Professional Documents
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Prepsa2009 PDF
Prepsa2009 PDF
Question: 1
You are evaluating a 6-month-old child who has a ventricular septal defect and is scheduled for
cardiac surgery. The childs weight is 6 kg (3rd percentile), length is at the 30th percentile, and
head circumference is at the 50th percentile. His mother states she prepares the formula by
adding 1 scoop of powder to 2 oz of water. She estimates that he drinks 24 oz of formula per
day. You estimate the babys intake is approximately 500 kcal per day of cow milk formula,
which is the recommended dietary allowance (RDA) for his age. According to his mother, he
spits up three times a day and passes two soft stools daily. On physical examination, you hear a
3/6 holosystolic murmur and palpate the liver 1 cm below the right costal margin.
References:
McDaniel NL. Ventricular and atrial septal defects. Pediatr Rev. 2001;22:265-270. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/22/8/265
Sonneville K. Nutritional requirements: dietary reference intakes. In: Hendricks KM, Duggan C.
Manual of Pediatric Nutrition. 4th ed. Hamilton, Ontario, Canada: BC Decker; 2005:83-100
Question: 2
You are admitting a 750-g female infant to the neonatal intensive care unit (NICU) for treatment
of respiratory distress and presumed sepsis. The pregnancy was complicated by
chorioamnionitis and preterm labor. The infants trachea was intubated, a single dose of
exogenous surfactant administered, and both an umbilical venous catheter and umbilical arterial
catheter were placed successfully in the delivery room. In the NICU, the infant is placed on a
radiant warmer. The nurse caring for the infant asks if the infant will need to be transferred to an
isolette incubator.
Of the following, the MOST likely reason for this infant to be relocated into an isolette incubator is
References:
Dollberg S, Hoath SB. Temperature regulation in preterm infants: role of the skin-environment
interface. NeoReviews. 2001;2:e282-e291. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/2/12/e282
Sedin G. The thermal environment of the newborn infant. In: Martin RJ, Fanaroff AA, Walsh MC,
eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby
Elsevier; 2006:585-596
Question: 3
You are seeing a 1-month-old girl for follow-up after a hospitalization for acute gastroenteritis
caused by rotavirus. Her diarrhea had decreased in the hospital while taking oral rehydration
solution, but when her mother resumed her usual cow milk formula, the girl began to have an
increased number of very watery stools. She appears well hydrated, and findings on her
abdominal examination are normal.
Of the following, the MOST appropriate approach to managing this infants diarrhea is to
B. dilute the cow milk formula with oral rehydration solution for the next few days
C. give her only oral rehydration solution until the diarrhea resolves
References:
Dalby-Payne J, Elliott E. Gastroenteritis in children. BMJ Clinical Evidence. 2007. Available for
subscription at: http://clinicalevidence.bmj.com/ceweb/conditions/chd/0314/0314.jsp
Heyman MB; Committee on Nutrition. Lactose intolerance in infants, children, and adolescents.
Pediatrics. 2006;118:1279-1286. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/3/1279
King CK, Glass R, Bresee, Duggan C. Managing acute gastroenteritis among children: oral
rehydration, maintenance, and nutritional therapy. MMWR Morbid Mortal Wkly Rep Recomm
Rep. 2003;52(RR-16):1-16. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
Question: 4
During a prenatal visit with expectant parents, they report that they are strict vegans. They ask
you to advise them on a healthy diet and any required supplements. The mother plans to
breastfeed the newborn exclusively for the first 6 months.
Of the following, you are MOST likely to tell them that their newborn may require supplemental
A. calcium
B. folate
C. iron
D. vitamin B6
E. vitamin B12
References:
Kleinman RE. Nutritional aspects of vegetarian diets. In: Pediatric Nutrition Handbook. 5th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2003:191-208
Mangels AR, Messina V. Considerations in planning vegan diets: infants. J Am Diet Assoc.
2001:101:670-677. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/11424546
Messina V, Mangels AR. Considerations in planning vegan diets: children. J Am Diet Assoc.
2001:101:661-669. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/11424545
Moilanen BC. Vegan diets in infants, children and adolescents. Pediatr Rev. 2004:25:174-176.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/5/174
Perry CL, McGuire MT, Neumark-Sztainer D, Story M. Adolescent vegetarians: how well do
their dietary patterns meet the Healthy People 2010 objectives? Arch Pediatr Adolesc Med.
2002; 156:431-437. Available at: http://archpedi.ama-assn.org/cgi/content/full/156/5/431
Question: 5
You are treating a child who has suffered a splenic injury and is being transfused with large
volumes of packed red blood cells for severe anemia. He weighs 10 kg and has received 4 units
thus far.
Of the following, the finding on electrocardiography that is MOST likely to represent a serious
complication of his therapy is
A. atrial flutter
B. delta waves
C. prominent U waves
D. supraventricular tachycardia
E. tall-peaked T waves
References:
Galel SA, Naiman JL. Use of blood and blood products. In: Rudolph CD, Rudolph AM, eds.
Rudolph's Pediatrics. 21st ed. New York, NY: McGraw-Hill Medical Publishing Division;
2003:1576-1581
Vetter V. Arrhythmias. In: Moller JH, Hoffman JIE, eds. Pediatric Cardiovascular Medicine.
Philadelphia, Pa: Churchill Livingstone; 2000:833-884
Critique: 5
Critique: 5
In Wolff-Parkinson-White syndrome, delta waves (arrows) are present that represent pre-
excitation depolarization of the QRS complex. (Courtesy of A. Friedman)
Critique: 5
The U wave (arrow) may be observed in hypokalemia (shown here in which there is also ST
depression and flattening of the T wave) or hypercalcemia. (Courtesy of A. Friedman)
Critique: 5
In third-degree heart block that may result from severe hypercalcemia, P waves are completely
dissociated from QRS complexes. (Courtesy of A. Friedman)
Critique: 5
Question: 6
A 15-year-old girl presents to the emergency department with a 4-week history of nasal
drainage and face pain and a 2-week history of frontal headaches and fatigue. Her mother
complains that her daughter has an "attitude" and has not been respectful or seemed to care
about anything for the past 2 weeks. The daughter awoke this morning with a headache and
vomited. On physical examination, the adolescent is afebrile and has normal vital signs. She
responds slowly to questions and is not oriented to the date. She complains of pain to palpation
of her cheeks and forehead. She has no nuchal rigidity and no focal weakness. The remainder
of the physical examination findings are normal.
References:
Goodkin HP, Harper MB, Pomeroy SL. Intracerebral abscess in children: historical trends at
Children's Hospital Boston. Pediatrics. 2004;113:1765-1770. Available at:
http://pediatrics.aappublications.org/cgi/content/full/113/6/1765
Haslam RHA. Brain abscess. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2524-2525
Critique: 6
Brain abscess: Contrast-enhanced computed tomography scan of the head reveals a rim-
enhancing lesion extending to an area of bony destruction in an opacified left frontal sinus.
Vasogenic edema surrounding the abscess creates a mass effect and shift of the midline to the
right. (Courtesy of D. Krowchuk)
Question: 7
A 5-year-old girl who is new to your practice presents to the clinic for a prekindergarten physical
examination. Her primary caretaker, the maternal grandmother, reports that the childs mother
used multiple street drugs throughout her pregnancy as well as medications prescribed for
seizure and bipolar disorders. The grandmother is concerned that this childs speech
development is delayed. On physical examination, you note that the girl has wide-spaced eyes,
a short nose, and midface hypoplasia.
Of the following, the substance that is MOST likely to be associated with this childs dysmorphic
features is
A. lithium
C. marijuana
D. methamphetamine
E. phenobarbital
References:
Gallagher RC, Kingham K, Hoyme HE. Fetal anticonvulsant syndrome. In: Cassidy SB, Allanson
JE, eds. Management of Genetic Syndromes. 2nd ed. Hoboken, NJ: Wiley-Liss; 2005:239-250
Phenobarbital, lithium, LSD, marijuana, methamphetamine. Teris. Available for subscription at:
http://depts.washington.edu/terisweb/teris
Critique: 7
Wide-spaced eyes and a short upturned nose are facial features of the fetal anticonvulsant
syndrome. This child was exposed to phenytoin. (Courtesy of M. Rimsza)
Critique: 7
Nail hypoplasia is observed in a child who has fetal anticonvulsant syndrome. (Courtesy of the
Media Lab at Doernbecher)
Question: 8
A 15-year-old girl comes to the urgent care clinic complaining of lower abdominal pain for 48
hours. She is nauseated but has had no fever, vomiting, or diarrhea. She is afebrile and denies
abdominal trauma. She localizes the pain to the left lower quadrant and describes it as
intermittent, stabbing pain episodes separated by intervals of more continuous dull pain. She has
never been sexually active. Her last menstrual period was 1 week ago. She has had no vaginal
discharge or itching. On physical examination, she has left lower quadrant guarding and rebound
tenderness. Her pelvic examination shows no vaginal discharge or uterine tenderness, although
there is an exquisitely tender mass in the left adnexal area.
A. appendicitis
B. endometritis
C. ovarian torsion
D. sacroiliitis
E. splenic rupture
References:
Adams Hillard PJ. Pelvic masses. In: Neinstein LS, eds. Adolescent Health Care: A Practical
Guide. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008:706-713
Growdon WB, Laufer MR. Ovarian torsion. UpToDate Online 15.3. 2008. Available for
subscription at: http://www.utdol.com/utd/content/topic.do?topicKey=gyn_surg/5273
Laufer MR, Goldstein DP. Gynecologic pain: dysmenorrhea, acute and chronic pelvic pain,
endometriosis, and premenstrual syndrome. In: Emans SJH, Laufer MR, Goldstein DP, eds.
Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins;
2005:417-476
Varras M, Tsikini A, Polyzos D, Samara Ch, Hadjopoulos G, Akrivis Ch. Uterine adnexal torsion:
pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol. 2004;31:34-38.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/14998184
Critique: 8
Ovarian torsion: Color flow Doppler ultrasonography of the right ovary shows abundant flow in
the adjacent pelvic tissue (blue, red, and orange color seen inferiorly) but none in the ovary (the
area within the dashed line).
Question: 9
A 2-year-old boy who has chronic renal failure is brought to the emergency department for
evaluation of nausea, fatigue, and muscle weakness. On physical examination, the boy has a
heart rate of 140 beats/min, decreased perfusion, and palpable pulses. You obtain
electrocardiography (Item Q9). Electrolyte measurements include a potassium concentration of
7.5 mEq/L (7.5 mmol/L) and a glucose value of 72.0 mg/dL (4.0 mmol/L).
A. calcium chloride
B. insulin
E. verapamil
Question: 9
References:
Greenbaum LA. Electrolyte and acid-base disorders: potassium. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:279-284
Hauser GJ, Kulick AF. Electrolyte disorders in the pediatric intensive care unit. In: Wheeler DS,
Wong HR, Shanley TP, eds. Pediatric Critical Care Medicine: Basic Science and Clinical
Evidence. New York, NY: Springer-Verlag; 2007:1156-1175
Critique: 9
Question: 10
A 13-year-old girl who has just moved to the United States from Brazil comes to your office
because her mother is worried that she is not "developing yet." On physical examination, her
height is 50 inches, and she has a triangular face, a low hairline, high-arched palate, and a shield-
shaped chest (Item Q10). Breast tissue is not visible or palpable, but there is Sexual Maturity
Rating 3 pubic hair. You obtain bone age radiography and a karyotype and measure serum
luteinizing hormone and follicle-stimulating hormone.
A. adrenocorticotropic hormone
B. prolactin
C. 17-hydroxyprogesterone
D. testosterone
E. thyroid-stimulating hormone
Question: 10
Shield-shaped chest and lack of breast development, as described for the girl in the vignette.
(Courtesy of M. Rimsza)
References:
Doswell BH, Visootsak J, Brady AN, Graham JM Jr. Turner syndrome: an update and review for
the primary pediatrician. Clin Pediatr. 2006;45:301-313. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16703153
Frias JL, Davenport ML, Committee on Genetics and Section on Endocrinology. Health
supervision for children with Turner syndrome. Pediatrics. 2003;111:692-702. Available at:
http://pediatrics.aappublications.org/cgi/content/full/111/3/692
Matura LA, Ho VB, Rosing DR, Bondy CA. Aortic dilatation and dissection in Turner syndrome.
Circulation. 2007;116:1663-1670. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17875973
Question: 11
A 2-month-old infant has lost the vision in both of his eyes due to bilateral retinoblastoma. His
distressed parents ask how the infants blindness will affect his behavior and development.
References:
Davidson PW, Burns CM. Visual impairment and blindness. In: Levine MD, Carey WB, Crocker
AC, eds. Developmental- Behavioral Pediatrics. 3rd ed. Philadelphia, Pa: WB Saunders
Company; 1999:571-578
Msall ME. Visual impairment. In: Parker S, Zukerman B, Augustyn M. Developmental and
Behavioral Pediatrics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:366-369
Olitsky SE, Hug D, Smith LP. Disorders of vision. In: Kleigman RM, Behrman RE, Jenson HB,
Stanton BF, eds. Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:2573-2576
Critique: 11
Leukokoria may be observed in patients who have retinoblastoma. (Courtesy of R.G. Weaver,
Jr)
Question: 12
A 15-year-old boy presents to the clinic because of a persistent cough. According to his mother,
his cough has been present for approximately 2 weeks, but it seems to be getting worse. He
does not cough all the time, but the coughing episodes tend to come in bursts. This morning she
became very worried because he passed out during a coughing spell. Physical examination
reveals a healthy-appearing male in no apparent distress. He is afebrile, and his vital signs are
normal. He has petechiae on his face but no other skin lesions. His lungs are clear.
Of the following, the MOST appropriate antimicrobial agent to prescribe for this patient is
A. azithromycin
B. clarithromycin
C. doxycycline
D. erythromycin
E. trimethoprim-sulfamethoxazole
References:
American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Long
SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:498-520
Tiwari T, Murphy TV, Moran J. Recommended antimicrobial agents for the treatment and
postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR Recomm Rep.
2005;54(RR14):1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm
Question: 13
A 15-year-old male presents for evaluation of a progressively enlarging lesion on his left forearm
that began 5 days ago. He explains that the lesion initially looked like a "spider bite" with a blister,
but over the last several days, a black scab has developed in the center of the lesion, and there
is a large area of redness around the scab. The lesion has been pruritic but not painful. Except
for low-grade fevers for the last 2 days, he has had no other systemic symptoms. He returned 1
week ago from a school trip to Morocco, where he visited a leather tannery, went shopping in
the large outdoor marketplace, visited some historic sites, and took a camel ride in the desert.
He states that the students stayed in a hostel in Morocco, but there were no screens on the
windows, and spiders, ants, and other insects were visible in the rooms. On physical
examination, the boy is afebrile, and his left forearm is edematous, with a 3x3-cm black eschar
surrounded by a 5-cm area of erythema and induration (Item Q13). The lesion is not tender to
palpation, and there is no drainage. There are several 1.5-cm tender lymph nodes in his left
axilla. Findings on the remainder of his examination are within normal limits.
A. Bacillus anthracis
B. Francisella tularensis
C. Loxosceles laeta
E. Yersinia pestis
Question: 13
Eschar, as desribed for the patient in the vignette. (Courtesy of the Centers for Disease Control
and Prevention, Public Health Image Library, James H. Steele)
References:
American Academy of Pediatrics. Anthrax. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:208-211
Butler T, Dennis DT. Yersinia species, including plague. In: Mandell GL, Bennett JE, Dolin R,
eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th ed. New
York, NY: Elsevier Churchill Livingstone; 2005:2691-2700
Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon: medical and
public health management. JAMA. 1999;281:1735-1745. Available at: http://jama.ama-
assn.org/cgi/content/full/281/18/1735
King MD, Humphrey BJ, Wang YF, Kourbatova EV, Ray SM, Blumberg HM. Emergence of
community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the
predominant cause of skin and soft-tissue infections. Ann Intern Med. 2006;144:309-317.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16520471
Penn RL. Francisella tularensis (tularemia). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell,
Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th ed. New York, NY:
Elsevier Churchill Livingstone; 2005:2674-2685
Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N
Engl J Med. 2005;352:700-707. Extract available at:
http://content.nejm.org/cgi/content/extract/352/7/700
Critique: 13
Critique: 13
The classic lesion of cutaneous anthrax is a black eschar with surrounding swelling, erythema,
and induration. The affected area is not painful. (Courtesy of the Centers for Disease Control and
Prevention, Public Health Image Library)
Critique: 13
Initial lesions of staphylococcal skin infection may be small tender papules that often are
attributed to spider bites (yellow arrows). Frequently, lesions enlarge and develop an overlying
pustule (black arrow). (Courtesy of Bernard Cohen, MD, DermAtlas; www.dermatlas.org)
Critique: 13
An eschar with surrounding painful erythema and swelling is observed following the bite of a
brown recluse spider. (Courtesy of M. Smith)
Critique: 13
An ulcerated papule may appear at the site of inoculation of Francisella tularensis. (Courtesy of
the Centers for Disease Control and Prevention, Public Health Image Library, Dr. Thomas F.
Sellers)
Question: 14
A 3-month-old infant who has a history of renal dysplasia associated with obstructive uropathy
has marked polyuria. He is breastfeeding and receiving supplemental cow milk-based formula.
In an effort to reduce the high urine output, you consider reducing the renal solute load by
changing feedings from the milk-based formula currently being used.
References:
Fiorino KN, Cox J. Nutrition and growth. In: Robertson J, Shilkofski N, eds. Harriet Lane
Handbook: A Manual for Pediatric House Officers. 17th ed. Philadelphia, Pa: Elsevier Mosby;
2005:525-608
Hall RT, Carroll RE. Infant feeding. Pediatr Rev. 2000;21:191-200. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/21/6/191
Ziegler EE, Fomon SJ. Potential renal solute load of infant formulas. J Nutr. 1989;119 (12
suppl):1785-1788. Available at: http://jn.nutrition.org/cgi/reprint/119/12_Suppl/1785
Question: 15
A mother brings in her 13-month-old daughter for evaluation because her girl developed a
perioral rash and "hives" on two occasions last week. One episode occurred while eating yogurt
and another happened immediately after eating a bagel with cream cheese. She states that her
daughter has eaten other foods such as eggs and bread without problems but is breastfeeding
and never has been given milk-based formulas or cow milk. The infant has been given rice milk,
but she became fussy and seems to prefer breastfeeding. The mother is concerned that her
daughter may be allergic to milk but would like to stop breastfeeding.
References:
Bhatia J, Greer F, and the Committee on Nutrition. The use of soy protein-based formulas in
infant feeding. Pediatrics. 2008;121:1062-1068. Available at:
http://pediatrics.aappublications.org/cgi/content/full/121/5/1062
Saarinen KM, Pelkonen AS, Mkel MJ, Savilahti E. Clinical course and prognosis of cow's milk
allergy are dependent on milk-specific IgE status. J Allergy Clin Immunol. 2005;116:869-875.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16210063
Sampson HA, Leung DYM. Adverse reactions to foods. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:986-989
Question: 16
A 16-year-old girl is brought to the emergency department after being found unresponsive in her
bedroom. Her parents report finding a note in which she wrote of "wanting to end the pain." In
addition, they found several empty, unlabeled pill vials on her dresser. On physical examination,
the girl is responsive only to painful stimuli. Her heart rate is 60 beats/min, respiratory rate is 16
breaths/min, blood pressure is 90/60 mm Hg, and oxygen saturation is 92%. Her pupils are 3
mm, equal in size, and sluggishly reactive. The remainder of findings on her physical
examination are normal.
Of the following, the MOST important diagnostic test to obtain when evaluating this patient is a
A. carboxyhemoglobin concentration
E. serum osmolality
References:
Erikson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose.
Emerg Med Clin North Am. 2007;25:249-281. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17482020
Lavallee M, Olsson J Jr, Cheng TL. In brief: unknown poison. Pediatr Rev. 2004;25:370-371.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/10/370
McKay CA Jr. Can the laboratory help me? Toxicology laboratory testing in the possibly
poisoned pediatric patient. Clin Pediatr Emerg Med. 2005;6:116-122
Valez LI, Shepherd JG, Goto CS. Approach to the child with occult toxic exposure. UpToDate
Online 15.3. 2008. Available for subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=ped_tox/3023&selectedTitle=4~150&source
=search_result
Critique: 16
Critique: 16
Question: 17
You are following a 3-month-old infant who was born at 30 weeks gestation, underwent a distal
ileal resection for necrotizing enterocolitis at 2 weeks of age, and subsequently was placed on
parenteral nutrition for 2 months. The baby has residual cholestasis from the parenteral nutrition
(total bilirubin, 5.0 mg/dL [85.5 mcmol/L]; direct bilirubin, 3.0 mg/dL [51.3 mcmol/L]). Currently,
she is receiving a cow milk protein hydrolysate formula concentrated to 24 kcal/oz (0.8
kcal/mL). You are considering adding a dietary supplement to increase the caloric density of the
formula.
Of the following, the supplement that is the MOST likely to be tolerated and cause less diarrhea
in this infant is
A. flaxseed oil
C. olive oil
E. soybean oil
References:
Courtney E, Grunko A, McCarthy T. Enteral nutrition. In: Hendricks KM, Duggan C. Manual of
Pediatric Nutrition. 4th ed. Hamilton, Ontario, Canada: BC Decker; 2005:252-316
Question: 18
You have admitted a 750-g male infant to the neonatal intensive care unit (NICU) for treatment of
respiratory distress and presumed sepsis. The Apgar scores were 1, 5, and 7 at 1, 5, and 10
minutes, respectively. The infant received one dose of exogenous surfactant in the delivery
room. In the NICU, the infant is being cared for on a radiant warmer. At 4 hours after birth,
physical examination reveals a temperature of 97.0F (36.1C), heart rate of 180 beats/min,
respiratory rate of 40 breaths/min (assisted breaths on the ventilator), blood pressure of 45/27
mm Hg, mean arterial blood pressure of 30 mm Hg, and pulse oximetry of 92%. The infant is
receiving synchronized intermittent mechanical ventilation with a peak inflation pressure of 18
cm H2O over a positive end-expiratory pressure of 4 cm H2O at a rate of 40 breaths/min and an
FiO2 of 0.40. Umbilical catheters are present in the umbilical artery and vein. On physical
examination, you note a soft, flat anterior fontanelle. You auscultate equal mechanical breath
sounds bilaterally over the chest and note minimal subcostal retractions. The skin is thin and
somewhat moist, and many veins are visible through it. The ears are flattened against the
cranium and lack any cartilage or recoil. There is a small phallus and an empty scrotum. The
infant is laying on the warmer with legs and arms extended. The neuromotor tone is decreased,
and the infant does not appear to be very active, but he does respond to tactile stimuli with
movement of the arms and legs in seemingly random and purposeless activity.
References:
Donovan EF, Tyson JE, Ehrenkranz RA, et al. Inaccuracy of Ballard scores before 28 weeks'
gestation. National Institute of Child Health and Human Development Neonatal Research
Network. J Pediatr. 1999;135:147-152. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10431107
Marn GMA, Martn Moreiras J, Llitera Fleixas G, et al. Assessment of the new Ballard score to
estimate gestational age [in Spanish]. An Pediatr (Barc). 2006;64:140-145. English abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/16527066
Sedin G. The thermal environment of the newborn infant. In: Martin RJ, Fanaroff AA, Walsh MC,
eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby
Elsevier; 2006:585-596
Thilo EH, Rosenberg AA. The newborn infant. In: Hay WW Jr, Levin MJ, Sondheimer JM,
Deterding RR, eds. Current Pediatric Diagnosis & Treatment. 18th ed. New York, NY: The
McGraw-Hill Companies, Inc; 2007:chap 1
Question: 19
You are called to the newborn nursery to evaluate a 1-day-old girl whose hands and feet are
blue. She was born at term via a cesarean section, and there were no complications. Apgar
scores were 9 at both 1 and 5 minutes. Her respiratory rate is 40 breaths/min, heart rate is 140
beats/min, and blood pressure is normal. Pulse oximetry is 98% on room air. Her lungs are
clear, and there is no murmur. Her lips are pink, but her hands and feet are cyanotic (Item Q19),
and capillary refill is less than 2 seconds.
A. cold environment
B. polycythemia
D. sepsis
Question: 19
Cyanosis of the feet, as exhibited by the infant in the vignette. (Courtesy of the Media Lab at
Doernbecher)
References:
Bernstein D. Evaluation of the cardiovascular system: history and physical examination. In:
Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th
ed. Philadelphia, Pa: Saunders Elsevier; 2007:1857-1863
Critique: 19
Acrocyanosis is a blue discoloration of the hands and feet. (Courtesy of the Media Lab at
Doernbecher)
Critique: 19
Central cyanosis, as exhibited by this infant who has tetralogy of Fallot, is observed best in highly
vascularized areas, such as the lips, tongue, mucous membranes, and nail beds. (Courtesy of
M. Rimsza)
Question: 20
A frustrated mother requests referral of her 15-month-old child to an allergy and asthma
specialist because the boy never seems to have stopped coughing and wheezing over the 6
months of the past respiratory virus season. During the history taking, the mother states that the
baby only occasionally is exposed to wood smoke at the familys barbecue restaurant and to
cosmetic chemicals used at the grandmothers hair salon. Both the father and grandfather
smoke cigarettes in the home.
Of the following, the environmental exposure that is MOST likely to be causing the childs
respiratory symptoms is exposure to
A. cigarette smoke
B. cleaning fluids
C. dust mites
D. hairspray
E. wood smoke
References:
Brunnhuber K, Cummings KM, Feit S, Sherman S, Woodcock J.Putting evidence into practice:
smoking cessation. BMJ Clinical Evidence. 2007. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/resources/index.jsp
Kum-Nji P, Meloy L, Herrod HG. Environmental tobacco smoke exposure: prevalence and
mechanisms of causation of infections in children. Pediatrics. 2006;117:5:1745-1754. Available
at: http://pediatrics.aappublications.org/cgi/content/full/117/5/1745
Roseby R, Waters E, Polnay A, Campbell R, Webster P, Spencer N. Family and carer smoking
control programmes for reducing children's exposure to environmental tobacco smoke.
Cochrane Database Syst Rev. 2003;3:CD001746. Available at:
http://www.cochrane.org/reviews/en/ab001746.html
Stein RT, Holberg CJ, Sherrill D, et al. Influence of parental smoking on respiratory symptoms
during the first decade of life: The Tucson Children's Respiratory Study. Am J Epidemiol.
1999;149:1030-1037. Available at: http://aje.oxfordjournals.org/cgi/reprint/149/11/1030
U.S. Environmental Protection Agency. Health effects of wood smoke. Available at:
http://www.epa.gov/woodstoves/healtheffects.html
U.S. Environmental Protection Agency. National volatile organic compound emission standards
for consumer products. Available at: http://www.epa.gov/fedrgstr/EPA-AIR/1998/September/Day-
11/a22660.htm
Question: 21
You are evaluating a newborn 6 hours after his birth. Labor and delivery were uncomplicated,
but amniocentesis performed during the pregnancy revealed trisomy 21. Fetal
echocardiography at 20 weeks gestation showed normal findings. The infant currently is
sleeping and is well-perfused, with a heart rate of 140 beats/min and no audible murmurs. His
physical features are consistent with Down syndrome.
A. barium swallow
C. echocardiography
D. head ultrasonography
References:
Committee on Genetics. Health supervision for children with Down syndrome. Pediatrics.
2001;107:442-449. Available at: http://pediatrics.aappublications.org/cgi/content/full/107/2/442
Silberbach M, Hannon D. Presentation of congenital heart disease in the neonate and young
infant. Pediatr Rev. 2007;28:123-131. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
Critique: 21
Question: 22
A 4-year-old boy presents with headache and difficulty walking. On physical examination, he is
afebrile, all growth parameters are within normal limits, and his mentation appears normal. The
optic discs are clearly visible and appear normal. He has normal eye position in primary gaze
but cannot abduct his right eye fully. He has normal tone, strength, and reflexes in his upper
limbs, but has bilateral hyperreflexia at the knees and ankle clonus. On gait examination, he toe-
walks.
C. lumbar puncture
References:
Avellino AM. Hydrocephalus. In: Singer HS, Kossoff EH, Hartman AL, Crawford TO, eds.
Treatment of Pediatric Neurologic Disorders. Boca Raton, Fla: Taylor & Francis; 2005:25-36
Garton HJ, Piatt JH Jr. Hydrocephalus. Pediatr Clin North Am. 2004;51:305-325. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/15062673
Kuttesch J Jr, Ater JL. Brain tumors in childhood. In: Behrman RE, Kliegman RM, Jenson HB,
Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:2128-2136
Piatt JH Jr. Recognizing neurosurgical conditions in the pediatrician's office. Pediatr Clin North
Question: 23
Parents who are new to your area bring in their 3-year-old daughter for evaluation because they
are concerned about her delayed speech. They say that she uses about 50 single words. The
girl has had tetralogy of Fallot repaired surgically and recurrent upper respiratory tract infections
with otitis media, for which tympanostomy tubes have been placed. Findings on physical
examination include microcephaly, underfolded pinnae, a broad nasal bridge, cleft uvula, and a
small chin. In addition, the childs speech has a hypernasal quality. The family history is
negative for birth defects and developmental delays.
Of the following, the contiguous gene deletion syndrome that BEST fits this childs features is
A. Angelman
B. Beckwith-Wiedemann
C. 4p-
D. Prader-Willi
E. 22q11
References:
Battaglia A, Carey JC, Wright TJ. Wolf-Hirschhorn syndrome. GeneReviews. 2006. Available at:
http://www.geneclinics.org/servlet/access?db=geneclinics&site=gt&id=8888891&key=OvKiicpzcf
vnc&gry=&fcn=y&fw=vH7o&filename=/profiles/whs/index.html
Lin RJ, Cherry AM, Bangs CD, Hoyme HE. FISHing for answers: the use of molecular
cytogenetic techniques in neonatology. NeoReviews. 2003;4:e94-e98. Available for subscription
at: http://neoreviews.aappublications.org/cgi/content/full/4/4/e94
McDonald-McGinn DM, Emanuel BS, Zackai EH. 22q11.2 deletion syndrome. GeneReviews.
2005. Available at:
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=gr_22q11deletion
Shprintzen RJ. Velo-cardio-facial syndrome. In: Cassidy SB, Allanson JE, eds. Management of
Genetic Syndromes. 2nd ed. Hoboken, NJ: Wiley-Liss; 2005:615-632
Williams CA. Angelman syndrome. In: Cassidy SB, Allanson JE, eds. Management of Genetic
Syndromes. 2nd ed. Hoboken, NJ: Wiley-Liss; 2005:53-62
Williams CA, Driscoll DJ. Angelman syndrome. GeneReviews. 2007. Available at:
http://www.geneclinics.org/servlet/access?db=geneclinics&site=gt&id=8888891&key=OvKiicpzcf
vnc&gry=&fcn=y&fw=tkPG&filename=/profiles/angelman/index.html
Critique: 23
Prader-Willi syndrome is characterized by short stature, obesity, hypogonadism, and small hands
and feet. (Courtesy of Y. Lacassie)
Critique: 23
Angelman syndrome: Note the prominent mandible and happy expression. (Reprinted with
permission from Jonas DM, Demmer LA. Genetic syndromes determined by alterations in
genomic imprinting pathways. NeoReviews. 2007;8:e120-e126.)
Critique: 23
Note the macroglossia, salmon patch on the forehead, prominent eyes, and infraorbital creases in
a 3-month-old infant who has Beckwith-Wiedemann syndrome. (Reprinted with permission from
Jonas DM, Demmer LA. Genetic syndromes determined by alterations in genomic imprinting
pathways. NeoReviews. 2007;8:e120-e126.)
Critique: 23
Question: 24
A 13-year-old girl presents with severe lower abdominal pain of 24 hours duration. She states
that the pain is sharp and constant and that she has had similar pain for several days
approximately monthly over the past 4 months. She has no vomiting or diarrhea with the pain,
but she is constipated frequently, having a bowel movement about every 3 to 4 days. She feels
that her jeans are getting tighter around the waist, although she remains active, playing soccer
daily. She has never had a menstrual period and denies ever being sexually active. On physical
examination, she is afebrile, her heart rate is 85 beats/min, and her blood pressure is 110/70 mm
Hg. Her weight is at the 60th percentile and her height at the 50th percentile for age. Her breasts
and genitalia are at Sexual Maturity Rating 5. Abdominal examination reveals a firm and tender
midline mass that is inferior to the umbilicus.
A. bladder obstruction
B. endometriosis
C. hematocolpos
D. megacolon
E. ovarian cyst
References:
Adams Hillard PJ, Deitch HF. Gynecologic disorders. In: Osborn LM, DeWitt TG, First LR, Zenel
JA, eds. Pediatrics. Philadelphia, Pa: Elsevier Mosby;2005:1461-1471
Laufer MR, Goldstein DP, Hendren WH. Structural abnormalities of the female reproductive
tract. In: Emans SJH, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th
ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:334-416
Critique: 24
Bulging of an imperforate hymen. (Reprinted with permission from Torok K, Bhende MS. Index of
suspicion (case 2). Pediatr Rev. 2008;29:25-30.)
Question: 25
During teaching rounds, the pediatric ward resident reports on a 4-month-old circumcised male
infant who was admitted to the pediatric ward for fever that morning. The infant is now afebrile
and has had respiratory rates of 40 breaths/min while sleeping and greater than 60 breaths/min
when awake. The infant has a soft, flat fontanelle on physical examination and is not irritable.
The only diagnostic studies obtained on admission were a urinalysis and complete blood count,
the results of which were normal, except for a white blood cell count of 16.0x103/mcL
(16.0x109/L).
B. chest radiography
C. lumbar puncture
E. urine culture
References:
Sectish TC, Prober CG. Pneumonia. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:1795-
1799
Question: 26
A 6-year-old boy who has severe vomiting and dehydration is admitted to the hospital. Initial
laboratory studies demonstrate a serum sodium concentration of 126.0 mEq/L (126.0 mmol/L),
potassium of 5.3 mEq/L (5.3 mmol/L), and pH of 7.26. After 24 hours of rehydration with 0.9%
saline, his serum sodium concentration is 129.0 mEq/L (129.0 mmol/L) and potassium is 4.9
mEq/L (4.9 mmol/L). On physical re-examination, you note that his knees, elbows, dorsal
fingers, and tongue are somewhat pigmented (Item Q26), and his skin is darker than that of
other family members.
Of the following, the MOST useful diagnostic laboratory study at this time is measurement of
serum
Question: 26
Hyperpigmentation (arrows), as exhibitied by the boy in the vignette. (Courtesy of the Media Lab
at Doernbecher)
References:
Auchus RJ, Rainey WE. Adrenarche-physiology, biochemistry and human disease. Clin
Endocrinol. 2004;60:288-296. Available at: http://www.blackwell-
synergy.com/doi/full/10.1046/j.1365-2265.2003.01858.x
Coco G, Dal Pra XC, Presotto F, et al. Estimated risk for developing autoimmune Addison's
disease in patients with adrenal cortex antibodies. J Clin Endocrinol Metab. 2006;91:1637-1645.
Available at: http://jcem.endojournals.org/cgi/content/full/91/5/1637
Donohoue PA. Diagnosis of adrenal insufficiency in children. UpToDate Online 15.3. 2008.
Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/20697
Perry R, Kecha O, Paquette J, Huot C, van Vliet G, Deal C. Primary adrenal insufficiency in
children: twenty years experience at the Sainte-Justine Hospital, Montreal. J Clin Endocrinol
Metab. 2005;90:3243-3250. Available at: http://jcem.endojournals.org/cgi/content/full/90/6/3243
Wilson TA, Speiser P. Adrenal insufficiency. eMedicine Specialties, Pediatrics: General Medicine,
Endocrinology. 2007. Available at: http://www.emedicine.com/ped/TOPIC47.HTM
Critique: 26
Question: 27
A mother of a 6-year-old boy in your practice is concerned that her son may have dyslexia. She
has brought a sample of his printing to the visit in which the boy wrote "ded" instead of "bed" and
"dad" instead of "bad." She wants your advice on what she should do to help her son learn how
to write properly.
A. reassure the mother that letter reversal can be normal through 7 years of age
D. refer the child for an occupational therapy evaluation and services to improve his writing skills
References:
Committee on Children With Disabilities, American Academy of Pediatrics (AAP) and American
Academy of Ophthalmology (AAO), and American Association for Pediatric Ophthalmology and
Strabismus (APOS). Learning disabilities, dyslexia, and vision: a subject review. Pediatrics.
1998;102:1217-1219. Available at:
http://pediatrics.aappublications.org/cgi/content/full/102/5/1217
Fletcher JM, Lyon GR, Fuchs LS, Barnes MA. Reading disabilities: word recognition. In:
Learning Disabilities: From Identification to Intervention. New York, NY: The Guilford Press:
2007:85-163
Shaywitz SE, Shawitz BA. Dyslexia (specific reading disability). Pediatr Rev. 2003;24:147-153.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/24/5/147
Question: 28
A 14-year-old girl presents to the emergency department with a 2-day history of fever and a
rash. The rash has been progressive, and now her mouth and eyes hurt. Upon further
questioning, she reports that she was started on an antibiotic 7 days ago for some complaints of
dysuria, but she does not remember its name. Physical examination reveals a moderately toxic-
appearing female whose temperature is 102.6F (39.2C), respiratory rate is 25 breaths/min,
heart rate is 105 beats/min, and blood pressure is 105/70 mm Hg. Her bulbar conjunctivae are
erythematous (Item Q28A), and she has some early bullous lesions developing in her mouth.
She has right upper quadrant tenderness and multiple target lesions (Item Q28B) on her chest,
abdomen, arm, back, upper thighs, buttocks, and face.
Of the following, the antimicrobial agent that is MOST likely to be associated with these clinical
findings is
A. amoxicillin
B. azithromycin
C. cefdinir
D. clindamycin
E. trimethoprim-sulfamethoxazole
Question: 28
Conjunctival erythema, as exhibited by the girl in the vignette. (Reprinted with permission from
Bullen LK, Zenel J. Visual diagnosis: a 15-year-old who has cough, rash, and painful swallow.
Pediatr Rev. 2005;26:176-181
Question: 28
(Courtesy of D. Krowchuk)
References:
Critique: 28
Wheals with unusul shapes are characteristic of urticaria, a hypersensitivity reaction that may be
triggered by antibiotics such as trimethoprim-sulfamethoxazole. (Courtesy of D. Krowchuk)
Critique: 28
A phototoxic eruption has the appearance of a severe sunburn, and bullae may be present. The
eruption may be caused by a number of drugs, including tetracyclines, sulfonamides, and
fluoroquinolones. In this patient, the eruption was caused by doxycycline. (Courtesy of D.
Krowchuk)
Critique: 28
In toxic epidermal necrolysis, erythematous patches appear (top), bullae form (bottom arrow),
and later rupture, leaving widespread erosions. (Courtesy of D. Krowchuk)
Question: 29
A 14-year-old girl presents for evaluation after 4 days of a temperature to 103.0F (39.5C),
nausea, abdominal cramping, and profuse bloody diarrhea. She reports that she has not
traveled anywhere, has no pets, and has had no ill contacts or unusual food exposures. One
week ago, she was diagnosed with a methicillin-sensitive Staphylococcus aureus chronic
osteomyelitis of her distal radius and has been receiving intravenous cefazolin therapy via a
peripherally inserted central catheter line. Physical examination reveals an uncomfortable
teenager who complains of severe abdominal pain and has a temperature of 102.8F (39.4C)
and moist mucous membranes. Her abdomen is diffusely tender, with voluntary guarding but no
rebound tenderness on palpation. Rectal examination demonstrates normal sphincter tone with
no fissures or other lesions. Laboratory findings include a peripheral white blood cell count of
15.0x103/mcL (15.0x109/L); hemoglobin of 13.0 g/dL (130.0 g/L); platelet count of
300.0x103/mcL (300.0x109/L); and a differential count of 65% neutrophils, 25% lymphocytes,
and 10% monocytes. Her stool appears watery and grossly bloody.
Of the following, the MOST appropriate treatment for this patients condition is
A. ceftriaxone
B. clindamycin
C. metronidazole
D. trimethoprim-sulfamethoxazole
E. vancomycin
References:
American Academy of Pediatrics. Clostridium difficile. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:261-263
Klein EJ, Boster DR, Stapp JR, et al. Diarrhea etiology in a children's hospital emergency
department: a prospective cohort study. Clin Infect Dis. 2006;43:807-813. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16941358
Thielman NM, Wilson KH. Antibiotic-associated colitis. In: Mandell GL, Bennett JE, Dolin R, eds.
Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th ed. New
York, NY: Elsevier Churchill Livingstone; 2005:1249-1263
Question: 30
A 14-year-old girl who has a history of insulin-dependent diabetes mellitus (IDDM) presents with
vomiting, increased urination, and decreased energy. Physical examination reveals Kussmaul
breathing and delayed capillary refill. Laboratory findings include:
Sodium, 136.0 mEq/L (136.0 mmol/L)
Potassium, 5.2 mEq/L (5.2 mmol/L)
Chloride, 100.0 mEq/L (100.0 mmol/L)
Bicarbonate, 10.0 mEq/L (10.0 mmol/L)
Blood urea nitrogen, 24.0 mg/dL (8.6 mmol/L)
Creatinine, 0.9 mg/dL (79.6 mcmol/L)
Glucose, 550.0 mg/dL (30.5 mmol/L)
The patient receives initial hydration with 20 mL/kg of normal saline.
References:
Rose BD, Post TW. Potassium homeostasis. In: Clinical Physiology of Acid-base and Electrolyte
Disorders. 5th ed. New York, NY: McGraw-Hill Medical Publishing Division; 2001:372-375
Rose BD, Post TW. The total body water and the plasma sodium concentration. In: Clinical
Physiology of Acid-base and Electrolyte Disorders. 5th ed. New York, NY: McGraw-Hill Medical
Publishing Division; 2001:241-243
Question: 31
You have just assisted in the delivery of a 38-week gestational age male infant who was born via
cesarean section to a 25-year-old woman. As you are completing the infants initial physical
examination, the father mentions that he and his wife have allergic rhinitis and asthma. He asks
whether his son is at increased risk for allergies and how they can reduce the boys chance for
developing such allergic disorders.
A. explain that because both parents have asthma, breastfeeding will not reduce the risk of
eczema
B. explain that breastfeeding or formula choices do not matter now because the mother did not
restrict her diet during pregnancy
C. measure the cord blood immunoglobulin E concentration to help establish the newborns risk
for atopic disorders
D. recommend exclusive breastfeeding for 4 months with the addition of a hypoallergenic formula
if needed
E. start the newborn on a cow milk formula for the first month, then switch to strict breastfeeding
if he develops eczema
References:
Greer FR, Sicherer SH, Burks AW, Committee on Nutrition and Section on Allergy and
Immunology. Effects of early nutritional interventions on the development of atopic disease in
infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction
of complementary foods and hydrolyzed formulas. Pediatrics. 2008;121:183-191. Available at:
http://pediatrics.aappublications.org/cgi/content/full/121/1/183
Mihrshahi S, Ampon R, Webb K, et al for the CAPS Team. The association between infant
feeding practices and subsequent atopy among children with a family history of asthma. Clin Exp
Allergy. 2007;37:671-679. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17456214
Prescott SL, Bjrkstn B. Probiotics for the prevention or treatment of allergic disease. J Allergy
Clin Immunol. 2007;120:255-262. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17544096
Snijders BEP, Thijs C, Dagnelie PC, et al. Breast-feeding duration and infant atopic
manifestations, by maternal allergic status, in the first two years of life (KOALA study). J Pediatr.
2007;151:347-351. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17889066
Question: 32
A 2-year-old girl who has a 4-day history of varicella presents to the office with agitation. Her
mother reports that she treated the fever, rash, and pruritus with acetaminophen and
diphenhydramine regularly, which provided some relief. This morning her daughter seemed
more irritable, had a higher fever than yesterday, and "seemed delirious." On physical
examination, the agitated and inconsolable child has a temperature of 104.2F (40.1C), heart
rate of 160 beats/min, respiratory rate of 36 beats/min, and blood pressure of 135/87 mm Hg.
Her pupils are dilated and sluggishly reactive. Examination of the skin reveals numerous small,
crusted erosions without surrounding erythema. Neurologic examination demonstrates no focal
findings, and the patient is not ataxic.
A. diphenhydramine overdose
B. hypoglycemia
C. intracranial hemorrhage
D. Reye syndrome
E. varicella cerebellitis
References:
Burns MJ, Linden CH, Graudins A, Brown RM, Fletcher KE. A comparison of physostigmine and
benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000;35:374-
381. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/10736125
Carey RG, Balisteri WF. Mitochondrial hepatopathies. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:1696-1697
Gershon AA, LaRussa P. Varicella-zoster virus infections. In: Gershon AA, Hotez PJ, Katz SL,
eds. Krugman's Infectious Diseases of Children. 11th ed. Philadelphia, Pa: Mosby; 2004:785-816
Critique: 32
Purpura fulminans may follow varicella and is characterized by hemorrhagic necrosis of the skin
and disseminated intravascular coagulation. (Courtesy of Bernard Cohen, MD, DermAtlas,
www.dermatlas.org)
Question: 33
A 7-month-old child presents for a follow-up office visit after undergoing a Kasai procedure for
biliary atresia at 6 weeks of age. The mother states that the boy is irritable when his right arm is
moved. On physical examination, the infant is jaundiced. You detect tenderness in the anterior
radial head. Radiography of the affected region demonstrates metaphyseal fraying (Item Q33)
and a fracture.
Of the following, the MOST appropriate laboratory studies to obtain next are
Question: 33
Metaphyseal fraying, cupping, and widening, as described for the infant in the vignette. (Couretsy
of R. Schwartz)
References:
Campbell KM, Bezerra JA. Biliary atresia. In: Walker WA, Goulet O, Kleinman RE, Sherman PM,
Shneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4th ed. Hamilton, Ontario,
Canada: BC Decker; 2004:1122-1138
Question: 34
You are examining a 3.5-kg term infant 48 hours after his birth. Results of the physical
examination are normal, and you are considering discharging him from the hospital. He is being
fed formula from a bottle, and the nurses report intakes of 30 mL every 3 hours. He has wet at
least six diapers daily for the past 2 days, but he has not passed any meconium or expressed
any stool since birth.
A. ileal atresia
B. imperforate anus
C. meconium ileus
References:
Albanese CT, Sylvester KG. Pediatric surgery. In: Doherty GM, Way LW, eds. Current Surgical
Diagnosis and Treatment. 12th ed. New York, NY: The McGraw-Hill Companies, Inc; 2006:chap
45
Burge D, Drewett M. Meconium plug obstruction. Pediatr Surg Int. 2004;20:108-110. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/14760494
Casaccia G, Trucchi A, Spirydakis I, et al. Congenital intestinal anomalies, neonatal short bowel
syndrome, and prenatal/neonatal counseling. J Pediatr Surg. 2006;41:804-807. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/16567197
Magnuson DK, Parry RL, Chwals WJ. Selected abdominal gastrointestinal anomalies. In: Martin
RJ, Fanaroff AA, Walsh MC, eds: Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed.
Philadelphia, Pa: Mosby Elsevier; 2006:1381-1402
Nurko S. Motility of the colon and anorectum. NeoReviews. 2006;7:e34-e48. Available for
subscription at: http://neoreviews.aappublications.org/cgi/content/full/7/1/e34
Sutton TL. Index of suspicion in the nursery. NeoReviews. 2006;7:e269-e271. Available for
subscription at: http://neoreviews.aappublications.org/cgi/content/full/7/5/e269
Thilo EH, Rosenberg AA. The newborn infant. In: Hay WW Jr, Levin M, Sondheimer JM,
Deterding RR, eds. Current Pediatric Diagnosis & Treatment. 18th ed. New York, NY: The
McGraw-Hill Companies, Inc; 2007:chap 1
Question: 35
A 4-year-old boy who recently emigrated from Central America is brought to your clinic because
of 2 weeks of colicky abdominal pain that recently has worsened. His vital signs are normal, and
he is afebrile. Physical examination reveals mild diffuse tenderness, but there is no rebound or
guarding. After your examination, he has an episode of vomiting. Examination of the vomitus
reveals long, slim objects that resemble worms (Item Q35).
A. albendazole
B. iodoquinol
C. metronidazole
D. praziquantel
E. voriconazole
Question: 35
(Courtesy of M. Rimsza)
References:
American Academy of Pediatrics. Amebiasis. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:204-208
American Academy of Pediatrics. Ascaris lumbricoides infections. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:218-219
Dent AE, Kazura JW. Ascariasis (Ascaris lumbricoides). In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:1495
Critique: 35
Ascaris sp causes the most common human roundworm infection. Adult worms may reach 30
cm in length. (Courtesy of M. Rimsza)
Critique: 35
Fertilized Ascaris lumbricoides eggs are rounded and have a thick shell. (Courtesy of the
Centers for Disease Control and Prevention, Public Health Image Library, M Melvin)
Question: 36
An 8-month-old boy who has Down syndrome and a large ventriculoseptal defect has had
recurrent otitis media and sinusitis during the respiratory virus season that required four
separate courses of antibiotics in 4 months. At todays visit, his mother states that his rhinitis
and otitis media symptoms have resolved, but she is concerned about a recurrent diaper rash
that is unresponsive to both barrier creams and repeated use of the nystatin cream prescribed
last month. Examination reveals white plaques (Item Q36A) on the buccal mucosa just inside the
lips and a diaper rash (Item Q36B).
A. oral fluconazole
B. oral griseofulvin
C. oral itraconazole
Question: 36
White plaques, as described for the infant in the vignette. (Courtesy of D. Krowchuk)
Question: 36
(Reprinted with permission from Krowchuk DP, Mancini AJ, eds. Pediatric Dermatology. A Quick
Reference Guide. Elk Grove Village, Ill: American Academy of Pediatrics; 2007)
References:
American Academy of Pediatrics. Candidiasis (moniliasis, thrush). In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:242-246
American Academy of Pediatrics. Drugs for invasive and other serious fungal infections in
children. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the
Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of
Pediatrics; 2006:780
American Academy of Pediatrics. Recommended doses of parenteral and oral antifungal drugs.
In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the
Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of
Pediatrics; 2006:777-779
American Academy of Pediatrics. Topical drugs for superficial fungal infections. In: Pickering LK,
Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:781-784
Weisse ME, Aronoff SC. Candida. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson's Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1207-1310
Question: 37
You are called to the newborn nursery to evaluate a 2-hour-old male who was born at term. The
pregnancy was uncomplicated, but meconium staining was noted at delivery. The baby weighs
3.8 kg, is afebrile, and has a heart rate of 165 beats/min and a respiratory rate of 70
breaths/min. You note tachypnea and hyperpnea with clear breath sounds, no murmurs, and
strong distal pulses. His oxygen saturation in room air is 68%. You place a nonrebreather mask
to deliver an Fio2 of 1.0. After 5 minutes, the oxygen saturation is 72%.
Of the following, the BEST explanation for the findings of the hyperoxia test is
C. pneumonia
References:
Driscoll D, Allen HD, Atkins DL, et al. Guidelines for evaluation and management of common
congenital cardiac problems in infants, children, and adolescents. A statement for healthcare
professionals from the Committee on Congenital Cardiac Defects of the Council on
Cardiovascular Disease in the Young, American Heart Association. Circulation. 1994;90:2180-
2188. Available at: http://circ.ahajournals.org/cgi/reprint/90/4/2180
Ranjit MS. Common congenital cyanotic heart defects--diagnosis and management. J Indian
Med Assoc. 2003;101:71-72, 74. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/12841486
Silberbach M, Hannon D. Presentation of congenital heart disease in the neonate and young
infant. Pediatr Rev. 2007;28:123-131. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
Critique: 37
Transposition of the great arteries: Computed tomography angiography of the heart with three-
dimensional reconstruction shows the aorta (Ao) arising from the right ventricle (RV) and the
pulmonary artery (PA) arising from the left ventricle (LV). (Courtesy of D. Mulvihill)
Question: 38
The mother of a 10-month-old child who has mild hypotonia brings him to the office after he has
an unprovoked seizure. On physical examination, you note several hypopigmented macules on
the trunk (Item Q38A). Magnetic resonance imaging of the brain reveals several thickened
areas of cerebral cortex (Item Q38B), with abnormal signal and abnormalities along the walls of
the lateral ventricles (Item Q38C).
A. incontinentia pigmenti
B. neurofibromatosis type 1
C. Sturge-Weber syndrome
D. tuberous sclerosis
Question: 38
(Courtesy of D. Krowchuk)
Question: 38
T2-weighted axial magnetic resonance imaging reveals dysplastic cortical gyri (arrows), as
described for the infant in the vignette. (Courtesy of D. Krowchuk)
Question: 38
Axial magnetic resonance imaging demonstrates lesions along the walls of the lateral ventricles
(arrows), as described for the infant in the vignette. (Courtesy of D. Krowchuk)
References:
Haslam RHA. Neurocutaneous syndromes. In: Kliegman RM, Behrman RE, Jenson HB, Stanton
BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2483-
2488
Kandt RS. Tuberous sclerosis complex. In: Singer HS, Kossoff EH, Hartman AL, Crawford TO,
eds. Treatment of Pediatric Neurologic Disorders. Boca Raton, Fla: Taylor & Francis; 2005:553-
560
Critique: 38
Critique: 38
Swirled hyperpigmentation following the lines of Blaschko is characteristic of the third stage of
incontinentia pigmenti. (Courtesy of D. Krowchuk)
Critique: 38
Critique: 38
Lisch nodules (iris hamartomas [arrow]) are one of the diagnostic criteria for neurofibromatosis
type 1. (Courtesy of Wake Forest University Eye Center)
Critique: 38
A port wine stain involving the distribution of the first and second branches of the trigeminal nerve
is observed in Sturge-Weber syndrome. (Courtesy of M. Rimsza)
Question: 39
You are called to the emergency department to evaluate a 5-month-old boy who has new-onset
seizures. On physical examination, you note that he is thin and has marked hepatomegaly. The
mother tells you that he has been irritable the past several mornings when he awakened from a
full nights sleep. This morning, she found him seizing in his crib and called 911. Laboratory tests
performed on specimens taken prior to starting intravenous fluids reveal hypoglycemia, lactic
acidosis, hyperuricemia, and hyperlipidemia. You suspect a diagnosis of glycogen storage
disease.
Of the following, the MOST appropriate long-term management of this disorder includes
D. protein restriction
References:
Hoffmann GF, Nyhan WL, Zschocke J, Kahler SG, Mayatepek E. Approach to the patient with
hepatic disease. In: Inherited Metabolic Diseases. Philadelphia, Pa: Lippincott Williams & Wilkins;
2002:191-214
Nyhan WL, Barshop BA, Ozand PT. Disorders of carbohydrate metabolism. In: Atlas of
Metabolic Diseases. 2nd ed. London, England: Hodder Arnold; 2005:371-402
Question: 40
A 13-year-old girl comes to your office because her menstrual periods are irregular. She
attained menarche at 12 years of age and states that she has had only four menstrual periods
over the past year. The periods last for 5 to 7 days and require the use of four pads per day.
She has never been sexually active. She plays no sports, but she swims in the summer for fun.
On physical examination, her weight and height are at the 50th percentile for age. She has
minimal facial acne and no hirsutism or other skin lesions. Her breast and genital development is
at Sexual Maturity Rating 5.
Of the following, the MOST appropriate management strategy for this patient is to
References:
Emans SJ. Amenorrhea in the adolescent. In: Emans SJH, Laufer MR, Goldstein DP, eds.
Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins;
2005:214-269
Ohlemeyer CL. Menstrual disorders. In Osborn LM, DeWitt TG, First LR, Zenel JA eds.
Pediatrics. Philadelphia, Pa: Elsevier Mosby; 2005:1455-1460
Question: 41
You are evaluating a 20-month-old boy who has a rectal temperature of 106F (41.1C) and a
history of coughing. His mother reports that the child has had a decrease in activity and eating
over the past 2 days. On physical examination, the boy appears moderately ill but is alert and
easily interacts with you. He occasionally grunts, has a heart rate of 140 beats/min, and has a
respiratory rate of 55 breaths/min. His neck is supple, he is circumcised, and he has no
evidence of otitis media.
Of the following, the BEST initial test in the evaluation of this child is
A. chest radiography
D. lumbar puncture
E. urinalysis
References:
Brook I. Unexplained fever in young children: how to manage severe bacterial infection. BMJ.
2003;327:1094-1097. Available at: http://www.bmj.com/cgi/content/full/327/7423/1094
McCarthy PL. Evaluation of the sick child in the office and clinic. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:363-365
Question: 42
You are called to the emergency department to see an 8-year-old girl in whom congenital
adrenal hyperplasia was diagnosed at birth. She is being treated with oral mineralocorticoid daily
(9-alpha-fludrocortisone 0.1 mg) and hydrocortisone 5 mg orally every 8 hours. She is febrile
(temperature of 102.0F [38.9C]) and has vomited twice. According to her mother, other family
members recently recovered from a gastrointestinal illness that started with fever and vomiting.
References:
Donohoue PA. Treatment of adrenal insufficiency in children. UptoDate Online 15.3. 2008.
Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/19876
Shulman DI, Palmert MR, Kemp SF, for the Lawson Wilkins Drug and Therapeutics Committee.
Adrenal insufficiency: still a cause of morbidity and death in childhood. Pediatrics. 2007;119:e484-
e494. Available at: http://pediatrics.aappublications.org/cgi/content/full/119/2/e484
Wilson TA, Speiser P. Adrenal insufficiency. eMedicine Specialties, Pediatrics: General Medicine,
Endocrinology. 2007. Available at:
http://www.emedicine.com/ped/TOPIC47.HTM
Question: 43
A 9-year-old girl has been evaluated by a learning consultant and found to have a slow reading
rate, weakness in short-term memory, and problems with reading comprehension. Her parents
ask you what subjects other than reading will be most challenging for her due to these learning
difficulties.
Of the following, the subject that this child should find MOST challenging is
A. art
B. creative writing
C. mathematics
D. music
E. social studies
References:
Fletcher JM, Lyon GR, Fuchs LS, Barnes MA. Reading disabilities: comprehension. In: Learning
Disabilities: From Identification to Intervention. New York, NY: The Guilford Press; 2007:184-206
Shaywitz SE, Shaywitz BA. Dyslexia (specific reading disability). Pediatr Rev. 2003;24:147-153.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/24/5/147
Question: 44
As you are leaving the supermarket, the cashier tells you that she is worried because her child
recently had a positive tuberculin skin test. She had to take him to the health department for skin
testing because he had been in contact with her father, who recently was diagnosed with active
pulmonary tuberculosis. They told her that the boys skin test was positive at "25," but his chest
radiograph was normal. She is concerned because the doctor told her that the case is a little
unusual because of the type of tuberculosis her father has. She asked the physician at the
health department to write it down, and she hands you a piece of paper that says "INH
resistant." The mother asks you what type of medication her boy should receive.
Of the following, the MOST appropriate antituberculous agent to prescribe for this boy is
A. ciprofloxacin
B. ethambutol
C. isoniazid
D. pyrazinamide
E. rifampin
References:
Alsayyed B, Adam HM. In brief: rifampin. Pediatr Rev. 2004;25:216-217. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/6/216
American Academy of Pediatrics. Tuberculosis. In: Pickering LK, Baker CJ, Long SS, McMillan
JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:678-698
Bliziotis IA, Ntziora F, Lawrence KR, Falagas ME. Rifampin as adjuvant treatment of Gram-
positive bacterial infections: a systemic review of comparative clinical trials. Eur J Clin Microbiol
Infect Dis. 2007;26:849-856. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17712583
Question: 45
You are speaking to a group of medical students about different antibiotic classes that can be
used in the treatment of meningitis. One student asks you about chloramphenicol, a drug with
which he is not familiar.
Of the following, the MOST common adverse effect associated with chloramphenicol therapy is
B. drug eruption
E. optic neuritis
References:
Kauffman RE, Miceti JN, Strebel L, Buckley JA, Done AK, Dajani AS. Pharmacokinetics of
chloramphenicol and chloramphenicol succinate in infants and children. J Pediatr. 1981;98:315-
320. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/7463235
Myers B, Salvatore M. Tetracyclines and chloramphenicol. In: Mandell GL, Bennett JE, Dolin R,
eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th ed. New
York, NY: Elsevier Churchill Livingstone, 2005:356-373
Pickering LK, Hoecker JL, Kramer WG, Kohl S, Cleary TG. Clinical pharmacology of two
chloramphenicol preparations in children: sodium succinate (IV) and palmitate (oral) esters. J
Pediatr. 1980;96:757-761. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/6987361
Rahal JJ Jr, Simberkoff MS. Bactericidal and bacteriostatic action of chloramphenicol against
meningeal pathogens. Antimicrob Agents Chemother. 1979;16:13-18. Available at:
http://aac.asm.org/cgi/reprint/16/1/13?view=long&pmid=38742
Question: 46
A 2-year-old boy presents with fever and abdominal pain. Urinalysis reveals a specific gravity of
1.010, pH of 5.5, 2+ protein, no blood, and negative leukocyte esterase and nitrite tests.
Microscopy findings are negative.
Of the following, the MOST appropriate diagnostic test to assess the severity of proteinuria in
this child is
A. a random urine sample measurement for quantitative protein and creatinine concentrations
B. measurement of serum albumin concentration and correlation with urine protein concentration
measured by dipstick
References:
Chahar OP, Bundella B, Chahar CK, Purohit M. Quantitation of proteinuria by use of single
random spot urine collection. J Indian Med Assoc. 1993;91:86-87. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/8409488
Gregianin LJ, McGill AC, Pinheiro CM, Brunetto AL. Vanilmandelic acid and homovanillic acid
levels in patients with neural crest tumor: 24-hour urine collection versus random sample.
Pediatr Hematol Oncol. 1997;14:259-265. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/9185210
Question: 47
A 12-month-old girl presents with a 3-month history of a pruritic rash that involves her cheeks,
neck, anterior trunk, and antecubital and popliteal areas. The rash improves after use of an over-
the-counter topical steroid cream but still is present most days, and the infant often wakes up at
night scratching. On physical examination, you observe a raised erythematous rash that has
areas of lichenification (Item Q47).
Question: 47
(Courtesy of D. Krowchuk)
References:
Greer FR, Sicherer SH, Burks AW, Committee on Nutrition and Section on Allergy and
Immunology. Effects of early nutritional interventions on the development of atopic disease in
infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction
of complementary foods and hydrolyzed formulas. Pediatrics. 2008;121:183-191. Available at:
http://pediatrics.aappublications.org/cgi/content/full/121/1/183
Sampson HA, Leung DYM. Adverse reactions to foods. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:986-989
Question: 48
The mother of a 2-year-old boy calls you because she found her son holding an open bottle of
liquid dishwasher detergent. He is crying, drooling profusely, and has vomited three times. In
answer to your questions, she reports that he is not sleepy and did not seem to get it in his eyes
or on his skin. On examination in your office, you note an ulcer on his lower lip and several
ulcers on his tongue.
Of the following, the most appropriate next step in the evaluation and management of this boy
is to
References:
Cordero B, Savage RR, Cheng TL. In brief: corrosive ingestions. Pediatr Rev. 2006;27:154-155.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/4/154
Ferry GD. Caustic esophageal injury in children. UpToDate. 2008. Available for subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=pedigast/11441&view=print
Question: 49
A 12-year-old boy has had cholestasis since infancy from Alagille syndrome. He has been lost
to medical follow-up for the last several years. He now presents to your office with pain in his
right upper thigh after a fall. His thigh is intensely tender, and ultrasonography demonstrates a
large hematoma in his quadriceps. The parents state that he has tended to bruise easily in the
past few months.
Of the following, the condition MOST likely to account for this patients symptoms is
C. vitamin C deficiency
D. vitamin K deficiency
References:
Cranenburg ECM, Shurgers LJ, Vermeer C. Vitamin K: the coagulation vitamin that became
omnipotent. Thromb Haemost. 2007;98:120-125. Available at:
http://www.schattauer.de/index.php?id=1268&pii=th07070120&no_cache=1
Kamath BM, Piccoli DA. Heritable disorders of the bile ducts. Gastroenterol Clin North Am.
2003;32:857-875. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/14562578
Sokol RJ. Fat-soluble vitamins and their importance in patients with cholestatic liver diseases.
Gastroenterol Clin North Am. 1994;23:673-705. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/7698827
Critique: 49
The broad forehead and pointed chin characteristic of Alagille syndrome. (Courtesy of M.
Rimsza)
Critique: 49
Question: 50
A term infant is delivered by emergency cesarean section following the acute onset of maternal
vaginal bleeding and profound fetal bradycardia on electronic fetal heart rate monitoring. The
Apgar scores are 1, 2, and 3 at 1, 5, and 10 minutes, respectively. Resuscitation includes
intubation and assisted ventilation, chest compressions, and intravenous epinephrine. The infant
is admitted to the neonatal intensive care unit and has seizures at 6 hours of age.
Of the following, a TRUE statement about infants who have seizures following perinatal asphyxia
is that most
A. develop epilepsy
B. develop microcephaly
References:
Ronen GM, Buckley D, Penney S, Streiner DL. Long-term prognosis in children with neonatal
seizures: a population-based study. Neurology. 2007;69:1816-1822. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17984448
Tekgul H, Gauvreau K, Soul J, et al. The current etiologic profile and neurodevelopmental
outcome of seizures in term newborn infants. Pediatrics. 2006;117:1270-1280. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/4/1270
Critique: 50
Critique: 50
Question: 51
A 16-year-old girl who is new to your practice complains of a nearly constant headache for the
past year. She describes the pain as a band around her head that often is throbbing and is
worse during the middle of the day. She denies nausea or vomiting but reports occasional
fatigue. There is no family history of headaches. She has missed more than 20 days of school
this year because of the headache, and she is struggling to maintain a C average. She admits to
hating school and does not participate in extracurricular activities because she "doesnt like
anything." Findings on her physical examination, including complete neurologic and funduscopic
evaluation, are normal.
Of the following, the BEST next step in the management of this girls headaches is to
References:
Silver N. Headache (chronic, tension type). BMJ Clinical Evidence. 2007. Available for
subscription at: http://clinicalevidence.bmj.com/ceweb/conditions/nud/1205/1205_guidelines.jsp
Strine TW, Okoro CA, McGuire LC, Balluz LS. The associations among childhood headaches,
emotional and behavioral difficulties, and health care use. Pediatrics. 2006;117: 1728-1735.
Available at: http://pediatrics.aappublications.org/cgi/content/full/117/5/1728
Question: 52
When a 14-year-old girl had frequent complaints of shoulder pain made worse by pitching
softball a few months ago, you diagnosed overuse injury. Nonsteroidal anti-inflammatory drugs
and rest have provided some relief. She presents today with complaints of recurrent upper arm
pain that is unrelated to exercise and sometimes awakens her from sleep. Physical examination
reveals a slightly larger circumference of the left proximal humerus compared with the right.
There is minimal tenderness on palpation over the area, although the girl reports a constant
ache. She has full range of motion of the arm at the shoulder and elbow. You obtain a shoulder
radiograph (Item Q52).
A. acromioclavicular separation
B. acute osteomyelitis
C. chronic osteomyelitis
D. osteosarcoma
Question: 52
motion. The diagnosis can be made by an anteroposterior radiograph, which can demonstrate
excessive separation of the AC joint (Item C52B). Supracondylar fracture of the humerus
usually is caused by falling onto the extremity (often outstretched) and may be associated with
acute pain, swelling, and deformity near the elbow (Item C52C).
References:
Arndt CAS. Neoplasms of bone. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson's Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2146-2150
Cripe TP. Osteosarcoma. eMedicine Specialties, Pediatrics, Oncology. 2006. Available at:
http://www.emedicine.com/ped/topic1684.htm
Gorlick R, Anderson P, Andrulis I, et al. Biology of childhood osteogenic sarcoma and potential
targets for therapeutic development. Clin Cancer Res. 2003;9:5442-5453. Available at:
http://clincancerres.aacrjournals.org/cgi/content/full/9/15/5442
Gurney JG, Swensen AR, Bulterys M. Malignant bone tumors. In: Ries LAG, Smith MA, Gurney
JG, et al, eds. Cancer Incidence and Survival Among Children and Adolescents: United States
SEER Program 1975-1995. Bethesda, Md: National Cancer Institute, SEER Program; 1999:88-
110. Available at: http://seer.cancer.gov/publications/childhood/bone.pdf
Seade LE, Bryan, WJ, Bartz RL, Josey R. Acromioclavicular joint injury. eMedicine Specialties,
Sports Medicine, Shoulder. 2006. Available at: http://www.emedicine.com/sports/TOPIC3.HTM
Critique: 52
Intense periosteal new bone formation extending into soft tissue is characteristic of osteogenic
sarcoma. (Courtesy of the Media Lab at Doernbecher)
Critique: 52
Anteroposterior radiograph of a normal shoulder (top): A line drawn on the underside of the
clavicle intersects the achromion. In acromioclavicular separation (bottom), this line does not
intersect the achromion, indicating that the distal end of the clavicle is no longer in contact with the
achromion. There is an incidental finding of separation of the VP shunt tubing in the neck (arrow).
(Courtesy of D. Mulvihill)
Critique: 52
Lateral radiograph of the elbow in supracondylar fracture of the humerus: the posterior fat pad
(darker area noted by arrow) is displaced from the supracondylar fossa by hemorrhage into the
joint. There is posterior displacement of the capitellum (the anterior humeral line passes along the
anterior edge of the capitellum rather than through its center). (Courtesy of D. Mulvihill)
Question: 53
A 7-month-old female has undergone the second stage of surgical palliation (Glenn operation)
for hypoplastic left heart syndrome. She was discharged from the hospital 1 week ago, and her
mother brings her to the office because of irritability that began this morning. On physical
examination, the infant is awake and irritable, with a heart rate of 150 beats/min and a respiratory
rate of 50 breaths/min. She has cyanosis of the face and mucosal surfaces and swelling of the
arms and head.
Of the following, the BEST explanation for this patients clinical presentation is
A. polycythemia
B. postpericardiotomy syndrome
C. protein-losing enteropathy
References:
Moore P. Obstructive lesions. In: Rudolph CD, Rudolph AM, eds. Rudolph's Pediatrics. 21st ed.
New York, NY: McGraw-Hill Medical Publishing Division; 2003:1800-1813
Silberbach M, Hannon D. Presentation of congenital heart disease in the neonate and young
infant. Pediatr Rev. 2007;28:123-131. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
Critique: 53
Superior vena cava syndrome is characterized by swelling of the head and neck and
engorgement of veins on the chest wall. (Courtesy of M. Rimsza)
Question: 54
A 6-year-old boy presents with a sudden-onset loss of awareness characterized by staring,
drooling, and chewing movements for more than 15 minutes, followed by confusion, then deep
sleep. On physical examination in the emergency department, the child is afebrile and appears
to be returning to normal. Vital signs and general examination findings are normal, and there are
no focal findings. Head computed tomography scan shows a large, contrast-enhancing cerebral
mass (Item Q54) without edema or midline shift.
A. arteriovenous malformation
C. ependymoma
D. glioblastoma multiforme
E. herpes encephalitis
Question: 54
(Courtesy of D. Gilbert)
References:
Huang J, Gailloud PH, Tamargo RJ. Vascular malformations. In: Singer HS, Kossoff EH,
Hartman AL, Crawford TO, eds. Treatment of Pediatric Neurologic Disorders. Boca Raton, Fla:
Taylor & Francis; 2005:409-414
Thai Q, Moriarty JL, Tamargo RJ. Central nervous system vascular malformations in pediatric
patients. In: Maria BL, ed. Current Management in Child Neurology. 3rd ed. Hamilton, Ontario,
Canada: BC Decker Inc; 2005:595-605
Critique: 54
Computed tomography scan with contrast demonstrates a tortuous vascular mass without
midline shift or edema. (Courtesy of D. Gilbert)
Critique: 54
Critique: 54
Axial computed tomography scan 2 weeks after the onset of symptoms of herpes simplex virus
encephalitis shows necrosis in the right temporal lobe. (Courtesy of D. Gilbert)
Question: 55
While examining a newborn, you note a persistent curve in the spine regardless of the babys
position. You order spine radiographs, which reveal multiple vertebral malformations and
segmentation defects (Item Q55).
Of the following, the MOST appropriate studies to guide further management are
Question: 55
Vertebral malformations (arrows), as described for the newborn in the vignette. (Courtesy of T.
Jewett)
References:
Arlet V, Odent T, Aebi M. Congenital scoliosis. Eur Spine J. 2003;12:456-463. Abstract available
at: http://www.ncbi.nlm.nih.gov/pubmed/14618384
Ferguson RL. Medical and congenital comorbidities associated with spinal deformities in the
immature spine. J Bone Joint Surg Am. 2007;89:34-41
Critique: 55
Congenital scoliosis: Left thoracic scoliosis is associated with multiple vertebral anomalies (red
arrows) and rib abnormalities (eg, rib fusion, yellow arrow). (Courtesy of T. Jewett)
Question: 56
A community group asks you to speak at a forum on teenage pregnancy. The number of
pregnancies among young adolescents at the local middle school has increased this year, and
several community members want more information about adolescent pregnancy and its long-
term effects.
Of the following, the MOST appropriate statement to include in your talk about pregnant and
parenting adolescents in the United States is that
B. adolescents who become pregnant have the same vocational opportunities as their
nonpregnant female peers
References:
Klein JD, and the AAP Committee on Adolescence. Adolescent pregnancy: current trends and
issues. Pediatrics. 2005;116:281-286. Available at:
http://pediatrics.aappublications.org/cgi/content/full/116/1/281
Question: 57
You are treating a 14-year-old boy in the pediatric intensive care unit who suffered a traumatic
brain injury in a motor vehicle crash earlier today and underwent surgery to drain a right-sided
epidural hematoma. He is currently receiving mechanical ventilation and is sedated. The nurse
calls you to the bedside because the intraventricular catheter is clotted and no intracranial
pressure waveform is seen on the monitor. On physical examination, you note that his right pupil
is dilated and unresponsive to light, which differs from findings on your examination immediately
after surgery.
A. administration of fentanyl
B. administration of mannitol
C. cerebral angiography
E. ophthalmology consultation
References:
Avner JR. Altered states of consciousness. Pediatr Rev. 2006:27:331-338. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/9/331
Frankel LR. Neurological emergencies and stabilization. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:405-410
Critique: 57
Uncal herniation may result in ipsilateral pupillary dilation, diminished level of consciousness, and
contralateral hemiparesis. (Courtesy of the Media Lab at Doernbecher)
Question: 58
The mother of a 10-year-old boy, whom you have been following since he was 3 years old,
complains that he is always hungry and is gaining weight. The mother, who is overweight,
reports that the boy refuses to exercise, and she cannot control his diet. She just read an article
in a magazine about weight gain from Cushing syndrome and wonders if he could have this
condition.
Of the following, the growth chart shown in Item 58 that suggests Cushing syndrome is
A. Growth chart A
B. Growth chart B
C. Growth chart C
D. Growth chart D
E. Growth chart E
Question: 58
(Courtesy of L. Levitsky)
References:
Batista DL, Riar J, Keil M, Stratakis CA. Diagnostic tests for children who are referred for the
investigation of Cushing syndrome. Pediatrics. 2007;120:e575-e586. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/3/e575
Greening JE, Storr HL, McKensie SA, et al. Linear growth and body mass index in pediatric
patients with Cushing's disease or simple obesity. J Endocrinol Invest. 2006;29:885-887.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17185896
Klish WJ. Clinical evaluation of the obese child and adolescent. UpToDate Online 15.3. 2008.
Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pedigast/11089
Magiakou MA, Mastorakas G, Oldfield EH, et al. Cushing's syndrome in children and
adolescents. Presentation, diagnosis, and therapy. N Engl J Med. 1994;331:629-636. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/8052272
Critique: 58
Attenuation of linear growth is observed in most patients who have Cushing syndrome.
(Courtesy of L. Levitsky)
Critique: 58
Violaceous striae may be seen in patients who have Cushing syndrome. (Courtesy of M.
Rimsza)
Question: 59
The parents of an 8-year-old boy are concerned because he recently has begun to struggle in
school. In the past, he always had been an attentive and motivated student. His current teacher
reports that at times when he is speaking in class, he stops speaking abruptly, stares with
glassy eyes, then resumes speaking. At home, his parents note that he "spaces out" when
eating dinner. His parents ask your input and the best approach to treat his issues.
B. educational evaluation
C. electroencephalography
References:
American Psychiatric Association. Diagnostic criteria for ADHD. In: Diagnostic and Statistical
Manual of Mental Disorders. 4th ed. Text revision. Arlington, Va: American Psychiatric
Association; 2000:85-94
American Psychiatric Association. Diagnostic criteria for learning disability. In: Diagnostic and
Statistical Manual of Mental Disorders. 4th ed. Text revision. Arlington, Va: American Psychiatric
Association; 2000:49-56
Posner E. Absence seizures in children. BMJ Clinical Evidence. 2007. Available for subscription
at: http://clinicalevidence.bmj.com/ceweb/conditions/chd/0317/0317_background.jsp
Pritchard D. Attention deficit hyperactivity disorder in children. BMJ Clinical Evidence. 2006.
Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0312/0312_background.jsp
Question: 60
You are seeing a young girl for a health supervision visit. Her older brother recently underwent a
bone marrow transplant, and you inquire about his health. The mother is tearful as she tells you
it has been difficult, explaining that he has had fever for about 10 days, his "counts are still
down," and they are planning to start amphotericin B just in case he has a fungal infection. She is
concerned because she was told about potential adverse effects of the medication and how they
need to watch the "electrolytes in his blood" very closely. She doesnt know what "electrolytes"
are, but asks what parameter in his blood might be affected.
Of the following, the MOST clinically important parameter to monitor during the initiation of
amphotericin B therapy is
A. bicarbonate
B. creatinine
C. glucose
D. potassium
E. sodium
References:
American Academy of Pediatrics. Antifungal drugs for systemic fungal infections. In: Pickering
LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on
Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:774-
776
Zaoutis TE, Benjamin DK, Steinbach WJ. Antifungal treatment in pediatric patients. Drug Resist
Update. 2005;8:235-245. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16054422
Question: 61
You are evaluating an 8-year-old boy who has acute lymphoblastic leukemia and is in septic
shock caused by Klebsiella pneumoniae. The antibiotic susceptibilities for the organism reveal
that it is resistant to ampicillin, cefazolin, ceftriaxone, and gentamicin.
A. cefuroxime
B. clindamycin
C. meropenem
D. penicillin G
E. piperacillin
References:
Balfour JA, Bryson HM, Brogden RN. Imipenem/cilastatin: an update of its antibacterial activity,
pharmacokinetics and therapeutic efficacy in the treatment of serious infections. Drugs.
1996;51:99-136. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/8741235
Nicolau DP. Carbapenems: a potent class of antibiotics. Expert Opin Pharmacother. 2008;9:23-
37. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/18076336
Norrby SR. Carbapenems. Med Clin North Am. 1995;79:745-759. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/7791421
Wiseman LR, Wagstaff AJ, Brogden RN, Bryson HM. Meropenem: a review of its antibacterial
activity, pharmacokinetic properties and clinical efficacy. Drugs. 1995;50:73-101. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/7588092
Zhanel GG, Wiebe R, Diley L, et al. Comparative review of the carbapenems. Drugs.
2007;67:1027-1052. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17488146
Question: 62
A 10-year-old boy has marked fluid intake, frequent urination, and decreased visual acuity. On
physical examination, the boy is short (<5th percentile), neurologic evaluation findings are
normal, and no edema is present. His electrolyte values are normal. Other laboratory results
include:
Blood urea nitrogen, 36.0 mg/dL (12.9 mmol/L)
Creatinine, 2.0 mg/dL (176.8 mcmol/L)
Hemoglobin, 6.5 g/dL (65.0 g/L)
Urine specific gravity, 1.005
Urine pH, 6
Urine protein, 1+
A. Alport syndrome
B. diabetic nephropathy
C. juvenile nephronophthisis
D. Lowe syndrome
E. nephropathic cystinosis
References:
Hildebrandt F. Nephronophthisis-medullary cystic kidney disease. In: Avner ED, Harmon WE,
Niaudet P, eds. Pediatric Nephrology. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins;
2004:665-673
Niaudet P. Inherited nephropathies. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:195-212.
Critique: 62
Critique: 62
Critique: 62
Critique: 62
Slitlamp examination of the cornea in a boy who has nephropathic cystinosis reveals fine crystals
packing the full thickness of the cornea. This produces the speckled appearance of the cornea.
(Courtesy of National Eye Institute, National Institute of Health)
Question: 63
A mother brings in her 11-month-old son after he broke out in "hives" today during breakfast.
The infant had stayed home from child care with a low-grade fever, and the mother had let him
eat eggs for the first time. Immediately after breakfast, the mother noted a diffuse erythematous,
pruritic rash covering the boys trunk and extremities. She is concerned that her son may have
an egg allergy.
Of the following, the BEST statement regarding immunoglobulin E-mediated egg food allergy is
that
B. egg is the most common food allergy in the first postnatal year
References:
Sampson HA, Leung DYM. Adverse reactions to foods. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:986-989
Critique: 63
Question: 64
A 12-year-old boy is brought to the emergency department by emergency medical services
after sustaining a lower leg injury sliding into home plate during a baseball game. He tells you that
he thinks his leg twisted when he slid. He reports that he had immediate pain in his right ankle
and has been unable to walk since the injury occurred. Prior to transport, the paramedics
splinted his right lower leg. On physical examination, he has significant swelling and ecchymosis
around his distal tibia and fibula. Following the administration of analgesia, radiographs are
obtained (Item Q64).
B. osteochondritis desiccans
C. osteomyelitis
Question: 64
References:
Dinolfo EA, Adam HM. In brief: fractures. Pediatr Rev. 2004;25:218-219. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/6/218
Gholve PA, Hosalkar HS, Wells L. Common fractures. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:2834-2841
Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: pediatric growth plate injuries. Am
J Emerg Med. 2002;20:50-54. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/11781914
Critique: 64
Salter-Harris classification system for fractures of the growth plate. See Item C64B for
description of fractures, treatment, and prognosis. M= metaphysis, E=epiphysis (Reprinted with
permission from Metzl JD, Sports Medicine in the Pediatric Office. Elk Grove Village, Ill: American
Academy of Pediatrics; 2008.
Critique: 64
Critique: 64
Oblique view of the ankle reveals a Salter-Harris type IV fracture of the tibia that passes through
the metaphysis, growth plate, and epiphysis (yellow arrows); there is also a frature of the distal
fibula (red arrow). This unique fracture occurs in adolescence before there is complete closure of
the growth plate. (Courtesy of D. Mulvihill)
Critique: 64
Critique: 64
Unicameral bone cyst: Anteroposterior radiograph of the knee shows a metaphyseal bony defect
in the tibia. There is minimal expansion of the bony contours and few septations. (Courtesy of D.
Mulvihill)
Question: 65
A 4-month-old male infant presents for his initial examination. The family recently immigrated to
the United States from southeast Asia. They describe progressive abdominal distention (Item
Q65A) in the infant over the past 2 months. Physical examination demonstrates a firm liver edge
2 cm below the right costal margin and a spleen tip palpable 3 cm below the costal margin.
Abdominal ultrasonography demonstrates a fluid-filled abdomen (Item Q65B).
Of the following complications from his underlying disorder, this child is MOST at risk for
A. acute intussusception
C. gastrointestinal bleeding
D. pneumococcal meningitis
E. renal failure
Question: 65
Abdominal distention, as described for the infant in the vignette. (Courtesy of M. Rimsza)
Question: 65
Abdominal ultrasonography of the abdomen demonstrates anechoic fluid surrounding the bladder.
(Courtesy of A. Bousvaros)
References:
Shepherd RW, Ramm GA. Liver function and dysfunction: fibrogenesis and cirrhosis. In: Walker
WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR. Pediatric
Gastrointestinal Disease. 4th ed. Hamilton, Ontario, Canada: BC Decker; 2004:80-88
Question: 66
A 2.1-kg, 34-week gestation infant is delivered to a mother who has chorioamnionitis and had a
positive group B streptococcal urinary tract infection at 30 weeks of gestation. Four hours after
birth, the infant requires admission to the intensive care nursery because of respiratory distress.
Physical examination reveals a temperature of 96.8F (36.0C), heart rate of 160 beats/min,
respiratory rate of 80 breaths/min, blood pressure of 60/30 mm Hg, mean arterial pressure of 40
mm Hg, and pulse oximetry of 82% on room air. The infant audibly grunts, has flaring of the ala
nasi and intercostal and subcostal chest wall retractions, and is poorly perfused, with a capillary
refill time of 4 seconds and mild acrocyanosis. There is no heart murmur.
Of the following, the MOST likely radiographic findings expected for this infant are
A. air bronchograms, diffusely hazy lung fields, and low lung volume
C. fluid density in the horizontal fissure, hazy lung fields with central vascular prominence, and
normal lung volume
D. gas-filled loops of bowel in the left hemithorax and opacification of the right lung field
E. patchy areas of diffuse atelectasis, focal areas of air-trapping, and increased lung volumes
References:
Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev.
2004;25:201-208. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/6/201
Herting E, Gefeller O, Land M, van Sonderen L, Harms K, Robertson B, and Members of the
Collaborative European Multicenter Study Group. Surfactant treatment of neonates with
respiratory failure and group B streptococcal infection. Pediatrics. 2000;106:957-964. Available
at: http://pediatrics.aappublications.org/cgi/content/full/106/5/957
Sivit CJ. Diagnostic imaging. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's
Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby Elsevier; 2006:713-732
Thilo EH, Rosenberg AA. The newborn infant. In: Hay WW Jr, Levin M, Sondheimer JM,
Deterding RR, eds. Current Pediatric Diagnosis & Treatment. 18th ed. New York, NY: The
McGraw-Hill Companies, Inc; 2007:chap 1
Critique: 66
The chest radiograph in neonatal pneumonia may show features identical to those of respiratory
distress syndrome, including underinflation, a "ground glass" appearance, and air bronchograms
(arrows). (Courtesy of B. Carter)
Critique: 66
Chest radiograph of an infant who has transposition of the great vessels reveals prominent
pulmonary vessels (arrows), suggesting pulmonary overcirculation. (Reprinted with permission
from Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev.
2004;25:201-208.)
Critique: 66
Chest radiograph of transient tachypnea of the newborn shows increased pulmonary interstitial
markings and fluid in the interlobar fissures (arrows). (Reprinted with permission from Aly H.
Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev. 2004;25:201-
208.)
Critique: 66
Plain radiograph of the chest and abdomen in a patient who has congenital diaphragmatic hernia
shows bowel in the left chest, with displacement of the heart to the right. (Courtesy of B. Carter)
Critique: 66
Question: 67
A 16-month-old boy is brought to your clinic because his mother says he is "walking funny"
today. She states that he has been walking for 4 months and is very active, but she is unaware
of any trauma or falls. She denies fever or other symptoms. He appears well and has normal
vital signs. Physical examination reveals mild tenderness to palpation over the medial aspect of
the lower leg just above the ankle. There is no overlying bruising, erythema, or edema, and you
can elicit full range of motion in the hips, knees, and ankles.
B. ankle sprain
C. fracture
D. osteomyelitis
E. transient synovitis
References:
Eiff MP, Hatch RL. Boning up on common pediatric fractures. Contemp Pediatr. 2003;20:30-59
Kellogg ND and the Committee on Child Abuse and Neglect. Evaluation of suspected child
physical abuse. Pediatrics. 2007;119:1232-1241. Available at:
http://pediatrics.aappublications.org/cgi/content/full/119/6/1232
Critique: 67
Oblique (left) and anteroposterior (right) views of the distal tibia reveal a nondisplaced spiral
(toddler's) fracture. (Courtesy of D. Mulvihill)
Critique: 67
A greenstick fracture is characterized by a fracture in one cortex (yellow arrow) and buckling of
the opposite side. This phenomenon occurs because of the elasticity of children's bones.
(Courtesy of D. Mulvihill)
Critique: 67
Metaphyseal corner (chip) fractures may be observed in children who are the victims of
nonaccidental trauma. (Courtesy of D. Krowchuk)
Critique: 67
Spiral fracture of the femur in a 6-week-old infant who had been physically abused. (Courtesy of
D. Krowchuk)
Critique: 67
Aneurysmal bone cyst: Lateral radiograph of the humerus shows a lytic, expansile lesion with thin
internal strands and a thin continuous rim of bone. (Courtesy of D. Mulvihill)
Question: 68
An 11-year-old girl presents 2 weeks after an office visit for a presumed viral illness
characterized by fever, malaise, and flushing of the cheeks. Today, her mother notes that she
no longer has a fever, but she complains of pain in her knees and elbows. On physical
examination, the left knee is slightly swollen and warm but not erythematous. The girl reports
pain on movement of both elbows, but there are no physical findings on examination of the
elbows or other joints. The remainder of the physical examination findings are normal, except for
an oral temperature of 100.6F (38.1C). Results of laboratory studies include a white blood cell
count of 8.9x103/mcL (8.9x109/L) with 40% polymorphonuclear leukocytes, 45% lymphocytes,
and 15% monocytes; hemoglobin of 11.0 g/dL (110.0 g/L); platelet count of 472.0x103/mcL
(472.0x109/L); and erythrocyte sedimentation rate of 20 mm/hr.
Of the following, the MOST likely pathogen to cause this childs joint complaints is
A. Borrelia burgdorferi
B. Coxsackievirus
D. influenza A virus
E. parvovirus B19
References:
American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, Eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:610-620
American Academy of Pediatrics. Influenza. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
Eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:401-411
2006:484-487
Koch WC. Parvovirus B19. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson's Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1357-1359
Lehman HW, Knll, A, Kster RM, Modrow S. Frequent infection with a viral pathogen,
parvovirus B19, in rheumatic diseases of childhood. Arthritis Rheum. 2003;48:1631-1638.
Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/104536478/HTMLSTART
Siegel DM. In brief: antinuclear antibody (ANA) testing. Pediatr Rev. 2003;24:320-321. Available
at: http://pedsinreview.aappublications.org/cgi/content/full/24/9/320
Tse SML, Laxer RM. Approach to acute limb pain in childhood. Pediatr Rev. 2006;27:170-180.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/5/170
Critique: 68
Question: 69
You are prescribing atenolol for a 15-year-old boy in whom you diagnosed hypertrophic
cardiomyopathy. There is a family history of asthma. He is concerned about the potential
adverse effects of medicines.
Of the following, a TRUE statement about treatment with this drug is that
References:
Feld LG, Corey H. Hypertension in childhood. Pediatr Rev. 2007;28:283-298. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/8/283
Opie LH, Sonnenblick EH, Frishman WH, Thadani U. Beta-blocking agents. In: Opie LH, ed.
Drugs for the Heart. 4th ed. Philadelphia, Pa: W.B. Saunders Co; 1995:1-30
Critique: 69
Question: 70
A 14-year-old girl is brought to the emergency department because she has back pain and a
sudden inability to walk. Neurologic examination shows normal upper limb strength. However,
her legs are flaccid, relatively symmetrically weak, areflexic, and numb to pinprick. Vibratory and
position sense in the legs persists. A sensory deficit exists below the sixth thoracic dermatome.
Rectal examination shows low rectal tone. The remainder of her physical examination findings,
including vital signs, are normal.
B. lumbar puncture
References:
Hakimi KN, Massagli TL. Anterior spinal artery syndrome in two children with genetic thrombotic
disorders. J Spinal Cord Med. 2005;28:69-73. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15832907
Haslam RHA. Spinal cord disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2526-
2530
Menkes JH, Ellenbogen RC. Traumatic brain and spinal cord injuries in children. In: Maria BL,
ed. Current Management in Child Neurology. 3rd ed. Hamilton, Ontario, Canada: BC Decker Inc;
2005:515-527
Nance JR, Golomb MR. Ischemic spinal cord infarction in children without vertebral fracture.
Pediatr Neurol. 2007;36:209-216. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17437902
Question: 71
An infant in the newborn nursery is normally grown and normally formed, except for a
preauricular pit (preauricular sinus) bilaterally (Item Q71). He has passed his newborn hearing
screening. When you meet the babys mother, you learn that she has progressive, bilateral
sensorineural hearing loss for which she uses hearing aids.
Of the following, the MOST helpful test to aid in diagnosis and management of this babys
condition is
A. chromosome analysis
B. head ultrasonography
C. ophthalmology consultation
E. renal ultrasonography
Question: 71
(Courtesy of P. Sagerman)
References:
Adam M, Hudgins L. The importance of minor anomalies in the evaluation of the newborn.
NeoReviews. 2003;4:e99-e104. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/4/4/e99
Arora RS, Pryce R. Is ultrasonography required to rule out renal malformations in babies with
isolated preauricular tags? Arch Dis Child. 2004;89:492-493
Huang XY, Tay GS, Wansaicheong GK-L, Low WK. Preauricular sinus: clinical course and
associations. Arch Otolaryngol Head Neck Surg. 2007;133:65-68. Available at:
http://archotol.ama-assn.org/cgi/content/full/133/1/65
Wang RY, Earl DL, Ruder RO, Graham JM Jr. Syndromic ear anomalies and renal ultrasounds.
Pediatrics. 2001;108:e32. Available at:
http://pediatrics.aappublications.org/cgi/content/full/108/2/e32
Critique: 71
Question: 72
A 16-year-old girl comes to your office with complaints of a thick white vaginal discharge. She is
sexually active with one partner with whom she always uses condoms. She has no complaints
of fever or abdominal pain, but she reports external "burning" of the vaginal area when she
urinates. On physical examination, she is afebrile. Pelvic examination reveals fiery red labia
majora and minora and an adherent white discharge on the vaginal walls, with a moderate
amount of white discharge in the vaginal vault. The speculum examination is uncomfortable for
her, but there is no cervical motion, uterine, or adnexal tenderness, and the cervix shows no
friability or discharge.
Of the following, the MOST likely pathogen responsible for this patients symptoms is
A. Candida albicans
B. Chlamydia trachomatis
C. group A Streptococcus
D. Neisseria gonorrhoeae
E. Trichomonas vaginalis
References:
American Academy of Pediatrics. Chlamydia trachomatis. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report on the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:252-257
American Academy of Pediatrics. Gonococcal infections. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report on the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:301-309
American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report on the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:610-620
Emans SJ. Office evaluation of the child and adolescent. In: Emans SJH, Laufer MR, Goldstein
DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, Pa: Lippincott, Williams &
Wilkins; 2005:1-50
Workowski KA, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Critique: 72
Critique: 72
Question: 73
An 18-month-old boy fell into a swimming pool 12 hours ago. He had no heart rate when he was
pulled from the pool, and cardiopulmonary resuscitation (CPR) was initiated at the scene. The
CPR was continued for 30 minutes until spontaneous circulation was restored in the emergency
department. He is now in the pediatric intensive care unit, receiving mechanical ventilation with
maximal intensive care support. Over the past several hours, his blood pressure has increased,
he has developed persistent bradycardia, and he exhibits no movement in response to
stimulation. He has not received any neuromuscular blockers or sedation. In addition, his pupils
are dilated bilaterally and do not respond to light. Bedside electroencephalography demonstrates
generalized burst suppression with loss of reactivity to external stimuli.
In discussion with his parents, you inform them that these recent changes are MOST likely a
result of
A. agitation
C. myocardial failure
References:
Doherty DR, Hutchison JS. Hypoxic ischemic encephalopathy after cardiorespiratory arrest. In:
Wheeler DS, Wong HR, Shanley T, eds. Pediatric Critical Care Medicine: Basic Science and
Clinical Evidence. New York, NY: Springer-Verlag; 2007:935-946
Kallas HJ. Drowning and submersion injury. In: Kliegman RM, Behrman RE, Jenson HB, Stanton
BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:438-
449
Meyer RJ, Theodorou AA, Berg RA. Childhood drowning. Pediatr Rev. 2006;27:163-169.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/5/163
Question: 74
On the initial health supervision visit of a 7-year-old boy who is new to your practice, you note
that his height is 43 inches, which is at the 50th percentile for a 5-year-old, and that his weight is
appropriate for his age. His parents say that he has been wearing the same size clothes for at
least the past year. The boy also has dry skin. You suspect he has hypothyroidism and decide
to measure thyroid-stimulating hormone concentrations.
Of the following, the MOST appropriate additional study needed to evaluate this child for
hypothyroidism is
D. measurement of tri-iodothyronine
E. thyroid ultrasonography
References:
Hunter I, Greene SA, MacDonald TM, Morris AD. Prevalence and aetiology of hypothyroidism in
the young. Arch Dis Child. 2000;83:207-210. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10952634
Ferry RJ Jr, Bauer AJ. Hypothyroidism. eMedicine Specialties, Pediatrics, Endocrinology. 2006.
Available at: http://www.emedicine.com/ped/TOPIC1141.HTM
Question: 75
An 8-year-old boy has difficulty in academics and a short attention span. His father states that
he had the same problems when he was a child. Physical examination reveals macrocephaly,
multiple caf au lait macules (Item Q75A) and axillary freckles (Item Q75B). Upon questioning,
the father explains that he has similar skin findings.
A. fragile X syndrome
B. hypomelanosis of Ito
C. neurofibromatosis type 1
D. tuberous sclerosis
E. velocardiofacial syndrome
Question: 75
Caf au lait macules, as described for the child in the vignette. (Courtesy of P. Fisher)
Question: 75
Axillary freckling and a caf au lait macule, as described for the child in the vignette. (Courtesy
of D. Krowchuk)
References:
Haslam RHA. Neurocutaneous syndromes. In: Kliegman RM, Behrman RE, Jenson HB, Stanton
BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2483-
2488
Kates WR, Antshel KM, Femont W, Roizen, NJ, Shprintzen RJ. Velocardiofacial syndrome. In:
Accardo PJ, ed. Capute & Accardo's Neurodevelopmental Disabilities in Infancy and Childhood.
Volume II: The Spectrum of Neurodevelomental Disabilities. 3rd ed. Baltimore, Md: Paul H.
Brookes Publishing Co; 2008:363-373
Lyon GR, Shaywitz SE, Shaywitz BA. Dyslexia. In: Kliegman RM, Behrman RE, Jenson HB,
Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:150-151
Morelli JG. Hyperpigmented lesions. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2682-
2685
Nowicki ST, Hansen RL, Hagerman RJ. X-linked intellectual disabilities In: Accardo PJ, ed.
Capute & Accardo's Neurodevelopmental Disabilities in Infancy and Childhood. Volume II: The
Spectrum of Neurodevelomental Disabilities. 3rd ed. Baltimore, Md: Paul H Brookes Publishing
Co; 2008:331-351
Critique: 75
Hypomelanosis of Ito is characterized by swirled, hypopigmented patches that follow the lines of
Blaschko, the paths of embryonic neural crest cell migration. (Courtesy of D. Krowchuk)
Critique: 75
Question: 76
A 6-year-old girl presents with a history of swelling on her jaw of 1 months duration. The mother
has been to a "couple of emergency rooms," but nobody can tell her what is wrong with the girl.
The childs father died about 3 years ago from pneumonia, and the mother reports that she has
"no energy," but she has not sought medical care. The mother states that her daughter has
been fairly healthy except for frequent ear infections. On physical examination, the girl is afebrile;
her weight is 16 kg (3rd percentile); her height is 105 cm (3rd percentile); and she has scarred
tympanic membranes, bilateral parotid swelling, mild clubbing, and some fine crackles on lung
examination.
A. bacterial parotitis
D. lymphoma
E. mumps
References:
American Academy of Pediatrics. Mumps. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:464-468
Burchett SK, Pizzo PA. HIV infection in infants, children, and adolescents. Pediatr Rev.
2003;24:186-194. Available at: http://pedsinreview.aappublications.org/cgi/content/full/24/6/186
Critique: 76
Purulent material emanating from Stensen's duct in an infant who has staphylococcal parotitis.
(Courtesy of the Red Book Online.)
Critique: 76
Mumps may present with unilateral (as shown here) or bilateral parotid swelling. (Courtesy of M.
Rimsza)
Question: 77
You are evaluating a 2-year-girl who recently was adopted from Russia for a 4-day history of
temperature to 102.5F (39.2C), rash, coryza, malaise, conjunctivitis, and cough that have
worsened over the last 24 hours. She had nasal congestion and rhinorrhea for 5 days prior to
developing the fever, rash, and cough. The girl has been in the United States for 7 days. She
was adopted from a rural orphanage, where she was exposed to farm animals, but information
regarding her past medical history and immunizations is unavailable. Physical examination
shows a tired-appearing, irritable toddler who is clinging to her adopted mother. She has a
temperature of 103.0F (39.5C), bilateral conjunctival injection, profuse clear rhinorrhea, an
erythematous buccal mucosa with scattered whitish specks (Item Q77A) on the left side, and an
erythematous posterior pharynx with no tonsillar exudates. There is a confluent erythematous
maculopapular rash on her face, trunk, and abdomen (Item Q77B), with scattered patches on
her legs.
Of the following, the test MOST likely to confirm the diagnosis for this child is
A. blood culture
C. serology
D. throat culture
E. urine culture
Question: 77
White papules on the buccal mucosa (arrow), as described for the girl in the vignette. (Courtesy
of W.W. Tunnessen, Jr)
Question: 77
(Courtesy of the Centers for Disease Control and Prevention, Public Health Image Library, Dr.
Heinz F. Eichenwald)
References:
American Academy of Pediatrics. Measles. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:441-452
Centers for Disease Control and Prevention. Measles, mumps, and rubella - vaccine use and
strategies for elimination of measles, rubella, and congenital rubella syndrome and control of
mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep. 1998;47(RR-8):1-57. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
Maldonado YA. Rubeola virus (measles and subacute sclerosing panencephalitis). In: Long SS,
Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed.
Philadelphia, Pa: Churchill Livingstone; 2003:1148-1155
Question: 78
You employ voiding cystourethrography (VCUG) to evaluate a 4-year-old girl who had a febrile
urinary tract infection 1 month ago. The study reveals a smooth-walled bladder, absence of
vesicoureteral reflux, and a mildly narrowed urethra.
B. no treatment
References:
Brock WA, Kaplan GW. Abnormalities of the lower urinary tract. In: Edelmann CM Jr, Bernstein
J, Meadow SR, Spitzer A, Travis LB, eds. Pediatric Kidney Disease. 2nd ed. Boston, Ma: Little,
Brown, and Company; 1992:2037-2076
McKenna PH, Herndon CD, Connery S, Ferrer FA. Pelvic floor muscle retraining for pediatric
voiding dysfunction using interactive computer games. J Urol. 1999;162:1056-1063. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/10458431
Metwalli AR, Cheng EY, Kropp BP, Pope JC 4th. The practice of urethral dilation for voiding
dysfunction among fellows of the Section on Urology of the American Academy of Pediatrics. J
Urol. 2002;168:1764-1767. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/12352355
Question: 79
An 18-year-old girl is admitted to the hospital for intravenous therapy for a complicated urinary
tract infection that failed to respond to outpatient therapy with a sulfa-based antibiotic. Her urine
culture shows more than 100,000 colony-forming units/mL of Pseudomonas aeruginosa that is
sensitive to aztreonam and imipenem. As you take her medical history, she mentions she is
"highly allergic" to penicillin.
A. a nonpruritic maculopapular rash that occurs in patients who receive amoxicillin during
mononucleosis is a contraindication for future penicillin therapy
C. desensitization can be used to administer penicillin safely to patients who have experienced
Stevens-Johnson reactions to penicillin
D. skin testing to major and minor determinants of penicillin can exclude IgE-mediated and non-
IgE-mediated reactions
E. a patient who can only recall a childhood history of penicillin allergy but does not remember the
details is very likely to react to future penicillin courses
References:
Boguniewicz M, Leung DYM. Adverse reactions to drugs. In: Kleigman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:990-994
Wolf R, Orion E, Marcos B, Matz H. Life-threatening acute adverse cutaneous drug reactions.
Clin Dermatol. 2005;23:171-181. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15802211
Critique: 79
Critique: 79
Morbilliform eruption that occurred in an adolescent who had infectious mononucleosis and
received amoxicillin. (Courtesy of D. Krowchuk)
Question: 80
A 5-year-old boy is brought to the emergency department because of a nose bleed that has
lasted 1} hours. His mother reports that he has had nose bleeds in the past that usually
stopped when she pinched his nose, but this time he continued to bleed. She says that he does
pick his nose and that he has had cold symptoms for the past 3 days. There is no family history
of bleeding disorders, and he had no excessive bleeding after circumcision. On physical
examination, the awake, alert, and anxious patient is holding a bloody washcloth to his nose. His
heart rate is 140 beats/min, respiratory rate is 24 breaths/min, blood pressure is 100/60 mm Hg,
and oxygen saturation is 98%. There is active bleeding from his right naris, but an active anterior
bleeding site is not visible. Bleeding is controlled with phenylephrine instillation and packing.
A. chest radiograph
D. nasopharyngoscopy
E. no further evaluation
References:
Haddad J Jr. Acquired disorders of the nose. In: Kleigman RM, Behrman RE, Jenson HB,
Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:1744-1745
McGarry G. Nosebleeds in children. BMJ Clinical Evidence. 2006. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0311/0311.jsp
Messner AH. Epidemiology and etiology of epistaxis in children. UpToDate Online 15.3. 2008.
Available for subscription at: http://www.utdol.com/utd/content/topic.do?topicKey=ped_lryn/5986
Messner AH. Evaluation of epistaxis in children. UpToDate Online 15.3. 2008. Available for
subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=ped_lryn/6248&selectedTitle=4~150&sourc
e=search_result
Sandoval C, Dong S, Visintainer P, Ozkaynak MF, Jayabose S. Clinical and laboratory features
of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol. 2002;24:47-49. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/11902740
Question: 81
A 4-month-old infant who has gastroschisis underwent surgical repair on the first day after birth,
but continues to require support with parenteral nutrition and lipids. He now has developed poor
feeding, irritability, and progressive diarrhea. Radiography demonstrates metaphyseal fraying,
but calcium, phosphorus, and 25-hydroxyvitamin D concentrations are normal. When you
review his prior laboratory studies, you note he has had neutropenia for the past 4 weeks.
A. copper deficiency
B. magnesium deficiency
C. vitamin A deficiency
D. vitamin B6 deficiency
E. zinc deficiency
References:
Collier S, Gura KM, Richardson D, Duggan C. Parenteral nutrition. In: Hendricks KM, Duggan C.
Manual of Pediatric Nutrition. 4th ed. Hamilton Ontario, Canada: BC Decker; 2005:317-375
Giles E, Doyle LW. Copper in extremely low-birthweight or very preterm infants. NeoReviews.
2007;8:e159-e164. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/8/4/e159
Question: 82
You are counseling a 23-year-old woman who has diabetes mellitus and has been your patient
for the past 18 years. She recently found out that she is pregnant and asks you about potential
complications for her unborn child.
Of the following, the MOST likely complications to expect for this womans child are
References:
Cowett RM. The infant of the diabetic mother. NeoReviews. 2002;3:e173-e189. Available for
subscription at: http://neoreviews.aappublications.org/cgi/content/full/3/9/e173
Sivit CJ. Diagnostic imaging. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's
Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby Elsevier; 2006:713-732
Critique: 82
Question: 83
A 17-year-old girl complains of an itchy rash all over her back and trunk for 2 weeks. Topical
hydrocortisone has not relieved the rash or itching. She denies fever or other symptoms, and
her vital signs are normal. Examination of the skin reveals multiple 5- to 8-mm salmon-colored
thin scaling plaques over her trunk (Item Q83). There is one similar lesion on her abdomen that
measures 2x3 cm. There are no other lesions, and the remaining findings of her physical
examination are normal.
Question: 83
(Courtesy of D. Krowchuk)
References:
Chuh AAT, Dofitas BL, Comisel GG, et al. Interventions for pityriasis rosea. Cochrane Database
Syst Rev. 2007;2:CD005068. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005068/frame.html
Morelli JG. Diseases of the epidermis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2702-
2707
Wolfrey JD, Billica WH, Gulbranson SH, et al. Pediatric exanthems. Clin Fam Pract. 2003;5:557-
588
Critique: 83
The herald patch of pityriasis rosea is a round or oval erythematous scaling patch that may be
mistaken for tinea corporis. (Courtesy of D. Krowchuk)
Critique: 83
In pityriasis rosea, the long axes of lesions are aligned parallel to lines of skin stress. As a result,
the distribution of lesions may have the appearance of the branches of a fir tree. (Courtesy of D.
Krowchuk)
Critique: 83
The eruption of secondary syphilis often involves the palms and soles. (Courtesy of C.
Haverstock)
Question: 84
A 4-year-old boy who has had mild eczema in the past that was treated successfully with
emollients presents with the worst exacerbation he ever has had. He has multiple lichenified
lesions, especially in the antecubital fossae (Item Q84) and popliteal fossa, which is usual for
him, but he also has nummular lesions on the trunk. His mother reports no changes in
detergents or personal hygiene products. The boy has been going to a summer day camp at the
local community center for the first time.
Of the following, the factor MOST likely involved in his eczema exacerbation is
Question: 84
Lichenified and crusted plaques, as described for the boy in the vignette. (Courtesy of D.
Krowchuk)
References:
Ashcroft DM, Chen L-C, Garside R, Stein K, Williams HC. Topical pimecrolimus for eczema.
Cochrane Database Syst Rev. 2007;4:CD005500. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005500/frame.html
Bath-Hextall F, Williams H. Eczema (atopic). BMJ Clinical Evidence. 2006. Available for
subscription at: http://clinicalevidence.bmj.com/ceweb/conditions/skd/1716/1716_I15.jsp
Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with
skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006;155:145-
151. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16792766
Byremo G, Rd G, Carlsen KH. Effect of climatic change in children with atopic eczema. Allergy.
2006;61:1403-1410. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17073869
Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational
interventions for atopic eczema in children. Cochrane Database Syst Rev. 2007;3:CD004054.
Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004054/frame.html
Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or
both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev.
2006;3:CD000133. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000133/frame.html
Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food
intolerance in infants. Cochrane Database Syst Rev. 2003;4:CD003664. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003664/frame.html
Osborn DA, Sinn JK. Probiotics in infants for prevention of allergic disease and food
hypersensitivity. Cochrane Database Syst Rev. 2007;4:CD006475. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006475/frame.html
Osborn DA, Sinn J. Soy formula for prevention of allergy and food intolerance in infants.
Cochrane Database Syst Rev. 2006;4:CD003741. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003741/frame.html
Question: 85
You are called by the mother of 3-year-old girl because the child appears confused and is pale
and sweating. The mother thinks the child may have taken some of her grandmothers
imipramine. You advise her to contact emergency medical services for immediate transport to
the emergency department, where you plan to meet them.
Of the following, the MOST appropriate action to take in the emergency department is
References:
Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in
predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic
antidepressants. N Engl J Med. 1985;313:474-479. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/4022081
Hatcher-Kay C, King CA. Depression and suicide. Pediatr Rev. 2003;24:363-371. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/24/11/363
Liebelt EL, Francis PD, Woolf AD. ECG lead aVR versus QRS interval in predicting seizures and
arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med. 1995;26:195-201.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/7618783
Prez-Fontn J, Lister G. The acutely ill infant and child. In: Rudolph CD, Rudolph AM, eds.
Rudolph's Pediatrics. 21st ed. New York, NY: McGraw-Hill Medical Publishing Division; 2003:364-
365
Question: 86
A 4-year-old boy who has neuroblastoma presents with back pain and an inability to urinate. He
is alert, with normal general examination findings and normal mental status. Strength and tone in
the arms are normal, but tone is low in the legs, and patellar reflexes are diminished.
A. lumbar puncture
E. voiding cystourethrography
References:
Haslam RHA. Spinal cord disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2526-
2530
Kim S, Chung DH. Pediatric solid malignancies: neuroblastoma and Wilms' tumor. Surg Clin
North Am. 2006;86:469-487
Critique: 86
T1-weighted sagittal magnetic resonance imaging of the spine demonstrating spinal cord
compression by an extramedullary mass (arrow). (Courtesy of P. Fisher)
Question: 87
The mother of a boy in your practice is contemplating another pregnancy and asks for your
advice. The woman is tall and thin and works as a model part-time. She had previously reported
to you a history of bulimia. She is extremely concerned about any "extra" weight she may gain
during the pregnancy, and she confides that she sometimes smokes cigarettes to avoid eating.
Additionally, she occasionally has taken her sons methylphenidate to suppress her appetite.
When asked about alcohol use, she describes herself as a "social drinker."
Of the following, the MOST accurate statement to make in counseling this woman is that
B. cigarette smoking increases the risk of sudden infant death syndrome in the exposed infant
C. one or two alcoholic beverages per day will do no harm to the embryo/fetus
E. vitamin supplements reduce the risk of defects associated with prenatal alcohol exposure
References:
Cogswell ME, Weisberg P, Spong C. Cigarette smoking, alcohol use and adverse pregnancy
outcomes: implications for micronutrient supplementation. J Nutr. 2003;133:1722S-1731S.
Available at: http://jn.nutrition.org/cgi/content/full/133/5/1722S
Kunz LH, King JC. Impact of maternal nutrition and metabolism on health of the offspring. Semin
Fetal Neonatal Med. 2007;12;71-77. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17200031
Micali N, Simonoff E, Treasure J. Risk of major adverse outcomes in women with eating
disorders. Br J Psychiatry. 2007;190:255-259. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17329747
Question: 88
An 18-year-old young man comes to your office with complaints of burning pain with urination
over the past 24 hours. He has seen a small amount of yellowish discharge from his penis
during this time. He also complains of some lower back pain over the past 48 hours. He denies
fever or rashes, but his eyes are a little irritated. He is sexually active and uses condoms "most
of the time." On physical examination, he is afebrile, his palpebral and bulbar conjunctivae are
mildly injected (Item Q88), and his back is tender at the lower lumbar area, but there is no
costovertebral angle tenderness. Genital examination reveals no scrotal tenderness and scant
yellow discharge at the urethral orifice.
A. Chlamydia trachomatis
B. Gardnerella vaginalis
C. Neisseria gonorrhoeae
D. Treponema pallidum
E. Trichomonas vaginalis
Question: 88
(Courtesy of P. Sagerman)
References:
Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases
treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of
gonococcal infections. MMWR Morbid Mortal Wkly Rep. 2007;56:332-336. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Fortenberry JD, Neinstein LS. Syphilis. In: Neinstein LS, ed. Adolescent Health Care: A Practical
Guide. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008:825-833
Workowski KA, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Yu DT. Reactive arthritis (formerly Reiter syndrome): definition, diagnosis, and management.
UpToDate Online 15.3. 2008. Available for subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=spondylo/7349
Question: 89
You are evaluating an 18-month-old girl for vomiting. She has a history of febrile seizures and
recurrent ear infections. She is receiving no medications. Over the past several weeks, her
parents have noticed that she has been "increasingly clumsy." She has vomited each of the last
three mornings but has had no diarrhea or fever. Physical examination findings are normal
except for an ataxic gait and hyperreflexia.
A. administration of an antiemetic
C. electroencephalography
D. lumbar puncture
References:
Frankel LR. Neurological emergencies and stabilization. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:405-412
Larsen GY, Goldstein B. Consultation with the specialist: increased intracranial pressure. Pediatr
Rev. 1999;20:234-239. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/20/7/234
Question: 90
A 16-year-old girl comes to your office complaining that her menstrual periods have been
irregular and scanty. Her last period was 3 months ago and lasted for only 2 days. Among the
findings on physical examination are fine, moist skin; firm, palpable thyroid gland (Item Q90); and
finger tremor. Results of laboratory studies include a thyroid-stimulating hormone value of less
than 0.05 mIU/L (normal, 0.5 to 5.0 mIU/L) and free thyroxine value of 1.9 ng/dL (24.5 pmol/L)
(normal, 0.6 to 1.3 ng/dL [7.7 to 16.8 pmol/L]).
Of the following, the additional physical examination finding that BEST supports the diagnosis of
hyperthyroidism is
A. abdominal obesity
C. hepatomegaly
D. hirsutism
E. muscle weakness
Question: 90
(Courtesy of M. Rimsza)
References:
Fenton CL, Gold JG. Hyperthyroidism. eMedicine Specialties, Pediatrics, Endocrinology. 2006.
Available at: http://www.emedicine.com/ped/topic1099.htm
Ferry RJ Jr, Levitsky LL. Graves disease. eMedicine Specialties, Pediatrics, Endocrinology.
2006. Available at: http://www.emedicine.com/ped/topic899.htm
Critique: 90
Critique: 90
Question: 91
An infant in the newborn nursery does not appear to respond to visual or auditory input. On
physical examination, he shows evidence of intrauterine growth restriction (IUGR), absent red
reflexes, and numerous bluish papules (Item Q91). The mother, who immigrated to the United
States during her third trimester, did not receive prenatal care. She denies use of alcohol, drugs,
or tobacco products during pregnancy. She reports that she had a low-grade fever and rash
during the second month of the pregnancy.
Of the following, the MOST likely infectious cause of the findings in this infant is
A. cytomegalovirus
C. rubella virus
D. Toxoplasma gondii
E. varicella-zoster virus
Question: 91
References:
Adler SP, Marshall B. Cytomegalovirus infections. Pediatr Rev. 2007;28:92-100. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/3/92
Mason W. Rubella. In: Kliegman RM, Behrman RE, Jenson HB, Stanton, BF, eds. Nelson
Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1337-1341
McLeod R, Remington JS. Toxoplasmosis (Toxoplasma gondii). In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:1486-1495
Myers MG, Seward J, La Russa P. Varicella-zoster virus. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:1366-1372
Stagno S. Cytomegalovirus. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1377-1379
Critique: 91
Critique: 91
Purpuric macules and papules may be present in congenital rubella, creating a "blueberry muffin"
appearance. (Courtesy of M. Rimsza)
Question: 92
A 6-month-old boy presents to the emergency department with a 2-day history of fever and a 1-
day history of left cheek swelling. You discover that his parents do not believe in providing their
children with immunizations. Despite this, the boy has never been ill. He has two older siblings,
and nobody is sick at home. The mother denies any recent bug bites or trauma to the area on
his cheek. Physical examination reveals a mildly toxic-appearing child who has a temperature of
103.0F (39.4C), heart rate of 145 beats/min, respiratory rate of 26 breaths/min, and blood
pressure of 80/45 mm Hg. His anterior fontanelle is slightly bulging, his tympanic membranes are
erythematous, his left cheek is indurated and appears erythematous to slightly violaceous (Item
Q92), and he is irritable.
Of the following, the MOST likely organism to cause this childs illness is
B. Neisseria meningitidis
C. Staphylococcus aureus
D. Streptococcus pneumoniae
E. Streptococcus pyogenes
Question: 92
(Courtesy of D. Krowchuk)
References:
American Academy of Pediatrics. Haemophilus influenzae infections. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:310-318
Critique: 92
In buccal cellulitis caused by Haemophilus influenzae type b infection, the affected area is
indurated and has an erythematous-to-violaceous color. (Courtesy of D. Krowchuk)
Critique: 92
Epiglottitis: Swelling and erythema of the epiglottis caused by Haemophilus influenzae type b
infection. (Courtesy of K. Woodin)
Question: 93
You are seeing a 5-year-old boy who has developed diplopia, dysphagia, dry mouth, diarrhea,
weakness in his arms, and shortness of breath over the past 18 hours. According to his
records, he received his diphtheria, tetanus, acellular pertussis (DTaP), poliovirus inactivated
(IPV), measle-mumps-rubella (MMR), and varicella booster immunizations about 1 month ago.
He attended a class picnic 3 weeks ago that was held in a state park. He has no history of
unusual exposures or ill contacts, and except for falling off his bike 5 days ago and scraping his
arm, he has had no other trauma. Physical examination reveals an awake and alert boy who
complains of "seeing double" and of pain with swallowing. His pupils are 3 mm bilaterally and
sluggish, and his mucous membranes are dry. He takes shallow breaths, but his lungs are
clear, and his abdomen is mildly distended. His left arm has a 4x4-cm abrasion that is mildly
swollen, erythematous, and tender, with some serosanguineous drainage. His left arm has 2/5
strength and decreased tone. He has 1+ reflexes in the upper and lower extremities.
A. botulism
C. Guillain-Barr syndrome
D. tetanus
E. tick paralysis
References:
American Academy of Pediatrics. Botulism and infant botulism (Clostridium botulinum). In:
Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee
on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics;
2006:257-260
American Academy of Pediatrics. Tetanus (lockjaw). In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:648-653
Bleck TP. Clostridium botulinum (botulism). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell,
Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa:
Elsevier Churchill Livingstone; 2005:2822-2828
Mathieu ME, Wilson BB. Ticks (including tick paralysis). In: Mandell GL, Bennett JE, Dolin R,
eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed.
Philadelphia, Pa: Churchill Livingstone; 2005:3312-3315
Parke JT. Peripheral neuropathies. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD Jr,
eds. Oski's Pediatrics Principles and Practice. 4th ed. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2006:2310-2316
Schlagger B, Kornberg AJ, Prensky AL. Cerebrovascular disease in childhood. In: McMillan JA,
Feigin RD, DeAngelis CD, Jones MD Jr, eds. Oski's Pediatrics Principles and Practice. 4th ed.
Philadelphia, Pa: Lippincott Williams & Wilkins; 2006:2270-2279
Question: 94
An 8-month-old girl who has a history of cardiomyopathy following viral myocarditis presents
with poor weight gain. She is receiving a 20-kcal/oz milk-based formula and has no history of
vomiting or diarrhea. Her only medication is furosemide. Physical examination findings include a
heart rate of 130 beats/min, respiratory rate of 60 breaths/min, and blood pressure of 88/44 mm
Hg.
Of the following, the MOST appropriate initial strategy to increase weight gain for this girl is to
References:
Kelleher DK, Laussen P, Teixeira-Pinto A, Duggan C. Growth and correlates of nutritional status
among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure.
Nutrition. 2006; 22:237-244. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16500550
Question: 95
An 18-month-old girl has been having an intermittent nonproductive cough for the past 6 months.
Her parents state that the cough awakens the toddler at night a few times a month and occurs
when playing vigorously. During a recent upper respiratory tract illness, her cough worsened
and occurred daily for 3 weeks. On physical examination, there is no nasal discharge, and the
toddler appears healthy.
A. asthma
B. atypical pneumonia
C. gastroesophageal reflux
D. sinusitis
References:
Liu AH, Covar RA, Spahn JD, Leung DYM. Childhood asthma. In: Kleigman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:953-969
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not
asthma. Pediatrics. 2007;120:855-864. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/4/855
Critique: 95
Question: 96
A 10-year-old boy comes to the office 2 days after falling off of his bicycle and injuring his
forehead. He denies vomiting or headache but complains of a runny nose. Physical examination
reveals a well-appearing boy who has a large ecchymotic swelling over the central portion of his
forehead with an overlying abrasion. The area is diffusely tender to palpation, and there is a
depression over the right lateral aspect of the swelling. Erythema around the abrasion is minimal,
and no purulent drainage is present. Clear fluid is draining from his right naris. The remainder of
his physical examination findings are normal. You order a computed tomography scan (Item
Q96).
Of the following, the MOST appropriate treatment of this boys injury should include
A. decongestants
B. nasal packing
C. no specific treatment
D. prophylactic antibiotics
E. surgical repair
Question: 96
(Courtesy of D. Mulvihill)
References:
Kellman RM. Maxillofacial trauma. In: Cummings CW, Flint PW, Haughey BH, Robbins KT,
Thomas JR eds. Cummings Otolaryngology: Head & Neck Surgery. 4th ed. Philadelphia, Pa:
Mosby Elsevier; 2005:chap 26
Kerr JT, Chu FW, Bayles SW. Cerebrospinal fluid rhinorrhea: diagnosis and management.
Otolaryngol Clin North Am. 2005;38:597-611. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16005720
Kravitz PR, Koltai PJ. Pediatric facial fractures. In: Cummings CW, Flint PW, Haughey BH,
Robbins KT, Thomas JR eds. Cummings Otolaryngology: Head & Neck Surgery. 4th ed.
Philadelphia, Pa: Mosby Elsevier; 2005:chap 202
Critique: 96
Axial computed tomography scan of the head, as described for the child in the vignette, shows
fractures through the anterior and posterior walls of the right frontal sinus and air within the
cranium. (Courtesy of D. Mulvihill)
Question: 97
A 16-year-old boy in your practice has cystic fibrosis. As a complication of his illness, he has
developed cirrhosis and cholestasis. He now complains of shaky hands. Neurologic examination
demonstrates hyporeflexia and tremor with hands outstretched.
Of the following, the patients symptoms are MOST consistent with deficiency of
A. vitamin A
B. vitamin B1 (thiamine)
C. vitamin C
D. vitamin D
E. vitamin E
References:
Harmatz P, Burensky E, Lubin B. Nutritional anemias. In: Walker WA, Watkins JB, Duggan C,
eds. Nutrition in Pediatrics. 3rd ed. Hamilton, Ontario, Canada: BC Decker; 2003:830-847
Spinozzi NS. Hepatobiliary diseases. In: Hendricks KM, Duggan C. Manual of Pediatric Nutrition.
4th ed. Hamilton, Ontario, Canada: BC Decker; 2005:586-592
Question: 98
You are making rounds with medical students in the neonatal intensive care unit and examining a
2-kg, 34 weeks gestation newborn whose mother had gestational diabetes mellitus. The infant
has no respiratory distress. A medical student asks how to test for fetal lung maturity to predict
the risk of neonatal respiratory distress syndrome in the offspring of a pregnant woman who has
diabetes mellitus.
B. lecithin:sphingomyelin ratio
C. phosphatidylglycerol presence
D. phosphatidylinositol presence
References:
Jobe AH. Lung development and maturation. In: Martin RJ, Fanaroff AA, Walsh MC, eds.
Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby Elsevier;
2006:1069-1086
Grenache DG, Gronowski AM. Fetal lung maturity. Clin Biochem. 2006;39:1-10. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/16303123
Winn-McMillan T, Karon BS. Comparison of the TDx-FLM II and lecithin to sphingomyelin ratio
assays in predicting fetal lung maturity. Am J Obstet Gynecol. 2005;193:778-782. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/16150274
Question: 99
At the end of the summer, you notice an increase in the number of preparticipation sports
examinations you are performing. You are pleased at the number of your patients who are
involved in sports activities but are reminded that many medical conditions preclude sports
participation and must be screened for during the preparticipation visit.
Of the following, the medical condition that is considered a CONTRAINDICATION for sports
participation is
A. a boy who has chronic leukemia and splenomegaly wishing to play golf
References:
American Academy of Pediatrics Committee on Sports Medicine and Fitness. Medical conditions
affecting sports participation. Pediatrics. 2001;107:1205-1209. Available at:
http://pediatrics.aappublications.org/cgi/content/full/107/5/1205
Metzl JD. Preparticipation examination of the adolescent athlete: part 1. Pediatr Rev.
2001;22:199-204. Available at: http://pedsinreview.aappublications.org/cgi/content/full/22/6/199
Metzl JD. Preparticipation examination of the adolescent athlete: part 2. Pediatr Rev.
2001;22:227-239. Available at: http://pedsinreview.aappublications.org/cgi/content/full/22/7/227
Critique: 99
Critique: 99
Question: 100
A child presents to a clinic associated with a disaster relief shelter after a hurricane destroys the
community. The mother states that they have run out of the creams prescribed for her
daughters eczema before the storm, and the child is itchy. She is concerned because there are
some blisters and crusting in the antecubital fossae and popliteal fossa where the itching is
worst. Physical examination reveals erosions (Item Q100) and erythema surrounding areas of
lichenification, with a few vesicles both in clusters and scattered.
Of the following, the MOST likely pathogen involved in this pattern of infection is
B. human papillomavirus
C. Sporothrix sp
D. varicella-zoster virus
E. viridans streptococci
Question: 100
Erosions that have a "punched-out" appearance, as described for the child in the vignette.
(Reprinted with permission from Stricker T, Lips U, Sennhauser FH. Visual diagnosis: an 8-
month-old who has an erupting rash. Pediatr Rev. 2007;28:231-234.)
References:
American Academy of Pediatrics. Sporotrichosis. In: Pickering LK, Baker CJ, Long SS, McMillan
JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:595-597
Bunikowski R, Mielke M, Skarabis H, et al. Prevalence and role of serum IgE antibodies to the
Staphylococcus aureus-derived superantigens SEA and SEB in children with atopic dermatitis. J
Allergy Clin Immunol. 1999;103:119-124. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/9893195
Horii KA, Simon SD, Liu DY, Sharma V. Atopic dermatitis in children in the United States, 1997-
2004: visit trends, patient and provider characteristics, and prescribing patterns. Pediatrics.
2007;120:e527-e534. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/3/e527
Knoell KA, Greer KE. Atopic dermatitis. Pediatr Rev. 1999;20:46-52. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/20/2/46
Stanbury LR. Herpes simplex virus. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson's Textbook of Pediatrics. Philadelphia, Pa: Saunders Elsevier; 2007:1360-1365
Waggoner-Fountain LA, Grossman LB. Herpes simplex virus. Pediatr Rev. 2004;25:86-93.
Critique: 100
When infected with S aureus, lesions of atopic dermatitis become moist and crusted. (Courtesy
of D. Krowchuk)
Critique: 100
Critique: 100
Question: 101
A 4-week-old infant who was born at term without any complications ate well and gained weight
for the first 3 weeks after birth. Over the last week, however, his mother reports that he appears
hungry but fatigues with feeding and now takes twice as long to complete his feeding as he did 1
week ago. He also breathes fast during his feedings and stops frequently to "catch his breath."
Of the following, the MOST likely explanation for the symptoms in this infant is
A. aspiration syndrome
E. pneumonia
References:
Balfour I. Management of chronic congestive heart failure in children. Curr Treat Options
Cardiovasc Med. 2004;6:407-416. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15324616
Dreyer WJ, Fisher DJ. Clinical recognition and management of chronic congestive cardiac
failure. In: Garson A Jr, Bricker JT, Fisher DJ, Neish SR, eds. The Science and Practice of
Pediatric Cardiology. 2nd ed. Baltimore, Md: Williams & Wilkins, 1998:2309-2325
Silberbach M, Hannon D. Presentation of congenital heart disease in the neonate and young
infant. Pediatr Rev. 2007;28:123-131. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
Talner NS, McGovern JJ, Carboni MP. Congestive heart failure. In: Moller JH, Hoffman JIE, eds.
Pediatric Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone; 2000:817-829
Question: 102
A 10-year-old boy has double vision and drooping eyelids. On physical examination, he is
afebrile and has normal mentation. Pupillary responses are normal, but he has bilateral ptosis.
He cannot fully adduct his right eye. You note that his ptosis increases with sustained upward
gaze (Item Q102). Bedside forced vital capacity is normal.
C. edrophonium test
D. lumbar puncture
References:
Mehta S. Neuromuscular disease causing acute respiratory failure. Respir Care. 2006;51:1016-
1023. Available at: http://www.rcjournal.com/contents/09.06/09.06.1016.pdf
Parr JR, Jayawant S. Childhood myasthenia: clinical subtypes and practical management. Dev
Med Child Neurol. 2007;49:629-635. Available at: http://www.blackwell-
synergy.com/doi/abs/10.1111/j.1469-8749.2007.00629.x
Sarnat HB. Disorders of neuromuscular transmission and of motor neurons. In: Kliegman RM,
Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia,
Pa: Saunders Elsevier; 2007:2554-2558
Question: 103
You are called to the newborn nursery to evaluate an infant who has a limb anomaly. The infant
is normally grown and vigorous. On physical examination, you note a terminal transverse limb
defect at the distal aspect of the right forearm, resulting in absence of the hand on that side (Item
Q103).
Of the following, these findings are MOST likely related to prenatal exposure to
A. alcohol
B. cocaine
C. marijuana
D. methamphetamine
E. tobacco
Question: 103
Terminal transverse limb defect, as exhibited by the infant described in the vignette. (Courtesy of
V. Shashi)
References:
Hoyme HE, May PA, Kalberg WO, et al. A practical clinical approach to diagnosis of fetal alcohol
spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics.
2005;115:39-47. Available at: http://pediatrics.aappublications.org/cgi/content/full/115/1/39
Critique: 103
Limb reduction defects may result from vascular disruptive events. (Courtesy of V. Shashi)
Critique: 103
Question: 104
A 16-year-old girl who attends boarding school in your community comes to your office because
she is feeling depressed. You see her alone for the visit, and she relates that she feels suicidal
at this time and has a plan to kill herself.
Of the following, the BEST description of your obligation to alert her parents to her situation is
that
E. parental notification is prohibited by the Health Insurance Portability and Accountability Act
References:
English A, Kenney KE. State Minor Consent Laws: A Summary. 2nd ed. Chapel Hill, NC: Center
for Adolescent Health & the Law; 2003
Joffe A. Legal and ethical issues in adolescent health care. In: Osborn LM, DeWitt TG, First LR,
Zenel JA eds. Pediatrics. Philadelphia, Pa: Elsevier Mosby; 2005:1428-1430.
Weddle M, Kokotailo P. Adolescent substance abuse: confidentiality and consent. Pediatr Clin
North Am. 2002;49:301-315. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/11993284
Weddle M, Kokotailo PK. Confidentiality and consent in adolescent substance abuse: an update.
Virtual Mentor: American Medical Association Journal of Ethics. 2005;7(3). Available at:
http://virtualmentor.ama-assn.org/2005/03/pfor1-0503.html
Question: 105
You are assisting a pediatric resident in evaluating a 12-year-old girl who has type 1 diabetes
and has been vomiting for the past 12 hours. Initial laboratory results include:
Blood glucose, 630.0 mg/dL (35.0 mmol/L)
Serum sodium, 150.0 mEg/L (150.0 mmol/L)
Serum potassium, 6.0 mEq/L (6.0 mmol/L)
Serum chloride, 90.0 mEq/L (90.0 mmol/L)
Serum bicarbonate, 10.0 mEq/L (10.0 mmol/L)
The anion gap for this child is CLOSEST to
A. 4
B. 10
C. 50
D. 80
E. 323
References:
Greenbaum LA. Electrolyte and acid-base disorders. In; Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:267-308
Schwaderer AL, Schwartz GJ. Back to basics: acidosis and alkalosis. Pediatr Rev. 2004;25:350-
357. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/10/350
Question: 106
The parents of a 12-year-old girl in whom you recently diagnosed type 1 diabetes mellitus ask
you about potential long-term complications. In your discussion, you stress the importance of
blood glucose control to prevent complications and review risk factors for diabetes
complications, including hyperglycemia and tobacco smoking.
Of the following, the MOST important additional risk factor for diabetes complications is
A. celiac disease
B. hypertension
C. hypothyroidism
E. undernutrition
References:
Freemark M, Levitsky LL. Screening for celiac disease in children with type 1 diabetes: two
views of the controversy. Diabetes Care. 2003;26:1932-1939. Available at:
http://care.diabetesjournals.org/cgi/content/full/26/6/1932
Gallego PH, Wiltshire E, Donaghue KC. Identifying children at particular risk of long-term
diabetes complications. Pediatr Diabetes. 2007;8(suppl 6):40-48. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17727384
Glastras SJ, Mohsin F, Donaghue KC. Complications of diabetes mellitus in childhood. Pediatr
Clin North Am. 2005;52:1735-1753. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16301091
Herbst A, Kordonouri O, Schwab KO, Schmidt F, Holl RW, on behalf of the DPV Initiative of the
German Working Group for Pediatric Diabetology Germany. Impact of physical activity on
cardiovascular risk factors in children with type 1 diabetes. Diabetes Care. 2007;30:2098-2100.
Available at: http://care.diabetesjournals.org/cgi/content/full/30/8/2098
Levitsky LL, Misra M. Complications and screening in children and adolescents with type 1
diabetes mellitus. UpToDate Online 15.3. 2008. Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/17677
Raile K, Galler A, Hofer S, et al. Diabetic nephropathy in 27,805 children, adolescents, and adults
with type 1 diabetes: effect of diabetes duration, A1C, hypertension, dyslipidemia, diabetes
onset, and sex. Diabetes Care. 2007;30:2523-2528. Available at:
http://care.diabetesjournals.org/cgi/content/full/30/10/2523
Question: 107
A 12-year-old boy recently took a standardized achievement test at school. His score dropped
from 105 on last years achievement test to 95 on the most recent test. Last season the boy
played hockey and fell down, hitting his head, although he did not lose consciousness. He had
no previous head injury. He was evaluated in the emergency department and had normal
findings on computed tomography scan. The mother asks whether the boy had suffered brain
injury due to his fall that caused him to lose academic skills.
C. restrict the childs contact sports activity for the next season
References:
Ewen JB, Shapiro BK. Specific learning disabilities. In: Accardo PJ. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume II: The Spectrum of
Neurodevelomental Disabilities. 3rd ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2008:553-
577
Mahone EM. Psychological assessment. In: Accardo PJ, ed. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume II: The Spectrum of
Neurodevelopmental Disabilities. 3rd ed. Baltimore, MD: Paul H. Brookes Publishing Co;
2008:261-281
Question: 108
The microbiology laboratory called your junior partner today to tell her that the blood culture from
a patient she admitted 2 days ago is growing Haemophilus influenzae type b. Because she has
never treated an infection caused by this organism, she wants to know what antimicrobial agent
would be best to use for her patient.
Of the following, the MOST appropriate antimicrobial agent to treat this infection is
A. ampicillin
B. cefotaxime
C. clindamyin
D. gentamicin
E. vancomycin
References:
American Academy of Pediatrics. Haemophilus influenzae infections. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:310-318
Question: 109
A 9-year-old previously healthy boy presents for evaluation of a progressively worsening
cellulitis of his left leg. Two days ago, he sustained an abrasion to his shin after falling off his
bicycle onto a gravel road. Over the last 12 hours, he has developed a temperature of 102.0F
(38.9C), and the wound has become very erythematous, swollen, and tender, with some red
streaking. On physical examination, the boy has a temperature of 101.5F (38.6C) and a 5x6-
cm abrasion of the anterior lateral surface of his left shin that is draining a serosanguineous
discharge. The abrasion is surrounded by an 8-cm area of erythema, swelling, and induration,
with a red streak extending up toward his knee. The area is tender to palpation, and he limps
when walking. There is some shotty left inguinal adenopathy. A complete blood count shows a
peripheral white blood cell count of 16.0x103/mcL (16.0x109/L) with a differential count of 65%
neutrophils, 5% band forms, 25% lymphocytes, and 5% monocytes.
Of the following, the MOST likely pathogen causing this patients condition is
C. Staphylococcus epidermidis
D. Streptococcus pyogenes
E. Streptococcus pneumoniae
relatively rare and typically follows an upper respiratory tract infection (otitis and sinusitis) or
neurosurgical conditions.
Staphylococcus epidermidis does not cause cellulitis. S pneumoniae is a cause of preseptal
cellulitis but is not associated with other forms of cellulitis. The cellulitis caused by S aureus
(methicillin-sensitive or -resistant) is not associated with lymphangitis, and progression is not as
rapid as with group A streptococcal cellulitis.
References:
Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med.
1996;334:240-246. Extract available at: http://content.nejm.org/cgi/content/extract/334/4/240
Bisno AL, Stevens DL. Streptococcus pyogenes. In: Mandell GL, Bennett JE, Dolin R, eds.
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed.
Philadelphia, Pa: Elsevier Churchill Livingstone; 2005:2362-2379
Sellers BJ, Woods ML, Morris SE, Saffle JR. Necrotizing group A streptococcal infections
associated with streptococcal toxic shock syndrome. Am J Surg. 1996;172:523-528. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/8942557
Stevens DL. Dilemmas in the treatment of invasive Streptococcus pyogenes infections. Clin
Infect Dis. 2003;37:341-343. Available at:
http://www.journals.uchicago.edu/doi/full/10.1086/376652
Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new
concepts in treatment. Emerg Infect Dis. 1995;1:69-78. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/8903167
Critique: 109
Critique: 109
In patients who have scarlet fever, erythema or petechiae may be concentrated in skin folds in
the antecubital fossae (ie, Pastia lines). (Courtesy of D. Krowchuk)
Critique: 109
The rash of scarlet fever is comprised of fine erythematous papules that have a rough or
"sandpaper" feel. (Courtesy of D. Krowchuk)
Critique: 109
In nonbullous impetigo, vesicles rupture and serous fluid dries, leaving a yellow or "honey-
colored" crust. (Courtesy of D. Krowchuk)
Critique: 109
Critique: 109
In necrotizing fasciitis, affected areas of the skin become dusky or violaceous and bullae appear.
(Courtesy of Bernard Cohen, MD, DermAtlas; www.dermatlas.org)
Question: 110
A 6-year-old boy presents to an urgent care center with the complaint of bright red blood and
clots in the urine. There is no history of trauma, and the boy has no dysuria, frequency,
urgency, abdominal pain, or back pain. On physical examination, his temperature is 98.6F
(37C), heart rate is 76 beats/min, respiratory rate is 14 breaths/min, and blood pressure is
110/68 mm Hg. He has no abdominal tenderness, flank tenderness, or edema. Urinalysis
reveals a specific gravity of 1.025, pH of 6.5, 3+ blood, trace protein, and negative leukocyte
esterase and nitrite. Microscopy shows more than 100 red blood cells/high-power field (HPF),
less than 5 white blood cells/HPF, and no casts. Electrolyte values are normal, blood urea
nitrogen is 14.0 mg/dL (5.0 mmol/L), and creatinine is 0.5 mg/dL (44.2 mcmol/L).
D. renal biopsy
E. renal/bladder ultrasonography
References:
Brody AS, Frush DP, Huda W, Brent RL, and the Section on Radiology. Radiation risk to children
from computed tomography. Pediatrics. 2007;120:677-682. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/3/677
Moxey-Mims M. Hematuria and proteinuria. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:129-141
Pan CG. Evaluation of gross hematuria. Pediatr Clin North Am. 2006;53:401-412. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/16716787
Critique: 110
Wilms tumor: A transverse image from a computed tomography scan demonstrates a normal
right kidney and a very large tumor originating from the displaced left kidney. (Courtesy of D.
Mulvihill)
Question: 111
A 10-year-old boy presents with a 2-month history of chronic cough. His parents are unsure of a
specific preceding trigger. They are concerned because the school nurse has called on multiple
occasions requesting that the boy be taken home due to his persistent cough. The boy denies
any chest pain, dyspnea, or syncope. Use of a sedating antihistamine and over-the-counter cold
and cough liquid has not alleviated his symptoms. On physical examination, the boy has vital
signs within the normal range and appears healthy. A thorough examination reveals no
abnormalities. During the encounter, the boy repeatedly exhibits a harsh, "barky" cough that
resolves when you leave the examination room, only to recur when you return. You suspect he
has a psychogenic cough.
Of the following, the MOST accurate statement regarding psychogenic cough is that
D. symptoms persist during the day and while the child is asleep
E. the cough noise often is dramatically different from the postnasal drip syndrome cough
References:
Linz AJ. The relationship between psychogenic cough and the diagnosis and misdiagnosis of
asthma: a review. J Asthma. 2007;44:347-355. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17613629
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not
asthma. Pediatrics. 2007;120:855-864. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/4/855
Question: 112
A 6-year-old girl fell onto her outstretched right arm while roller skating yesterday. She continued
to skate, but on returning home, she noticed that her right forearm was swollen and painful. Her
mother applied ice and gave her ibuprofen, but the swelling is worse today. On physical
examination, the girl has moderate swelling over the right distal radius with minimal pain on
palpation. She has full range of motion of her wrist and hand. Radiographs are obtained (Item
Q112).
B. reduction of the fracture is not necessary if there is less than 15 degrees of angulation
Question: 112
Radiograph of the forearm, as described for the child in the vignette. (Courtesy of E. Anthony)
References:
Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin
North Am. 2006;53:41-67. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16487784
Gholve PA, Hosalkar HS, Wells L. Common fractures. In: Kleigman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:2834-2841
Critique: 112
Greenstick fractures are incomplete fractures characterized by a cortical break on one side of
the bone (area of lucency, yellow arrow) and intact periosteum on the opposite side. This patient
also has a greenstick fracture of the ulna (red arrow). (Courtesy of E. Anthony)
Critique: 112
In some greenstick fractures, the bone may bend but not break (arrow). (Courtesy of D.
Krowchuk)
Critique: 112
Torus (buckle) fracture of the left distal radius (yellow arrows) and the radial side of the ulna (red
arrow). The term "torus" is used because of the similarity of appearance of the fracture with the
convex molding often used at the base of columns. (Courtesy of E. Anthony)
Question: 113
A 5-year-old child is admitted to the hospital with epigastric pain and vomiting. On physical
examination, she has a tender epigastrium, but no peritoneal signs. Her amylase is 400 U/L and
lipase is 670 U/L. Abdominal ultrasonography demonstrates a prominent pancreatic head, but no
gallstones or biliary tract dilation. Review of her chart demonstrates two prior hospitalizations
over the past 3 years due to pancreatitis. She has no other significant findings in her medical
history and no history of trauma preceding any of these episodes.
Of the following, the condition that BEST explains the patients history is
A. alpha-1-antitrypsin deficiency
B. colipase deficiency
C. hereditary pancreatitis
References:
Pietzak MM, Thomas DW. Pancreatitis in childhood. Pediatr Rev. 2000;21: 406-412. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/21/12/406
Question: 114
You admit a term newborn to the neonatal intensive care unit because of noisy breathing.
Findings on physical examination include mild micrognathia, an intact palate, and inspiratory
stridor with suprasternal retractions when the infant is in the supine position that diminish but do
not disappear when the infant is prone. Stridor becomes more audible when the infant cries.
When the infant is asleep and prone, the breath sounds are clear and equal bilaterally, with no
stridor or wheezing. There is no heart murmur. Pulse oximetry is 94% on room air.
A. cleft lip
B. laryngomalacia
C. tracheal hemangioma
D. tracheomalacia
References:
Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev.
2004;25:201-208. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/6/201
Brodsky L. Consultation with the specialist: congenital stridor. Pediatr Rev. 1996;17:408-411.
Available at: http://pedsinreview.aappublications.org/cgi/reprint/17/11/408
Sprecher RC, Arnold JE. Upper airway lesions. In: Martin RJ, Fanaroff AA, Walsh MC, eds.
Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby Elsevier;
2006:1146-1154
Vicencio AG, Parikh S, Adam HM. In brief: laryngomalacia and tracheomalacia: common
dynamic airway lesions. Pediatr Rev. 2006;27:e33-e35. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/4/e33
Critique: 114
Question: 115
A 13-year-old boy who plays baseball comes to your office for a preparticipation sports physical
examination. He always has been an average player and is interested in a preseason
conditioning program to improve his strength and agility because he wants to play on his school
team. His mother is concerned about the program because it involves weight training, and she
asks for your advice.
Of the following, a TRUE statement about conditioning programs for young athletes is that these
programs
A. have been shown to decrease ultimate linear growth if begun before puberty
C. should begin with low-resistance exercise, with weight added in small increments as tolerated
References:
American Academy of Pediatrics Committee on Sports Medicine and Fitness. Strength training
by children and adolescents. Pediatrics. 2001;107:1470-1472. Available at:
http://pediatrics.aappublications.org/cgi/content/full/107/6/1470
Metzl JD. Preparticipation examination of the adolescent athlete: part 2. Pediatr Rev.
2001;22:227-239. Available at: http://pedsinreview.aappublications.org/cgi/content/full/22/7/227
Question: 116
A 10-year-old boy who recently emigrated from Central America is referred by the school nurse
for evaluation of obesity.Physical examination reveals an obese but generally healthy boy who
has acanthosis nigricans (Item Q116).He has had limited access to medical care in the past.
Of the following, the physical finding MOST likely to suggest an underlying cause for the child's
obesity is
B. abdominal striae
Question: 116
(Courtesy of M. Rimsza)
References:
Arterburn DE. Obesity in children. BMJ Clinical Evidence. 2007. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0325/0325.jsp
Rodearmel SJ Wyatt HR, Stroebele N, Smith SM, Ogden LG, Hill JO. Small changes in dietary
sugar and physical activity as an approach to preventing excessive weight gain: the America on
the Move Family Study. Pediatrics. 2007;120:e869-e879 Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/4/e869
Schneider MB, Brill SR. Obesity in children and adolescents. Pediatr Rev. 2005;26:155-162.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/26/5/155
Shaw K, Gennat H, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane
Database Syst Rev. 2006;4:CD003817. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003817/frame.html
Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. Interventions for
preventing obesity in children. Cochrane Database Syst Rev. 2005;3:CD001871. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001871/frame.html
Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight
and obesity. Cochrane Database Syst Rev. 2007;3:CD005105. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005105/frame.html
Critique: 116
Prader-Willi syndrome is characterized by short stature, obesity, hypogonadism, and small hands
and feet. (Courtesy of Y. Lacassie)
Critique: 116
The striae observed in patients who have Cushing syndrome often have a violaceous color.
(Courtesy of M. Rimsza)
Question: 117
You are evaluating a 14-year-old girl in the clinic. She has had a fever for nearly 2 weeks, which
she has attributed to a "cold," although she has not had cough or upper respiratory tract
symptoms. She is concerned about some "spots" that she has noticed on her palms and soles.
On physical examination, you note splenomegaly and erythematous, nontender macules on her
fingers, palms (Item Q117), and soles of her feet. Additionally, she has lost 8 lb since her visit 6
months ago.
Of the following, the MOST appropriate next study for evaluation of this patient is
A. antinuclear antibody
B. echocardiography
C. Lyme titers
D. ophthalmologic examination
Question: 117
(Courtesy of M. Rimsza)
References:
Baltimore RS. Infective endocarditis in children. Pediatr Infect Dis J. 1992;11:907-912. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/1454430
Taubert KA, Dajani AS. Infective endocarditis. In: Moller JH, Hoffman JIE, eds. Pediatric
Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone; 2000:768-779
Critique: 117
Roth spots are retinal hemorrhages that have a pale center (arrow). (Courtesy of SY Lesnik
Oberstein and eyetext.net)
Critique: 117
Janeway lesions are painless erythematous or hemorrhagic macules on the fingers, palms, or
soles. (Courtesy of M. Rimsza)
Question: 118
A mother brings her 8-year-old daughter to your office after the girl experiences a first
unprovoked generalized tonic-clonic seizure at school. The child had been seen in an
emergency department, and results of a head computed tomography scan performed there
were normal. Her development, school performance, and results of physical examination are
normal. You review safety concerns (no unsupervised time in bathtub or pools, wearing a
bicycle helmet) and seizure first aid with the mother. Following published guidelines, you obtain
routine electroencephalography (EEG), which a neurologist interprets as normal. The mother
asks you about anticonvulsant therapy to prevent further seizures.
References:
Gilbert DL, Buncher CR. An EEG should not be obtained routinely after first unprovoked seizure
in childhood. Neurology. 2000;54:635-641. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10680796
Gilbert DL, DeRoos S, Bare MA. Does sleep or sleep deprivation increase epileptiform
discharges in pediatric electroencephalograms? Pediatrics. 2004;114:658-662. Available at:
http://pediatrics.aappublications.org/cgi/content/full/114/3/658
Gilbert DL, Sethuraman G, Kotagal U, Buncher CR. Meta-analysis of EEG test performance
shows wide variation among studies. Neurology. 2003;60:564-570. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/12601093
Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in
children: report of the Quality Standards Subcommittee of the American Academy of Neurology,
the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000;55:616-623.
Available at: http://www.neurology.org/cgi/content/full/55/5/616
Hirtz D, Berg A, Bettis D, et al. Practice parameter: treatment of the child with a first unprovoked
seizure: report of the Quality Standards Subcommittee of the American Academy of Neurology
and the Practice Committee of the Child Neurology Society. Neurology. 2003;60:166-175.
Available at: http://www.neurology.org/cgi/content/full/60/2/166
Stroink H, van Donselaar CA, Geerts AT, Peters AC, Brouwer OF, Arts WF. The accuracy of
the diagnosis of paroxysmal events in children. Neurology. 2003;60:979-982. Abstract available
at: http://www.ncbi.nlm.nih.gov/pubmed/12654963
Question: 119
You receive a call from a local neonatologist because the mother of a newly admitted baby has
identified you as her pediatrician. The baby was born at term and had Apgar scores of 1, 2, and
4 at 1, 5, and 10 minutes, respectively. She is requiring significant ventilatory and fluid support,
and she has multiple congenital anomalies, including bilateral microtia, depressed nasal bridge,
ocular hypertelorism, cleft palate, and macrocephaly. Echocardiography shows truncus
arteriosus, and head ultrasonography reveals dilated ventricles consistent with hydrocephalus.
Of the following, the teratogenic agent that is MOST likely responsible for this infants features is
A. alcohol
B. isotretinoin
C. phenobarbital
D. phenytoin
E. thalidomide
References:
Isotretinoin, alcohol, phenytoin, phenobarbital, thalidomide. Teris. Available for subscription at:
http://depts.washington.edu/terisweb/teris/
Jones KL. Retinoic acid embryopathy. In: Smith's Recognizable Patterns of Human
Malformation. 6th ed. Philadelphia, Pa; Elsevier Saunders; 2006:660-661
Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embryopathy. N Engl J Med. 1985;313:837-
841. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/3162101
Critique: 119
Characteristic facial appearance of a newborn who has fetal alcohol syndrome includes midface
hypoplasia, a relatively smooth philtrum, and a narrow upper lip with a poorly defined "cupid's
bow." (Courtesy of M. Rimsza)
Critique: 119
Arched eyebrows, wide-spaced eyes, and a short upturned nose are characteristic of infants
exposed to phenytoin during pregnancy. (Courtesy of M. Rimsza)
Question: 120
You are evaluating a 14-year-old boy for his preparticipation sports physical examination before
he tries out for the freshman football team. He has no chronic health problems and no previous
history of head injuries. His mother expresses concern about recent reports of professional
football players sustaining cognitive damage due to repeated concussions.
Of the following, the MOST appropriate statement to include in your counseling regarding head
injuries in contact sports is that
A. baseline, detailed neuropsychological testing has been well established as a tool to use in the
management of head injuries in pediatric athletes
C. return-to-play guidelines for pediatric athletes are well established and evidence-based
D. seasonal and lifetime sports exclusion guidelines for pediatric athletes after head injury are
well established and evidence-based
E. the preparticipation visit history of an athlete should include the number of prior concussions,
timing and severity of each, and description of resulting symptoms
References:
Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate
and high school football players. Am J Sports Med. 2000;28:643-650. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/11032218
Kirkwood MW, Yeates KO, Wilson PE. Pediatrics sport-related concussion: a review of the
clinical management of an oft-neglected population. Pediatrics. 2007;117:1359-1371. Available
at: http://pediatrics.aappublications.org/cgi/content/full/117/4/1359
Question: 121
You are evaluating a 1-year-old girl who was admitted to the pediatric intensive care unit
following 3 days of diarrhea and decreased oral intake. Her heart rate is 160 beats/min,
respiratory rate is 30 breaths/min, blood pressure is 70/40 mm Hg, and she has weak peripheral
pulses. An arterial blood gas evaluation on room air reveals pH of 7.08, Paco2 of 25 mm Hg,
Pao2 of 100 mm Hg, and HCO3 of 5.0 mEq/L (5.0 mmol/L). Initial electrolyte values are: sodium
of 130.0 mEq/L (130.0 mmol/l), potassium of 4.0 mEq/L (4.0 mmol/L), chloride of 95.0 mEq/L
(95.0 mmol/L), bicarbonate of 6.0 mEq/L (6.0 mmol/L), and glucose of 100.0 mg/dL (5.6 mmol/L).
References:
Greenbaum LA. Electrolyte and acid-base disorders. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:267-308
Schwaderer AL, Schwartz GJ. Back to basics: acidosis and alkalosis. Pediatr Rev. 2004;25:350-
357. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/10/350
Question: 122
A 3-year-old girl presents to the emergency department in an almost unresponsive state. Her
parents say that she has become increasingly ill over the past 5 days and has been very thirsty,
with increased urination. This morning she began to vomit and could not keep down fluids.
Findings on physical examination in addition to unresponsiveness include rapid, sighing
respirations and flushed cheeks. You estimate that she is 10% dehydrated. Initial laboratory
studies reveal a blood glucose concentration of 700.0 mg/dL (38.9 mmol/L), sodium of 130.0
mEq/L (130.0 mmol/L), potassium of 4.6 mEq/L (4.6 mmol/L), chloride of 96.0 mEq/L (96.0
mmol/L), bicarbonate of 8.0 mEq/L (8.0 mmol/L), and a venous pH of 7.0.
Of the following, the MOST appropriate action to decrease this childs risk for cerebral edema
during treatment is to
A. avoid potassium replacement until the serum potassium value is less than 4.0 mEq/L (4.0
mmol/L)
References:
Dunger DB, Sperling MA, Acerini CL, et al. European Society for Paediatric
Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic
ketoacidosis in children and adolescents. Pediatrics. 2004;113:e133-e140. Available at:
http://pediatrics.aappublications.org/cgi/content/full/113/2/e133
Edge JA, Jakes RW, Roy Y, et al. The UK case-control study of cerebral oedema complicating
diabetic ketoacidosis in children. Diabetologia. 2006;49:2002-2009. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16847700
Wolfsdorf J, Craig ME, Daneman D, et al; International Society for Pediatriac and Adolescent
Diabetes. Diabetic ketoacidosis. Pediatr Diabetes. 2007;8:28-43
Question: 123
A 14-year-old boy has been receiving occupational therapy due to weakness in his graphomotor
(eg, handwriting) skills. During the school annual Individualized Education Plan (IEP) meeting, his
mother asks about alternative strategies that could be used to help him compensate for his area
of weakness.
A. allow him to use print rather than cursive writing for his notes
References:
Thorne G. Graphomotor Skills: Why Some Kids Hate to Write. Center for Development and
Learning. Covington, La. 2006. Available at: http://www.cdl.org/resource-
library/articles/graphomotor.php
Shaywitz SE, Shaywitz BA. Dyslexia (specific reading disability) Pediatr Rev. 2003;24:147-153.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/24/5/147
Question: 124
During hospital rounds, you are evaluating a 7-year-old boy who has been hospitalized for 1
month after developing a perforated appendix. He recently started eating solid foods, but today
he developed loose stools and a mild amount of abdominal discomfort. He has had four bowel
movements within the past 6 hours that are described as watery and nonbloody. His parents are
very concerned that this is another complication of his perforated appendix. On your physical
examination, the boy is afebrile and has active bowel sounds and only minor discomfort on
palpation to his abdomen.
Of the following, the MOST likely organism to be causing this patients diarrhea is
A. Campylobacter jejuni
B. Clostridium difficile
C. Salmonella enteritidis
D. Shigella sonnei
E. Yersinia enterocolitica
References:
American Academy of Pediatrics. Clostridium difficile. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:261-263
Critique: 124
Question: 125
You are evaluating a 7-year-old boy who has human immunodeficiency virus (HIV) infection and
failure to thrive. Over the last 2 months, he has had intermittent temperatures to 102.5F
(39.2C), anorexia, abdominal pain, diarrhea, and a 6-lb weight loss. His HIV infection has been
poorly controlled because of noncompliance with medications. His viral load is 150,000 copies,
and his CD4 count is 40 cells/mm3. Physical examination shows a thin, small-for-age boy who is
playing quietly. He weighs 15.8 kg (<5th percentile). He has some oral thrush, cervical and
inguinal adenopathy, and mild diffuse abdominal tenderness to palpation.
Of the following, the MOST likely pathogen causing this patients illness is
A. Cryptosporidium
B. cytomegalovirus
E. Salmonella sp
References:
Gordin FM, Horsburgh CR Jr. Mycobacterium avium complex. In: Mandell GL, Bennett JE, Dolin
R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed.
Philadelphia, Pa: Elsevier Churchill Livingstone; 2005:2897-2909
Question: 126
You are seeing a 7-year-old boy for occasional nocturnal enuresis. His weight and height are at
the 50th percentile for age, his blood pressure is 110/66 mm Hg, and there are no unusual
findings on physical examination. Urinalysis shows a specific gravity of 1.030, pH of 6.5, 2+
blood, and no protein. Urine microscopy reveals 10 to 20 red blood cells/high-power field and no
casts or crystals. Results of a repeat urine sample 3 weeks later are unchanged. Laboratory
findings include:
Blood urea nitrogen, 12.0 mg/dL (4.3 mmol/L)
Creatinine, 0.4 mg/dL (35.4 mcmol/L)
Complement component 3 (C3), 110.0 mg/dL (normal, 86.0 to 166.0 mg/dL)
Complement component 4 (C4), 22.0 mg/dL (normal, 13.0 to 32.0 mg/dL)
Antinuclear antibody, negative
Erythrocyte sedimentation rate, 6 mm/hr
D. renal/bladder ultrasonography
References:
Moxey-Mims M. Hematuria and proteinuria. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:129-141
Patel HP, Bissler JJ. Hematuria in children. Pediatr Clin North Am. 2001;48:1519-1537. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/11732128
Critique: 126
Numerous red blood cells (arrows) on microscopic examination of urine. (Reprinted with
permission from Schumann GB, Friedman SK. Wet Urinalysis. Chicago, Ill: ASCP Press; 2007.
2007, American Society for Clinical Pathology.)
Question: 127
An 8-year-old girl presents with multiple episodes of "bronchitis." For the past 2 years, she has
had problems with coughing, wheezing, and difficulty catching her breath during vigorous
exercise. Treatment with a metered dose beta2 agonist inhaler has improved her symptoms. In
your office, you discuss the different tests to assess lung function.
Of the following, the BEST test to measure lung function for this girl is
D. pulse oximetry
E. spirometry
References:
Guill MF. Asthma update: clinical aspects and management. Pediatr Rev. 2004;10:335-344.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/10/335
Liu AH, Covar RA, Spahn JD, Leung DYM. Childhood asthma. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:953-969
Silkoff PE, Carlson M, Bourke T, Katial R, Ogren E, Szefler SJ. The Aerocrine exhaled nitric
oxide monitoring system NIOX is cleared by the US Food and Drug Administration for monitoring
therapy in asthma. J Allergy Clin Immunol. 2004;114:1241-1256. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15536442
Question: 128
A 4-year-old girl is brought to the emergency department after sticking a hair pin in a household
electrical outlet. The mother reports that she heard the child scream, and when she investigated,
smoke was coming from the outlet and the child was crying, holding her right hand. There was a
black imprint on her fingers in the shape of the hair pin. She washed the fingers with soap and
water and drove the child to the emergency department for further evaluation. On physical
examination, the child is tearful but awake and alert. Her right index finger and thumb have
erythematous burn imprints with small blisters surrounded by soot. She has no other burns or
other findings of note on the remainder of her examination.
A. arrhythmias
B. compartment syndrome
C. immunization status
D. myoglobinuria
E. skin grafting
References:
Chen EH, Sareen A. Do children require ECG evaluation and inpatient telemetry after household
electrical exposures? Ann Emerg Med. 2007;49:64-67
Pinto DS, Clardy PF. Environmental electrical injuries. UpTo Date Online 15.3. 2008 Available for
subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=ad_emerg/2283&selectedTitle=1~150&sour
ce=search_result
Price TG, Cooper MA. Electrical and lightning injuries. In Marx JA, ed. Rosen's Emergency
Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2006:chap
140
Rosen CL, Adler JN, Rabban JT, et al. Early predictors of myoglobinuria and acute renal failure
following electrical injury. J Emerg Med. 1999;17:783-789. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10499690
Critique: 128
Oral burns may result from chewing on an electrical cord. (Courtesy of M. Wright)
Question: 129
A 12-year-old girl has had intermittent periumbilical abdominal pain for the past 4 years.
Sometimes the pain worsens when she drinks a glass of milk. A lactose breath hydrogen test
demonstrates a breath hydrogen of 40 ppm after 1 hour (normal, <20 ppm).
Of the following, the food that this girl is MOST likely to tolerate is
A. buttermilk
B. cheddar cheese
C. ice cream
D. skim milk
E. whole milk
References:
Thiessen PN. Recurrent abdominal pain. Pediatr Rev. 2002;23:39-46. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/23/2/39
Critique: 129
Question: 130
You are treating a former extremely low-gestational age newborn (ELGAN) who was born at 26
weeks gestation weighing 700 g. She is now 4 weeks old. Her nurse asks when the eye
examination for retinopathy of prematurity (ROP) will be performed and what risk for significant
visual impairment exists in this infant.
Of the following, the BEST time to obtain the first ROP screening eye examination in this infant is
References:
Bharwani SK, Dhanireddy R. Systemic fungal infection is associated with the development of
retinopathy of prematurity in very low birth weight infants: a meta-review. J Perinatol. 2007;28:61-
66. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/18046338
Darlow BA, Hutchinson JL, Henderson-Smart DJ, Donoghue DA, Simpson JM, Evans NJ on
behalf of the Australian and New Zealand Neonatal Network. Prenatal risk factors for severe
retinopathy of prematurity among very preterm infants of the Australian and New Zealand
Neonatal Network. Pediatrics. 2005;115:990-996. Available at:
http://pediatrics.aappublications.org/cgi/content/full/115/4/990
Hagadorn JI, Richardson DK, Schmid CH, Cole CH. Cumulative illness severity and progression
from moderate to severe retinopathy of prematurity. J Perinatol. 2007;27:502-509. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/17568754
Karlowicz MG, Giannone PJ, Pestian J, Morrow AL, Shults J. Does candidemia predict threshold
retinopathy of prematurity in extremely low birth weight (<1000 g) neonates? Pediatrics.
2000;105:1036-1040. Available at:
http://pediatrics.aappublications.org/cgi/content/full/105/5/1036
Lee BH, Stoll BJ, McDonald SA, Higgins RD for the National Institute of Child Health and Human
Development Neonatal Research Network. Adverse neonatal outcomes associated with
antenatal dexamethasone versus antenatal betamethasone. Pediatrics. 2006;117:1503-1510.
Available at: http://pediatrics.aappublications.org/cgi/content/full/117/5/1503
Critique: 130
Reprinted with permission from the Section on Ophthalmology, American Academy of Pediatrics,
American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and
Strabismus. Screening examination of premature infants for retinopathy of prematurity.
Pediatrics. 2006; 117:572-576.
Question: 131
A 15-year-old boy who has mild persistent asthma is brought to the emergency department
because of increased work of breathing of 1 days duration. He reports a low-grade fever and
nonproductive cough for the past 4 days, but this morning he developed difficulty breathing and
a cough that produced a small amount of yellowish sputum. His respiratory rate is 24
breaths/min, heart rate is 80 beats/min, and temperature is 99.0F (37.3C). He appears in no
respiratory distress, but his lung examination reveals bilateral rales and occasional wheezes. A
chest radiograph shows bilateral diffuse infiltrates with no effusions.
Of the following, the MOST likely etiologic agent causing his symptoms is
A. Haemophilus influenzae
B. Mycobacterium tuberculosis
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
E. Streptococcus pneumoniae
References:
American Academy of Pediatrics. Mycoplasma pneumoniae infections. In: Pickering LK, Baker
CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:468-470
Gavranich JB, Chang AB. Antibiotics for community acquiredlower respiratory tract infections
(LRTI) secondary to Mycoplasma pneumoniae in children. Cochrane Database Syst Rev.
2005;3:CD004875. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004875/frame.html
Critique: 131
Critique: 131
Critique: 131
Anteroposterior radiograph of the chest demonstrates consolidation in the right upper lobe and
focal air collection within lung parenchyma consistent with a pneumatocele (arrow). (Courtesy of
D. Mulvihill)
Critique: 131
Question: 132
A resident in continuity clinic approaches you to review the laboratory values obtained at a
patients 12-month health supervision visit. The fingerstick hemoglobin measurement was 10.5
g/dL (105.0 g/L), and the lead concentration was 11.0 mcg/dL (0.53 mcmol/L).
is succimer, followed 4 hours later by CaNa2EDTA, because children who present with lead
encephalopathy may deteriorate when treated with CaNa2EDTA alone. D-penicillamine is not
recommended as first-line therapy because adverse effects and allergy are common (33%).
Dimercaprol is not a first-line drug because the rate of adverse effects approaches 50%.
Serious adverse effects of chelation therapy may occur due to chelation of other electrolytes.
NaEDTA has been associated with fatal hypocalcemia and, therefore, is contraindicated. The
clinician should be careful not to confuse CaNa2EDTA with NaEDTA. Chelation therapy should
be conducted in conjunction with a pediatric toxicologist or pharmacist under very close
supervision. Oral agents may be used, but succimer is not palatable and must be emptied from
a capsule onto food.
Once lead has been ingested, the percentage absorbed may be modified by essential
nutrients. A healthy diet can be recommended for both lead-exposed and nonexposed children.
Particular attention must be given to calcium and iron intake. If iron deficiency is diagnosed,
supplemental iron should be prescribed. For children who are not iron-deficient, a multivitamin
with iron can be recommended, but its efficacy is unproven. Similarly, no published data support
a role for therapeutic administration of calcium or iron as treatment for lead poisoning in the
absence of deficiency. Such studies are being conducted.
Blood lead concentrations fall precipitously after completion of chelation, but rebound within
weeks, even if there is no further exposure to lead, due to release of lead from bone stores. In
general, the concentrations do not return to the high values seen before chelation, and a second
course of chelation rarely is indicated.
References:
Binns,HJ, Campbell,C, Brown,MJ for the Advisory Committee on Childhood Lead Poisoning
Prevention. Interpreting and managing blood lead levels of less than 10 mcg/dL in children and
reducing childhood exposure to lead: recommendations of the Centers for Disease Control and
Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Pediatrics.
2007;120:e1285-e1298. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/5/e1285
Centers for Disease Control and Prevention. Lead program: state and local programs. Available
at: http://www.cdc.gov/nceh/lead/grants/contacts/CLPPP%20Map.htm
Laraque D, Trasande L. Lead poisoning: successes and 21st century challenges. Pediatr Rev.
2005;26:435-443. Available at: http://pedsinreview.aappublications.org/cgi/content/full/26/12/435
Yuan W, Holland SK, Cecil KM, et al. The impact of early childhood lead exposure on brain
organization: a functional magnetic resonance imaging study of language function. Pediatrics.
2006;118:971-977. Available at: http://pediatrics.aappublications.org/cgi/content/full/118/3/971
Question: 133
You are evaluating a 15-year-old boy in the emergency department who presents with fever,
chills, malaise, and blood in his urine. On physical examination, he appears comfortable and alert
and has a temperature of 102.7F (39.3C), a blood pressure of 110/40 mm Hg, no rashes, and
clear breath sounds. He has a diastolic murmur heard best in the sitting position (Item Q133).
You elicit no abdominal or flank tenderness.
Of the following, the BEST next step in the management of this patient is
B. blood cultures
C. renal ultrasonography
D. transesophageal echocardiography
E. urine culture
References:
Baltimore RS. Infective endocarditis in children. Pediatr Infect Dis J. 1992;11:907-912. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/1454430
Taubert KA, Dajani AS. Infective endocarditis. In: Moller JH, Hoffman JIE, eds. Pediatric
Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone; 2000:768-779
Question: 134
A 6-year-old boy has had difficulty walking and lower leg pain for 2 days. Five days ago, he had
fever and cough that had lasted for 3 days. On physical examination, the child has no fever, and
vital signs are normal, as are cranial nerves, speech, and language. Muscle bulk, tone, and
reflexes are normal and symmetric, but his lower legs are painful to palpation. Serum creatine
kinase is 2,000 U/L, and urine is negative for myoglobin.
A. dermatomyositis
C. Guillain-Barr syndrome
D. metabolic myopathy
E. viral myositis
References:
Moughan B. Musculoskeletal symptom complexes. In: Long SS, Pickering LK, Prober CG, eds.
Principles and Practice of Pediatric Infectious Diseases. New York, NY: Churchill Livingstone;
2003:150-159
Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell,
Douglas, and Bennett's Principals and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa:
Elsevier Churchill Livingstone; 2005:1194-1203
Roos KL. Viral infections. In: Goetz CG, ed. Textbook of Clinical Neurology. 3rd ed. Saunders
Elsevier; 2007:chapt 41
Critique: 134
Violaceous discoloration of the cheeks and eyelids (ie, heliotrope) in a child who has
dermatomyositis. (Courtesy of J. Jorizzo)
Critique: 134
Gottron papules: Erythematous scaling papules overlying the knuckles in a child who has
dermatomyositis. (Courtesy of D. Krowchuk)
Critique: 134
Question: 135
The pregnant mother of a child in your practice recently learned that her grandmother had a
child who died of "probable metabolic disease" at 2 days of age. She does not know details, and
medical records on that child no longer are available. The mother asks if her pregnancy can be
tested to see if the fetus could be affected with the same disorder.
Of the following, the MOST accurate statement regarding metabolic disease in the prenatal
setting is that
B. knowing the parents ethnic backgrounds aids in determining which tests should be offered
C. level 2 ultrasonography during the second trimester is likely to be helpful in detecting metabolic
disease
References:
Driscoll DA, Sehdev HM, Marchiano DA. Prenatal carrier screening for genetic conditions.
NeoReviews. 2004;5:e290-e295. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/5/7/e290
Prenatal diagnosis: emerging technologies for prenatal diagnosis. In: Nussbaum RL, McInnes
RR, Willard HF, eds. Thompson & Thompson Genetics in Medicine. 7th ed. Philadelphia, Pa:
Elsevier Saunders; 2007:456
Critique: 135
Question: 136
A 17-year-old young man comes to your office for a preparticipation sports physical examination
for high school wrestling. He reports that his coach would like him to wrestle in a weight category
that is 10 lb less that his current weight. After you determine that his desired weight is in the
range of healthy weight for his height, you counsel him regarding safe weight loss.
Of the following, the MOST appropriate statement regarding healthy weight control practices for
young athletes is that
B. dehydration causes greater body heat storage, reduces blood volume, and results in
increased exercise tolerance
C. most high school boys who participate in "weight-sensitive" sports practice unhealthy weight
loss behaviors
D. optimal values for body composition have been established for all sports
E. weight loss beyond 1.5% of body weight per week results in muscle weakness
References:
American Academy of Pediatrics Council on Sports Medicine and Fitness and Council on School
Health. Active healthy living: prevention of childhood obesity through increased physical activity.
Pediatrics. 2006;117:1834-1842. http://pediatrics.aappublications.org/cgi/content/full/117/5/1834
McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd
International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39:196-
204. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15793085
Question: 137
You are evaluating a 2-week-old breastfed infant who is 15% below his birthweight and has been
lethargic and fed poorly over the past 4 days. You administer a normal saline fluid bolus.
Laboratory results include:
Blood glucose of 126.0 mg/dl (7.0 mmol/L)
Serum sodium of 170.0 mEq/L (170.0 mmol/L)
Serum potassium of 5.0 mEq/L (5.0 mmol/L)
Blood urea nitrogen of 31.0 mg/dL (11.1 mmol/L)
Serum creatinine of 2.9 mg/dL (256.4 mcmol/L)
Of the following, the MOST appropriate initial fluid for correction is a solution containing 5%
dextrose and
KCl (mEq/L): 40
Duration of Infusion(hr): 12 to 24
KCl (mEq/L): 0
Duration of Infusion(hr): 48 to 72
KCl (mEq/L): 40
Duration of Infusion(hr): 12 to 24
KCl (mEq/L): 0
Duration of Infusion(hr): 12 to 24
KCl (mEq/L): 40
Duration of Infusion(hr): 48 to 72
Water deficit (mL)= 4 mL x ideal body weight (kg) x desired change in serum sodium
concentration
References:
Greenbaum LA. Electrolyte and acid-base disorders. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:267-308
Moritz ML, Ayus JC. Disorders of water metabolism in children: hyponatremia and
hypernatremia. Pediatr Rev. 2002:23:371-380. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/23/11/371
Question: 138
You are asked to see a 7-year-boy in whom medulloblastoma (primitive neuroectodermal tumor)
was diagnosed at age 3 years. Treatment at that time consisted of chemotherapy and
craniospinal irradiation. During the past year, he grew 2 cm, although he is eating normally, and
his weight is appropriate for height. Despite spinal irradiation, the upper-to-lower segment ratio is
normal for his age.
C. Cushing syndrome
E. tumor recurrence
References:
Darzy KH, Pezzoli SS, Thorner MO, Shalet SM. The dynamics of growth hormone (GH)
secretion in adult cancer survivors with severe GH deficiency acquired after brain irradiation in
childhood for nonpituitary brain tumors: evidence for preserved pulsatility and diurnal variation
with increased secretory disorderliness. J Clin Endocrinol Metab. 2005;90:2794-2803. Available
at: http://jcem.endojournals.org/cgi/content/full/90/5/2794
Rose SR. Growth failure after childhood cancer: role of growth hormone deficiency. UpToDate
online 15.3. 2008. Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=ped_onco/2817
Question: 139
A 24-month-old child has been evaluated and found eligible for early intervention services
because of language delay. His mother is reluctant to pursue therapy because she feels that his
language will improve without intervention.
A. agree with the mother that his speech probably will improve without therapy
B. explain that therapy at this age is parent-based training to promote appropriate development in
the home setting
C. explain that therapy is critical for the child or the child will have regression in her language
development
E. warn the mother that if she does not enroll the child in therapy, she can be reported for child
neglect
References:
American Academy of Pediatrics Committee on Children With Disabilities. Role of the pediatrician
in family-centered early intervention services. Pediatrics. 2001;107:1155-1157. Available at:
http://pediatrics.aappublications.org/cgi/content/full/107/5/1155
American Academy of Pediatrics Committee on Children With Disabilities. The pediatrician's role
in development and implementation of an Individual Education Plan and/or and Individual Family
Service Plan. Pediatrics. 1999;104:124-127. Available at:
http://pediatrics.aappublications.org/cgi/content/full/104/1/124 Policy reaffirmed. Pediatrics.
2006;117:1846-1847. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/5/1846
Question: 140
A 10-year-old boy presents with a 1-day history of fever and a swollen leg. According to his
mother, the boy developed a small abrasion on his leg while playing outside 3 days ago. Last
night he began to complain of pain in the area and had a low-grade fever. This morning his
temperature was 102.4F (39.1C) and the area around the abrasion looked very red and was
tender to palpation. About 2 hours later, the swelling had increased. Physical examination
reveals a boy in no apparent distress who has a temperature of 101.4F (38.6C), a heart rate of
93 beats/min, a respiratory rate of 23 breaths/min, and a blood pressure of 95/65 mm Hg. All
other findings are normal, except for a small erythematous abrasion just above the medial
malleolus that has no discharge. Erythema from this area extends to a well-demarcated region
of the mid-calf and is tender to touch (Item Q140).
A. Pseudomonas aeruginosa
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Streptococcus pyogenes
E. Vibrio vulnificans
Question: 140
References:
Jaggi P, Shulman ST. Group A streptococcal infections. Pediatr Rev. 2006;27:99-105. Available
at: http://pedsinreview.aappublications.org/cgi/content/full/27/3/99
Critique: 140
Critique: 140
Necrotizing fasciitis is characterized by pain, erythema, and swelling that progress to necrosis
and bullae formation. It may be caused by infection with a number of agents. (Courtesy of
Bernard Cohen, MD; DermAtlas; www.dermatlas.org)
Question: 141
You are evaluating a previously healthy 3-year-old boy for a 3-day history of nausea; vomiting;
and profuse watery, nonbloody diarrhea that has worsened over the last 24 hours. He can keep
down water and an oral electrolyte maintenance solution but has no interest in eating solid food.
The family returned 5 days ago from a 1-week vacation at a resort in Acapulco, Mexico. On
physical examination, the tired-appearing little boy has a temperature of 100.8F (38.3C), moist
mucous membranes, and a soft abdomen with mild diffuse tenderness to palpation. Laboratory
tests document a peripheral white blood cell count of 6.7x103/mcL (6.7x109/L); hemoglobin of
12.0 g/dL (120.0 g/L); platelet count of 230.0x103/mcL (230.0x109/L); and a differential count of
50% neutrophils, 40% lymphocytes, and 10% monocytes.
Of the following, the MOST likely pathogen causing this patients condition is
A. Campylobacter jejuni
B. Escherichia coli
C. Giardia lamblia
D. Salmonella sp
E. Shigella sp
References:
Donnenberg MS. Enterobacteriaceae. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell,
Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa:
Elsevier Churchill Livingstone; 2005:2567-2586
Ericsson CD, DuPont HL. Travelers' diarrhea: approaches to prevention and treatment. Clin
Infect Dis. 1993;16:616-626
Guerrant RL, Bobak DA. Nausea, vomiting, and noninflammatory diarrhea. In: Mandell GL,
Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious
Diseases. 6th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2005:1236-1249
Nataro JP, Kaper JB. Diarrheogenic Escherichia coli. Clin Microbiol Rev. 1998;11:142-201.
Available at: http://cmr.asm.org/cgi/content/full/11/1/142?view=long&pmid=9457432
Critique: 141
Question: 142
A 5-year-old boy presents with dark red urine, fever, and rhinorrhea. He was well until 2 days
ago, when he developed rhinorrhea and mild cough. He denies urgency, frequency, dysuria,
back pain, or musculoskeletal complaints. On physical examination, the slightly ill-appearing boy
has a temperature of 99.5F (37.5C), heart rate of 130 beats/min, respiratory rate of 18
breaths/min, and blood pressure of 104/58 mm Hg. He has pale conjunctivae, mild scleral
icterus, a hyperdynamic precordium, and a I/VI systolic murmur at the left upper sternal border.
There is no edema, and musculoskeletal and neurologic examination results are normal.
Urinalysis results include: red appearance, a specific gravity of 1.030, pH of 6.5, 3+ blood, and
no protein. Microscopy reveals fewer than 5 red blood cells/high-power field (HPF), fewer than 5
white blood cells/HPF, and no casts.
C. renal/bladder ultrasonography
D. urine culture
References:
Kalia A, Travis LB. Hematuria, leukocyturia, and cylindruria. In: Edelmann CM Jr, Bernstein J,
Meadow SR, Spitzer A, Travis LB, eds. Pediatric Kidney Disease. 2nd ed. Boston, Ma: Little,
Brown and Company; 1992:553-563
Moxey-Mims M. Hematuria and proteinuria. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:129-141
Schwartz G. Clinical assessment of renal function. In: Kher KK, Schnaper HW, Makker SP, eds.
Clinical Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:71-93
Question: 143
You are evaluating a 16-year-old girl during her biannual asthma follow-up visit. She has a
history of mild persistent asthma that is well-controlled on a low-dose inhaled corticosteroid. You
review the asthma guidelines and recommend that she receive the influenza vaccine. Her
mother immediately replies, "Oh no, my daughter has a severe egg allergy and was told to never
get the influenza vaccine."
Of the following, the vaccine that is contraindicated in a patient who has a severe
immunoglobulin E-mediated egg allergy is
B. measles-mumps-rubella
C. tetanus diphtheria
D. varicella
E. yellow fever
References:
American Academy of Pediatrics. Active immunization. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:9-10
Cerecedo Carballo I, Dieguez Pastor MC, Bartolom Zavala B, Snchez Cano M, de la Hoz
Caballer B. Safety of measles-mumps-rubella vaccine (MMR) in patients allergic to eggs. Allergol
Immunopathol (Madr). 2007;35:105-109. Available at: http://db.doyma.es/cgi-
bin/wdbcgi.exe/doyma/mrevista.pubmed_full?inctrl=05ZI0102&rev=105&vol=35&num=3&pag=10
5
Cox JE, Cheng TL. In brief: egg-based vaccines. Pediatr Rev. 2006;27:118-119. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/3/118
Question: 144
A 3-month-old infant is brought to the office for fussiness, increased sleeping, and poor feeding.
According to his mother, he was doing well until 4 days ago, when his formula intake decreased
from 6 oz every 3 to 4 hours to 1 to 2 oz every 4 hours and she had to awaken him to feed. He
has had no vomiting, diarrhea, or fever. He was born at term, and the mother had no antenatal
infections. On physical examination, the infant is difficult to console and has a high-pitched cry.
His temperature is 98.2F (36.8C), heart rate is 160 beats/min, and respiratory rate is 30
breaths/min. His anterior fontanelle is flat, pupils are 4 mm and equally reactive, and there is no
evidence of corneal abrasions. His lungs are clear, heart sounds are normal, and abdominal
evaluation findings are benign. His extremities are warm, well-perfused, and have normal tone.
Results of the initial laboratory evaluation, including a complete blood count with differential
count, electrolytes, and urinalysis, are normal. The fecal occult blood test result is negative.
A. abdominal ultrasonography
B. chest radiography
References:
Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007;25:1137-1159. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/17950139
Keenan HT, Runyan DK, Marshall SW, Nocerna MA, Merten DF. A population-based
comparison of clinical and outcome characteristics of young children with serious inflicted and
noninflicted traumatic brain injury. Pediatrics. 2004;114:633-639. Available at:
http://pediatrics.aappublications.org/cgi/content/full/114/3/633
Laskey AL, Holsti M, Runyan DK, Socolar RRS. Occult head trauma in young suspected victims
of physical abuse. J Pediatr. 2004;144:719-722. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15192615
Newton AW, Vandeven AM. Update on child maltreatment with a special focus on shaken baby
syndrome. Curr Opin Pediatr. 2005;17:246-251. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15800421
Sirotnak AP, Grigsby T, Krugman R. Physical abuse of children. Pediatr Rev. 2004;25:264-277.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/8/264
Critique: 144
Critique: 144
Computed tomography scan without contrast in a 3-year-old who was the victim of nonaccidental
trauma shows a large left subdural hematoma (arrows) with 4-mm left-to-right midline shift.
(Courtesy of D. Krowchuk)
Question: 145
A 13-year-old boy who has a 1-year history of abdominal pain in the epigastric and periumbilical
regions presents for further evaluation. According to his history, the pain occurs one to three
times per week and sometimes interferes with school attendance and physical activity. Findings
on physical examination are normal. You review the diagnostic studies that have been
performed in the past year.
Of the following, the finding that MOST warrants referral for upper endoscopy is
References:
Fox VL. Gastrointestinal endoscopy: patient preparation and surgical considerations. In: Walker
WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR, eds. Pediatric
Gastrointestinal Disease. 4th ed. Hamilton, Ontario, Canada: BC Decker; 2004:1666-1673
Question: 146
You are called to the newborn nursery to see a 2.1-kg term infant whose bedside glucose
screening test value is 30 mg/dL (1.7 mmol/L). The nurse describes the baby as being generally
lethargic, jittery with stimulation, and intolerant of oral feeding attempts at 4 hours of age (poor
oral suckling and emesis of the small volumes of formula taken). He was born at 41 weeks
gestation to a mother who had poor weight gain, smoked cigarettes, and had hypertension. The
Apgar scores following a vaginal delivery were 6 and 8 at 1 and 5 minutes, respectively. There is
no history of maternal diabetes, illicit drug use, or intrapartum difficulties. On physical
examination, the babys vital signs are normal except for tachypnea (respiratory rate of 80
breaths/min), with pulse oximetry of 90% on room air. The infant has plethora, acrocyanosis,
and generalized low tone. He exhibits rapid, shallow tachypnea, with clear lungs bilaterally on
auscultation. There is a soft I/VI systolic murmur along the lower left sternal border and no
gallop. Upon stimulation, he has jittery hand movements. Laboratory findings include:
Serum glucose, 45.0 mg/dL (2.5 mmol/L)
White blood cell count, 7.0x10 3/mcL (7.0x109/L) with a normal differential count
Platelet count, 150.0x10 3/mcL (150.0x109/L)
Hematocrit, 70% (0.70)
An arterial blood gas reveals a pH of 7.40, Pao2 of 75 mm Hg, Paco2 of 30 mm Hg, and base
excess of -7 mEq/L.
Of the following, the MOST appropriate treatment for this infants underlying problem is
A. administration of amphotericin B
E. phototherapy
Polycythemia cannot be treated solely with intravenous crystalloid because this fluid leaves
the circulatory compartment easily. Because the patient does not have evidence of systemic
fungal infection, amphotericin B is not indicated and would not treat polycythemia. The infant in
the vignette does not have hypoxemia or hypercarbia that warrants intubation and assisted
ventilation. Phototherapy does not treat polycythemia, only the hyperbilirubinemia that follows. A
double-volume exchange transfusion is used to treat severe hyperbilirubinemia.
References:
Ceriani Cernadas JM, Carroli G, Pellegrini L, et al. The effect of timing of cord clamping on
neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial.
Pediatrics. 2006;117:e779-e786. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/4/e779
Luchtman-Jones L, Schwartz AL, Wilson DB. Blood component therapy for the neonate. In:
Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th
ed. Philadelphia, Pa: Mosby Elsevier; 2006:1344-1356
Philip AGS, Saigal S. When should we clamp the umbilical cord? NeoReviews. 2004;5:e142-
e154. Available for subscription at: http://neoreviews.aappublications.org/cgi/content/full/5/4/e142
Critique: 146
Question: 147
A worried mother brings her 4-year-old son to your office because his right eye has been red for
3 days. She assumed it was pink eye that he contracted at child care, but she now is concerned
because he has developed swelling in front of his right ear, and his eye has become redder.
They live in a wooded area and got a new kitten 6 weeks ago, but there is no history of the kitten
scratching the child. Physical examination reveals a well-appearing child who has obvious
conjunctival injection (Item Q147A) of the right eye but no discharge or pain. You palpate a 2x2-
cm tender, mobile preauricular lymph node (Item Q147B) and a 2x3-cm anterior cervical lymph
node on the right. The remainder of the physical examination findings are normal.
Of the following, the MOST likely pathogen causing this boys symptoms is
A. Bartonella henselae
B. Francisella tularensis
C. Haemophilus influenzae
D. Pasteurella multocida
E. Staphylococcus aureus
Question: 147
(Courtesy of M. Rimsza)
Question: 147
(Courtesy of M. Rimsza)
References:
American Academy of Pediatrics. Cat-scratch disease. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:246-248.
Critique: 147
Critique: 147
Critique: 147
A papule at the site of inoculation may be observed and precedes the development of
lymphadenopathy by 1 to 2 weeks. (Courtesy of M. Rimsza)
Question: 148
A mother brings in her 3-month-old boy because he has had a worsening cough over the past 2
days. She reports that he has been afebrile but not feeding as well as he normally does. You
note a few coarse breath sounds, rare wheezing, and intermittent subcostal retractions on
physical examination. His respiratory rate is 56 breaths/min and temperature is 101.5F
(38.6C). There is a family history of asthma. A trial of albuterol results in minimal improvement in
his chest findings. His oxygen saturation is 89% on room air.
References:
Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev.
2006;3:CD001266. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001266/frame.html
Lozan JM. Bronchiolitis (updated). BMJ Clinical Evidence. 2007. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0308/0308.jsp
Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis hospitalizations
in the United States.Pediatrics 2006;118:2418-2423. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/6/2418
Willson DF, Horn SD, Hendley JO, Smout R, Gassaway J. Effect of practice variation on
resource utilization in infants hospitalized for viral lower respiratory illness. Pediatrics.
2001;108;851-855. Available at: http://pediatrics.aappublications.org/cgi/content/full/108/4/851
Question: 149
A 15-year-old patient is brought to your office with a complaint of chest pain. She had been
healthy until 3 days ago, when she developed a fever. The pain is precordial, referred to the
epigastrium, and exacerbated by deep breathing and coughing. She refuses to lie down and
prefers to sit leaning forward.
E. T-wave flattening
References:
Cava J, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am.
2004;51:1553-1568. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15561173
Fahey J. Chest pain. In: Rudolph C, Rudolph A, eds. Rudolph's Pediatrics. 21st ed. New York,
NY: McGraw Hill Medical Publishing Division; 2003:1894-1897
Nowlen TT, Bricker JT. Pericardial disease. In: Moller JH, Hoffman JIE, eds. Pediatric
Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone; 2000:780-792
Critique: 149
Critique: 149
Pre-excitation (early depolarization of the QRS complex) manifests as delta waves (arrows) and
is a feature of Wolff-Parkinson-White syndrome. (Courtesy of A. Friedman)
Critique: 149
Critique: 149
Question: 150
A 14-year-old boy who has epilepsy presents to the emergency department after a generalized
tonic-clonic seizure that began on the playground at school. He continued to convulse en route
in the ambulance, where he received 15 mg diazepam rectally and intravenous access was
achieved. In the emergency department, he continues to be unresponsive, exhibiting
tachycardia and nonsuppressable bilateral synchronous rhythmic clonic jerks.
References:
Johnston MV. Seizures in childhood. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2457-
2475
Riviello JJ Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child
with status epilepticus (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology and the Practice Committee of the Child
Neurology Society. Neurology. 2006;67:1542-1550. Available at:
http://www.neurology.org/cgi/content/full/67/9/1542
Riviello JJ Jr, Holmes GL. The treatment of status epilepticus. Semin Pediatr Neurol.
2004;11:129-138. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15259866
Critique: 150
Question: 151
A 2-day-old male is approaching hospital discharge from the regular nursery. You receive an
urgent call from the nurse caring for him, who says that he would not awaken for his last feeding
and is now difficult to arouse. A blood glucose determination is normal. You arrange for
laboratory tests and call the neonatologist to evaluate the baby while you make plans to leave
your office. When you arrive at the hospital 45 minutes later, the baby has been transferred to
the neonatal intensive care unit, is now comatose, and has irregular breathing. Results of a
complete blood count with differential count, platelets, and a chemistry panel, including renal and
liver function tests, are normal.
Of the following, the MOST appropriate laboratory test for diagnosis and formulating a treatment
plan for this baby is
A. acylcarnitine profile
B. serum ammonia
References:
Burton BK. Inborn errors of metabolism in infancy: a guide to diagnosis. Pediatrics. 1998;102:e69-
e78. Available at: http://pediatrics.aappublications.org/cgi/content/full/102/6/e69
Hoffmann GF, Nyhan WL, Zschocke J, Kahler SG, Mayatepek E. Approach to the patient with
metabolic disease. In: Inherited Metabolic Diseases. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2002:19-94
Niemi A-K, Enns GM. Pharmacology review: sodium phenylacetate and sodium benzoate in the
treatment of neonatal hyperammonemia. NeoReviews. 2006;7:e486-e495. Available for
subscription at: http://neoreviews.aappublications.org/cgi/content/full/7/9/e486
Nyhan WL, Barshop NA, Ozand PT. Hyperammonemia and disorders of the urea cycle:
introduction to hyperammonemia and disorders. In: Atlas of Metabolic Diseases. 2nd ed.
London, England: Hodder Arnold; 2005:191-198
Critique: 151
Question: 152
During the annual health supervision visit of a 16-year-old patient, he reports smoking a pack of
cigarettes daily. He plans to become a vocal music major in college and is concerned that
smoking may affect his voice, but he is uncertain if he wants to stop smoking at this time.
Of the following, the MOST appropriate statement to include in your counseling regarding
smoking cessation is that
A. chronic obstructive lung disease is the first pulmonary problem to arise in cigarette smokers
D. initial symptoms of nicotine dependence occur in some teens after only a few cigarettes
References:
Ammerman SD. Tobacco. In: Neinstein LS, ed. Adolescent Health Care: A Practical Guide. 5th
ed. Philadelphia, Pa: Lippincott Williams & Wilkins;, 2008:888-907
Centers for Disease Control and Prevention. Youth Risk Behavior Survey: 2007. Available at:
http://www.cdc.gov/Features/RiskBehavior/
Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States,
2005. MMWR Surv Summ. 2006;55(No.SS-5). Available at:
http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf
Klein JD, Camenga DR. Tobacco prevention and cessation in pediatric patients. Pediatr Rev.
2004;25:17-26. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/1/17
Question: 153
You are evaluating a 2-month-old girl who has suspected infantile botulism. On physical
examination, she has a weak cry, poor head control, dilated pupils, and a markedly decreased
gag reflex. Her respiratory rate is 30 breaths/min, and she has decreased breath sounds
bilaterally at her lung bases. Her oxygen saturation on room air is 85%, but has increased to
90% on 3 L/min of oxygen administered by nasal cannula. An arterial blood gas evaluation on 3
L/min oxygen shows a pH of 7.24, a Paco2 of 60 mm Hg, and a Pao2 of 70 mm Hg.
References:
Frankel LR. Respiratory distress and failure. In: Kliegman RM, Behrman RE, Jenson HB,
Stanton, BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:421-423
Pope J, McBride J. Consultation with the specialist: respiratory failure in children. Pediatr Rev.
2004;25:160-167. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/5/160
Question: 154
A 12-year-old girl who developed type 1 diabetes at age 3 years comes in with her parents for a
health supervision visit. Her diabetes control has been excellent. Physical examination reveals
Sexual Maturity Rating 2 pubic hair and breast development and a palpable and somewhat firm
thyroid gland.
A. Graves disease
B. Hashimoto thyroiditis
C. iodine deficiency
D. multinodular goiter
References:
Aldasouqi SA, Akinsoto OPA, Jabbour SA. Polyglandular autoimmune syndrome type 1.
eMedicine Specialties, Endocrinology, Multiple Endocrine Disease and Miscellaneous Endocrine
Disease. 2006. Available at: http://www.emedicine.com/med/topic1867.htm
LaFranchi S. Thyroiditis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson
Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2327-2329
Question: 155
A 9-year-old child has been struggling in his regular third-grade classroom and has not yet
received additional educational support. A comprehensive psychoeducational evaluation reveals
a significant discrepancy between cognitive testing scores and academic performance for
reading and writing.
References:
American Academy of Pediatrics Committee on Children With Disabilities. The pediatrician's role
in development and implementation of an Individual Education Plan and/or an Individual Family
Service Plan. Pediatrics. 1999;104:124-127. Available at:
http://pediatrics.aappublications.org/cgi/content/reprint/104/1/124
Ewen JB, Shapiro BK. Specific learning disabilities. In: Accardo PJ. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume II: The Spectrum of
Neurodevelomental Disabilities. 3rd ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2008:553-
577
Fessler MA, Plourde PA. Psychoeducational assessment. In: Accardo PJ. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume II: The Spectrum of
Neurodevelomental Disabilities. 3rd ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2008:591-
610
Question: 156
You are the physician for the child care center that your child attends. When an outbreak of
diarrhea occurs at the center, the director calls you. She knows infections due to Giardia lamblia
are common in child care centers, but asks if she needs to be worried about anything else.
Of the following, the organism MOST likely to cause a child care outbreak is
A. Aeromonas hydrophila
B. Campylobacter jejuni
C. Salmonella sp
D. Shigella sp
E. Yersinia enterocolitica
References:
American Academy of Pediatrics. Children in out-of-home child care. In: Pickering LK, Baker CJ,
Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases.
27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:130-145.
American Academy of Pediatrics. Shigella infections. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:589-591
Spence JT, Cheng TL. In brief: Shigella species. Pediatr Rev. 2004;25:329-330. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/9/329
Question: 157
A frantic mother brings in her three children, all of whom suddenly developed fevers, red and
sore eyes, headaches, and sore throats 2 days after attending a swimming party at a country
club. The mother states that five other children and 10 adults who attended the party have
similar symptoms. On physical examination, all of the children have temperatures higher than
102.0F (38.9C), bilateral conjunctivitis, nasal congestion, and exudative pharyngitis.
A. adenovirus
B. Chlamydia trachomatis
C. Epstein-Barr virus
D. Leptospira sp
E. Mycoplasma pneumoniae
References:
American Academy of Pediatrics. Adenovirus infections. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:202-204
American Academy of Pediatrics. Chlamydia trachomatis. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:252-257
American Academy of Pediatrics. Leptospirosis. In: Pickering LK, Baker CJ, Long SS, McMillan
JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:424-426
American Academy of Pediatrics. Mycoplasma pneumoniae infections. In: Pickering LK, Baker
CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:468-470
Singh-Naz N, Rodriguez W. Adenoviral infections in children. Adv Pediatr Infect Dis. 1996;11:365-
388
Critique: 157
Question: 158
A 16-year-old girl presents with symptoms of burning with micturition and back pain. Her
temperature is 101.3F (38.5C), heart rate is 88 beats/min, respiratory rate is 14 breaths/min,
and blood pressure is 108/64 mm Hg. You can elicit costovertebral angle tenderness on the left
side and suprapubic tenderness. Her urinalysis demonstrates a urine specific gravity of 1.025,
pH of 6.5, 2+ blood, 1+ protein, 3+ leukocyte esterase, and positive for nitrite. Microscopy
reveals 5 to 10 red blood cells/high-power field (HPF), 50 to 100 white blood cells/HPF, 4+
bacteria, and occasional squamous epithelial cells.
B. acute glomerulonephritis
C. acute pyelonephritis
D. bacterial urethritis
E. nephrolithiasis
References:
Ginsburg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics.
1982;69;409-412. Available at: http://pediatrics.aappublications.org/cgi/content/abstract/69/4/409
Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract
infection in febrile infants. J Pediatr. 1993;123:17-23. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/8320616
Johnson CE. New advances in childhood urinary tract infections. Pediatr Rev. 1999:20:335-342.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/20/10/335
Question: 159
A 17-year-old boy presents to the emergency department with respiratory distress and hypoxia
(room air Po2, 86%). His parents called 911 after their son started "gasping for air." The boy
has a history of moderate persistent asthma that recently worsened after a viral infection. He
uses a daily inhaled corticosteroid and an as-needed beta2 agonist inhaler. During the past 2
days, he has not been able to go to school because of his breathing problems, and his parents
have used his nebulizer every 2 hours over the past 12 hours. On physical examination, the boy
is awake and responsive to questions, but his respiratory rate is 34 breaths/min, and he has
nasal flaring and intercostal retractions. Lung examination demonstrates equal breath sounds
bilaterally but obvious expiratory wheezing with a prolonged expiratory phase. The results of an
arterial blood gas on a nonrebreather with 100% oxygen are: pH of 7.35 (normal, 7.35 to 7.45),
Pco2 of 45 mm Hg (normal, 35 to 45 mm Hg), bicarbonate of 24.0 mEq/L (24.0 mmol/L)(normal,
22.0 to 26.0 mEq/L [22.0 to 26.0 mmol/L]), and Po2 of 90 mm Hg (normal, 75 to 100 mm Hg).
Of the following, a TRUE statement regarding the management of this boys condition is that
A. a normal carbon dioxide value on an arterial blood gas measurement makes an asthma
exacerbation unlikely
D. the parents should have doubled his inhaled corticosteroid dose when his beta2 agonist was
not working
E. the patient should blow into a paper bag to help calm him
References:
Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid
to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363:271-275.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/14751699
Keeley D, McKean M. Asthma and other wheezing disorders in children. BMJ Clinical Evidence.
2006. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0302/0302.jsp830Q1
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines
for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol.
2007;120:S94-S138. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17983880
Question: 160
You are camping with a group of boys at a rural campground in the southeastern United States
when one of the campers is bitten by a snake. His tent mates kill the snake (Item Q160). The
victim is crying and guarding his right hand. On examination of the boys hand, you note several
small, erythematous abrasions but no swelling or ecchymosis.
Question: 160
Snake, as described in the vignette. (Courtesy of D. Krowchuk, wih special thanks to Sci Works,
Winston-Salem, NC)
References:
Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med. 2002;347:347-356.
Extract available at: http://content.nejm.org/cgi/content/extract/347/5/347
Schmidt JM. Antivenom therapy for snakebites in children: is there evidence? Curr Opin Pediatr.
2005;17:234-238. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15800419
Singletary EM, Rochman AS, Bodmer JCA, Holstege CP. Envenomations. Med Clin North Am.
2005;89:1195-1224. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16227060
Critique: 160
Critique: 160
Southern copperhead. (Courtesy of the Centers for Disease Control and Prevention, Public
Health Image Library, Edward J. Wozniak)
Critique: 160
Comparison of venomous snakes (pit vipers) and nonvenomous snakes in the United States.
(Reprinted with permission from Gold BS, Dart RC, Barish RA. Bites of venoumous snakes. New
Engl J Med. 2002;347:347-356 Copyright 2002 Massachusetts Medical Society. All rights
reserved.
Critique: 160
Arizona coral snake: Note the wide red and black rings separated by narrow pale yellow rings.
The coral snake can be distinguished from similarly colored harmless snakes by the adjacent red
and yellow bands ("red on yellow, kill a fellow"). See item C160E. (Courtesy of J Brashears and
M Feldner)
Critique: 160
Nonvenomous milk snake: Although the markings are similar to those of a coral snake, red and
black (not yellow) bands are adjacent ("red on black, friend of Jack"). (Courtesy of the Centers
for Disease Control and Prevention, Public Health Image Library, Edward J. Wozniak)
Critique: 160
Ecchymosis, swelling, and ruptured hemorrhagic bullae may be observed following the bite of a
venomous snake. (Courtesy of M. Rimsza)
Question: 161
An 8-year-old girl presents to the emergency department with a history of recurrent severe
vomiting. According to the family, she has had four similar episodes in the past 6 months. Each
time, the child awakens from sleep, vomits every 20 minutes for 6 hours, and then goes back to
bed. Between episodes, which occur approximately every 4 to 6 weeks, the child is happy and
playful. Normal results have been found on prior head magnetic resonance imaging, upper
gastrointestinal radiograph series, and renal ultrasonography. In the emergency department, the
girl is quiet, somewhat listless, and prefers to be in a dark room with an emesis basin. Results of
physical examination are unremarkable, and optic discs are sharp. After 8 hours of intravenous
hydration, the symptoms resolve, and she is discharged.
Of the following, the MOST appropriate medication to treat her underlying condition is
A. amitriptyline
B. lubiprostone
C. omeprazole
D. ranitidine
E. sucralfate
References:
Li BU, Misiewicz L. Cyclic vomiting syndrome: a brain-gut disorder. Gastroenterol Clin North Am.
2003;32:997-1019. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/14562585
Question: 162
You are examining a preterm infant who was delivered at 34 weeks gestation due to premature
labor and a maternal urinary tract infection. His mother is 23 years old and has had insulin-
dependent diabetes mellitus for many years. Her diabetes reportedly was well managed during
the pregnancy, and a recent hemoglobin A1c measurement was 7.0%. On physical examination,
the infant is appropriately grown for gestational age, weighs 2 kg, and has a gestational age
assessment that equates to 34 weeks. He requires supplemental oxygen with an FiO2 of 0.40
administered by continuous nasal positive airway pressure.
Of the following, the GREATEST concerns for this infant related to his mothers diabetes are
References:
Cowett RM. Neonatal care of the infant of the diabetic mother. NeoReviews. 2002;3:e190-e196.
Available for subscription at: http://neoreviews.aappublications.org/cgi/content/full/3/9/e190
Cowett RM. The infant of the diabetic mother. NeoReviews. 2002;3:e173-e189. Available for
subscription at: http://neoreviews.aappublications.org/cgi/content/full/3/9/e173
Kalhan SC, Parimi PS. Disorders of carbohydrate metabolism. In: Martin RJ, Fanaroff AA, Walsh
MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed. Philadelphia, Pa: Mosby
Elsevier; 2006:1467-1490
Question: 163
You are discussing the pharmacokinetics and potential interactions of drugs used in the pediatric
population with a group of medical students. One of them asks you if medications should be
taken with food, and you respond that interactions between food and drugs may either reduce or
increase the drug absorption, depending on the type of medication.
Of the following, the MOST accurate advice regarding taking medications with food is that
References:
Gal P, Reed M. Principles of drug therapy. In: Kliegman RM, Behrman RE, Jenson HB, Stanton
BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:331-
338
Schmidt LE, Dalhoff K. Food-drug interactions. Drugs. 2002;62:1481-1502. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/12093316
Critique: 163
Question: 164
During the health supervision visit of a term newborn boy, his mother relates that a cousin's child
died at age 4 months from sudden infant death syndrome. She asks what she can do to prevent
such an occurrence in her son.
References:
Colson ER, Levenson S, Rybin D, et al. Barriers to following the supine sleep recommendation
among mothers at four centers for the Women, Infants, and Children Program. Pediatrics.
2006;118:e243-e250. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/2/e243
Creery D, Mikrogianakis A. Sudden infant death syndrome. BMJ Clinical Evidence. 2006.
Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0315/0315.jsp
Farrell PA, Weiner GM, Lemons JA. SIDS, ALTE, apnea, and the use of home monitors. Pediatr
Rev. 2002;23:3-9. Available at: http://pedsinreview.aappublications.org/cgi/content/full/23/1/3
Fu LY, Moon RY. Apparent life-threatening events (ALTES) and the role of home monitors.
Pediatr Rev. 2007;28:203-208. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/6/203
Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death
syndrome? A meta-analysis. Pediatrics. 2005;116:e716-e723. Available at:
http://pediatrics.aappublications.org/cgi/content/full/116/5/e716
Hein HA, Pettit SF. Back to Sleep: good advice for parents but not for hospitals? Pediatrics.
2001;107:537-539. Available at: http://pediatrics.aappublications.org/cgi/content/full/107/3/537
Moon RY, Fu LY. Sudden infant death syndrome. Pediatr Rev. 2007;28:209-214. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/6/209
Question: 165
You are leading teaching rounds with the residents at the hospital. They present an 18-month-
old boy who has had 6 days of a temperature to at least 102.3F (39.1C). He also has
nonexudative conjunctivitis, a polymorphous rash, erythema of his lips, and swelling of his hands
and feet. The residents ask you to comment on the use of echocardiography in this condition.
Of the following, the MOST accurate statement about echocardiography in this disease is that
References:
American Academy of Pediatrics. Kawasaki disease. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Disease. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:412-415
Newburger JW, Takahashi M, Gerber MA, et al. AHA scientific statement. Diagnosis, treatment,
and long-term management of Kawasaki disease. A statement for health professionals from the
Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on
Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110:2747-
2771. Available at: http://circ.ahajournals.org/cgi/content/full/110/17/2747
Satou GM, Giamelli J, Gewitz MH. Kawasaki disease: diagnosis, management, and long-term
implications. Cardiol Rev. 2007;15:163-169. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17575479
Critique: 165
Question: 166
A 6-year-old boy presents in late summer to the emergency department with a severe headache
and muscle pains. He recently returned from a camping trip. On physical examination, he is
febrile and has no focal weakness, but he suffers a prolonged tonic-clonic seizure and becomes
unresponsive. Head computed tomography scan reveals no abnormalities. Acyclovir and
fosphenytoin are administered. Magnetic resonance imaging shows subtle, diffuse signal change
and thickening in the cerebral cortex, no signal changes in temporal lobes, and no meningeal
enhancement.
A. arbovirus
B. Borrelia burgdorferi
D. Listeria monocytogenes
E. Taenia solium
References:
Halstead S. Arborvirus encephalitis in North America. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:1405-1408
Mazzulli T. Laboratory diagnosis of infection due to viruses, Chlamydia, and Mycoplasma. In:
Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious
Diseases. 2nd ed. New York, NY: Churchill Livingstone; 2003:1392-1408
Critique: 166
Axial computed tomography scan in herpes simplex virus encephalitis shows necrosis in the right
temporal lobe (arrow). (Courtesy of D. Gilbert)
Critique: 166
Question: 167
A 7-month-old boy presents to the emergency department with vomiting and diarrhea. Findings
on physical examination are normal except for dehydration and lethargy. Laboratory tests reveal
a serum glucose concentration of 30.0 mg/dL (1.7 mmol/L). The mother tells you that she
recently had the flu. Family history is negative for any serious or chronic illnesses. You are
considering an inborn error of metabolism.
A. serum calcium
B. serum lipids
C. serum sodium
D. urine ketones
References:
Burton BK. Inborn errors of metabolism in infancy: a guide to diagnosis. Pediatrics. 1998;102:e69-
e78. Available at: http://pediatrics.aappublications.org/cgi/content/full/102/6/e69
Hoffmann GF, Nyhan WL, Zschocke J, Kahler SG, Mayatepek E. Approach to the patient with
metabolic disease. In: Inherited Metabolic Diseases. Philadelphia, Pa. Lippincott Williams &
Wilkins; 2002:19-94
Nyhan WL, Barshop BA, Ozand PT. Disorders of carbohydrate metabolism. In: Atlas of
Metabolic Diseases. 2nd ed. London, England: Hodder Arnold; 2005:371-372
Nyhan WL, Barshop BA, Ozand PT. Hyperammonemia and disorders of the urea cycle:
introduction to hyperammonemia and disorders of the urea cycle. In: Atlas of Metabolic
Diseases. 2nd ed. London, England: Hodder Arnold; 2005:191-192
Nyhan WL, Barshop BA, Ozand PT. Organic acidemia: introduction. In: Atlas of Metabolic
Diseases. 2nd ed. London, England: Hodder Arnold; 2005:1-3, 191-192,371-372
Question: 168
A 15-year-old young woman has had joint pain for the past 3 days. She developed fever, chills,
and fatigue 4 days ago, but the fever has resolved. In addition, she explains that her left elbow,
right knee, and right wrist are all painful, red, and swollen, and she has a rash on her hands and
feet that looks like pus-filled bumps. She is sexually active, with inconsistent condom use for
contraception. Physical examination reveals an afebrile young woman who has swelling,
tenderness, and mild erythema of the left elbow, right knee, and right wrist. She has a few
pustules and vesicles on the right palm and bilateral soles (Item Q168). The abdomen is not
tender and is without masses.
Of the following, the MOST likely pathogen causing this patients symptoms is
A. Chlamydia trachomatis
C. Neisseria gonorrhoeae
D. parvovirus B19
E. Treponema pallidum
Question: 168
References:
American Academy of Pediatrics. Syphilis. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:631-644
Goldenberg DL, Sexton DJ. Disseminated gonococcal infection. UpToDate Online 15.3. 2008.
Available for subscription at: http://www.utdol.com/utd/content/topic.do?topicKey=stds/9841
Workowski KA, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Critique: 168
Patients who have disseminated gonococcal infection often exhibit necrotic pustules that have a
gray appearance. (Courttesy of D. Krowchuk)
Critique: 168
Critique: 168
Critique: 168
Critique: 168
The eruption of secondary syphilis often involves the palms and soles. (Courtesy of C.
Haverstock)
Question: 169
A 5-year-old boy has been receiving mechanical ventilation in the pediatric intensive care unit for
1 week due to complicated adenoviral pneumonia. Over the past several days, he has
developed markedly increased oxygen requirements and progressive opacification of his
bilateral lung fields on chest radiography (Item Q169). He now meets the clinical criteria for
acute respiratory distress syndrome (ARDS). His parents ask about the prognosis.
Of the following, the MOST accurate statement regarding the natural history of ARDS is that
Question: 169
Chest radiography findings, as observed for the child in the vignette. (Courtesy of D. Mulvihill)
References:
Frankel LR. Respiratory distress and failure. In: Kliegman RM, Behrman RE, Jenson HB,
Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:421-423
Vish M, Shanley TP. Acute lung injury and acute respiratory distress syndrome. In: Wheeler DS,
Wong HR, Shanley TP, eds. Pediatric Critical Care Medicine: Basic Science and Clinical
Evidence. New York, NY: Springer-Verlag; 2007:395-411
Critique: 169
Anteroposterior chest radiograph in acute respiratory distress syndrome demonstrates diffuse air
space disease bilaterally without focal consolidation or effusions. (Courtesy of D. Mulvihill)
Question: 170
A 6-month-old baby whose family has just emigrated from Ecuador is brought to your office by
the maternal grandmother. Physical examination reveals length at the 5th percentile, weight at
the 10th percentile, head circumference at the 25th percentile, a sallow complexion with
jaundice, hoarse cry, dry skin, and large tongue. The anterior fontanelle measures 3x4 cm. You
diagnose primary hypothyroidism and start appropriate thyroid hormone replacement therapy.
A. adrenal insufficiency
B. microcephaly
E. precocious puberty
References:
American Academy of Pediatrics, Rose SR and the Section on Endocrinology and Committee on
Genetics, American Thyroid Association, Brown RS and the Public Health Committee, Lawson
Wilkins Pediatric Endocrine Society. Update of newborn screening and therapy for congenital
hypothyroidism. Pediatrics. 2006;117:2290-2303. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/6/2290
Kempers MJ, van der Sluijs Veer L, Nijhuis-van der Sanden RW, et al. Neonatal screening for
congenital hypothyroidism in the Netherlands: cognitive and motor outcome at 10 years of age. J
Clin Endocrinol Metab. 2007;92:919-924. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17164300
Question: 171
You are meeting with a family that recently moved to the United States. The two children, ages
11 months and 24 months, show evidence of global developmental delays. The parents ask
what services are available for their children. You explain that United States federal law provides
children with early intervention services.
Of the following, the BEST explanation about the provisions of the law is that
E. services for infants and toddlers must be family-based and culturally competent
References:
American Academy of Pediatrics Committee on Children With Disabilities. Role of the pediatrician
in family-centered Early Intervention Services. Pediatrics. 2001;107:1155-1157. Available at:
http://pediatrics.aappublications.org/cgi/content/full/107/5/1155
Davidson L. In brief: law and the child. Pediatr Rev. 2003;24:213-214. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/24/6/213
Individuals with Disabilities Education Act 1997. Office of Special Education and Rehabilitative
Services. U.S. Department of Education. Available at:
http://www.ed.gov/about/offices/list/osers/policy.html
Question: 172
Results of a stool culture from a 2-year-old boy who has been hospitalized with bloody diarrhea
indicate that the causative agent is Shigella sp. The boy is allergic to trimethoprim-
sulfamethoxazole.
Of the following, the MOST appropriate antimicrobial agent to use for this patient is
A. amoxicillin
B. azithromycin
C. cefdinir
D. ciprofloxacin
E. linezolid
References:
American Academy of Pediatrics. Shigella infections. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:589-591
Spence JT, Cheng TL. In brief: Shigella species. Pediatr Rev. 2004;25:329-330. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/9/329
Question: 173
You are called to the delivery room to evaluate a term female infant born by precipitous normal
spontaneous vaginal delivery to an 18-year-old young woman who received no prenatal care.
The mother reports using marijuana and alcohol early in her pregnancy and was seen in the
emergency room on two occasions for urinary tract infections. She had several "colds" late in
her pregnancy. She lives with her boyfriend and has two dogs, a cat, and a turtle as pets.
Physical examination of the infant reveals a 2-kg lethargic, jaundiced infant who has a weak cry,
microcephaly, and a distended abdomen. Her liver is palpable 6 cm below the right costal
margin, and her spleen is palpable 4 cm below the left costal margin. She has a diffuse petechial
rash with areas of purpura on her extremities (Item Q173). Laboratory tests show a peripheral
white blood cell count of 10.6x103/mcL (10.6x109/L), hemoglobin of 12.0 mg/dL (120.0 g/L), and
platelet count of 60.0x103/mcL (60.0x109/L). The alanine aminotransferase measurement is 300
U/L, and the aspartate aminotransferase value is 420 U/L. Head ultrasonography shows
scattered intracerebral calcifications.
Of the following, the MOST rapid test for making the diagnosis in this infant is
A. blood culture
D. serology
E. urine culture
Question: 173
Purpura, as exhibited by the infant described in the vignette. (Reprinted with permission from
Stehel E, Sanchez PJ. NeoReviews. 2005;6:e38-e45.)
References:
American Academy of Pediatrics. Cytomegalovirus infection. In: Pickering LK, Baker CJ, Long
SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:273-277
Demmler GJ. Congenital cytomegalovirus infection and disease. Adv Pediatr Infect Dis.
1996;11:135-162
Demmler GJ. Cytomegalovirus. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, eds.
Textbook of Pediatric Infectious Diseases. 5th ed. Philadelphia, Pa: Saunders; 2004:1912-1932
Modlin JF, Grant PE, Makar RS, Roberts DJ, Krishnamoorthy KS. Case records of the
Massachusetts General Hospital. Weekly clinicopathological exercises. Case 25-2003: a
newborn boy with petechiae and thrombocytopenia. N Engl J Med. 2003;349:691-700
Critique: 173
Congenital cytomegalovirus infection may produce petechiae and purpura, as seen on the face of
this infant. (Reprinted with permission from Stehel E, Sanchez PJ. NeoReviews. 2005;6:e38-
e45.)
Critique: 173
Cytomegalovirus retinitis: White areas, often arranged along veins, represent edema due to
inflammation. Areas of early scarring (hyperpigmentation) are present. (Courtesy of R.G.
Weaver, Jr)
Question: 174
A 6-year-old girl is experiencing daytime and nighttime enuresis of 1 months duration. She
achieved daytime continence at age 3 and has been dry at night since age 4. She has no history
of fever, but does have some dysuria. The physical examination is remarkable only for
suprapubic tenderness. Urinalysis demonstrates a specific gravity of 1.015, pH of 6.5, 1+ blood,
trace protein, 3+ leukocyte esterase, and positive for nitrite. Microscopy reveals 2 to 5 red blood
cells/high-power field (HPF), 20 to 50 white blood cells/HPF, and 3+ bacteria. Results of a urine
culture are pending.
Of the following, the MOST appropriate empiric treatment for this patient is
A. amoxicillin
B. cefixime
C. cephalexin
D. ciprofloxacin
E. trimethoprim-sulfamethoxazole
References:
Jantausch B, Kher K. Urinary tract infection. In: Kher KK, Schnaper HW, Makker SP, eds.
Clinical Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:553-573
Keren R, Chan E. A meta-analysis of randomized, controlled trials comparing short- and long-
course antibiotic therapy for urinary tract infections in children. Pediatrics. 2002;109:e70.
Available at: http://pediatrics.aappublications.org/cgi/content/full/109/5/e70
Larcombe J. Urinary tract infection in children. BMJ Clinical Evidence. 2007. Available for
subscription at: http://clinicalevidence.bmj.com/ceweb/conditions/chd/0306/0306.jsp
Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral
antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev.
2003;1:CD003966. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003966/frame.html
Question: 175
An 8-year-old boy presents with wheezing, coughing, and difficulty breathing of 6 months
duration. Findings on his history and pulmonary function tests are suggestive of moderate
persistent asthma. In preparation for asthma management, you have reviewed the current
asthma guidelines, educated the patient on peak flow monitoring, and discussed possible
therapeutic options. You decide to start him on a daily inhaled corticosteroid.
Of the following, the MOST likely adverse event he may experience from inhaled corticosteroids
is
A. acne
C. mood swings
D. oral candidiasis
E. weight gain
References:
Allen DB, Bielory L, Derendorf H, Dluhy R, Colice GL, Szefler SJ. Inhaled corticosteroids: past
lessons and future issues. J Allergy Clin Immunol. 2003;112(3 suppl):S1-S40. Abstract available
at: http://www.ncbi.nlm.nih.gov/pubmed/14515117
Keeley D, McKean M. Asthma and other wheezing disorders in children. BMJ Clinical Evidence.
2006. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0302/0302.jsp830Q1
Schielmer RP, Spahn JD, Covar R, Szefler SJ. Glucocorticoids. In: Adkinson NF, Jr, Yunginger
JW, Busse WW, Bochner BS, Holgate ST, Simons FE, eds. Middleton's Allergy Principles and
Practice. 6th ed. Philadelphia, Pa: Mosby Inc; 2003:870-913
Question: 176
Your first patient of the day is a 2-year-old girl who is brought in by her mother after a brown
spider was found in the childs bed. The mother has brought the spider for you to inspect (Item
Q176A). On physical examination, there is a 2-cm bulla with 4 cm of surrounding erythema on
the medial aspect of the girls calf (Item Q176B). The child otherwise appears well and
occasionally scratches at the lesion.
Of the following, the MOST appropriate course of action for this patient is to
Question: 176
Type of spider brought by the family for inspection. (Courtesy of the Centers for Disease Control
and Prevention, Public Health Image Library)
Question: 176
Bulla with surrouding erythema, as described for the child in the vignette. (Courtesy of M.
Rimsza)
References:
Singletary EM, Rochman AS, Bodmer JCA, Holstege CP. Envenomations. Med Clin North Am.
2005;89:1195-1224. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16227060
Sjogren R, MacGregor RS, Zenel J. Visual diagnosis: an infant who has a red papule on a
swollen, tender arm. Pediatr Rev. 2004;25:182-185. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/5/182
Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N
Critique: 176
Female black widow spider: Note the red hourglass-shaped marking on the ventral abcominal
surface (the color of this marking is variable, however, and may be yellow, orange, or white).
(Courtesy of the Centers for Disease Control and Prevention, Public Health Image Library,
James Gathany)
Critique: 176
Brown recluse spider: Note the violin-shaped marking on the thorax (arrow). (Courtesy of the
Centers for Disease Control and Prevention, Public Health Image Library)
Critique: 176
Following the bite of a brown recluse spider, a bulla with surrounding erythema may develop.
(Courtesy of M. Rimsza)
Critique: 176
An eschar with surrounding erythema may occur following the bite of a brown recluse spider.
(Courtesy of M. Smith)
Critique: 176
Folliowing the bite of a brown recluse spider, an eschar may develop and subsequently separate,
leaving a deep ulcer. (Courtesy of M. Rimsza)
Question: 177
A 12-year-old boy has had intermittent heartburn for the past several years. Results of an upper
gastrointestinal radiographic series performed at age 11 years were normal. Over the past year,
he has had several episodes of "food getting stuck in his chest." The most common foods that
cause him difficulty are hot dogs, steak tips, and chicken strips. Physical examination findings
are unremarkable. He has been treated with omeprazole for 3 months, but symptoms persist.
References:
Furuta GT, Straumann A. Review article: the pathogenesis and management of eosinophilic
oesophagitis. Aliment Pharmacol Ther. 2006;24:173-182. Available at: http://www.blackwell-
synergy.com/doi/full/10.1111/j.1365-2036.2006.02984.x
Nelson SP, Chen EH, Syniar GM, Kaufer Christoffer K; for the Pediatric Practice Research
Group. Prevalence of symptoms of gastroesophageal reflux during childhood. Arch Pediatr
Adolesc Med. 2000;154:150-154.
Critique: 177
Eosinophilic esophagitis: Findings at endoscopy may include mucosal rings (A), furrows (B), and
exudates (C). (Reprinted with permission from Hopp R, Natarajan N. Index of suspicion (case
1). Pediatr Rev. 2007;28:389-394 and courtesy of Doernbecher Childrens Hospital)
Critique: 177
In severe esophagitis, the areas of erythema represent inflammation, and white exudates cover
erosions. (Courtesy of A. Bousvaros)
Question: 178
You are seeing a 12-month-old infant who was born at 26 weeks gestation. He receives daily
diuretics and nasal cannula oxygen with a baseline flow of 0.1 L/min, but his mother called this
morning reporting that he had a temperature of 100.5F (37.8C), nasal congestion, increased
work of breathing with a rapid respiratory rate, and a "wheezing" cough. You instructed her to
increase the oxygen flow rate to 0.5 L/min and come directly to the clinic. Physical examination
reveals intercostal and subcostal retractions, a respiratory rate of 80 breaths/min, and a
prolonged expiratory phase with audible wheezing. A copious, cloudy, green nasal discharge is
present. No heart murmur is audible. Pulse oximetry while receiving 0.5 L/min oxygen reveals an
oxygen saturation of 85% at rest.
Of the following, the BEST explanation for this childs presenting signs of respiratory distress is
C. gastroesophageal reflux
References:
Bancalari EH. Bronchopulmonary dysplasia and neonatal chronic lung disease. In: Martin RJ,
Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed.
Philadelphia, Pa: Mosby Elsevier; 2006:1155-1167
Baraldi E, Filippone M. Chronic lung disease after premature birth. N Engl J Med. 2007;357:1946-
1955. Extract available at: http://content.nejm.org/cgi/content/extract/357/19/1946
Biniwale MA, Ehrenkranz RA. The role of nutrition in the prevention and management of
bronchopulmonary dysplasia. Semin Perinatol. 2006;30:200-208. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16860160
Shaw NJ, Kotecha S. Management of infants with chronic lung disease of prematurity in the
United Kingdom. Early Hum Dev. 2005;81:165-170. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15748971
Question: 179
You are evaluating a 10-month-old boy brought to the emergency department because of
fussiness for 1 day. His mother reports that she was carrying him while answering the phone
yesterday and that he fell from her arms onto the linoleum floor. Physical examination reveals a
thin boy who is crying. He resists weight-bearing on the left leg, but you cannot elicit specific
tenderness. He has bruises on the left temporal region, upper arm, and thighs. You suspect
nonaccidental trauma and order a skeletal survey.
Of the following, the skeletal survey finding that is MOST specific for nonaccidental trauma is
References:
Jenny C; Committee on Child Abuse and Neglect. Evaluating infants and young children with
multiple fractures. Pediatrics. 2006;118:1299-1303. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/3/1299
Kellogg ND and the Committee on Child Abuse and Neglect. Evaluation of suspected child
physical abuse. Pediatrics. 2007;119:1232-1241. Available at:
http://pediatrics.aappublications.org/cgi/content/full/119/6/1232
Sirotnak AP, Grigsby T, Krugman RD. Physical abuse of children. Pediatr Rev. 2004;25:264-
277. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/8/264
Critique: 179
Metaphyseal fracture (arrow) of the left proximal humerus in an infant who had been physically
abused. (Courtesy of D. Krowchuk)
Critique: 179
Bucket handle metaphyseal fracture of the radius (arrow) in a child who has been physically
abused. (Courtesy of S. Sinal)
Critique: 179
Healing posterior rib fractures (arrows) in an infant who has been physically abused. (Courtesy
of D. Krowchuk)
Critique: 179
Right femur fracture in a 2-month-old child who had been physically abused. (Courtesy of D.
Krowchuk)
Critique: 179
Oblique (left) and anteroposterior (right) views of the distal tibia show a nondisplaced spiral
(toddler's) fracture. (Courtesy of D. Mulvihill)
Critique: 179
Retinal hemorrhages and papilledema in an infant who had been shaken. (Courtesy of M.
Rimsza)
Question: 180
A medical student notes on rounds that a 2-year-old girl admitted for pneumonia has a complete
blood count (CBC) that includes a hematocrit of 35% (0.35), hemoglobin of 11.5 g/dL (115.0 g/L),
mean corpuscular volume of 68.0 fL, and platelet and white blood cell counts that are normal for
age. During the bedside encounter with the childs mother, you advise her to start the child on a
multivitamin with iron and have her primary care physician obtain another CBC in a month or so.
The medical student asks why you recommended iron supplementation when the child has a
normal hematocrit.
Of the following, the BEST reason to prescribe supplemental iron therapy for this child at this
time is to prevent
B. fatigue
D. recurrent infections
E. short stature
References:
Konofal E, Lecendreux M, Arnulf I, Mouren MC. Iron deficiency in children with attention-
deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2004;158:1113-1115.
Lozoff B, De Andraca I, Castillo M, Smith JB, Walter T, Pino P. Behavioral and developmental
effects of preventing iron-deficiency anemia in healthy full-term infants. Pediatrics. 2003;112:846-
854. Available at: http://pediatrics.aappublications.org/cgi/content/full/112/4/846
Lozoff B, Jimenez E, Smith JB. Double burden of iron deficiency in infancy and low
socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years. Arch
Pediatr Adolesc Med. 2006;160:1108-1113.
Martins S, Logan S, Gilbert R. Iron therapy for improving psychomotor development and
cognitive function in children under the age of three with iron deficiency anaemia. Cochrane
Database Syst Rev. 2001;2;CD001444. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001444/frame.html
Wu AC, Lesperance L, Bernstein H. Screening for iron deficiency. Pediatr Rev. 2002;23:171-
178. Available at: http://pedsinreview.aappublications.org/cgi/content/full/23/5/171
Question: 181
The youngest child in a family affected by neurofibromatosis 1, who is 5 years old, has just had
the diagnosis confirmed. You begin the process of counseling the family.
Of the following, the MOST accurate statement about potential medical complications in affected
children is that they
E. should be screened annually for optic gliomas using computed tomography scan
References:
Hersh JH, Committee on Genetics. Health supervision for children with neurofibromatosis.
Pediatrics. 2008;121:633-642. Available at:
http://pediatrics.aappublications.org/cgi/content/full/121/3/633
Viskochil DH. Neurocutaneous disorders. In: Rudolph C, Rudolph A, eds. Rudolph's Pediatrics.
21st ed. New York, NY: McGraw Hill Medical Publishing Division; 2003:769-774
Critique: 181
Caf au lait macules and neurofibromas (arrow) are observed in neurofibromatosis type 1.
(Courtesy of the Media Lab at Doernbecher)
Question: 182
During the routine health supervision visit for a 4-month-old infant, you note low tone and poor
visual interaction. His head shape is symmetric and his head circumference is 36 cm (<2nd
percentile). He had been born at term with a head circumference of 32 cm (2nd percentile).
Of the following, the MOST helpful initial diagnostic test to explain the cause of the infants
abnormal examination findings is
B. electroencephalography
C. head ultrasonography
D. high-resolution karyotyping
References:
Kinsman SL, Johnston MV. Congenital anomalies of the central nervous system. In: Kliegman
RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed.
Philadelphia, Pa: Saunders Elsevier; 2007:2443-2456
Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global
developmental delay. Report of the Quality Standards Subcommittee of the American Academy
of Neurology and The Practice Committee of the Child Neurology Society. Neurology.
2003;60:367-380. Available at: http://www.neurology.org/cgi/content/full/60/3/367
Critique: 182
Question: 183
A 2-day-old infant is transferred from the regular nursery to the neonatal intensive care unit for
evaluation and management of poor feeding and lethargy. A serum metabolic panel reveals a
carbon dioxide concentration of 12.0 mEq/L (12.0 mmol/L) and a borderline low white blood cell
count. After stopping all feedings, a septic evaluation is performed, and intravenous antibiotics
are started. During this time, she becomes alert and vigorous, and her carbon dioxide value
normalizes. Three days later, results of the septic evaluation are negative, and the infant
resumes human milk feedings. Initially she does well, but after 2 days, she begins to vomit and
becomes less active. Serum metabolic panel shows a glucose concentration of 35.0 mg/dL (1.9
mmol/L), a carbon dioxide concentration of 8.0 mEq/L (8.0 mmol/L), and an anion gap of 25; the
serum ammonia value is twice the upper limit of normal. The baby is again made NPO and given
intravenous fluids.
Of the following, the MOST critical diagnostic test for this baby is
References:
Burton BK. Inborn errors of metabolism in infancy: a guide to diagnosis. Pediatrics. 1998;102:e69-
e78. Available at: http://pediatrics.aappublications.org/cgi/content/full/102/6/e69
Hoffmann GF, Nyhan WL, Zschocke J, Kahler SG, Mayatepek E. Approach to the patient with
metabolic disease. In: Inherited Metabolic Diseases. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2002:19-94
Nyhan WL, Barshop BA, Ozand PT. Organic acidemias. In: Atlas of Metabolic Diseases. 2nd ed.
London, England: Hodder Arnold; 2005:1-108
Question: 184
A 17-year-old young man comes to the clinic in the juvenile detention center with a penile
discharge. He has no other symptoms. He was tested 1 week ago at a sexually transmitted
infections clinic, and results of the rapid urine testing by nucleic acid amplification are positive for
Neisseria gonorrhoeae and negative for Chlamydia trachomatis.
References:
Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases
treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of
gonococcal infections. MMWR Morbid Mortal Wkly Rep. 2007;56:332-336. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Workowski KA, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Question: 185
A 3-year-old boy is admitted to the hospital for fever, cough, and increasing respiratory
insufficiency of 2 days duration. Chest radiography demonstrates a right middle lobe and lower
lobe pneumonia with a significant pleural effusion (Item Q185). You aspirate a sample of pleural
fluid and send it to the laboratory for analysis.
Question: 185
(Courtesy of B. Poss)
References:
Efrati O, Barak A. Pleural effusions in the pediatric population. Pediatr Rev. 2002:23:417-426.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/23/12/417
Schultz KD, Fan LL, Pinksy J, et al. The changing face of pleural empyemas in children:
epidemiology and management. Pediatrics. 2004;113:1735-1740. Available at:
http://pediatrics.aappublications.org/cgi/content/full/113/6/1735
Winnie GB. Pleurisy, pleural effusions, and empyema. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:1832-1834
Question: 186
You are seeing a short 9-year-old boy. He is growing steadily in height just below the third
percentile on the growth curve. His parents ask if he will be very short when he finishes growing.
Of the following, the MOST important information needed to answer this question is
A. ethnicity of family
B. parent heights
C. sibling heights
E. weight-for-age curve
References:
Ferry RJ Jr. Short stature. eMedicine Specialties, Pediatrics: General Medicine, Endocrinology.
2007. Available at: www.emedicine.com/ped/topic2087.htm
Plotnick LP, Miller RS. Growth, growth hormone, and pituitary disorders. In: McMillan JA, Feigin
RD, DeAngelis C, Jones MD Jr. Oski's Pediatrics, Principles & Practice. Philadelphia, Pa:
Lippincott, Williams & Wilkins; 2006:2084-2092
Rogol AD. Causes of short stature. UpToDate Online 15.3. 2008. Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/2279
Question: 187
A 4-year-old boy cannot attend a local nursery school because he is not toilet trained. His
development is otherwise normal. His parents explain that when they attempt to put him on the
toilet, he refuses and runs out of the bathroom. They ask how they can train him to use the toilet.
D. recommend the family find a different nursery school that allows children who are not toilet
trained
E. tell the parents to have him clean his own clothes after toilet accidents
References:
Parker S. Toilet training. In: Parker S, Zuckerman B, Augustyn M, eds. Developmental and
Behavioral Pediatrics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:355-357
Schmitt B. Toilet training: getting it right the first time. Contemp Pediatr. 2004;21:105
Wolraich ML, Tippins S, ed. Guide to Toilet Training. Elk Grove Village, Ill: American Academy of
Pediatrics; 2003
Question: 188
The nurse caring for a 5-day-old infant you have hospitalized calls your office to report that the
infants blood culture is growing gram-positive rods. You admitted the infant to the hospital
because of a rectal temperature of 102.0F (38.9C) measured by his mother at home.
A. Enterococcus sp
B. Escherichia coli
C. Listeria monocytogenes
D. Proteus mirabilis
E. Staphylococcus epidermidis
References:
Posfay-Barbe KM, Wald ER. Listeriosis. Pediatr Rev. 2004;25:151-159. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/5/151
Question: 189
A mother calls you to report that her 7-year-old son came home with a notice from school stating
that a child in his class was diagnosed with mumps. The mother does not know the immunization
status of the infected child but states that her son has received two measles-mumps-rubella
(MMR) vaccines and is up to date on all his other immunizations. Her son has been
asymptomatic, with no fever or other systemic complaints.
B. confirm that her son has received two doses of MMR vaccine
C. keep her son home from school for 9 days to observe for the development of symptoms
E. vaccinate her son immediately with another dose of MMR to prevent infection from this
exposure
References:
American Academy of Pediatrics. Mumps. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:464-468
Centers for Disease Control and Prevention (CDC). Notice to readers: updated
recommendations of the Advisory Committee on Immunization Practices (ACIP) for the control
and elimination of mumps. MMWR Morb Mortal Wkly Rep. 2006;55:629-630. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55e601a1.htm
Question: 190
A 4-year-old boy presents with periorbital edema. He is receiving no medications, and his family
history is negative for renal disease. On physical examination, he is afebrile; his heart rate is 88
beats/min, respiratory rate is 18 breaths/min, and blood pressure is 106/62 mm Hg; and he has
periorbital (Item Q190A) and pitting pretibial edema (Item Q190B). Laboratory evaluation shows
normal electrolyte values, blood urea nitrogen of 14.0 mg/dL (5.0 mmol/L), creatinine of 0.3
mg/dL (26.5 mcmol/L), and albumin of 1.6 g/dL (16.0 g/L). Urinalysis demonstrates a specific
gravity of 1.020; pH of 6.5; 3+ protein; and negative blood, leukocyte esterase, and nitrite.
Microscopy results are normal. Additionally, complement component (C3 and C4) values are
normal, and results of serologic testing for antinuclear antibody, hepatitis B and C, and human
immunodeficiency virus are negative.
Of the following, you are MOST likely to advise the parents that
B. disease relapse can be expected in fewer than 25% of those achieving remission
C. patients who relapse have a similar prognosis as those who do not respond to steroids
D. remission is expected in more than 75% of patients who receive corticosteroid treatment
E. tacrolimus is the preferred treatment for patients who do not respond to corticosteroids
Question: 190
Question: 190
Pretibial pitting edema (arrow), as exhibited by the boy in the vignette. (Reprinted with permission
from Cavanaurgh RM Jr. Orthostatic edema in adolescents: more than walking on water. Pediatr
Rev. 2005;26:115-124.)
References:
Niaudet P. Steroid-sensitive idiopathic nephrotic syndrome in children. In: Avner ED, Harmon
WE, Niaudet P, eds. Pediatric Nephrology. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins;
2004:543-556
Niaudet P. Steroid-resistant idiopathic nephrotic syndrome in children. In: Avner ED, Harmon
WE, Niaudet P, eds. Pediatric Nephrology. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins;
2004:557-573
Valentini RP, Smoyer WE. Nephrotic syndrome. In: Kher KK, Schnaper HW, Makker SP, eds.
Clinical Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:155-194
Question: 191
You are evaluating a 14-year-old girl for seasonal allergic rhinitis. Despite a regimen of multiple
allergy medications, she continues to have significant sneezing, rhinorrhea, and nasal
congestion. You decide to evaluate for possible allergic triggers and discuss the advantages and
disadvantages of allergy skin testing and blood testing.
Of the following, a TRUE statement regarding allergy skin and blood testing is that
References:
Cartwright RC, Dolen WK. Consultation with the specialist: who needs allergy testing and how to
get it done. Pediatr Rev. 2006;27:140-146. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/4/140
Mahr TA, Sheth K. Update on allergic rhinitis. Pediatr Rev. 2005;26:284-289. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/26/8/284
Question: 192
A 3-year-old boy is brought to the emergency department at 8 am after his parents found him
unresponsive in bed. The last time they had seen him awake was at 2 am, when they found him
playing in the living room as they were cleaning up after a cocktail party. On physical
examination, the child has diaphoresis and moans to painful stimuli. His vital signs include a
temperature of 96.4F (35.8C), heart rate of 145 beats/min, respiratory rate of 20 breaths/min,
blood pressure of 84/34 mm Hg, and oxygen saturation of 97% in room air. His pupils are mid-
sized and sluggishly reactive.
A. acetylcholinesterase determination
D. serum osmolality
References:
Ernst AA, Jones K, Nick TG, Sanchez J. Ethanol ingestion and related hypoglycemia in a
pediatric and adolescent emergency department population. Acad Emerg Med. 1996;3:46-49.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/8749967
Sperling M. Hypoglycemia. In: Kleigman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson
Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:655-670
Sunehag A, Haymond MW. Etiology of hypoglycemia in infants and children. UpToDate Online
15.3. 2008. Available for supscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=pediendo/11162&selectedTitle=4~29&sourc
e=search_result
Question: 193
A 3-year-old child presents to your office with chronic recurrent diarrhea of 3 months duration.
He attends child care during the week. He is one of four children in the family, the oldest of
whom is 8 years old. Stool microscopic analysis identifies Giardia lamblia. You treat the boy with
metronidazole for 10 days. On a follow-up visit 30 days after initiating treatment, the mother
states that the symptoms initially improved, but have recurred.
B. metronidazole resistance
C. persistent giardiasis
References:
American Academy of Pediatrics. Giardia intestinalis infections (giardiasis). In: Pickering LK,
Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:296-301
Huang DB, White AC. An updated review on Cryptosporidium and Giardia. Gastroenterol Clin
North Am. 2006;35:291-314. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16880067
Critique: 193
Photomicrograph of a Giardia lamblia cyst using an iodine stain. (Courtesy of the Public Health
Image Library, Centers for Disease Control and Prevention)
Critique: 193
Question: 194
You admit a 39 weeks gestation male who has respiratory distress to the intensive care
nursery. His mother had a negative group B Streptococcus screening culture and did not
receive antibiotics in labor. She did not have chorioamnionitis or prolonged rupture of the fetal
membranes. However, the amniotic fluid was meconium-stained at the time of delivery, and the
infant required tracheal intubation, with resultant meconium suctioned from below the vocal
cords. Apgar scores were 3 and 7 at 1 and 5 minutes, respectively. On physical examination, he
has marked work of breathing with tachypnea and retractions and episodic cyanosis when
agitated. Breath sounds are coarse and equal. There is no heart murmur. While receiving hood
oxygen at an FiO2 of 0.50, his oxygen saturation by pulse oximetry is 85%. You obtain a chest
radiograph.
Of the following, the radiographic findings MOST expected for this infant are
A. air bronchograms, diffusely hazy lung fields, and low lung volume
C. fluid density in the horizontal fissure, hazy lung fields with central vascular prominence, and
normal lung volume
D. gas-filled loops of bowel in the left hemithorax and opacification of the right lung field
E. patchy areas of diffuse atelectasis, focal areas of air-trapping, and increased lung volumes
References:
Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev.
2004;25:201-208. Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/6/201
Dargaville PA, Copnell B for the Australian and New Zealand Neonatal Network. The
epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome.
Pediatrics. 2006;117:1712-1721. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/5/1712
Miller MJ, Fanaroff AA, Martin RJ. Respiratory disorders in preterm and term infants. In: Martin
RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 8th ed.
Philadelphia, Pa: Mosby Elsevier; 2006:1122-1145
Ross MG. Meconium aspiration syndrome-more than intrapartum meconium. N Engl J Med.
2005;353:946-948. Extract available at: http://content.nejm.org/cgi/content/extract/353/9/946
Critique: 194
Meconium aspiration: There are areas of atelectasis (arrows) and hyperinflation (seen best at the
bases). (Reprinted with permission from Aly H. Respiratory disorders in the newborn:
identification and diagnosis. Pediatr Rev. 2004;25:201-208.)
Critique: 194
Critique: 194
Critique: 194
Chest radiograph from an infant who has transposition of the great vessels revealing prominent
pulmonary vessels (arrows), suggesting pulmonary overcirculation. (Reprinted with permission
from:Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev.
2004;25:201-208.)
Critique: 194
Chest radiograph in transient tachypnea of the newborn shows increased pulmonary interstitial
markings and fluid in the interlobar fissures (arrows). (Reprinted with permission from Aly H.
Respiratory disorders in the newborn: identification and diagnosis. Pediatr Rev. 2004;25:201-
208.)
Critique: 194
Plain radiograph of the chest and abdomen in a patient who has congenital diaphragmatic hernia
shows bowel in the left chest, with displacement of the heart to the right. (Courtesy of B. Carter)
Question: 195
A mother brings her 5-year-old girl to your office because she noticed a "lump" in her daughters
neck over the past several weeks. The girl appears well and has normal vital signs and no
fever. A 1x1-cm slightly soft mass (Item Q195) is apparent in the middle of her neck, and when
she swallows, the mass moves vertically. There is no drainage or overlying erythema.
B. cystic hygroma
C. reactive lymphadenopathy
E. thyroid nodule
Question: 195
References:
Camitta BM. The lymphatic system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Elsevier Saunders; 2007:2092-
2096
Tracy TF Jr, Muratore CS. Management of common head and neck masses. Semin Pediatr
Surg. 2007;16:3-13. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17210478
Waldhausen JH. Branchial cleft and arch anomalies in children. Semin Pediatr Surg. 2006;15:64-
69. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16616308
Critique: 195
Branchial cleft cysts do not appear in the midline. Typically, they are located laterally along the
anterior border of the sternocleidomastoid muscle. (Courtesy of D. Epstein)
Critique: 195
A thyroglossal duct cyst is a soft midline mass that moves vertically when the child swallows or
protrudes the tongue. (Courtesy of M. Rimsza)
Critique: 195
Cystic hygromas represent macrocystic lymphatic malformations. They typically are soft and not
localized only to the midline neck. (Courtesy of the Media Lab at Doernbecher)
Question: 196
You have been treating a 2-year-old girl for 1 month with ferrous sulfate after her hemoglobin
was 10.0 g/dL (100.0 g/L) and hematocrit was 29% (0.29). Today, her reticulocyte count is 4.2%
(0.042), hemoglobin is 11.5 g/dL (115.0 g/L), and hematocrit is 33% (0.33). The nurse
practitioner student with whom you are working asks if she can stop the iron supplement.
Of the following, the BEST reason for continuing iron therapy in this child is to
B. prevent infection
References:
Glader B. Iron deficiency anemia. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Elsevier Saunders; 2007:2014-2016
Kleinman RE. Nutrition and immunity. In: Pediatric Nutrition Handbook. 5th ed. Elk Grove Village,
Ill: American Academy of Pediatrics; 2004:609-628
Question: 197
You are performing screening sports participation examinations at the local high school. One of
the students, a 16-year-old boy, reports that his father has hypertrophic cardiomyopathy but
that none of his three older brothers has it. He also reports that he was seen by a cardiologist at
age 10 years and was "fine." As you take his history, you find that he has never had shortness
of breath, chest pain, exercise intolerance, dizziness, or fainting. He has always participated in
sports and has excelled.
A. chest radiography
B. electrocardiography
D. referral to a cardiologist
References:
Berger S, Utech L, Hazinski MF. Sudden death in children and adolescents. Pediatr Clin North
Am. 2004;51:1653-1677. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15561179
Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and
recreational sports participation for young patients with genetic cardiovascular diseases.
Circulation. 2004;109:2807-2816. Available at:
http://circ.ahajournals.org/cgi/content/full/109/22/2807
Maron BJ, Thompson PD, Ackerman MJ, et al. AHA scientific statements. Recommendations
and considerations related to preparticipation screening for cardiovascular abnormalities in
competitive athletes: 2007 update. A scientific statement from the American Heart Association
Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of
Cardiology Foundation. Circulation. 2007;115:1643-1655. Available at:
http://circ.ahajournals.org/cgi/content/full/115/12/1643
Question: 198
A 4-year-old boy recently underwent hematopoietic stem cell transplantation for acute
myelogenous leukemia. Fourteen days after his transplant, he experiences a seizure and
confusion. He is receiving cyclosporine, prednisone, ganciclovir, fluconazole, cefotaxime,
tobramycin, and omeprazole. Magnetic resonance imaging shows signal changes in bilateral
occipital lobes.
A. cyclosporine
B. fluconazole
C. ganciclovir
D. prednisone
E. tobramycin
References:
Abbott MB, Levin RH, Wu S. Medication potpourri. Pediatr Rev. 2006;27:283-288. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/8/283
Norman JK, Parke JT, Wilson DA, McNall-Knapp RY. Reversible posterior leukoencephalopathy
syndrome in children undergoing induction therapy for acute lymphoblastic leukemia. Pediatr
Blood Cancer. 2007;49:198-203. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16123992
Pound CM, Keene DL, Udjus K, Humphreys P, Johnston DL. Acute encephalopathy and
cerebral vasospasm after multiagent chemotherapy including PEG-asparaginase and intrathecal
cytarabine for the treatment of acute lymphoblastic leukemia. J Pediatr Hematol Oncol.
2007;29:183-186. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17356399
Question: 199
During the health supervision visit of a 2-week-old infant, you note that his weight remains below
his birthweight. The baby was delivered at term by a midwife in the parents home. There were
no complications, and the parents have declined all perinatal testing. His mother says that he
breastfeeds well, and her milk supply is good compared with that for her previous two children.
Recently, though, the infant has been vomiting after feedings. On physical examination, he has
total body jaundice, and his liver is enlarged to palpation. He is alert.
A. abdominal ultrasonography
References:
Nyhan WL, Barshop BA, Ozand PT. Organic acidemias. In: Atlas of Metabolic Diseases. 2nd ed.
London, England: Hodder Arnold; 2005:1-108
Question: 200
A 16-year-old young man presents to the emergency department with a 12-hour history of pain
in the scrotal area. He states that the pain started gradually and describes it as on the left side
and moderate in intensity. He is sexually active and uses condoms. He has some burning pain
with urination, but no penile discharge. He has felt warm but has not taken his temperature. He
has had no vomiting or diarrhea. He has had no previous similar symptoms. On physical
examination, the young man is afebrile and has normal findings on abdominal evaluation. He has
moderate swelling of the left scrotum without erythema and marked tenderness that involves
more of the posterolateral area. The testicular position is lower on the left than on the right. The
left spermatic cord is very tender. Urinalysis shows more than 10 white blood cells per high-
power field on a first-void specimen.
A. epididymitis
B. testicular torsion
C. testicular tumor
E. varicocele
References:
Adelman WP, Joffe A. Scrotal disorders. In: Neinstein, LS, ed. Adolescent Health Care: A
Practical Guide. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008:401-410
Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases
treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of
gonococcal infections. MMWR Morbid Mortal Wkly Rep. 2007;56:332-336. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Workowski AK, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Critique: 200
Question: 201
A 1-year-old boy who is intubated for severe asthma is demonstrating significant acute
respiratory and cardiac deterioration, as evidenced by tachycardia, tachypnea, decreased blood
pressure, and oxygen saturation of 75%. During your examination, you note a marked shift of
the trachea to the left and markedly decreased aeration on the right side.
Of the following, the MOST likely cause of this boys sudden respiratory deterioration is
D. tension pneumothorax
E. ventilator-associated pneumonia
References:
Chase MA, Wheeler DS. Disorders of the pediatric chest. In: Wheeler DS, Wong HR, Shanley T,
eds. Pediatric Critical Care Medicine: Basic Science and Clinical Evidence. New York, NY:
Springer-Verlag; 2007:361-375
Winnie GB. Pnuemothorax. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson
Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1835-1836
Critique: 201
Chest radiography demonstrating tension pneumothorax: There is collapse of the right lung,
flattening of the right hemidiaphragm, and shift of the heart and mediastinum to the left. (Courtesy
of D. Mulvihill)
Question: 202
During the health supervision visit of a 9}-year-old girl, you note that her height is just above the
97th percentile for age and her weight is at the 85th percentile. Her mother is 5 feet 5 inches tall
and father is 5 feet 10 inches. Her parents ask if she will be very tall when she has finished
growing.
Of the following, the MOST important element of the physical examination to help answer this
question is
C. eye examination
References:
Boom JA. Normal pediatric growth. UpToDate Online 15.3. 2008.Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=gen_pedi/13648
Cohen P, Shim M. Hyperpituitarism, tall stature, and overgrowth syndromes. In: Kliegman RM,
Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia,
Pa: Saunders Elsevier; 2007:2303-2307
Richmond EJ, Rogol AD. The child with abnormally rapid growth. UpToDate Online 15.3. 2008.
Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/7226
Question: 203
A mother brings in her 10-year-old daughter and 8-year-old son because they are fighting
constantly. The son says he hates having a sister and complains that his parents favor her and
give her everything she wants. The daughter says that her brother is spoiled and always
touches her stuff. The mother is frustrated by their constant fighting and asks for assistance in
handling the children.
A. explain that this is typical of siblings and she should ignore the behavior
References:
Faber A, Mazlish E. When the kids fight: how to step in so we can step out. In: Siblings Without
Rivalry: How to Help Your Children Live Together So You Can Live Too. New York, NY: Quill;
2002:146-177
Needlman R. Sibling rivalry. In: Parker S, Zuckerman B, Augustyn M, eds. Developmental and
Behavioral Pediatrics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:412-415
Question: 204
You are evaluating an 8-month-old boy who is having multiple "coughing spells." During these
spells, the boy sometimes turns blue and even vomits. You inform the mother that you are going
to prescribe an antimicrobial agent. She wants to know why you are giving her infant an
antimicrobial agent when he needs something for the cough.
Of the following, the BEST reason to prescribe an antimicrobial agent for this boy is that
treatment will decrease the
A. chance of death
B. cough
C. hypoxic episodes
D. infectivity
E. posttussive vomiting
References:
American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Long
SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:498-520
Tiwari T, Murphy RV, Moran J. Recommended antimicrobial agents for the treatment and
postexposure prophylaxis of pertussis. 2005 CDC guidelines. MMWR Recomm Rep.
2005;54(RR14):1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm
Waseem M, Kin LL. Index of suspicion: case 6. Pediatr Rev. 2005;26:23-33. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/26/1/23
Question: 205
You are evaluating a 17-month-old previously healthy girl who presents with an 8-month history
of recurrent cellulitis and abscesses on her lower right abdomen. Eight months ago, she
developed a "pimple" on her abdomen that rapidly enlarged to the size of a golf ball and became
very red, hard, and tender over 2 days. The lesion spontaneously drained a purulent material
and resolved. Over the last 8 months, the girl has had nine similar episodes. She was seen on
several occasions in an urgent care center and each time was placed on a course of
cephalexin, which resulted in no improvement until the lesion drained spontaneously. The patient
has no fever with the episodes. Physical examination shows a 2x3-cm erythematous, indurated,
very tender, fluctuant lesion on the patients right flank.
Of the following, the MOST likely organism causing this patients recurrent infections is
C. Staphylococcus epidermidis
D. Streptococcus pneumoniae
E. Streptococcus pyogenes
References:
Andes DR, Craig WA. Cephalosporins. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell,
Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa:
Elsevier Churchill Livingstone; 2005:294-310
Jantausch BA. Peripheral brain: cephalosporins. Pediatr Rev. 2003;24:128-136. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/24/4/128
Question: 206
A mother brings in her 4-year-old daughter because of decreased energy following a 3-day
history of diarrhea without vomiting. On physical examination, the girls temperature is 100.2F
(37.9C), heart rate is 130 beats/min, respiratory rate is 18 breaths/min, and blood pressure is
122/84 mm Hg. She has pale conjunctivae, a hyperdynamic precordium, and mild pretibial
edema. Laboratory evaluation reveals:
Sodium, 133.0 mEq/L (133.0 mmol/L)
Potassium, 5.2 mEq/L (5.2 mmol/L)
Chloride, 100.0 mEq/L (100.0 mmol/L)
Bicarbonate, 16.0 mEq/L (16.0 mmol/L)
Albumin, 2.5 g/dL (25.0 g/L)
Blood urea nitrogen, 40.0 mg/dL (14.3 mmol/L)
Creatinine, 1.4 mg/dL (123.8 mcmol/L)
Hemoglobin, 6.1 g/dL (610.0 g/L)
White blood cell count, 21.5x10 3/mcL (21.5x109/L)
Platelet count, 90.0x10 3/mcL (90.0x109/L)
References:
Ake JA, Jelacic S, Ciol MA, et al. Relative nephroprotection during Escherichia coli O157:H7
infections: association with intravenous volume expansion. Pediatrics. 2005;115:e673-e680.
Available at: http://pediatrics.aappublications.org/cgi/content/full/115/6/e673
Oakes RS, Siegler RL, McReynolds MA, Pysher T, Pavia AT. Predictors of fatality in
postdiarrheal hemolytic uremic syndrome. Pediatrics. 2006;117:1656-1662. Available at:
http://pediatrics.aappublications.org/cgi/content/full/117/5/1656
Mahan JD. Hemolytic uremic syndrome. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic
syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med.
2000;342:1930-1936. Available at: http://content.nejm.org/cgi/content/full/342/26/1930
Critique: 206
Schistocytes (arrows) are observed on the peripheral blood smear of patients who have
hemolytic-uremic syndrome. (Courtesy of S. Dabbagh)
Question: 207
A 16-year-old girl who has moderate persistent asthma presents to the emergency department
with coughing, wheezing, and increasing dyspnea. She states that she was feeling fine until she
was exposed to cologne that one of her classmates was wearing. An ambulance was called
after her symptoms did not improve following administration of two puffs of her beta2 agonist
inhaler. On physical examination, the teenager has a respiratory rate of 30 breaths/min, heart
rate of 90 beats/min, and pulse oximetry of 98% on room air. She has difficulty completing a
sentence and points to her neck, saying it is "hard to get air in." Her lungs are clear to
auscultation, and rhinolaryngoscopy demonstrates adduction of one of the vocal cords during
inspiration. Pulmonary function testing shows a blunted inspiratory loop (Item Q207).
Of the following, the MOST likely cause for this patients symptoms is
A. allergic rhinitis
B. asthma exacerbation
C. habit cough
D. sinusitis
Question: 207
Blunted inspiratory flow curve in pink (arrow), as exhibited by the patient in the vignette. A normal
curve is shown in blue. (Courtesy of K. Waibel)
References:
Liu AH, Covar RA, Spahn JD, Leung DYM. Childhood asthma. In: Kleigman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:953-969
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not
asthma. Pediatrics. 2007;120:855-864. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/4/855
Question: 208
A 7-year-old boy is brought to the emergency department because of altered mental status. His
parents report that he was well when he came home from school today, but when he came in
the house for dinner after playing outside with his friends, he complained of abdominal pain and
had an episode of nonbilious and nonbloody emesis. Over the next 30 minutes, he became
increasingly lethargic until his parents could not arouse him. They called emergency medical
services, and he was transported to the emergency department by ambulance. On physical
examination, he is unresponsive and drooling, his temperature is 98.8F (37.1C), heart rate is
50 beats/min, respiratory rate is 36 breaths/min, blood pressure is 100/60 mm Hg, and oxygen
saturation is 82% on room air. His pupils are mid-size and sluggishly reactive, and his breath
sounds are coarse bilaterally, with increased work of breathing. You suspect a toxin exposure.
A. atropine
B. N-acetylcysteine
C. naloxone
D. octreotide
E. physostigmine
References:
Bird S. Organophosphate and carbamate toxicity. UpToDate Online 15.3. 2008. Available for
subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=ad_tox/9425&selectedTitle=1~150&source=
search_result
Karr CJ, Solomon GM, Brock-Utne AC. Health effects of common home, lawn, and garden
pesticides. Pediatr Clin North Am. 2007;54:63-80. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17306684
Peter JV, Moran JL, Graham PL. Advances in the management of organophosphate poisoning.
Expert Opin Pharmacother. 2007;8:1451-1464. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17661728
Question: 209
You are evaluating a 2-day-old term infant because of abdominal distention. He fed normally the
first day after birth, but has had progressively increasing vomiting, which now is bilious. Physical
examination demonstrates upslanted palpebral fissures, a prominent tongue, and mild hypotonia.
Upon passage of a nasogastric tube, you aspirate 80 mL of green-yellow material from his
stomach. Abdominal radiographs, including a left lateral decubitus film, reveal dilated loops of
bowel and air-fluid levels but no evidence of pneumatosis (Item Q209).
Of the following, the condition that BEST explains this babys clinical findings is
A. duodenal atresia
B. Hirschsprung disease
C. meconium ileus
D. necrotizing enterocolitis
E. neonatal intussusception
Question: 209
(Courtesy of D. Mulvihill)
References:
de Lorijn F, Kremer LC, Reitsma JB, Benninga MA. Diagnostic tests in Hirschsprung disease: a
systematic review. J Pediatr Gastroenterol Nutr. 2006;42:496-505. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16707970
Imseis E, Gariepy CE. Hirschsprung disease. In: Walker WA, Goulet O, Kleinman RE, Sherman
PM, Shneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4th ed. Hamilton,
Ontario, Canada: BC Decker; 2004:1031-1043
Critique: 209
Facial features of Down syndrome in infants include upslanted palpebral fissures, a flat face, and
a broad nasal root. (Courtesy of M. Rimsza)
Critique: 209
Critique: 209
Spot radiograph from a barium enema series in a patient who has Hirschsprung disease showing
a contracted rectum (representing the aganglionic segment) with a short transition zone to a
normal dilated proximal rectum. (Courtesy of D. Mulvihill)
Question: 210
You are called to the neonatal intensive care unit to examine a newborn who has abdominal
distention and respiratory distress. She was born at 38 weeks gestation and weighs 4 kg. Apgar
scores were 3 and 6 at 1 and 5 minutes, respectively. She required tracheal intubation and
assisted ventilation. On physical examination, she has a large, distended, and tense abdomen
without bowel sounds. The abdominal wall is not erythematous, and there is no clearly palpable
mass. She does not display other evidence of body wall or scalp edema. The breath sounds are
coarse and equal bilaterally. There is no heart murmur. Radiograph of the chest appears normal,
but abdominal radiography shows background granular density, paucity of intraluminal bowel
gas, and a calcified mass in the left lower quadrant (Item Q210).
Of the following, the BEST explanation for this infants abdominal findings is
A. congenital lymphangioma
B. erythroblastosis fetalis
C. meconium peritonitis
D. ovarian cyst
E. urinary ascites
Question: 210
(Courtesy of B. Carter)
References:
Albanese CT, Sylvester KG. Pediatric surgery. In: Doherty GM, Way LW. Current Surgical
Diagnosis and Treatment. 12th ed. New York, NY: The McGraw-Hill Companies, Inc; 2006:chap
45
Chaudry G, Navarro OM, Levine DS, Oudjhane K. Abdominal manifestations of cystic fibrosis in
children. Pediatr Radiol. 2006;36:233-240. Abstract available at:
http://www.ncbi.nlm.nih.gov./pubmed/16391928
Kaye CI and the Committee on Genetics. Newborn screening fact sheets. Pediatrics.
2006;118:e934-e963. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/3/e934
Critique: 210
Abdominal radiograph in meconium peritonitis reveals a hazy appearance to the abdomen that
suggests ascites and a calcified mass (arrow) representing a meconium pseudocyst. (Courtesy
of B. Carter)
Critique: 210
Anteroposterior radiograph of the chest and abdomen demonstrates a paucity of gas in the
abdomen, with scattered calcifications typical of meconium peritonitis. (Courtesy of D. Mulvihill)
Question: 211
A 13-year-old girl comes to your office with a 1-day history of right eye pain and tearing. She
denies trauma, but says she rubbed her eyes a lot the day before because it was windy outside.
Her right bulbar and palpebral conjunctivae are very injected, and copious clear discharge is
present. There is no hyphema, and the pupils are normal. She complains of pain with the eye
examination. After applying fluorescein to the eye, you see a single linear abrasion on the
cornea. When you evert the eyelid, you find no foreign body.
A. oral analgesic
References:
Michael JG, Hug D, Dowd MD. Management of corneal abrasion in children: a randomized
clinical trial. Ann Emerg Med. 2002;40:67-72. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/12085075
Stout AU. Technical tip: corneal abrasions. Pediatr Rev. 2006;27:433-434. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/11/433
Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev.
2006;2:CD004764. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004764/frame.html
Critique: 211
Corneal abrasion (arrow) demonstrated after flourescein staining and examination with a Wood
lamp. (Courtesy of Wake Forest University Eye Center)
Question: 212
A previously healthy 15-year-old girl returns from summer camp in the mountains complaining of
dysuria, frequency, and urgency. You diagnose cystitis and prescribe trimethoprim-
sulfamethoxazole. Her mother phones 3 days later to report that the girl is very tired and
appears pale. You advise her mother to bring her to your office. On examination, she appears
pale and your order laboratory tests. The girls hemoglobin is 8.5 g/dL (85.0 g/L), a decrease
from the value of 11.5 g/dL (115.0 g/L) that was measured during her pre-camp physical
examination. Her reticulocyte count is 5.0% (0.050), and the red cell indices are normal except
for mild microcytosis with a mean corpuscular volume of 76 fL. You review a smear (Item
Q212).
Of the following, the MOST likely cause of this girls rapid onset of anemia is
B. hemoglobin SC disease
C. hereditary elliptocytosis
E. pyelonephritis
Question: 212
(Courtesy of Gulati G, Caro J. Blood Cells - An Atlas of Morphology with Clinical Relevance.
Chicago, Ill: ASCP Press; 2007. 2007, American Society for Clinical Pathology.)
References:
Frank JE. Diagnosis and management of G6PD deficiency. Am Fam Physician. 2005;72:1277-
1282. Available at: http://www.aafp.org/afp/20051001/1277.html
Segal GB. Enzymatic defects. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. Philadelphia, Pa: Saunders Elsevier; 2007:2039-2041
Segel GB, Hirsh MG, Feig SA. Managing anemia in a pediatric office practice: part 2. Pediatr
Rev. 2002;23:111-122. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/23/4/111
Critique: 212
Question: 213
A 13-year-old boy who has a bicuspid aortic valve and aortic stenosis with a 20-mm Hg (mild)
gradient by echocardiography (Item Q213) is interested in participating in sports. He asks for
your advice.
B. football is contraindicated
E. wrestling is contraindicated
References:
Dickhuth H-H, Kececioglu D, Schumacher YO. FIMS Position Statement: Congenital Heart
Disease and Sports. International Federation of Sports Medicine; January 2006. Available at:
http://www.fims.org/default.asp?PageID=120975716
Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and
recreational sports participation for young patients with genetic cardiovascular diseases.
Circulation. 2004;109:2807-2816. Available at:
http://circ.ahajournals.org/cgi/content/full/109/22/2807
Stefani L, Galanti G, Tonicelli L, et al. Bicuspid aortic valve in competitive athletes. Br J Sports
Med. 2008;42:31-35. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17548371
Critique: 213
In a bicuspid aortic valve, one of the commisures fails to form (arrow), resulting in two rather than
three leaflets. (Courtesy of P Lynch)
Question: 214
The mother of a 7-year-old girl who has epilepsy phones your office because her child has
developed a rash. The mother is worried that the rash may be due to her new antiseizure
medication.
References:
French JA, Kanner AM, Bautista J, et al. Efficacy and tolerability of the new antiepileptic drugs I:
treatment of new onset epilepsy. Report of the Therapeutics and Technology Assessment
Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and
the American Epilepsy Society. Neurology. 2004;62:1252-1260. Available at:
http://www.neurology.org/cgi/content/full/62/8/1252
Johnston MV. Seizures in childhood. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:2457-
2475
Critique: 214
Question: 215
A newborn male experiences prolonged oozing following circumcision. Hematologic evaluation
reveals that he has less than 1% of factor VIII clotting activity and a prolonged partial
thromboplastin time, consistent with severe hemophilia A. His family history is negative for any
individuals affected by clotting disorders.
Of the following, the MOST accurate statement for counseling this childs parents is that
A. another family member likely is affected, but the condition is so mild that the person has not
been diagnosed
B. in families such as this, 50% of affected boys have a spontaneous gene mutation
References:
Hamosh A. Clinical case studies illustrating genetic principles. In: Nussbaum RL, McInnes RR,
Willard HR, eds. Thompson & Thompson Genetics in Medicine. 7th ed. Philadelphia, Pa: Elsevier
Saunders; 2007:268-269
Question: 216
An 18-year-old young woman reports that she has "bumps" in her vaginal area. She recently
became sexually active with a single partner. She says that the lesions are not tender, and she
has no vaginal discharge or itching. Genital examination reveals several clusters of flesh-
colored, pedunculated lesions, primarily in the posterior fourchette, compatible with genital warts
(Item Q216). You counsel her about treatment options.
Of the following, the MOST accurate statement regarding management and treatment of genital
warts is that
B. no definitive evidence supports the superiority of any of the available genital wart treatments
C. single treatment with clinician- or patient-applied methods eradicates all lesions in most
patients
E. with her lesions, the patient is not currently a candidate for the human papillomavirus vaccine
Question: 216
Papules (arrow), as described for the patient in the vignette. (Courtesy of M. Rimsza)
References:
Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human
papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep. 2007;56(RR02):1-24. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm
Workowski KA, Berman SM, Centers for Disease Control and Prevention. sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Critique: 216
Question: 217
A 2-year-old girl is brought to the emergency department after being found unconscious at her
grandparents home. Her mother reports that she was in her usual good health when she was
dropped off at her grandparents 2 hours ago and that there is no history of trauma. Of note, the
grandmother found a spilled, opened bottle of her "blood pressure" medicine in the bathroom. On
physical examination, the girl is somnolent but arouses with stimulation. There is no sign of
trauma on physical examination. Her temperature is 98.0F (37.0C), heart rate is 60 beats/min,
respiratory rate is 25 breaths/min, and oxygen saturation is 93% on room air. Her pupils are 2
mm and reactive bilaterally. Her mouth and mucous membranes are dry, and she has no
rashes. You order serum electrolyte measurement and a urine toxicology screen.
References:
Avner JR. Altered states of consciousness. Pediatr Rev. 2006:27:331-338. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/9/331
Frankel LR. Neurological emergencies and stabilization. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier: 2007:405-412
Critique: 217
Question: 218
The parents of a 6-year-old boy are concerned because he has been developing pubic hair over
the past 6 months. On physical examination, you note a recent growth spurt, Sexual Maturity
Rating 3 pubic hair, a penis that is 8 cm in length and androgenized, and testes that are 5 mL in
volume. Other findings are normal. His bone age is 7 years. You order measurements of serum
testosterone, 17-hydroxyprogesterone, dehydroepiandrosterone, luteinizing hormone, and
follicle-stimulating hormone.
A. adrenocorticotropic hormone
B. estradiol
C. free testosterone
E. prolactin
References:
Rivarola MA, Belgorsky A, Mendilaharzu H, Vidal G. Precocious puberty in children with tumours
of the suprasellar and pineal areas: organic central precocious puberty. Acta Paediatr.
2001;90:751-756. Abstract available at: http://www.blackwell-
synergy.com/doi/abs/10.1111/j.1651-2227.2001.tb02800.x?journalCode=apa
Saenger P. Overview of precocious puberty. UpToDate Online 15.3. 2008. Available for
subscription at: http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/14867
Question: 219
During the health supervision visit for an infant, her mother mentions that the child has been
tolerating solid foods with no problem. When placed on her back to be examined, she brings her
feet to her mouth. Her mother holds a small mirror to the childs face to distract her during your
examination, and the baby reaches for the mirror and pats her image.
Of the following, these developmental milestones are MOST typical for an infant whose age is
A. 2 months
B. 4 months
C. 6 months
D. 9 months
E. 12 months
References:
Knobloch H, Stevens FM, Malone AF. The revised developmental stages. In: Manual of
Developmental Diagnosis: The Administration and Interpretation of the Revised Gesell and
Amatruda Developmental and Neurologic Examination. Albany, NY: Developmental Evaluation
Materials, Inc; 1987:17-120
Whitaker T, Palmer F. The developmental history. In: Accardo PJ. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume I: Neurodevelopmental
Diagnosis and Treatment. 3rd ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2008:297-310
Question: 220
You admitted a patient to the hospital yesterday who had acute onset of fever (temperature of
103.0oF [39.4oC]), a petechial rash, meningismus, and shock. She required blood pressure
support and mechanical ventilation during the night. As per the protocol for your hospital, you
placed this child into respiratory isolation upon admission. Today you are told that her blood
culture is growing Neisseria meningitidis. The nurse taking care of her asks you how long the
child needs to remain in respiratory isolation.
B. defervesces
C. is clinically stable
D. is extubated
References:
American Academy of Pediatrics. Meningococcal infections. In: Pickering LK, Baker CJ, Long
SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:452-460
Critique: 220
Question: 221
You are speaking to the mother of a previously healthy boy who has just broken out with
chickenpox lesions. His mother states that one of her sons classmates also has the disease.
No one else in the household is ill. He did not receive varicella vaccine, but all of his other
immunizations are up to date. His mother asks whether her son is at risk for developing a
severe case of the disease.
Of the following, the factor that is MOST likely to increase his risk for moderate-to-severe
varicella disease is
References:
American Academy of Pediatrics. Varicella-zoster infections. In: Pickering LK, Baker CJ, Long
SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.
Elk Grove Village, Ill: American Academy of Pediatrics; 2006:711-725
Arvin AM. Antiviral therapy for varicella and herpes zoster. Semin Pediatr Infect Dis. 2002;13:12-
21. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/12118839
Balfour HH Jr, Rotbart HA, Feldman S, et al. Acyclovir treatment of varicella in otherwise healthy
adolescents. The Collaborative Acyclovir Varicella Study Group. J Pediatr. 1992;120:627-633.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1313098
Whitley RJ. Approaches to the treatment of varicella-zoster virus infections. Contrib Microbiol.
1999;3:158-172
Critique: 221
Critique: 221
The chest radiograph in varicella pneumonia is characterized by bilateral infiltrates that, in the
early stages, may have a nodular component (arrow). (Courtesy of the Red Book Online.)
Question: 222
A father brings in his 8-year-old son because the boy has been "feeling tired" for the past few
weeks. The remainder of the history is unremarkable. His weight is at the 5th percentile, height
is less than the 5th percentile, temperature is 98.6F (37C), heart rate is 88 beats/min,
respiratory rate is 16 breaths/min, and blood pressure is 124/84 mm Hg. Urinalysis findings
include a specific gravity of 1.005, pH of 6.5, no blood, and 2+ protein. Other laboratory results
are:
Sodium, 134.0 mEq/L (134.0 mmol/L)
Potassium, 5.4 mEq/L (5.4 mmol/L)
Chloride, 96.0 mEq/L (96.0 mmol/L)
Bicarbonate, 14.0 mEq/L (14.0 mmol/L)
Blood urea nitrogen, 96.0 mg/dL (34.3 mmol/L)
Creatinine, 8.4 mg/dL (742.6 mcmol/L)
Of the following, the MOST likely additional finding expected for this child is
B. hypomagnesemia
E. reticulocytosis
References:
Fine RN, Whyte DA, Boydstun II. Conservative management of chronic renal insufficiency. In:
Avner ED, Harmon WE, Niaudet P, eds. Pediatric Nephrology. 5th ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2004:1291-1311
Wong CS, Mak RH. Chronic kidney disease. In: Kher KK, Schnaper HW, Makker SP, eds.
Clinical Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:339-352
Critique: 222
Anteroposterior radiograph of the knees shows diffuse demineralization of both cortical and
trabecular bone and fraying of the metaphyses. (Courtesy of D. Mulvihill)
Question: 223
A 4-year-old girl presents with a 2-week history of bilateral discolored rhinorrhea, nasal
congestion, and decreased oral intake. Her mother states that at the onset of this illness, she
developed clear rhinorrhea 2 days after attending child care. Despite using over-the-counter
antihistamines and decongestants, the childs symptoms have persisted. A quick review of her
chart shows that her immunizations are up to date, including her pneumococcal conjugate
vaccine series and her annual influenza vaccination. On physical examination, the child has
appropriate vital signs for her age, infraorbital edema bilaterally, and yellowish mucus in her
nares. You suspect acute bacterial rhinosinusitis (ABRS) and discuss evaluation and treatment
options with the mother.
A. a sinus radiograph should be performed prior to initiating antibiotic therapy for ABRS
B. ABRS can be distinguished easily from a viral upper respiratory tract infection
C. allergic rhinitis is the most common risk factor for developing ABRS
D. the gold standard test for organism identification in ABRS is a nasal swab culture
References:
Brook I, Foote PA, Hausfeld JN. Frequency of recovery of pathogens causing acute maxillary
sinusitis in adults before and after introduction of vaccination of children with the 7-valent
pneumococcal vaccine. J Med Microbiol. 2006;55:943-946. Available at:
http://jmm.sgmjournals.org/cgi/content/full/55/7/943
Taylor A, Adam HM. In brief: sinusitis. Pediatr Rev. 2006;27:395-397. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/10/395
Question: 224
A 5-year-old boy is brought to the emergency department following 2 days of headache, nausea,
and vomiting. His mother reports that he has had no fever or diarrhea and that everyone at
home, "including the dog," has the same symptoms. Physical examination demonstrates a heart
rate of 120 beats/min, respiratory rate of 24 breaths/min, blood pressure of 100/60 mm Hg, and
oxygen saturation of 100% on room air. The boy is mildly irritable, and his mucous membranes
appear bright red. His lungs are clear, and abdominal examination findings are unremarkable. As
you are completing your evaluation, the mother tells you that the furnace in their house has been
malfunctioning.
References:
Clardy PF, Manakar S. Carbon monoxide poisoning. UpToDate Online 15.3. 2008. Available for
subscription at:
http://www.utdol.com/utd/content/topic.do?topicKey=ad_tox/2932&selectedTitle=1~26&source=s
earch_result
Juurlink DN, Buckley NA, Stanbrook MB, Isbister GK, Bennett M, McGuigan MA. Hyperbaric
oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2005;1:CD002041.
Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002041/frame.html
Kind T, Etzel RA. In brief: carbon monoxide. Pediatr Rev. 2005;26:150-151. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/26/4/150
Question: 225
A 15-year-old girl presents with a history of abdominal pain. She is a competitive runner and has
required frequent ibuprofen for treatment of knee pain. On physical examination, you note
epigastric tenderness. Fecal occult blood test results are positive.
Of the following, the test that is MOST likely to provide a definitive diagnosis is
References:
De Giacomo C. Helicobacter pylori gastritis and peptic ulcer disease. In: Guandalini S, ed.
Textbook of Pediatric Gastroenterology and Nutrition. London, England: Taylor & Francis;
2004:73-94
Fox VL. Pediatric endoscopy. Gastrointest Endosc Clin North Am. 2000;10: 175-194. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/10618461
Critique: 225
Question: 226
You are seeing a 30-year-old multigravid woman for prenatal counseling. She has had immune
thrombocytopenic purpura for the past 5 years, and her spleen was removed 2 years ago. She
asks you about the effects that her disease might have on her unborn child.
C. maternal platelet transfusion during pregnancy will minimize the risk for neonatal
thrombocytopenia
D. operative delivery of the newborn will reduce the risk of intracranial hemorrhage
References:
Buyon JP, Nugent D, Mellins E, Sandborg C. Maternal immunologic diseases and neonatal
disorders. NeoReviews. 2002;3:e3-e10. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/3/1/e3
Question: 227
You are addressing a group of expectant mothers who are due to deliver their infants in the next
few weeks. You discuss the benefits of breastfeeding and explain that it is the best nutrition for
most babies. One woman asks you if it is acceptable to breastfeed if she has had hepatitis in the
past. You explain that there are only a few infections that would prevent a mother from being
able to breastfeed her baby.
C. is a cytomegalovirus carrier
E. is hepatitis C antibody-positive
References:
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human
milk. Pediatrics. 2005;115:496-506. Available at:
http://pediatrics.aappublications.org/cgi/content/full/115/2/496
Powers NG, Slusser W. Breastfeeding update 2: clinical lactation management. Pediatr Rev.
1997;18:147-161. Available at: http://pedsinreview.aappublications.org/cgi/content/full/18/5/147
Question: 228
A 6-month-old girl, who was born in Nigeria, presents for an urgent visit as soon as the family
arrives in the United States because of fever and irritability. Physical examination reveals a
fussy infant who has anorexia, a temperature of 100F (37.8C), and swelling of all of the fingers
of the right hand (Item Q228). The remainder of the examination findings are negative.
Of the following, the MOST likely cause of this pattern of swelling in this child is
A. cellulitis
C. malaria
E. trauma
Question: 228
Swelling of the digits, as exhibited by the infant in the vignette. (Courtesy of M. Rimsza)
References:
Gill FM, Sleeper LA, Weiner SJ, et al for the Cooperative Study of Sickle Cell Disease. Clinical
events in the first decade in a cohort of infants with sickle cell disease. Blood. 1995;86:776-783.
Available at: http://bloodjournal.hematologylibrary.org/cgi/reprint/86/2/776
Meremikwu MM. Sickle cell disease (updated). BMJ Clinical Evidence. 2007. Available for
subscription at: http://clinicalevidence.bmj.com/ceweb/conditions/bly/2402/2402.jsp
Miller ST, Sleeper LA, Pegelow CH, et al. Prediction of adverse outcomes in children with sickle
cell disease. N Engl J Med. 2000:342:2:83-89. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10631276
Critique: 228
Vaso-occlusive crises in infants who have sickle cell disease often are characterized by swelling
and tenderness of the fingers or toes. (Courtesy of M. Rimsza)
Question: 229
You work as a voluntary attending pediatrician in the resident continuity clinic at your local
hospital. You are precepting a resident, who tells you that she has just evaluated a 16-year-old
varsity volleyball player. The girls height is 71 inches, weight is 125 lb, and blood pressure is
115/74 mm Hg. The resident is concerned about scoliosis and a 3/6 holosystolic murmur heard
at the cardiac apex with radiation to the left axilla (Item Q229).
A. EhlersDanlos syndrome
B. infective endocarditis
C. Marfan syndrome
E. Williams syndrome
References:
Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and
recreational sports participation for young patients with genetic cardiovascular diseases.
Circulation. 2004;109:2807-2816. Available at:
http://circ.ahajournals.org/cgi/content/full/109/22/2807
Maron BJ, Thompson PD, Ackerman MJ, et al. AHA scientific statements. Recommendations
and considerations related to preparticipation screening for cardiovascular abnormalities in
competitive athletes: 2007 update. A scientific statement from the American Heart Association
Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of
Cardiology Foundation. Circulation. 2007;115:1643-1655. Available at:
http://circ.ahajournals.org/cgi/content/full/115/12/1643
Moodie DS. AAP: health supervision for children with Marfan syndrome. Clin Pediatr (Phila).
1997;36:489
Peirpont MEM. Connective tissue diseases. In: Moller JH, Hoffman JIE, eds. Pediatric
Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone; 2000:901-912
von Kodolitsch Y, Robinson PN. Marfan syndrome: an update of genetics, medical and surgical
management. Heart. 2007;93:755-760. Extract available at:
http://heart.bmj.com/cgi/content/extract/93/6/755
Critique: 229
Critique: 229
Critique: 229
Subluxed lens: The lens is displaced inferiorly (arrows show the border of the lens). In Marfan
syndrome, the lens typically is displaced superiorly and temporally. (Courtesy of the Wake
Forest University Eye Center)
Question: 230
The parents of a 6-month-old previously well infant bring her to your office. She had been
developing normally, but she stopped interacting with her parents over the last 24 hours. For
several days prior to this development, she had had unusual spells during which her head and
chin dropped to her chest. Now she is having clusters of these spells involving head drop and
body flexion. On physical examination, there is no bruising. The infant is afebrile and alert, her
tone is low, and she does not make persistent eye contact or track visually. You refer her to the
emergency department, where results of a complete blood count, electrolyte panel, urinalysis,
and a noncontrast head computed tomography scan are normal.
Of the following, the test that is MOST likely to reveal the correct diagnosis is
A. electroencephalography
B. electroretinography
C. lumbar puncture
D. muscle biopsy
References:
Kossoff EH. Infantile spasms. In: Singer HS, Kossoff EH, Hartman AL, Crawford TO, eds.
Treatment of Pediatric Neurologic Disorders. Boca Raton, Fla: Taylor & Francis; 2005:111-116
Mackay MT, Weiss SK, Adams-Webber T, et al. Practice parameter: medical treatment of
infantile spasms. Report of the American Academy of Neurology and the Child Neurology
Society. Neurology. 2004;62:1668-1681. Available at:
http://www.neurology.org/cgi/content/full/62/10/1668
Question: 231
While examining an infant in the newborn nursery, you note that the pupil of one eye seems
abnormally large, and little of the iris is visible. The baby appears otherwise normal. A
subsequent ophthalmologic evaluation confirms the diagnosis of partial aniridia.
Of the following, the MOST accurate statement regarding the diagnosis is that
E. routine abdominal ultrasonography should be performed every 3 months until age 5 years in
affected individuals
References:
Critique: 231
Aniridia appears as a large pupil with little iris. (Courtesy of the Media Lab at Doernbecher)
Question: 232
A 15-year-old girl presents with vaginal pain and burning accompanied by feelings of warmth and
generalized muscle aches for the past 24 hours. She has had no previous similar symptoms.
She is sexually active and does not use barrier methods for contraception. On physical
examination, you find multiple shallow ulcers of the labia minora that are surrounded by
erythema and are exquisitely tender to touch (Item Q232). There is no vaginal discharge.
E. no antiviral chemotherapy
Question: 232
(Courtesy of M. Rimsza)
References:
American Academy of Pediatrics. Herpes simplex. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2006:361-371
Workowski KA, Berman SM, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Critique: 232
Infection of the genitalia with herpes simplex virus produces painful ulcers. (Courtesy of M.
Rimsza)
Question: 233
A 16-year-old boy presents to the emergency department with an acute change in his mental
status. According to his parents, he was previously healthy and has suffered no recent trauma.
On physical examination, he is somnolent, has pinpoint pupils and mild hypotension, and
demonstrates shallow breathing.
Of the following, the test that is MOST likely to help determine the cause of his altered level of
consciousness is
B. chest radiography
C. electroencephalography
References:
Avner JR. Altered states of consciousness. Pediatr Rev. 2006:27:331-338. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/9/331
Frankel LR. Neurological emergencies and stabilization. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders
Elsevier; 2007:405-412
Question: 234
The parents of a 3-year-old boy in whom you recently diagnosed type 1 diabetes mellitus are
anxious about providing the best diabetes control for their son, but wish to avoid frequent
fingersticks to measure blood glucose. They have read that a hemoglobin A1c gives a measure
of blood glucose control and correlates with long-term complications of diabetes. They request
that this blood test be obtained at weekly intervals to give them assurance of good control.
Of the following, the MOST important information to provide them about hemoglobin A1c
measurement is that it
References:
McCulloch DK. Estimation of blood glucose control in diabetes mellitus. UpToDate Online 15.3.
2008. Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=diabetes/7913
McCulloch DK. Glycemic control and vascular complications in type 1 diabetes. UpToDate
Online 15.3. 2008. Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=diabetes/10573
Silverstein J, Klingensmith G, Copeland K, et al, Care of children and adolescents with type 1
diabetes: a statement of the American Diabetes Association. Diabetes Care. 2005;28:186-212.
Available at: http://care.diabetesjournals.org/cgi/content/full/28/1/186
Question: 235
A mother brings in her child for a health supervision visit. He is able to pull to stand, take a few
independent steps, and use two fingers to grasp pieces of cereal.
Of the following, these developmental milestones are MOST typical for a child whose age is
A. 6 months
B. 9 months
C. 12 months
D. 15 months
E. 18 months
References:
Blasco PA. Motor delays. In: Parker S, Zuckerman B, Augustyn M, eds. Developmental and
Behavioral Pediatrics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:242-247
Knobloch H, Stevens FM, Malone AF. The revised developmental stages. In: Manual of
Developmental Diagnosis: The Administration and Interpretation of the Revised Gesell and
Amatruda Developmental and Neurologic Examination. Albany, NY: Developmental Evaluation
Materials, Inc; 1987:17-120
Question: 236
A 5-year-old girl presents approximately 96 hours after being bitten by a dog on her leg. Her
mother states that she developed fever and swelling of the leg around the bite site over the past
12 hours. Physical examination reveals a nontoxic-appearing girl who has a temperature of
101.8F (38.8C) and an open wound with visible purulence and surrounding erythema.
Of the following, the MOST likely pathogen responsible for these symptoms is
A. Eikenella corrodens
B. Kingella kingae
C. Pasteurella multocida
D. Staphylococcus aureus
E. Streptococcus pyogenes
References:
American Academy of Pediatrics. Bite wounds. In: Pickering LK, Baker CJ, Long SS, McMillan
JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:191-195
Question: 237
A 10-year-old boy was bitten by a dog 2 days ago while visiting relatives in rural Mexico. He was
playing outside with his cousin when a stray dog suddenly ran up and bit him on the arm. After
the incident, the dog ran off and could not be found. His mother washed the wound with soap
and water, but no other medical attention was sought at that time. Physical examination today
reveals a moderately deep bite wound on the boys right forearm that is erythematous, mildly
indurated, and tender, with seropurulent drainage. You prescribe appropriate antibiotic therapy.
Of the following, the MOST appropriate postexposure prophylaxis regimen for this patient is
References:
American Academy of Pediatrics. Rabies. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:552-559
Centers for Disease Control and Prevention. Human rabies prevention - United States 1999:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
Recomm Rep. 1999;48(RR-1):1-21. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056176.htm
Rupprecht CE, Gibbons RV. Prophylaxis against rabies. N Engl J Med. 2004;351:2626-2635.
Extract available at: http://content.nejm.org/cgi/content/extract/351/25/2626
Question: 238
An 8-year-old boy presents with gross hematuria associated with intermittent right-sided flank
pain. There is no history of dysuria, urgency, frequency, or trauma. Physical examination
reveals a temperature of 98.6F (37C), heart rate of 76 beats/min, respiratory rate of 20
breaths/min, blood pressure of 106/66 mm Hg, and no abdominal or costovertebral angle
tenderness. Urinalysis shows a specific gravity of 1.025, pH of 6, 3+ blood, and trace protein.
Microscopy documents 20 to 50 red blood cells/high-power field. Renal ultrasonography reveals
a normal bladder with mild hydronephrosis on the right and an echogenic focus (Item Q238) with
shadowing in the right kidney.
Of the following, the MOST likely additional expected laboratory feature contributing to this
patients condition is
D. hypercalcemia
E. metabolic alkalosis
Question: 238
Longitudinal ultrasonography scan of the abdomen reveals an echogenic focus with distal
shadowing in a mildly dilated renal collecting system. (Courtesy of D. Mulvihill)
References:
Alon US, Srivastava T. Urolithiasis. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:539-551
Milliner DS. Urolithiasis. In: Avner ED, Harmon WE, Niaudet P, eds. Pediatric Nephrology. 5th ed.
Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:1091-1111
Question: 239
A 12-year-old boy presents with a 3-year history of hay fever in the spring. He experiences daily
nasal congestion, sneezing, and rhinorrhea from March to May that worsens when he is outside.
He is asymptomatic for the remainder of the year, but his parents are concerned because his
symptoms interfere with outdoor sports activities. Use of over-the-counter first-generation
antihistamines resulted in undesirable sedation.
Of the following, the BEST initial medication to treat this patient is a(an)
A. intranasal corticosteroid
B. intranasal decongestant
D. oral decongestant
References:
Atkins D, Leung DYM. Principles of treatment of allergic disease. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa:
Saunders Elsevier; 2007:942-948
Mahr TA, Sheth K. Update on allergic rhinitis. Pediatr Rev. 2005;26:284-289. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/26/8/284
Question: 240
You are examining a 7-year-old boy who has a 2-day history of abdominal pain. The pain began
2 nights ago after he ate pizza with the rest of his family and initially was crampy and diffuse. No
one else became ill. He continued to complain of pain through the day yesterday, and this
morning he vomited once, prompting his mother to bring him to the office. The emesis was
nonbilious and nonbloody, and he has had no diarrhea, fever, or urinary symptoms. On physical
examination, the boy is afebrile, has normal vital signs, and has diminished bowel sounds with
involuntary guarding in the right lower quadrant. There are no peritoneal signs, and Rovsing,
obturator, and psoas signs are negative.
A. abdominal radiograph
E. procalcitonin determination
References:
Bundy DG, Byerly JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have
appendicitis? JAMA. 2007;298:438-451. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17652298
Kwok MY, Kim MK, Gorelick MH. Evidence-based approach to the diagnosis of appendicitis in
children. Pediatr Emerg Care. 2004;20:690-698
Wesson DE. Evaluation and diagnosis of appendicitis in childhood. UpToDate Online 15.3. 2008.
Available at:
http://www.utdol.com/utd/content/topic.do?topicKey=ped_surg/4980&selectedTitle=4~150&sourc
e=search_result
Critique: 240
Computed tomography scan of the abdomen in a reformatted coronal projection shows a fluid-
filled tubular structure with a thick wall consistent with an obstructed appendix. (Coutesy of D.
Mulvihill)
Question: 241
A 12-year-old boy who has a history of recurrent abdominal pain presents to your office for an
annual health supervision visit. The boy complains of periumbilical pain, unrelated to meals,
occurring twice a month and lasting 15 minutes. Physical examination findings are normal. Fecal
occult blood test results are negative. His father, who is a physician, asks if the boy should
undergo testing for Helicobacter pylori.
A. all children who have positive H pylori serologies should undergo endoscopy
B. antibiotic therapy for H pylori is most effective when combined with a proton pump inhibitor
References:
Ford A, McNulty C, Delaney B, Moayyedi A. Helicobacter pylori infection. BMJ Clinical Evidence.
2007. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/dsd/0406/0406.jsp
Gold BD, Colletti RB, Abbott M, et al; North American Society for Pediatric Gastroenterology and
Nutrition. Helicobacter pylori infection in children: recommendations for diagnosis and treatment.
J Pediatr Gastroenterol Nutr. 2000;31:490-497
Vilaichone RK, Mahachai V, Graham DY. Helicobacter pylori diagnosis and management.
Gastroenterol Clin North Am. 2006;35:229-247. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/16880064
Critique: 241
Critique: 241
Silver stain of a gastric biopsy demonstrating curved H pylori bacteria in a gastric crypt.
(Courtesy of J. Glickman)
Question: 242
A term newborn is delivered to a mother who has had a 5-day history of a nonspecific
gastroenteritis, some loose stools, generalized malaise, and low-grade fever. The infant had a
seizure at 6 hours of age and is ill, with an inspired oxygen requirement of 0.40, some petechiae,
and oozing from the umbilicus and phlebotomy sites. He is irritable on neurologic examination.
Laboratory findings include:
White blood cell count, 7.5x10 3/mcL (7.5x109/L)
Platelet count, 90.0x10 3/mcL (90.0x109/L)
Hematocrit, 45% (0.45)
Aspartate aminotransferase, 240.0 U/L
Alanine aminotransferase, 300.0 U/L
Fibrinogen, 90.0 mg/dL (2.6 mcmol/L)
Prothrombin time, 20 seconds
Partial thromboplastin time, 60 seconds
Internationalized Normalized Ratio (INR), 1.80
Serum glucose, 90.0 mg/dL (5.0 mmol/L)
A lumbar puncture reveals 35 white blood cells, with 50% polymorphonuclear cells and 50%
mononuclear cells; 1 red blood cell; glucose of 60.0 mg/dL (3.3 mmol/L); and protein of 100
mg/dL (1,000 g/L). No organisms are seen on cerebrospinal fluid (CSF) Gram stain.
D. the abnormal CSF glucose and protein values indicate bacterial meningitis
E. the abnormal liver function test results and CSF cell counts indicate herpes simplex virus
infection
References:
Heath PT, Nik Yusoff NK, Baker CJ. Neonatal meningitis. Arch Dis Child Fetal Neonatal Ed.
2003;88:F173-F178. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/12719388
Klinger G, Chin C-N, Beyene J, Perlman M. Predicting the outcome of neonatal bacterial
meningitis. Pediatrics. 2000;106:477-482. Available at:
http://pediatrics.aappublications.org/cgi/content/full/106/3/477
Miyairi I, Berlingieri D, Protic J, Belko J. Neonatal invasive group A streptococcal disease: case
report and review of the literature. Pediatr Infect Dis J. 2004;23:161-165. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/14872185
Moylett EH. Neonatal Candida meningitis. Semin Pediatr Infect Dis. 2003;14:115-122. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/12881799
Philip AGS. Neonatal meningitis in the new millennium. NeoReviews. 2003;4:e73-e80. Available
for subscription at: http://neoreviews.aappublications.org/cgi/content/full/4/3/e73
Polin RA, Harris MC. Neonatal bacterial meningitis. Semin Neonatol. 2001;6:157-172. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/11483021
Question: 243
A 5-month-old boy is brought to the emergency department by his mother because of
decreased activity and vomiting for 1 day. She reports occasional foul-smelling stools but no
recent changes in stool pattern. There has been no fever. As a neonate, the boy had difficulty
gaining weight and prolonged jaundice, but he has not required hospitalization. Physical
examination reveals an ill-appearing child who has mild dehydration, a heart rate of 120
beats/min, and otherwise normal vital signs. He appears somewhat cachectic, and his weight is
at the 3rd percentile. Laboratory values include a normal complete blood count and urinalysis,
sodium of 134.0 mEq/L (134.0 mmol/L), chloride of 86.0 mEq/L (86.0 mmol/L), potassium of 3.8
mEq/L (3.8 mmol/L), and carbon dioxide of 31.0 mEq/L (31.0 mmol/L). Blood urea nitrogen and
creatinine values are within normal limits.
A. Bartter syndrome
C. cystic fibrosis
D. Fanconi syndrome
References:
Boat TF, Acton JD. Cystic fibrosis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1803-
1816
Question: 244
A 15-month-old girl presents to the emergency department with a temperature of 103F (39.5C)
during respiratory virus season. Physical examination reveals rhinorrhea and mild cough but no
other focus of infection. However, she has diffuse bruises in various stages of healing on her
abdomen, subscapular area, and both extensor and flexor surfaces of her extremities.
Laboratory studies reveal a white blood cell count of 9.2x103/mcL (9.2x109/L) with a normal
differential count, platelet count of 376.0x103/mcL (376.0x109/L), hemoglobin of 13.0 g/dL (130.0
g/L), and hematocrit of 39% (0.39).
Of the following, the BEST next step in the evaluation of this child is
References:
Coulter K. In brief: bruising and skin trauma. Pediatr Rev. 2000;21:34-35. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/21/1/34
Kellogg ND and the Committee on Child Abuse and Neglect. Evaluation of suspected child
physical abuse. Pediatrics. 2007;119:1232-1241. Available at:
http://pediatrics.aappublications.org/cgi/content/full/119/6/1232
Klevens J, Sadowski L. Intimate partner violence towards women (update). BMJ Clinical
Evidence. 2007. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/woh/1013/1013_I5.jsp
Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are
diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. 2005;90:182-186.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15665178
Sugar NF, Taylor JA, Feldman KW and the Puget Sound Pediatric Research Network. Bruises in
infants and toddlers: those who don't cruise rarely bruise. Arch Pediatr Adolesc Med.
1999;153:399-403. Available at: http://archpedi.ama-assn.org/cgi/content/full/153/4/399
Critique: 244
Bruising on the back may be the result of nonaccidental trauma. (Courtesy of D. Krowchuk)
Question: 245
You receive a telephone call from the physician mother of a 1-week-old patient who was born at
24 weeks' gestation. He is being treated in the neonatal intensive care unit and has been stable
on the ventilator. She is concerned because when she visited him this morning, his blood
pressure was 44/26 mm Hg. His mean arterial pressure was 30 mm Hg. She is worried that his
blood pressure is low and that this may be harmful.
Of the following, the MOST accurate statement regarding blood pressure in the preterm infant is
that
A. blood pressure values for preterm infants should be compared with those for term infants
C. mean arterial pressure should be no less than the corrected gestational age in weeks
D. patent ductus arteriosus narrows the pulse pressure by raising the diastolic pressure
References:
Padbury JF. Neonatal hypotension and hypovolemia. In: Rudolph C, Rudolph A, eds. Rudolph's
Pediatrics. 21st ed. New York, NY: McGraw Hill Medical Publishing Division; 2003:137-140
Nwankwo MU, Lorenz JM, Gardiner JC. A standard protocol for blood pressure measurement in
the newborn. Pediatrics. 1997;99:E10. Available at:
http://pediatrics.aappublications.org/cgi/content/full/99/6/e10
Weindling AM, Subhedar NV. The definition of hypotension in very low-birthweight infants during
the immediate neonatal period. NeoReviews. 2007;8:e32. Available for subscription at:
http://neoreviews.aappublications.org/cgi/content/full/8/1/e32
Question: 246
A 17-year-old boy who receives carbamazepine for epilepsy presents to the emergency
department after a 40-minute generalized tonic-clonic seizure. He has been well, and there is no
history of trauma. On physical examination, he answers a few questions, but he is sleepy and
confused. He is afebrile, and his vital signs are normal. Although he is uncooperative, he moves
all limbs spontaneously with good strength.
Of the following, the diagnostic test that is MOST likely to explain this seizure is
C. prolonged electroencephalography
References:
Riviello JJ Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child
with status epilepticus (an evidence-based review). Report of the Quality Standards
Subcommittee of the American Academy of Neurology and the Practice Committee of the Child
Neurology Society. Neurology. 2006;67:1542-1550. Available at:
http://www.neurology.org/cgi/content/full/67/9/1542
Question: 247
A mother brings in her 4-month-old baby because she is concerned about the infants head
shape. The baby is growing and developing normally. Physical examination findings are normal
except for a flat occiput and a wide biparietal diameter with a flat forehead. The head
circumference is normal, and the anterior fontanelle is small but patent.
D. positional plagiocephaly
References:
Cohen MM Jr. Fibroblast growth factor receptor mutations. In: Cohen MM Jr, MacLean RE, eds.
Craniosynostosis: Diagnosis, Evaluation, and Management. 2nd ed. New York, NY: Oxford
University Press; 2000:77-94
Cohen MM Jr. History, terminology, and classification of craniosynostosis. In: Cohen MM Jr,
MacLean RE, eds. Craniosynostosis: Diagnosis, Evaluation, and Management. 2nd ed. New
York, NY: Oxford University Press; 2000:103-111
Critique: 247
Skull growth normally occurs in a direction perpendicular to each of the sutures. (Courtesy of A.
Johnson)
Critique: 247
Premature fusion of the coronal sutures (blue) results in brachycephaly, a prominent and
flattened frontal bone, flattening of the occiput, and anterior displacement of the vertex. (Courtesy
of A. Johnson)
Critique: 247
Metopic synostosis (blue) results in a triangular-shaped forehead and bossing of the parieto-
occipital regions. (Courtesy of A. Johnson)
Critique: 247
Sagittal suture synostosis (blue) causes the skull to be elongated (scaphocephaly). (Courtesy of
A. Johnson)
Critique: 247
In positional plagiocephaly (left), when viewed from above, the head has a parallelogram shape,
with unilateral occipitoparietal flattening, displacement of the ipsilateral ear anteriorly, and bossing
of the ipsilateral frontal skull. In contrast, in unilateral lambdoidal synostosis (right, [blue]), the
head has a trapezoidal shape, with unilateral occipital flattening, posterior displacement of the
ipsilateral ear, and bossing of the contralateral frontal skull. (Courtesy of A. Johnson)
Question: 248
The parents of a 14-year-old girl are concerned about her weight loss. Her weight today is 20 lb
less than a documented weight obtained 1 year ago at her camp physical examination. She
complains of frequent nausea, decreased appetite, and early satiety, even after eating very
small portions. She has no vomiting or diarrhea, but frequent constipation. She complains of
increased fatigue but is still able to participate in diving 5 days a week. She is doing well in school
academically. She attained menarche at 12 years of age and had monthly periods for about 18
months, but she has had no menses for the past 7 months. She has been a vegetarian for the
past 18 months and feels she is at a good weight currently. On physical examination, her body
mass index is 17.0. Her urine pregnancy test result is negative.
A. anorexia nervosa
B. depression
C. hypothalamic tumor
D. hypothyroidism
References:
Fisher M. Treatment of eating disorders in children, adolescents, and young adults. Pediatr Rev.
2006;27:5-16. Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/1/5
Rome ES, Ammerman S, Rosen DS, et al. Children and adolescents with eating disorders: the
state of the art. Pediatrics. 2003;111:e98-e108. Available at:
http://pediatrics.aappublications.org/cgi/content/full/111/1/e98
Rosen DS. Eating disorders in children and young adolescents: etiology, classification, clinical
features, and treatment. Adolesc Med. 2003;14:49-59. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/12529190
Question: 249
You are evaluating an 8-month-old infant in preparation for administering chloral hydrate to
perform a sedated brainstem auditory evoked potentials test.
References:
American Academy of Pediatrics, American Academy of Pediatric Dentistry, Cot CJ, Wilson S,
AAP Work Group on Sedation. Guidelines for monitoring and management of pediatric patients
during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics.
2006;118:2587-2602. Available at:
http://pediatrics.aappublications.org/cgi/content/full/118/6/2587
Koh JL, Palermo T. Conscious sedation: reality or myth? Pediatr Rev. 2007:28:243-248.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/28/7/243
Wetzel R. Anesthesia and perioperative care. In: Kliegman RM, Behrman RE, Jenson HB,
Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;
2007:460-474
Question: 250
You observe a child entering the waiting room, accompanied by her mother. She looks at the
receptionist and says "Hi." While holding her doll, the child turns to her mother and says "juice."
The mother gives her a cup of juice, and the child says "doll" and tries to give the doll a drink.
The mother shakes her head, and the child says "no." The child then points to her own mouth,
smiles, and says "mouth." The mother takes a tissue to clean the dolls face. The child says
"me" and begins to imitate her mothers action with another wipe. The child looks at her mother,
says "ma ma," and gives her mother a hug.
Of the following, these developmental milestones are MOST typical for a child whose age is
A. 12 months
B. 15 months
C. 18 months
D. 24 months
E. 30 months
References:
Knobloch H, Stevens FM, Malone AF. The revised developmental stages. In: Manual of
Developmental Diagnosis. Albany, NY: Developmental Evaluation Materials, Inc; 1987:17-120
Whitaker T, Palmer F. The developmental history. In: Accardo PJ. Capute & Accardo's
Neurodevelopmental Disabilities in Infancy and Childhood. Volume I: Neurodevelopmental
Diagnosis and Treatment. 3rd ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2008:297-310
Question: 251
The hospital laboratory calls your office to tell you that the rapid plasma reagin (RPR) test on the
cord blood of a newborn you saw yesterday in the hospital is positive at 1:4. You recall that the
physical examination findings for the infant were normal.
References:
American Academy of Pediatrics. Syphilis. In: Pickering LK, Baker CJ, Long SS, McMillan JA,
eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2006:631-644
Hyman EL, Adam HM. In brief: syphilis. Pediatr Rev. 2006;27:37-39. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/27/1/37
Critique: 251
Question: 252
You are speaking to a group of neonatal nurses about the laboratory methods that can be used
to make the diagnosis of human immunodeficiency virus infection/acquired immune deficiency
syndrome in high-risk infants.
Of the following, the test that is MOST likely to confirm the diagnosis is
D. p24 antigen
References:
American Academy of Pediatrics. Human immunodeficiency virus infection. In: Pickering LK,
Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:378-401
Maldarelli F. Diagnosis of human immunodeficiency virus infection. In: Mandell GL, Bennett JE,
Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th
ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2005:1506-1526
Read JS and the Committee on Pediatric AIDS. Diagnosis of HIV-1 infections in children younger
than 18 months in the United States. Pediatrics. 2007;120:e1547-e1562. Available at:
http://pediatrics.aappublications.org/cgi/content/full/120/6/e1547
Question: 253
The parents of a 3-year-old boy who has polyuria and polydipsia ask if anything can be done for
their childs symptoms and what the prognosis is for toilet training. After confirming a normal
serum glucose value and a negative urine culture, you arrange for a water deprivation test at the
hospital. The test begins at 9 am, and assessments are made hourly. At 0900, the patient weighs
14.1 kg, the serum osmolality is 290 mOsm/kg H2O, and the urine osmolality is 120 mOsm/kg
H2O. The measurements made over the course of the test are summarized in Item Q253. Per
protocol, the patient is given no food or fluids intravenously or orally. Aqueous vasopressin is
administered subcutaneously at 1101, immediately after the 1100 laboratory samples are taken.
After 4 hours, the test is stopped, and the patient is allowed to drink to prevent hypovolemia.
Question: 253
References:
Goodyer P. Disorders of tubular transport. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical
Pediatric Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:317-336
Knoers NVAM, Monnens LAH. Nephrogenic diabetes insipidus. In: Avner ED, Harmon WE,
Niaudet P, eds. Pediatric Nephrology. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins;
2004:777-787
Rose BD, Post TW. Hyperosmolal states-hypernatremia. In: Clinical Physiology of Acid-base
and Electrolyte Disorders. 5th ed. New York, NY: McGraw-Hill Medical Publishing Division;
2001:746-793
Question: 254
An 18-year-old boy who has mild persistent asthma presents to the emergency department with
a 2-week history of coughing and wheezing that has not improved with twice-daily use of his
beta2 agonist metered dose inhaler (MDI). On physical examination, the teenager is breathing
comfortably but often coughs and has audible expiratory wheezing. His vital signs are
appropriate for age, but a room air pulse oximetry reading is 95%. Chest radiography shows
some peribronchial streaking but no infiltrate, no consolidation, and a normal cardiac silhouette.
His only other medication is a medium-dose inhaled corticosteroid.
B. change his steroid inhaler to one that combines a steroid and long-acting beta2 agonist
References:
Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid
to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363:271-275.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/14751699
Keeley D, McKean M. Asthma and other wheezing disorders in children. BMJ Clinical Evidence.
2006. Available for subscription at:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0302/0302.jsp830Q1
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program.
Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007.
Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
Question: 255
A 15-year-old boy presents to the emergency department after falling off of his skateboard. He
was skating downhill at high speed when he hit a bump and fell off his board. He fell onto his left
shoulder and struck his abdomen on the curb. He now complains of left shoulder pain. On
physical examination, his heart rate is 110 beats/min, respiratory rate is 24 breaths/min and
shallow due to pain, and blood pressure is 130/75 mm Hg. He refuses to move his left shoulder.
His lung sounds are clear, and his abdomen is diffusely tender. Radiographs of his left shoulder
are reported as normal. You order an abdominal computed tomography (CT) scan.
B. duodenal hematoma
C. pancreatic transection
D. retroperitoneal hemorrhage
E. splenic laceration
References:
Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries
after blunt trauma. Ann Emerg Med. 2002;39:500-509. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/11973557
Wegner S, Colletti JE, Van Wie D. Pediatric blunt abdominal trauma. Pediatr Clin North Am.
2006;53:243-256. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/16574524
Critique: 255
Axial computed tomography scan of the abdomen shows disruption of the spleen with a large
hematoma. (Courtesy of D. Mulvihill)