizing enterocolitis, whereas the 7-year-old girl more likely has gastroenteritis.
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A 3-day-old boy presents with 12 hours of bilious vomiting, abdomi- nal pain, and abdominal distension. Which of the following is the most appropriate next step in management?
A. Order an abdominal ultrasonography. B. Order a computerized tomography scan of the abdomen. C. Order a upper GI contrast series. D. Order a barium enema. E. Order a chest radiograph. |
C. Order a upper GI contrast series. Fluid and electrolyte status should also be evaluated.
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A 9-year-old boy has 24 hours of persistent abdominal pain and vomiting. His physical examination reveals abdominal guarding and right lower quadrant rebound tenderness. Which of the following is the most likely diagnosis?
A. Appendicitis B. Gastroenteritis C. Gastroesophageal reflux D. Intussusception E. Pyloric stenosis |
A. This child most likely has appendicitis.
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A previously healthy 18-month-old child has vomiting and severe, parox- ysmal, writhing abdominal pain (he prefers to have his knees flexed to the chest) alternating with periods of relative comfort with a soft, only mildly tender abdomen. On abdominal examination you find a sausagelike mass. He has not stooled, but you find blood upon digital rectal examination. Which of the following is the best next step in management?
A. Administer morphine for pain control. B. Order a computerized tomography of the abdomen. C. Obtain an air contrast enema. D. Obtain serum acetaminophen levels. E. Begin antibiotics for Escherichia coli 0157:H7. |
C. The case describes the typical presentation of intussusception. Although a clinical diagnosis can be made, the diagnostic “gold” stan- dard and often treatment, is contrast enema. Air contrast usually is preferred because the complication risk is lower than with other forms of contrast material. Prior to diagnostic intervention, patients should undergo measurement of serum electrolyte and hemoglobin levels and receive fluid resuscitation. When suspicion for intussusception is high, a pediatric surgeon should be consulted. Classically described “currant jelly stools” are a late finding. Recurrence of intussusception following successful reduction occurs in 5% to 10% of cases.
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A 6-week-old male infant has projectile emesis after feeding. He has an olive-shaped abdominal mass on abdominal examination. Which of the following statements is accurate?
A. He likely has hypochloremic metabolic alkalosis. B. He likely has metabolic acidosis. C. This condition is more common in female infants. D. He should be restarted on feeds when the vomiting resolves. E. He likely will develop diarrhea. |
A. This infant has the features of pyloric stenosis, a condition four times more common in males and more common in first-born chil- dren. Affected infants usually present between the third and eighth week of life with increasing projectile emesis. Abdominal examina- tion may reveal an olive-shaped mass and visible peristaltic waves. Serum electrolyte levels usually reveal hypochloremic metabolic alka- losis. Ultrasonography is useful in confirming the diagnosis.
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A 7-month-old boy with respiratory difficulty is brought to the emer- gency department at 3 AM. His mother reports that several family mem- bers have had “colds” over the past week. He first developed cough and coryza 3 days ago, and the cough has become “barky.” On examination, he has an axillary temperature of 100.4°F (38°C), respiratory rate 55 breaths/min, and heart rate 140 bpm (beats/min). A moderately inflamed pharynx and inspiratory stridor are noted on physical exami- nation. Which of the following is the next step in management of this patient?
A. Reassure the child’s parents that his upper respiratory symptoms will resolve without antibiotics or other medication. B. Obtain a chest radiograph. C. Obtain a throat swab specimen for rapid testing for Streptococcus pyogenes. D. Administer aerosolized racemic epinephrine and corticosteroids immediately. E. Obtain blood, urine, and cerebrospinal cultures, and begin parenteral antibiotics. |
D. This child’s history and physical examination findings are typical of croup. Croup often presents at night when symptoms typically worsen. Cool mist is often used in an attempt to relieve laryngeal spasm; the evidence supporting its effectiveness is weak except in cases of allergic (spasmodic) croup. Aerosolized epinephrine and oral or aerosolized steroids are effective in reducing airway edema and relieving croup symptoms. Potentially irritating procedures (ie, use of tongue blades or needle sticks) are avoided unless necessary; agita- tion and crying aggravate the respiratory symptoms. Parenteral fluids rarely may be indicated if the child is not drinking well. Oxygen sat- uration should be monitored closely; a low saturation in croup indicates imminent airway obstruction.
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A 14-month-old girl has a 6-hour history of fever to 102.6°F (39.2°C) and an increasingly ill appearance. She is anxious and does not want to leave her mother’s arms, but she gives only a faint cry when approached. Her respiratory rate is 70 breaths/min and her neck is hyperextended. An area of moisture is noted on the shoulder of the mother’s blouse. Which of the following is the next most appropriate step in management?
A. Perform a complete physical examination with particular emphasis on the mouth and upper airway. B. Immediately secure the airway with an endotracheal tube in the emergency department. C. Arrange for immediate transfer to the operating room to secure the airway via tracheal intubation or tracheostomy. D. Administer aerosolized racemic epinephrine and nebulized steroids. E. Obtain blood, urine, and cerebrospinal cultures, and begin par- enteral antibiotics. |
C. This child’s clinical picture is consistent with epiglottitis, a med- ical emergency. She is kept calm and is transported to an operating room where the airway is examined and secured by a surgeon and anesthesia team skilled in tracheal intubation and tracheostomy. Visualizing the pharynx in the emergency department may cause air- way obstruction. Although rare in the United States, epiglottitis occasionally is seen in hypoimmunized children or as a result of infection with S pyogenes, S pneumoniae, or S aureus.
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A 2-year-old boy is seen in your office after his parents report a “rough night.” Following a few days of a mild upper respiratory symptoms but no fever, last night he had an episode of stridor and increased effort of breathing. He has done this twice previously in the last 2 months and was well before each episode. In the interim period he has been normal. Today, apart from some mild rhinorrhea, his physical examination is normal. Which of the following is the most likely etiology?
A. Spasmodic croup B. Foreign body aspiration C. Tracheomalacia D. Extraluminal compression of the trachea by a tumor E. S. pyogenes pharyngitis |
A. Children with spasmodic croup appear well during the daytime but develop nocturnal stridor and difficulty breathing; the cause is unknown. As this child’s symptoms resolved during the daytime and he previously has had two similar episodes, foreign body aspiration is less likely (although always considered in a toddler with respiratory distress). Infants with mild tracheomalacia have stridor only inter- mittently (eg, with crying), but it is first noted in early infancy. A tumor compressing the trachea usually causes persistent or progres- sive symptoms but less likely intermittent stridor. Streptococcal laryngitis causes fever and throat pain but generally not significant stridor.
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A 2-year-old boy with a 3-day history of upper respiratory congestion and cough now has inspiratory stridor, respiratory rate of 50 breaths/min, chest retractions, and a fever of 101°F (38.3°C). The next step in the management of his condition should be which of the following therapies?
A. Pseudoephedrine and dextromethorphan B. Albuterol and cromolyn C. Ampicillin and gentamicin D. Cool mist and herbs E. Aerosolized racemic epinephrine and steroids |
E. Aerosolized epinephrine and steroids are the only therapies that significantly improve symptoms of croup (in this case, likely viral). Systemic and nebulized steroids also reduce hospital admissions, length of hospital stay, and hospital reattendance.
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