JMN !

2015(c)SGU

FEVER

A 5 week old male is seen in the ED with a 2 day history of decreased PO intake and
increased fussiness. The baby was born at term via NVSD without complications and
had been well until onset of present symptoms. There is a two year old sibling at home
with a URI. Physical exam reveals a rectal temperature of 103* F without obvious
localization and irritability.

1. List 4 differential diagnoses for this infant"s fever.

2. Define sepsis.

3. Why are young infants at increased risk of sepsis and meningitis?

4. What other elements of the physical exam are important to assess in this infant?
Why?

5. What diagnostic evaluation would be appropriate for this infant? Be specific.

The CBC reveals WBC 26,000 with 72% polys, 14% bands and 14% lymphs.

6. Is this a normal CBC and differential for this infant? _____Yes _____No
If no, what would be a normal WBC/ diff for this infant?
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The CSF obtained by lumbar puncture is noted to be cloudy.

7. What pathogens are you concerned about? Explain the pathogenesis for each.

8. What antimicrobial regimen would you initiate empirically? Explain your choice.

9. For each set of CSF results, indicate the most likely diagnosis using the choices
below.

WBC %Polys/ RBC Glucose Protein Gram Most Likely

%Lymphs Stain Diagnosis

4 0-100 2 65 60 negative

100 0-100 2 0 150 negative

100 60-40 2 65 70 negative

100 40-60 500 40 90 negative

500 90-10 2 0 120 positive

Bacterial Meningitis
Early Viral Meningitis! ! ! Normal CSF
HSV Meningoencephalitis! ! ! Tuberculous Meningitis

10. Match the pathogen to the appropriate Gram stain.

! A. Gram positive diplococci! ! _____Listeria monocytogenes

! B. Gram negative diplococci! ! _____Hemophilus influenzae

! C. Gram negative bacilli! ! ! _____Streptococcus pneumoniae

! D. Gram negative pleomorphic rods! _____Neisseria meningitidis

! E. Gram postive cocci in chains! ! _____Escherichia coli

! F. Gram positive rods! ! ! _____Streptococcus agalactiae

JMN ! 2015(c)SGU

HEMATURIA / PROTEINURIA

A 7 year old male presents with a 2 day history of headache and a 10 minute
generalized tonic clonic seizure. Mom reports his urine has looked darker today - like
coca-cola. The nurse informs you his blood pressure is 150/90. You note a crusted
lesion on his chin and mild pitting edema of his lower extremities.

1. List your diagnoses for this patient.

2. What would your initial diagnostic evaluation include? Justify each test.

3. Explain the pathophysiologic basis for this patient"s edema.

4. Describe the recommended procedure for assessing blood pressure in children.

A 5 year old girl with a 4 day history of URI symptoms presents with diffuse abdominal
pain, bilateral ankle swelling and a palpable purpuric rash on her buttocks and lower
extremities. Urinalysis reveals numerous RBCs; on exam of the sediment you note
RBC casts.

5. What is the like;y diagnosis for this patient?

6. What additional diagnostic studies would you request? Why?

JMN ! 2015(c)SGU

A 15 year old previously healthy African-American male presents with sudden onset of
bright red urine with mild flank pain. There is no history of trauma, but he was at
basketball practice for several hours earlier today.

7. List three plausible diagnoses for this patient.

8. What diagnostic tests(s) would you request first?

A 2 year old male is referred to your practice. The child has a history of eyelid swelling
for a week, especially prominent on awakening in the morning. The patient was
diagnosed with allergic conjunctivitis at an Urgi-Center last week and prescribed eye
drops but Mom reports she now notices the patient"s hands and feet are also puffy and
his pants are tight around the waist. On dipstick his urine has 4+ protein. The sediment
has many RBCs but no RBC casts.

9. What is the most likely diagnosis for this patient?

10. Explain the pathophysiologic basis for this patient's edema.

11. What additional diagnostic studies would you request to confirm your diagnosis?
Justify each.

12. If your clinical suspicion is confirmed, what would your management plan include?
JMN ! 2015(c)SGU

ANEMIA

You are seeing a 15 month old male for a health maintenance visit. The baby has been
feeding well, taking about 40 ounces of whole cow"s milk daily since 8 months of age.
The development is appropriate for age. Physical examination reveals conjunctival
pallor and a grade II/VI short systolic murmur at the left midsternal border.

CBC reveals Hgb 8.2, Hct 25, MCV 60, retic 1%. RDW 18

1. Check the appropriate box for each of this infant's indices:

Normal High Low

Hemoglobin

MCV

Reticulocyte count

RDW

2. What is the most likely diagnosis for this infant's anemia?

3. Explain the pathogenesis for this anemia

4. What other diagnostic tests, if any, would you request to confirm your diagnosis?
Explain your reasoning.

5. How would you manage this infant's anemia?

JMN ! 2015(c)SGU

6. List to feeding practices and their corresponding nutritional deficiencies to be

considered in a 6 month old with a hemoglobin of 8.2 gm/dl and MCV 105.

! a)

! b)

7. When should cow's milk be introduced into the diet?

8. What should be the maximum daily intake of cow"s milk? _________ounces

Why?

9. What type of cow's milk is appropriate for a toddler?

Why?

10. What is the normal hemoglobin for a newborn? ______g/dl

! ! ! for a 2 month old? _______g/dl

This condition is commonly know as _________________________

! ! !
! ! ! for a 16 year old male? ________g/dl

! ! ! for a 16 year old female? ________g/dl

JMN ! 2015(c)SGU

FLUIDS AND ELECTROLYTES

You are evaluating a 5 month old infant in the ED with a 2 day history of profuse watery
diarrhea and occasional vomiting. On physical exam the weight is 6kg, HR 160, BP
100/65. You note poor skin turgor and capillary refill of 3 seconds. He is behind in his
immunizations.

1. How dehydrated is this infant? Explain your reasoning.

2. What fluid space(s) is/ are depleted in isonatremic dehydration?

3. What other findings are likely on this infant's physical exam?

4. Describe your initial fluid management in the ED. Be specific.

JMN ! 2015(c)SGU

The initial BMP reveals Na 133, K 3.6, Cl 110, HCO3 9, BUN 29, Creatinine 0.5

5. Check the appropriate box for each of this infant's lab values. Explain the
pathophysiologic basis of abnormal values.

Normal High Low Pathophysiology

Na+

K+

Cl-

HCO3-

BUN

Creatinine

BUN/Creatinine

Anion Gap

6. What is this infant's daily maintenance fluid requirement? How would you administer
this?

7. What additional component of fluid management needs attention in this infant? How
would you accomplish this?

8. Would your management change if the initial serum sodium was 165mEq/L? If yes,
how?

9. Would your management change if the initial serum sodium was 119mEq/L? If yes,
how?

10. What pathogen is likely responsible for this infant's gastroenteritis?

JMN ! 2015(c)SGU

MURMURS

A mom brings her 3 week old daughter to your office with the complaint that the baby
has not been feeding well for the last week. The baby was born at term without
complications and was discharged after 48 hours in the nursery. Birth weight was 7 lbs
and physical exam was reportedly normal. For the first two weeks the baby had been
taking 3 ounces of formula every three hours; each feeding lasted 10-15 minutes. This
past week, the baby is only able to take one ounce of formula over 10 minutes and then
becomes fussy and short of breath with beads of sweat on her forehead. She settles
down and resumes feeding after resting for 10-15 minutes but develops respiratory
distress and diaphoresis each time she feeds.

Physical exam reveals temp 98.6*F, HR180, RR 60, BP 90/60 room air O2 sat 98%,
weight 3.2 kg. A grade IV/VI harsh holosystolic murmur is audible at the lower left
sternal border and the liver edge is blunted and palpable 4cm below the right costal
margin.
1. List 3 diagnoses this infant is presenting with. Enter the positive/ negative findings
from the history and physical exam that support each diagnosis.

DIAGNOSIS #1:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS

DIAGNOSIS #2:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS

DIAGNOSIS #3:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS
JMN ! 2015(c)SGU

2. Provide a pathophysiologic explanation for why the murmur was not audible on
physical exam in the nursery.

3. Describe the grading system for murmurs.

4. How much weight should this infant have gained since birth?

5. What is this infant's chest X-ray likely to show?

6. What is the EKG likely to show?

7. What other diagnostic procedure(s) is/are indicated for this infant?

8. How should this infant be managed?

You are evaluating an asymptomatic 6 year old girl who wants to play soccer. On
physical exam you note a II/VI systolic ejection murmur at the upper left sternal border
with physiologic splitting of S2.

9. What is the likely diagnosis for this murmur? Why?

10. What is the clinical significance of the S2 findings in this patient?

11. Describe the characteristic physical exam findings of Still's murmur.

12. Describe the characteristic physical findings of a venous hum.

JMN ! 2015(c)SGU

WHEEZING

You are evaluating a 3 month old infant who presents to the ED on New Year's Day with
a history of rhinorrhea and cough for 3 days with rapid, labored breathing for one day.
PMH is significant for eczema. The patient's 4 year old sib has asthma and had URI
symptoms a week ago. Vital signs: temp 103, RR 70, HR 160, room air Sat 92%. On
exam you note nasal flaring, subcostal and intercostal retractions, decreased aeration
and bilateral wheezing.

1. What is the most likely diagnosis for this infant's respiratory distress/

2. Give 3 reasons to support your primary diagnosis.

3. List three important differential diagnostic considerations for this infant.

4. Explain the pathophysiology of wheezing. Which airways are primarily responsible?

Which patient has more severe disease--the one with inspiratory or expiratory
wheezing? Why?

5. What is the pathophysiologic explanation for the nasal flaring and retractions seen on
physical exam?

6. Is a chest X-ray indicated for this patient? Justify your decision.

JMN ! 2015(c)SGU

A blood gas reveals pH 7.32, pCO2 38, pO2 90, HCO3 15.
7. Interpret this blood gas.

8. Check the appropriate box for each of this patient's indices.

Normal High Low

pH

pCO2

pO2

HCO3

9. List 5 pathophysiologic causes of hypoxemia. Which likely explains this infant's pO2?

10. What is the difference between hypoxemia and hypoxia?

11. What would your management plan for this infant include?

12. Complete this table on the ambulatory management of pediatric asthma.

CLASSIFICATION MEDICATION MECHANISM MEDICATION MECHANISM

OF ACTION OF ACTION

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent
JMN ! 2015(c)SGU

LIMP

An 18 month old male is admitted with a one day history of fever and limp. He has had
URI symptoms for 3 days. Mom reports she has had to carry him around today as he
refuses to stand or walk. The nurse tells you the patient's temperature is 103.6*F
axillary. On exam he appears acutely ill, lying in the crib with his right leg flexed,
abducted and externally rotated at the hip. There is no obvious erythema of the skin but
you note warmth and tenderness on palpation of the right inguinal area. Passive range
of motion of the hip is very limited and the patient refuses to bear weight on the right leg
when you attempt to stand him up.

1. What is the most like;y diagnosis for this patient? Explain your choice.

2. List 2 differential diagnostic considerations?

The CBC reveals WBX 34.6 with 85% polys, 10% bands and 5% lymphs. Hemoglobin is
10.2 g/dl, MCV 75, Platelets 650,000.

3. Interpret the CBC. Explain abnormal values.

Your senior resident consults Orthopedics. 10cc of purulent material is aspirated from
the patient's right hip joint.

4. Describe the anatomic factors which make septic arthritis of the hip a medical/
surgical emergency in this age group.

5. What pathogens are you concerned about?

6.What antibiotic treatment would you initiate empirically pending cultures?

JMN ! 2015(c)SGU

7. What else would be included in your diagnostic and therapeutic plan for this patient?

A 4 year old female presents with a complaint of right knee pain for 3 weeks. She had
fallen off her new bike just prior to onset of symptoms. There is no associated URI but
mom reports tactile fever for the last week. On physical exam you note an ill-appearing
child with temperature 101.4*F, tenderness over the right proximal femur and full range
of motion at the hip and knee. Patient ambulates with a mild antalgic gait.

8. List your top three diagnostic considerations for this patient.

The CBC reveals WBC 34.6 (20%polys, 2%bands, 66%lymphs and 12% atypical
lymphs), hemoglobin 8.8g/dl, MCV 78, Platelets 50,000.

9. What is the most likely diagnosis?

10. What should be the next step in evaluation and management of this patient?

A 6 year old boy complains of left knee pain for 3 months. He was a 32 week premie
but has since been thriving with normal development. He is afebrile with limited range
of motion of the left hip, a normal knee exam and an obvious limp. CBC and Xrays are
normal.

11. What is the most likely diagnosis?

12. What test would you request to confirm your diagnosis?

A 16 year old obese male complains of acute right hip pain after playing baseball. He is
afebrile with limited range of motion of the right hip and inability to ambulate. CBC is
normal.

13. What is the most likely diagnosis?

14. What test would you request to confirm your diagnosis?