Beruflich Dokumente
Kultur Dokumente
Question: 1
You are evaluating a 6-month-old child who has a ventricular septal defect and is scheduled for cardiac
surgery. The child’s 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
baby’s 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.
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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
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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 infant’s 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
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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
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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 infant’s 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
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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
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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
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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
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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
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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
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Critique: 5
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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.
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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
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Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and
treatment. Headache. 2000;40:25-29. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/10759899
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Critique: 6
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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 child’s mother used
multiple street drugs throughout her pregnancy as well as medications prescribed for seizure and
bipolar disorders. The grandmother is concerned that this child’s 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 child’s dysmorphic
features is
A. lithium
C. marijuana
D. methamphetamine
E. phenobarbital
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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. Reprotox. Available for subscription at:
http://www.reprotox.org
Phenobarbital, lithium, LSD, marijuana, methamphetamine. Teris. Available for subscription at:
http://depts.washington.edu/terisweb/teris
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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)
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Critique: 7
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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
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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
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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).
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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
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Question: 9
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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
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Critique: 9
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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
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Question: 10
Shield-shaped chest and lack of breast development, as described for the girl
in the vignette. (Courtesy of M. Rimsza)
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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.
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Sybert VP, McCauley E. Turner's syndrome. N Engl J Med. 2004;351:1227-1238. Extract available at:
http://content.nejm.org/cgi/content/extract/351/12/1227
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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 infant’s blindness will affect his behavior and development.
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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
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Critique: 11
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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
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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
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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
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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)
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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
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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
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Critique: 13
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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.
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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
Linshaw MA. Congenital nephrogenic diabetes insipidus. Pediatr Rev. 2007;28:372-380. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/28/10/372
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
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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.
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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
Klemola T, Vanto T, Juntunen-Backman K, Kalimo K, Korpela R, Varjonen E. Allergy to soy formula and
to extensively hydrolyzed whey formula in infants with cow's milk allergy: a prospective, randomized
study with a follow-up to the age of 2 years. J Pediatr. 2002;140:219-224. Abstract available at:
http://www.ncbi.nlm.nih.gov/ pubmed/11865274
Saarinen KM, Pelkonen AS, Mäkelä 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
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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
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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
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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=searc
h_result
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Critique: 16
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Critique: 16
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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
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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
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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 97.0°F (36.1°C), 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.
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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
Marín GMA, Martín 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
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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
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Question: 19
Cyanosis of the feet, as exhibited by the infant in the vignette. (Courtesy of the
Media Lab at Doernbecher)
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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
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants.
Pediatr Clin North Am. 2004;51:999-1021. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15275985
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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 family’s barbecue restaurant and to cosmetic chemicals used at the
grandmother’s 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 child’s respiratory
symptoms is exposure to
A. cigarette smoke
B. cleaning fluids
C. dust mites
D. hairspray
E. wood smoke
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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
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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
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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
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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
Tennstedt C, Chaoui R, Körner H, Dietel M. Spectrum of congenital heart defects and extracardiac
malformations associated with chromosomal abnormalities: results of a seven year necropsy study.
Heart. 1999;82:34-39. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/10377306
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Critique: 21
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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
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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
Kestle JR. Pediatric hydrocephalus: current management. Neurol Clin. 2003;21:883-895. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/14743654
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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 Am.
2004;51:237-270. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15062671
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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
child’s 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 child’s features is
A. Angelman
B. Beckwith-Wiedemann
C. 4p-
D. Prader-Willi
E. 22q11
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history information.
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=OvKiicpzcfvnc&gry
=&fcn=y&fw=vH7o&filename=/profiles/whs/index.html
Bishara N, Clericuzio CL. Common dysmorphic syndromes in the NICU. NeoReviews. 2008;9:e29-e38.
Available for subscription at: http://neoreviews.aappublications.org/cgi/content/full/9/1/e29
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=OvKiicpzcfvnc&gry
=&fcn=y&fw=tkPG&filename=/profiles/angelman/index.html
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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.)
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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
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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
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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
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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
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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
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Question: 26
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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
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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
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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
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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
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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 102.6°F (39.2°C), 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
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Question: 28
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Question: 28
(Courtesy of D. Krowchuk)
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References:
Libecco JA, Powell KR. Trimethoprim/sulfamethoxazole: clinical update. Pediatr Rev. 2004;25:375-380.
Available at: http://pedsinreview.aappublications.org/cgi/content/full/25/11/375
Saidinejad M, Ewald MB, Shannon MW. Transient psychosis in an immune-competent patient after oral
trimethoprim-sulfamethoxazole administration. Pediatrics. 2005;115:e739-e741. Available at:
http://pediatrics.aappublications.org/cgi/content/full/115/6/e739
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Question: 29
A 14-year-old girl presents for evaluation after 4 days of a temperature to 103.0°F (39.5°C), 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 102.8°F (39.4°C) 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 patient’s condition is
A. ceftriaxone
B. clindamycin
C. metronidazole
D. trimethoprim-sulfamethoxazole
E. vancomycin
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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
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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.
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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
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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 infant’s 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 boy’s 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 newborn’s 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
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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
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Prescott SL, Björkstön 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
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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 104.2°F (40.1°C), 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
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References:
Burns JJ Jr. Toxicity, anticholinergic. eMedicine Specialties, Emergency Medicine, Toxicology. 2006.
Available at: http://www.emedicine.com/EMERG/topic36.htm
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
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Su M, Goldman M. Anticholinergic poisoning. UpToDate Online 15.3. 2008. Available for subscription
at:
http://www.utdol.com/utd/content/topic.do?topicKey=ad_tox/13958&selectedTitle=1~376&source=searc
h_result
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Critique: 32
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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
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Question: 33
Metaphyseal fraying, cupping, and widening, as described for the infant in the
vignette. (Couretsy of R. Schwartz)
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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
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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
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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
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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
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Question: 35
(Courtesy of M. Rimsza)
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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
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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)
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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 today’s 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
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Question: 36
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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)
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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
Goins RA, Ascher D, Waecker N, Arnold J, Moorefield E. Comparison of fluconazole and nystatin oral
suspensions for treatment of oral candidiasis in infants. Pediatr Infect Dis J. 2002;21:1165-1167.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/12506950
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
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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
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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:
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http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
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Critique: 37
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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
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Question: 38
(Courtesy of D. Krowchuk)
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Question: 38
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Question: 38
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References:
Ferner RE. Neurofibromatosis 1 and neurofibromatosis 2: a twenty first century perspective. Lancet
Neurol. 2007;6:340-351. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17362838
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
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Critique: 38
Lisch nodules (iris hamartomas [arrow]) are one of the diagnostic criteria for
neurofibromatosis type 1. (Courtesy of Wake Forest University Eye Center)
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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)
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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 night’s
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
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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
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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
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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
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Question: 41
You are evaluating a 20-month-old boy who has a rectal temperature of 106°F (41.1°C) 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
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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
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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 102.0°F [38.9°C]) and has vomited twice. According to her mother, other family
members recently recovered from a gastrointestinal illness that started with fever and vomiting.
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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
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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
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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
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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 boy’s 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
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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
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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
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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
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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
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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
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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
Pontremoli R, Leoncini G, Ravera M, et al. Microalbuminuria, cardiovascular, and renal risk in primary
hypertension. J Am Soc Nephrol. 2002;13:S169-S172. Available at:
http://jasn.asnjournals.org/cgi/content/full/13/suppl_3/S169
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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).
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Question: 47
(Courtesy of D. Krowchuk)
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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
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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
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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
Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy FH Jr. Predictability of esophageal injury
from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71:767-770.
Available at: http://pediatrics.aappublications.org/cgi/content/full/71/5/767
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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 patient’s symptoms is
C. vitamin C deficiency
D. vitamin K deficiency
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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
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Critique: 49
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Critique: 49
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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
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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
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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 "doesn’t 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 girl’s headaches is to
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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
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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
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radiograph for the patient in the vignette, however, shows a classic sunburst pattern, which is not
consistent with chronic osteomyelitis.
Acromioclavicular (AC) separation typically results in sudden pain and limited range of 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
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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 patient’s clinical presentation is
A. polycythemia
B. postpericardiotomy syndrome
C. protein-losing enteropathy
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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:
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http://pedsinreview.aappublications.org/cgi/content/full/28/4/123
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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
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Question: 54
(Courtesy of D. Gilbert)
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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
Klimo P Jr, Rao G, Brockmeyer D. Pediatric arteriovenous malformations: a 15-year experience with an
emphasis on residual and recurrent lesions. Childs Nerv Syst. 2007;23:31-37. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17053936
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
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Question: 55
While examining a newborn, you note a persistent curve in the spine regardless of the baby’s 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
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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
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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
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References:
American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and
Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics.
2001;108:498-502. Available at: http://pediatrics.aappublications.org/cgi/content/full/108/2/498
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
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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
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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
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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
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Question: 58
(Courtesy of L. Levitsky)
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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
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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
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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
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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 doesn’t 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
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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
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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
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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
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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
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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
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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.
Saunier S, Calado J, Benessy F, et al. Characterization of the NPHP1 locus: mutational mechanism
involved in deletions in familial juvenile nephronophthisis. Am J Hum Genet. 2000;66:778-789.
Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10712196
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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 boy’s 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
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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
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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
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Question: 64
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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
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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.
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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)
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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
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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
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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 96.8°F (36.0°C), 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
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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,
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eds. Current Pediatric Diagnosis & Treatment. 18th ed. New York, NY: The McGraw-Hill Companies,
Inc; 2007:chap 1
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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)
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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
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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
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Oblique (left) and anteroposterior (right) views of the distal tibia reveal a
nondisplaced spiral (toddler's) fracture. (Courtesy of D. Mulvihill)
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Metaphyseal corner (chip) fractures may be observed in children who are the
victims of nonaccidental trauma. (Courtesy of D. Krowchuk)
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Spiral fracture of the femur in a 6-week-old infant who had been physically
abused. (Courtesy of D. Krowchuk)
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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 100.6°F (38.1°C). 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 child’s joint complaints is
A. Borrelia burgdorferi
B. Coxsackievirus
D. influenza A virus
E. parvovirus B19
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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
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American Academy of Pediatrics. Parvovirus B19/erythema infectiosum, fifth 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; 2006:484-487
Khouqeer R, Cohen M. Viral arthritis. eMedicine Specialties, Rheumatology, Infectious Arthritis. 2006.
Available at: http://www.emedicine.com/med/topic3414.htm
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, Knöll, A, Küster 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
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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
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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
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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
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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
page 256
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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 baby’s 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 baby’s condition is
A. chromosome analysis
B. head ultrasonography
C. ophthalmology consultation
E. renal ultrasonography
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Question: 71
(Courtesy of P. Sagerman)
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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
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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 patient’s symptoms is
A. Candida albicans
B. Chlamydia trachomatis
C. group A Streptococcus
D. Neisseria gonorrhoeae
E. Trichomonas vaginalis
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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
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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
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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
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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
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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
LaFranchi S. Acquired hypothyroidism in childhood and adolescence. UpToDate Online 15.3. 2008.
Available for subscription at:
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pediendo/4633
Ferry RJ Jr, Bauer AJ. Hypothyroidism. eMedicine Specialties, Pediatrics, Endocrinology. 2006.
Available at: http://www.emedicine.com/ped/TOPIC1141.HTM
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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 café 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
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Question: 75
Café au lait macules, as described for the child in the vignette. (Courtesy of P.
Fisher)
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Question: 75
Axillary freckling and a café au lait macule, as described for the child in the
vignette. (Courtesy of D. Krowchuk)
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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
page 272
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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
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Question: 76
A 6-year-old girl presents with a history of swelling on her jaw of 1 month’s duration. The mother has
been to a "couple of emergency rooms," but nobody can tell her what is wrong with the girl. The child’s
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
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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
page 277
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Critique: 76
Mumps may present with unilateral (as shown here) or bilateral parotid
swelling. (Courtesy of M. Rimsza)
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Question: 77
You are evaluating a 2-year-girl who recently was adopted from Russia for a 4-day history of
temperature to 102.5°F (39.2°C), 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 103.0°F (39.5°C), 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
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Question: 77
White papules on the buccal mucosa (arrow), as described for the girl in the
vignette. (Courtesy of W.W. Tunnessen, Jr)
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Question: 77
(Courtesy of the Centers for Disease Control and Prevention, Public Health
Image Library, Dr. Heinz F. Eichenwald)
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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
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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
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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
page 285
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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
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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
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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
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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&source=searc
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h_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
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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
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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
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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 woman’s child are
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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
page 296
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Critique: 82
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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.
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Question: 83
(Courtesy of D. Krowchuk)
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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
page 300
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Critique: 83
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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)
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Critique: 83
The eruption of secondary syphilis often involves the palms and soles.
(Courtesy of C. Haverstock)
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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
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Question: 84
Lichenified and crusted plaques, as described for the boy in the vignette.
(Courtesy of D. Krowchuk)
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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, Rød 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:
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http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003741/frame.html
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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 grandmother’s 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
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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
Pérez-Fontán 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
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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
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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
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Critique: 86
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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 son’s 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
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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
Kouba S, Hällström T, Londholm C, Lindén Hirschbe A. Pregnancy and neonatal outcomes in women
with eating disorders. Obstet Gynecol. 2005;105:255-260. Available at:
http://www.greenjournal.org/cgi/content/full/105/2/255
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
page 314
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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
page 315
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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
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Question: 88
(Courtesy of P. Sagerman)
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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
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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
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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
page 320
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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
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Question: 90
(Courtesy of M. Rimsza)
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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
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Critique: 90
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Critique: 90
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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
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Question: 91
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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
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Critique: 91
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Critique: 91
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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 103.0°F (39.4°C), 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 child’s illness is
B. Neisseria meningitidis
C. Staphylococcus aureus
D. Streptococcus pneumoniae
E. Streptococcus pyogenes
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Question: 92
(Courtesy of D. Krowchuk)
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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
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Critique: 92
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Critique: 92
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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-Barré syndrome
D. tetanus
E. tick paralysis
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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
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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
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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
Pillo-Blocka F, Adatia I, Sharieff W, McCrindle BW, Zlotkin S. Rapid advancement to more concentrated
formula in infants after surgery for congenital heart disease reduces duration of hospital stay: a
randomized clinical trial. J Pediatr. 2004;145:761-766. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/15580197
Yahav J, Avigad S, Frand M, et al. Assessment of intestinal and cardiorespiratory function in children
with congenital heart disease on high-caloric formulas. J Pediatr Gastroenterol Nutr. 1985;4:778-785.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/4045636
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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
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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
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Critique: 95
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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 boy’s injury should include
A. decongestants
B. nasal packing
C. no specific treatment
D. prophylactic antibiotics
E. surgical repair
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Question: 96
(Courtesy of D. Mulvihill)
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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
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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)
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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 patient’s symptoms are MOST consistent with deficiency of
A. vitamin A
B. vitamin B1 (thiamine)
C. vitamin C
D. vitamin D
E. vitamin E
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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
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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
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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
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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
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References:
36th Bethesda conference: eligibility recommendations for competitive athletes with cardiovascular
abnormalities. J Am Coll Cardiol. 2005;45:1312-1375. Available at:
http://content.onlinejacc.org/cgi/reprint/45/8/1312
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
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http://pedsinreview.aappublications.org/cgi/content/full/27/11/418
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Critique: 99
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Critique: 99
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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 daughter’s
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
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Question: 100
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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
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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. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/3/86
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Critique: 100
When infected with S aureus, lesions of atopic dermatitis become moist and
crusted. (Courtesy of D. Krowchuk)
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Critique: 100
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Critique: 100
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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
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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
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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
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References:
Andrews PI. Autoimmune myasthenia gravis in childhood. Semin Neurol. 2004;24:101-110. Abstract
available at: http://www.ncbi.nlm.nih.gov/pubmed/15229797
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
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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
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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
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Question: 103
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References:
Cigarette smoking, methamphetamine, alcohol, cocaine, marijuana. Reprotox. Available for subscription
at: http://www.reprotox.org
Cigarette smoking, methamphetamine, alcohol, cocaine, marijuana. Teris. Available for subscription at
http://depts.washington.edu/terisweb/teris/
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
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Critique: 103
Limb reduction defects may result from vascular disruptive events. (Courtesy
of V. Shashi)
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Critique: 103
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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
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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
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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
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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
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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
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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
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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
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Question: 107
A 12-year-old boy recently took a standardized achievement test at school. His score dropped from 105
on last year’s 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 child’s contact sports activity for the next season
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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
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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
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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
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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 102.0°F (38.9°C), and the wound has
become very erythematous, swollen, and tender, with some red streaking. On physical examination, the
boy has a temperature of 101.5°F (38.6°C) 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 patient’s condition is
C. Staphylococcus epidermidis
D. Streptococcus pyogenes
E. Streptococcus pneumoniae
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associated with a preceding viral infection. The onset of disease usually is abrupt and is characterized
by fever, dyspnea, cough, and pleuritic chest pain. Chest radiography shows a consolidative lobar
pneumonia that has moderate-to-large pleural effusion or empyema. Meningitis due to group A
Streptococcus is 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
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Critique: 109
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Critique: 109
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Critique: 109
The rash of scarlet fever is comprised of fine erythematous papules that have
a rough or "sandpaper" feel. (Courtesy of D. Krowchuk)
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Critique: 109
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Critique: 109
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Critique: 109
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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 98.6°F (37°C), 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
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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
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Critique: 110
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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
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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
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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
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Question: 112
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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
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Critique: 112
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Critique: 112
In some greenstick fractures, the bone may bend but not break (arrow).
(Courtesy of D. Krowchuk)
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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)
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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 patient’s history is
A. alpha-1-antitrypsin deficiency
B. colipase deficiency
C. hereditary pancreatitis
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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
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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
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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
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Critique: 114
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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
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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
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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
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Question: 116
(Courtesy of M. Rimsza)
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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
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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
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Critique: 116
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Critique: 116
The striae observed in patients who have Cushing syndrome often have a
violaceous color. (Courtesy of M. Rimsza)
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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
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Question: 117
(Courtesy of M. Rimsza)
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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
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Critique: 117
Roth spots are retinal hemorrhages that have a pale center (arrow). (Courtesy
of SY Lesnik Oberstein and eyetext.net)
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Critique: 117
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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.
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References:
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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
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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 infant’s features is
A. alcohol
B. isotretinoin
C. phenobarbital
D. phenytoin
E. thalidomide
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References:
Isotretinoin, alcohol, phenytoin, phenobarbital, thalidomide. Reprotox. Available for subscription at:
http://www.reprotox.org
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
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Critique: 119
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Critique: 119
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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
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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
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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).
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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
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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 child’s 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)
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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
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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
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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
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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 patient’s diarrhea is
A. Campylobacter jejuni
B. Clostridium difficile
C. Salmonella enteritidis
D. Shigella sonnei
E. Yersinia enterocolitica
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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
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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 102.5°F (39.2°C), 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 patient’s illness is
A. Cryptosporidium
B. cytomegalovirus
E. Salmonella sp
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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
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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
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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
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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
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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
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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
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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&source=sear
ch_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
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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
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References:
Thiessen PN. Recurrent abdominal pain. Pediatr Rev. 2002;23:39-46. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/23/2/39
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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
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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
Markestad T, Kaaresen PI, Rønnestad A, et al on behalf of the Norwegian Extreme Prematurity Study
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Group. Early death, morbidity, and need of treatment among extremely premature infants. Pediatrics.
2005;115:1289-1298. Available at: http://pediatrics.aappublications.org/cgi/content/full/115/5/1289
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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 day’s 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 99.0°F (37.3°C). 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
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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
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Question: 132
A resident in continuity clinic approaches you to review the laboratory values obtained at a patient’s
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).
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Succimer is the drug of choice for children whose blood lead concentrations are 45.0 to 100.0
mcg/dL (2.17 to 4.8 mcmol/L). At values higher than 69.0 mcg/dL (3.3 mcmol/L), a second drug,
CaNa2EDTA, is added. For children who require two-drug treatment, the first dose always 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
Rischitelli G, Nygren P, Bougatsos C, Freeman M, Helfand M. Screening for Elevated Lead Levels in
Childhood and Pregnancy: An Update of a 1996 U.S. Preventive Services Task Force Review.
Rockville, Md: Agency for Healthcare Research and Quality, U.S. Department of Health and Human
Services; 2006. Available at: http://www.ahrq.gov/clinic/uspstf06/lead/leadsum.htm
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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
page 467
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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 102.7°F (39.3°C), 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
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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
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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-Barré syndrome
D. metabolic myopathy
E. viral myositis
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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
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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
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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
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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
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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
American Academy of Pediatrics Committee on Sports Medicine and Fitness. Promotion of healthy
weight-control practices in young athletes. Pediatrics. 2005;116:1557-1564. Available at:
http://pediatrics.aappublications.org/cgi/content/full/116/6/1557
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
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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
B. NaCl (%): 0.45
KCl (mEq/L): 0
Duration of Infusion(hr): 48 to 72
C. NaCl (%): 0.45
KCl (mEq/L): 40
Duration of Infusion(hr): 12 to 24
D. NaCl (%): 0.9
KCl (mEq/L): 0
Duration of Infusion(hr): 12 to 24
E. NaCl (%): 0.9
KCl (mEq/L): 40
Duration of Infusion(hr): 48 to 72
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Water deficit (mL)= 4 mL x ideal body weight (kg) x desired change in serum sodium concentration
Hypernatremia, especially if chronic, should be corrected slowly, with a desired goal of decreasing
the serum sodium by 0.5 mEq/L per hour to avoid cerebral edema. Severe hypernatremia (serum
sodium >170.0 mEq/L [170.0 mmol/L]), as described for the child in the vignette, should be corrected
over 48 to 72 hours. Fluid administration generally consists of 1/4 to 1/2 normal saline solutions.
Symptoms of overcorrection, such as changes in mental status or onset of seizures, suggest the
development of cerebral edema and should be treated with hypertonic saline and slowing of the sodium
correction. In general, potassium administration should be withheld in cases of severe hypernatremic
dehydration until adequate urine output is assured.
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
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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
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References:
Ballonoff A, Kavanagh B. Complications of cranial irradiation. UpToDate Online 15.3. 2008. Available
for subscription at: http://www.uptodateonline.com/utd/content/topic.do?topicKey=rad_ther/2462
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
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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
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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
page 485
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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 102.4°F
(39.1°C) 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 101.4°F (38.6°C), 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
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Question: 140
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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
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Critique: 140
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Critique: 140
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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 100.8°F (38.3°C), 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 patient’s condition is
A. Campylobacter jejuni
B. Escherichia coli
C. Giardia lamblia
D. Salmonella sp
E. Shigella sp
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References:
American Academy of Pediatrics. Escherichia coli diarrhea (including hemolytic-uremic syndrome). 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; 2006:291-296
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
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Critique: 141
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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 99.5°F (37.5°C), 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
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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
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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
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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, Bartolomé Zavala B, Sánchez 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=105
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
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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
98.2°F (36.8°C), 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
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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
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Critique: 144
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Critique: 144
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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
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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
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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 baby’s 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, 7.0x103/mcL (7.0x109/L) with a normal differential count
· Platelet count, 150.0x103/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 infant’s underlying problem is
A. administration of amphotericin B
E. phototherapy
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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
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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
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Critique: 146
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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 boy’s symptoms is
A. Bartonella henselae
B. Francisella tularensis
C. Haemophilus influenzae
D. Pasteurella multocida
E. Staphylococcus aureus
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Question: 147
(Courtesy of M. Rimsza)
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Question: 147
(Courtesy of M. Rimsza)
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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.
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Critique: 147
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Critique: 147
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Critique: 147
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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 101.5°F (38.6°C). 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.
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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
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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
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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
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Critique: 149
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Critique: 149
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Critique: 149
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Critique: 149
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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.
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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
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Critique: 150
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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
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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
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Critique: 151
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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
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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
page 530
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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.
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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
page 532
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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
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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
page 534
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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.
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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
Council on Children With Disabilities. Policy statement: provision of educationally related services for
children and adolescents with chronic diseases and disabling conditions. Pediatrics.
2007;119:1218-1223. Available at: http://pediatrics.aappublications.org/cgi/content/full/119/6/1218
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
page 536
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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
page 537
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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
page 538
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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 102.0°F (38.9°C), bilateral conjunctivitis,
nasal congestion, and exudative pharyngitis.
A. adenovirus
B. Chlamydia trachomatis
C. Epstein-Barr virus
D. Leptospira sp
E. Mycoplasma pneumoniae
page 539
2009 PREP SA on CD-ROM
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
page 540
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Critique: 157
page 541
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Question: 158
A 16-year-old girl presents with symptoms of burning with micturition and back pain. Her temperature is
101.3°F (38.5°C), 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
page 542
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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
page 543
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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 boy’s condition is that
A. a normal carbon dioxide value on an arterial blood gas measurement makes an asthma exacerbation
unlikely
E. the patient should blow into a paper bag to help calm him
page 544
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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.jsp#Q1
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
page 545
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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 boy’s hand, you note several small, erythematous
abrasions but no swelling or ecchymosis.
page 546
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Question: 160
page 547
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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
page 548
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Critique: 160
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Critique: 160
page 550
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Critique: 160
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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)
page 552
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Critique: 160
page 553
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Critique: 160
page 554
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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
page 555
2009 PREP SA on CD-ROM
References:
Cyclic Vomiting Syndrome Association of America web site. Available at: http://www.cvsaonline.org
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
page 556
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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 mother’s diabetes are
page 557
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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
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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
page 559
2009 PREP SA on CD-ROM
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
page 560
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Critique: 163
page 561
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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.
page 562
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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.
page 563
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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
page 564
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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 102.3°F (39.1°C). 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
page 565
2009 PREP SA on CD-ROM
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
page 566
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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
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Critique: 165
page 568
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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
page 569
2009 PREP SA on CD-ROM
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
page 570
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Critique: 166
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Critique: 166
page 572
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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
page 573
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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
page 574
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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 patient’s symptoms is
A. Chlamydia trachomatis
C. Neisseria gonorrhoeae
D. parvovirus B19
E. Treponema pallidum
page 575
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Question: 168
page 576
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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
page 577
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Critique: 168
page 578
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Critique: 168
page 579
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Critique: 168
page 580
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Critique: 168
page 581
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Critique: 168
The eruption of secondary syphilis often involves the palms and soles.
(Courtesy of C. Haverstock)
page 582
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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
page 583
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Question: 169
page 584
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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
page 585
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Critique: 169
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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
page 587
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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
Postellon DJ, Bourgeois MJ, Varma S. Congenital hypothyroidism. eMedicine Specialties, Pediatrics:
General Medicine, Endocrinology. 2007. Available at: www.emedicine.com/ped/topic501.htm
page 588
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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
page 589
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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
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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
page 591
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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
Niyogi SK. Increasing antimicrobial resistance-an emerging problem in the treatment of shigellosis. Clin
Microbiol Infect. 2007;13:1141-1143. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/17953700
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
page 592
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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
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Question: 173
page 594
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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
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Critique: 173
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Critique: 173
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Question: 174
A 6-year-old girl is experiencing daytime and nighttime enuresis of 1 month’s 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
page 598
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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
page 599
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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
page 600
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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.jsp#Q1
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
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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 child’s 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 girl’s 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
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Question: 176
Type of spider brought by the family for inspection. (Courtesy of the Centers
for Disease Control and Prevention, Public Health Image Library)
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Question: 176
Bulla with surrouding erythema, as described for the child in the vignette.
(Courtesy of M. Rimsza)
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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
page 605
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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
page 606
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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)
page 607
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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)
page 608
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Critique: 176
page 609
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Critique: 176
An eschar with surrounding erythema may occur following the bite of a brown
recluse spider. (Courtesy of M. Smith)
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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)
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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.
page 612
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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.
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Critique: 177
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Critique: 177
page 615
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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 100.5°F (37.8°C), 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 child’s presenting signs of respiratory distress is
C. gastroesophageal reflux
page 616
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References:
American Academy of Pediatrics Committee on Fetus and Newborn. Postnatal corticosteroids to treat
or prevent chronic lung disease in preterm infants. Pediatrics. 2002;109;330-338. Available at:
http://pediatrics.aappublications.org/cgi/content/full/109/2/330
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:
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http://www.ncbi.nlm.nih.gov/pubmed/15748971
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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
page 619
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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
page 620
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Critique: 179
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Critique: 179
Bucket handle metaphyseal fracture of the radius (arrow) in a child who has
been physically abused. (Courtesy of S. Sinal)
page 622
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Critique: 179
Healing posterior rib fractures (arrows) in an infant who has been physically
abused. (Courtesy of D. Krowchuk)
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Critique: 179
Right femur fracture in a 2-month-old child who had been physically abused.
(Courtesy of D. Krowchuk)
page 624
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Critique: 179
Oblique (left) and anteroposterior (right) views of the distal tibia show a
nondisplaced spiral (toddler's) fracture. (Courtesy of D. Mulvihill)
page 625
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Critique: 179
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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 child’s 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
page 627
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References:
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
page 628
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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
page 629
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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
Lama G, Graziano L, Calabrese E, et al. Blood pressure and cardiovascular involvement in children
with neurofibromatosis type 1. Pediatr Nephrol. 2004;19:413-418. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/14991390
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
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Critique: 181
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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 infant’s abnormal
examination findings is
B. electroencephalography
C. head ultrasonography
D. high-resolution karyotyping
page 632
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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
Shevell M, Majnemer A, Platt RW, Webster R, Birnbaum R. Developmental and functional outcomes in
children with global developmental delay or developmental language impairment. Dev Med Child
Neurol. 2005;47:678-683. Available at:
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1469-8749.2005.tb01053.x
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Critique: 182
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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
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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
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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.
page 637
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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
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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.
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Question: 185
(Courtesy of B. Poss)
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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
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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
page 642
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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
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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
page 644
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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
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Question: 188
The nurse caring for a 5-day-old infant you have hospitalized calls your office to report that the infant’s
blood culture is growing gram-positive rods. You admitted the infant to the hospital because of a rectal
temperature of 102.0°F (38.9°C) measured by his mother at home.
A. Enterococcus sp
B. Escherichia coli
C. Listeria monocytogenes
D. Proteus mirabilis
E. Staphylococcus epidermidis
page 646
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References:
American Academy of Pediatrics. Listeria monocytogenes infections (listeriosis). 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; 2006:426-428
Posfay-Barbe KM, Wald ER. Listeriosis. Pediatr Rev. 2004;25:151-159. Available at:
http://pedsinreview.aappublications.org/cgi/content/full/25/5/151
page 647
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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
page 648
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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
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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
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Question: 190
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Question: 190
page 652
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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
page 653
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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
page 654
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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
page 655
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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 96.4°F (35.8°C), 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
page 656
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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&source=sear
ch_result
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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
page 658
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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
page 659
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Critique: 193
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Critique: 193
page 661
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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
page 662
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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
page 663
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Critique: 194
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Critique: 194
page 665
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Critique: 194
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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.)
page 667
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Critique: 194
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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)
page 669
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Question: 195
A mother brings her 5-year-old girl to your office because she noticed a "lump" in her daughter’s 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
page 670
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Question: 195
page 671
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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
page 672
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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)
page 673
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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)
page 674
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Critique: 195
page 675
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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
page 676
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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
page 677
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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
page 678
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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,
page 679
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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
page 680
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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
page 681
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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
page 682
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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
page 683
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References:
Nyhan WL, Barshop BA, Ozand PT. Organic acidemias. In: Atlas of Metabolic Diseases. 2nd ed.
London, England: Hodder Arnold; 2005:1-108
page 684
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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
page 685
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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
page 686
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Critique: 200
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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 boy’s sudden respiratory deterioration is
D. tension pneumothorax
E. ventilator-associated pneumonia
page 688
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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
page 689
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Critique: 201
page 690
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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
page 691
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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
page 692
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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
page 693
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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
page 694
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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
page 695
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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
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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 patient’s right flank.
Of the following, the MOST likely organism causing this patient’s recurrent infections is
C. Staphylococcus epidermidis
D. Streptococcus pneumoniae
E. Streptococcus pyogenes
page 697
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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
page 698
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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 girl’s temperature is 100.2°F (37.9°C), 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, 21.5x103/mcL (21.5x109/L)
· Platelet count, 90.0x103/mcL (90.0x109/L)
page 699
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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:
page 700
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http://pediatrics.aappublications.org/cgi/content/full/117/5/1656
Mahan JD. Hemolytic uremic syndrome. In: Kher KK, Schnaper HW, Makker SP, eds. Clinical Pediatric
Nephrology. 2nd ed. London, England: Informa Healthcare; 2007:235-244
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
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Critique: 206
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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 patient’s symptoms is
A. allergic rhinitis
B. asthma exacerbation
C. habit cough
D. sinusitis
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Question: 207
page 704
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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
page 705
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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 98.8°F (37.1°C), 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
page 706
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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
page 707
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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 baby’s clinical findings is
A. duodenal atresia
B. Hirschsprung disease
C. meconium ileus
D. necrotizing enterocolitis
E. neonatal intussusception
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Question: 209
(Courtesy of D. Mulvihill)
page 709
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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
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Critique: 209
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Critique: 209
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Critique: 209
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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 infant’s abdominal findings is
A. congenital lymphangioma
B. erythroblastosis fetalis
C. meconium peritonitis
D. ovarian cyst
E. urinary ascites
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Question: 210
(Courtesy of B. Carter)
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References:
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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
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Critique: 210
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Critique: 210
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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
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References:
Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal
abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005;12: 467-473. Abstract available
at: http://www.ncbi.nlm.nih.gov/pubmed/15860701
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
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Critique: 211
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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 girl’s 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 girl’s rapid onset of anemia is
B. hemoglobin SC disease
C. hereditary elliptocytosis
E. pyelonephritis
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Question: 212
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based on hemolysis without stressors. Iron deficiency does not cause hemolysis or jaundice.
Pyelonephritis may result from ascending infection from cystitis but normally is associated with fever
and other constitutional symptoms in addition to fatigue. Hemolysis can result from infection in persons
unaffected by G6PD deficiency but usually not to the degree noted in the child described in the vignette.
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
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Critique: 212
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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
page 728
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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
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Critique: 213
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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.
page 731
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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
page 732
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Critique: 214
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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 child’s 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
page 734
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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
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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
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Question: 216
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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
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Critique: 216
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Question: 217
A 2-year-old girl is brought to the emergency department after being found unconscious at her
grandparent’s 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 98.0°F (37.0°C), 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.
page 740
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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
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Critique: 217
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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
page 743
2009 PREP SA on CD-ROM
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
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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 child’s 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
page 745
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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
page 746
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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
page 747
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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
Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54(RR07):1-21.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm
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Critique: 220
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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 son’s 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
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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
Whitley RJ. Therapeutic approaches to varicella-zoster virus infections. J Infect Dis. 1992;166(suppl
1):S51-S57. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1378081
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Critique: 221
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Critique: 221
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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 98.6°F (37°C), 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
page 754
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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
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Critique: 222
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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
child’s 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
page 757
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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
page 758
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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.
page 759
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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=search_r
esult
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
page 760
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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
page 761
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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
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Critique: 225
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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.
A. if her newborn has thrombocytopenia, he or she will be treated with intravenous immunoglobulin
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
page 764
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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
Murphy MF, Bussel JB. Advances in the management of alloimmune thrombocytopenia. Br J Haematol.
2007;136:366-378. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17233844
page 765
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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
page 766
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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
Chandran L, Gelfer P. Breastfeeding: the essential principles. Pediatr Rev. 2006;27:409-417. Available
at: http://pedsinreview.aappublications.org/cgi/content/full/27/11/409
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
page 767
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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 100°F (37.8°C), 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
page 768
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Question: 228
page 769
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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
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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)
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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 girl’s 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. Ehlers—Danlos syndrome
B. infective endocarditis
C. Marfan syndrome
E. Williams syndrome
page 772
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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
page 773
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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
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Critique: 229
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Critique: 229
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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)
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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
page 778
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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
page 779
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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
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References:
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Critique: 231
Aniridia appears as a large pupil with little iris. (Courtesy of the Media Lab at
Doernbecher)
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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
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Question: 232
(Courtesy of M. Rimsza)
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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
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Critique: 232
Infection of the genitalia with herpes simplex virus produces painful ulcers.
(Courtesy of M. Rimsza)
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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
page 787
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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
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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
page 789
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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
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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
page 791
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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
page 792
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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 101.8°F (38.8°C) 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
page 793
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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
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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 boy’s 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
page 795
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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
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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 98.6°F (37°C), 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 patient’s
condition is
D. hypercalcemia
E. metabolic alkalosis
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Question: 238
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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
page 799
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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
page 800
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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
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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
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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&source=sear
ch_result
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Critique: 240
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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
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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
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Critique: 241
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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, 7.5x103/mcL (7.5x109/L)
· Platelet count, 90.0x103/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
page 809
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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
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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
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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
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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
page 813
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Question: 244
A 15-month-old girl presents to the emergency department with a temperature of 103°F (39.5°C) 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
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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.
page 815
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Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001;108:271-276. Available
at: http://pediatrics.aappublications.org/cgi/content/full/108/2/271
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
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Critique: 244
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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
page 818
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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
Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to
neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure
Study Group. J Perinatol. 1995;15:470-479. Abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/8648456
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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
page 820
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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
page 821
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Question: 247
A mother brings in her 4-month-old baby because she is concerned about the infant’s 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
page 822
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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
Robin NH, Falk MJ, Hlademan-Englert CR. FGFR-related craniosynostosis syndromes. GeneReviews.
2007. Available at:
http://www.geneclinics.org/servlet/access?db=geneclinics&site=gt&id=8888891&key=xAcWBcrjmZrVo&
gry=&fcn=y&fw=MR4U&filename=/profiles/craniosynostosis/index.html
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Critique: 247
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Critique: 247
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Critique: 247
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Critique: 247
page 827
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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)
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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
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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
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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.
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References:
American Academy of Pediatrics, American Academy of Pediatric Dentistry, Coté 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
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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 doll’s face. The child says "me" and begins to imitate
her mother’s 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
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References:
Dedrick C. Developmental milestones. Developmental Behavioral Pediatrics Online. 2005. Available at:
http://dbpeds.org/articles/detail.cfm?TextID=%20701
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
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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.
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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
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Critique: 251
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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
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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
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Question: 253
The parents of a 3-year-old boy who has polyuria and polydipsia ask if anything can be done for their
child’s 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.
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Question: 253
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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
page 842
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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
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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.jsp#Q1
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
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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
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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
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Critique: 255
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