NBME PEDs 1 and 2 NBME MASTERY

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17yo girl brought to ED after found lying on the street. Outside temp is 40F. En route to hospital, paramedics administered O2 and ECG showed *J-wave*. She is lethargic and poorly responsive to verbal commands. Temp is 32 (89.6F). Puls = 60, RR = 12, BP = 90/60. There is an odor of ethanol on her breath. Which of the following is most likely explanation for the patient’s cardiac findings?

a. cocaine toxicity
b. ethanol toxicity
c. hyperkalemia
d. hypocalcemia
e. hypothermia
f. increased intracranial pressure
g. MI

e. hypothermia (J wave = hypothermia)

A 3 yr old comes to the ED after an episode of syncope followed by a tonic-clonic seizure. She becomes fully alert, then stops talking, closes her eyes, and has 3-4 rhythmic jerks of her arm. During this second episode, an ECG was recorded that showed P waves at 80/min with no QRS complexes. NSR resumes shortly thereafter. She becomes alert one minute after. Most likely diagnosis?

A) Absence seizure
B) Adams-Stokes attack
C) Adverse effect of medication
D) Breath-holding episode
E) Carotid artery trauma
F) Narcolepsy-cataplexy
G) Vasovagal episode
H) Ventricular tachyarrhythmia

B) Adams-Stokes attack
cause of recurrent infection
impaired humoral immunity
mixed metabolic acidosis and resp alkalosis
salicylate poisoning
patchy irregular uptake of radioisotope
Multinodular goiter
What is anotehr name for multinodular goiter
lymphocytic thyroiditis/ infiltration
14 day feevr headache and green nasal discharge in a 14 yr old kid. Post pharyngeal wall is erythematous and covered with thin gray mucous
Sinusitis
SCID has an abscence of what cells
T cells – leads to B cell impairment too. Both are low
recurrent infection – bacterial, fungal and viral
SCID
Pt has foreign body, next step
bronchoscopy – take it out
kid has fever and right foot pain. itching rash stared between the second and third toes of both feel. PLays sports in highschool. Lymphnode in groin is tender

Pseudomonas – becasue he has fever.

Keep in mind that athletes foot, Trichophyton rubrum is a fungus that most common cause of athletes foot, jock itch and ringworm but IT DOES NOT HAVE FEVER or TENDER LYMPH NODE

2 days after delivery a male newborn has dribbling. on PE he has a 6 cm round midline suprapubic pelvic mass
Posterior urethral valves
Hep A ab +
Hep B core Ab +
Hep B surface ag +
Hep B surface ab –
Hep A virus – immune
Hep B virus – not immune
2 yr olld boy with anorexia poor coordination and sporadic vomiting over teh last month. Lab shows hypochromic microcytic anemia.
lead poisoning (not iron def)
ashleaf spots – Skin hypopigmentation, four periventricular nodules – cortical tubers
Tuberous sclerosis
what can TMPSMX cause on labs
neutropenia** ( low segmented neutrophils)
14 yr old girl pt with suprapubic tenderness for 6 mo. She has a red smooth bulge between the labia. Next step?
impreforate hymen – do cruciate incision of the hymen
pt with anorexia is at risk for what bone morphology?
osteoporosis
A low pitched vibratory murmur is heard through the cardiac cycle and is most prominent at the left upper sternal border when the child is in the sitting position. The murmur dissapears when his neck is rotated in the sitting position
Venous hymm – when he turns his head left it cuts it off. Venous hum is when he blood goes through the internal jugular vein

5 ear old with fatigue for 3 weeks, acute onset of fever and chills for 2 hours. Traveled to asia 1 month ago and *received chloroquine*. Exam shows *pallor and splenomegaly*. HCT 22, leuko 18, platelets 80.

assay for strep
assay for heterophile
measure PT and PTT
Measure AST and ALT
thick and thin blood smears

thick and thin blood smears: to look for look at blood for heinz bodies and bite cells
14 yr old girl with downs is evaluated for polycythemia vera. she has cyanosis and clubbing. There is an S2 increased in intensity. she has a large ventricular septal defect and a dilated main pulmonary artery. What is causing the polycythemia?
Pulmonary artery HTN
fundoscopic examination shows an abscence of venous pulsations
increased intercranial pressure, papillemdema, cerebral edema etc.

A 5lb 5 oz newborn is delivered at 37 weeks gestation to a 32 year old women, gravida 1 para 1, following an uncomplicated delivery. The mom has history of IV drug use and received no prenatal care. She did not take any med during pregnancy. Rapid HIV testing of the mother after delivery is positive. Exam of newborn shows no abnormalities. Which of the following is the best next step to manage the newborn?

A) A 6-week course of oral AZT beginning at the 2 week exam
B) A 6-week course of oral AZT only if CD4 count decreases to less than 200/mm
C) A 6-week course of oral AZT within 12 hours after delivery
D) A 6-week course of triple antiretroviral therapy beginning at the 2 week exam
E) A 6-week course of triple antiretroviral therapy if the CD4 T count decrease to less than 200/mm
F) A 6-week course of triple antiretroviral therapy within 24 hours after delivery

C) A 6-week course of oral AZT within 12 hours after delivery

“click” or more precisely “clunk” in the hip may be detected. Ortolani maneuver and the Barlow maneuver

main types are the result of either laxity of the supporting capsule or an abnormal acetabulum.

“developmental dysplasia of the hip” (DDH) to “congenital dislocation of the hip” (CDH)- include subluxation, dysplasia, and dislocation

U/S until 3 mo – then can do xray. xray cant visualize calcification

16 yr boy old with a painless lump in is right breast. 1cm smooth firm mass under right nipple. no nipple or skin retraction or lymphadenopathy
Physiologic pubertal development
diarrhea with chicken
salmonella – cook meat properly

An 18-month-old boy is brought to the physician because of diarrhea for 3 days. He attends day care, and several other children at the center have similar symptoms. The water source for the day-care center is a private well. The center has a pet turtle and two canaries. The patient’s temperature is 37.7°C (99.9°F). He is well hydrated. The remainder of the examination shows no abnormalities. Examination of the stool for ova and parasites is negative. A stool culture grows no enteric pathogens. *Rotavirus testing is positive.*

Laboratory studies show

Hemoglobin 12 g/dL
Leukocyte count 8400/mm3
Segmented neutrophils 39%
Bands 1%
Lymphocytes 60%
Platelet count 240,000/mm3

Cholera immunization
Cooking meats completely
Day-care center closure
Removing the pets from the day-care center
Strict hand-washing techniques at the day-care center
Swimming prohibition in the lake
Typhoid immunization
Use of only disposable diapers at the day-care center
Well water filtration

strict handwashing techniques at the day care center

Healthy 16yo from Africa has painless lesion on vulva for 4 days. *Sexually active* with one male and no contraception used. 10-mm, *sharply demarcated, elevated, round lesion* on right labium majus. Base of the lesion is smooth and nonpurulent. Organism??

A. Chlamydia
B. Gardnerella Vaginitis
C Haemophilus ducrey
D. HSV
E. HPV
F. Neisseria Gonorrhea
G. Treponema pallidum
H. Trichomonas vaginalis

G. Treponema pallidum
bowing of legs outward in a kid
Rickets
anterior bowing of the tibia caused by
hereditary syphilis
9 yr old with bowing of her right leg – right knee bowed outwad on walking. X ray of pt standing shows collapse of the medial aspect of the metaphysis of the proximal tibia
Tibia Vara
next step in caustic ingestion after stabilization of airway
fiberoptic endoscopy

Previously healthy 3 week old newborn with progressive jaundice for past 6 mos. Stools light in color for past 3 days. Full term with no complications. Formula since birth. Total bilirubin is 14, direct is 6. What is mechanism for condition?

Hepatic enzyme deficiency
Decreased conjugation of bilirubin
Decreased excretion of bilirubin
Increased enterohepatic circulation of bilirubin
Increased production of bilirubin

decreased excretion of bili
holosystolic murmur with mid-diastolic murmur at the apex.
VSD
rickets mechanism of deformity
metabolic
12 yr old boy is shortest boyin class but has a tall dad. how do you confirm the dx
determination of bone age

7 month old brought to ER 35 min after seizure onset. *Jerking mvts began in left arm the to right arm and both legs*. Cyanotic. Temp 39.7, pulse 160, resp 30, BP 90/60. upward deviation of eyes. generalized rigidity and hyperextension of neck, back, all extremities. Clonic jerking mvts. oxygen administered. next step?

A. acetaminophen
B. diazepam
C. Glucose
D. Naloxone
E. Thiamine

diazepam

Treatment for prolonged seizures usually involves giving an anti-seizure medication and monitoring the child’s heart rate, blood pressure, and breathing. If the seizure stops on its own, anti-seizure medication is not required. After a simple febrile seizure, most children do not need to stay in the hospital unless the seizure was caused by a serious infection requiring treatment in the hospital.

After the seizure has stopped, treatment for the fever is started, usually by giving oral or rectal acetaminophen or ibuprofen and sometimes by sponging with room temperature (not cold) water.

when do you give penecillin or pneumoccal vaccine for asplenia?
penecillin until 5 yrs old
pneumococcal vaccination after 5
absent cremestaric reflex on right
torsion of testis
14 yr old tired, longer menses and heavier. thyroid gland easily palpated.
Hypothyroidism

A previously healthy 3 year old boy brought to doc b/c fever, sore throat, malaise, poor appetite for 2 days. He says that his throat feels scratchy. There has been no vomiting, diarrhea, rhinorrhea. Active and alert. Temp of 38.7. Exam shows no abnormalities of tympanic membrane or pharynx. Leukocyte count is 9500.

A. acetaminophen
B. IV antibiotics
C. IVIG
D. IM ceftriaxone
E. Oral antibiotics
F. Oral corticosteroid
G. Xray chest

A. acetaminophen

no abnormalities of pharynx,
no exudate of white count
normal WBC count

tx for diabetic who does intense exercise to reduce diabetes related complications
decrease insulin dosage by 10-15% only exercise days
outcome for post strep glomerulonephritis
recovery without renal sequelae – post strep is usually self limiting

A *3 month boy* with 2 day history of fever and irritability. 50th percentile for length weight and head circumference. Temp of 100.6 F, pulse 130, respiration 26/min, BP 85/50. Fussy throughout exam.

Urinalysis shows-
specific gravity: 1.015
glucose negative
protein 1+
RBC 0-3 hpf
WBC 20-50 hpf
bacteria few gram-negative rods
Urine culture shows greater than 100,00 colonies of E.Coli. Started antibiotics. Next appropriate step in diagnosis?

intravenous pyelography
renal digital subtraction angiography
renal ultrasonography
ct scan of abdomen
renal dimercaptosuccinic acid sca

renal U/S – pyelonephritis

4 mo female brought for exam. spent few months in hospital, where she was treated for sepsis and respiratory distress syndrome. currently receiving oxygen and diuretic therapy. 5th percentile for length and wight, fever, pulse 104, respirations 32/min, BP of 115/67 in right arm and 105/67 in left arm. breath sounds decreased bilaterally, wheezing heard occasionally. pronounced s2 and precordial heave. hepatomegaly on abdominal exam. ecg shows right axis deviation and right ventricular hypertrophy. normal sized kidneys on ultrasound. cause of increased BP?

bronchopulmonary dysplasia
coartation of aorta
essential HTN
Pheochromocytoma
Renal artery thrombosis

bronchopulmonary dysplasia
14 yr old girl with high BP and weak femoral pulses, next step
turners – karyotype analysis
18 mo old with fever, painful swelling of left knee. anemia, leukopenia, thrombocytopenia, combs test +, protein in urine
SLE
which one is in INFANTS and which one blanches?
strawberry hemangioma, vs cherry hemangioma
-strawberry hemangioma – get bigger before they go away and they BLANCH in INFANTS. tx: observation
-Cherry hemangioma DOES NOT blanch

A 7 year old fainted while on field trip. Progressively lethargic over past winter, and *complexion darkened*. Her height and weight at 50th percentile. “BP 80/40”. Lab test?

A. plasma cortisol
B. serum glucose
C. serum gonadotropin
D. serum PTH
E. serum TSH

A. plasma cortisol

likely adrenal insufficiency

LOW CORTISOL

30 mo old kid with left flank mass with normal bone marrow, and normal kidneys on US

Neuroblastoma

Wilm’s tumor – intrarenal mass. does not cross midline. 3-4 yrs old
Neuroblastoma – extrarenal mass. crosses midline 1-2 yrs old – (up to 36 mo)

4wk old girl brought in because 2weeks of irritability and passing stools streaked with mucus and blood. No vomiting. *2 weeks ago, switched from cow’s milk-based formula to soy milk-based formula*. She is at 35%ile for length, weight, and head circum. Weight remains unchanged from 2wks ago. Most appropriate next step is to begin what?

A. Electrolyte rehydration solution for 24hrs
B. Formula with evaporated milk, water, and corn syrup
C. Formula with hydrolyzed casein
D. Oral Amoxicillin
E. Oral Ranitidine

C. Formula with hydrolyzed casein
36 hr baby has jaundice. bilirubin 22. next step

bilirubin approaching 25 – do a exchange trasnfusion.

if it was alot less like 12 then do phototherapy

Previously healthy 2yo boy presents with acute fever and inspiratory stridor. Has had rhinorrhea for the last day. Symptoms improve “when mom took him outside to come to the emergency department” [no idea what that is supposed to mean]. Immunizations UTD, exam significant for retractions and stridor, nothing else.

A) Alveolar atelectasis
B) Edema of the epiglottis
C) Narrowing of moderate-sized airways
D) Pulmonary parenchymal inflammation
E) Subglottic edema

E) Subglottic edema (this is croup)
– barking cough hoarsness too
15 yr old girl has multiple areas on her chest and upper back that are lighter than the rest of her skin. she has mild itching over these areas when she plays volley ball. PE shows multiple falt oval, hypopigmented lesions.
Tinea versicolor
8 yr old boy with 9 mo hx of productive cough that is worse at night and SOB during physical activity. colds seem to goto his chest and linger. CXRAY shows mild hyperinflation. next step
E- spirometry

A 6-month-old boy gets a UTI and is successfully treated with antibiotics. Renal ultrasonography shows no abnormalities. What is the next appropriate step in management?

A) Observe for recurrent symptoms
B) Repeat urine culture in 3 months
C) IV pyelography
D) Voiding cystourethrography
E) Cystoscopy

D) Voiding cystourethrography

A 2-year-old boy has a 5-day fever of up to 104 F. He appears ill. Temp = 102.2 F, pulse = 130, BP = 90/60. A 3/6 systolic murmur is heard at the left sternal border, though the child has no history of murmur. Splenomegaly present. In addition to echocardiography, which of the following is most likely to confirm the diagnosis?

A) ANA
B) ESR
C) Cardiac enzymes
D) Blood cultures
E) ECG

D) Blood cultures

A 4-day-old female newborn has lower extremity jaundice and icterus. She has been breastfeeding with normal stool and urine output. Born at term, needed vacuum delivery. She had a large cephalhematoma at birth and currently as well. The newborn is O+, and the mother is A+. Direct Coombs is negative. Total bill is 20.8. What is the next best step in management?

A) Cessation of breast feeding
B) Supplementation of breast-feeding with formula
C) Repeat bili in 6 hours
D) Phototherapy
E) IV fluid bolus
F) Partial exchange transfusion
G) No intervention necessary

D) Phototherapy

phototherapy is indicated for bili>20
exchange transfusion = bili>25

A 28-month-old boy is brought to the ED 20 minutes after swallowing an unknown amount of drain cleaner. He is crying, drooling, and in respiratory distress with stridor and suprasternal retractions. Temp = 100.4 F, Pulse = 124/min, respirations = 40/min, BP = 122/87. He has blisters on the lips and erythematous areas on the tongue. After stabilizing the airway, what’s the best next step?

A) Lateral x-ray of the neck and soft tissues
B) ECG
C) CT of head and neck
D) Esophagography
E) Fiberoptic endoscopy

E) Fiberoptic endoscopy

Esophagography=radiography of esophagus

13yo girls brought in for 6 weeks of constant abdominal pressure, breast tenderness, and weight gain. Never had menstrual period. Vitals are normal. Breast and pubic hair Tanner 3. Abdominal exam shows a nontender mass below umbilicus. Next step in diagnosis?

a. urinalysis
b. measure serum alpha-fetorotein
c. measure serum beta-hCG
d. x-ray of abdomen
e. CT scan of pelvice

c. measure serum beta-hCG (best 1st step working up amenorrhea, even if primary)
1 week old newborn has 1 day history of difficulty breathing and discoloration of extremities. Appears ill, temp = 97.5, pulse = 160, resp = 52, BP = 60/36 in upper extremities and unobtainable in lower extremities. Skin, mucous membranes, and nail beds are dusky, and there is mottled discoloration of the extremeties. Moderate intercostal retractiosn and grunting. Lungs clear. Holosystolic murmuc along left sternal border. Liver edge palpable 4cm below costal margin.
pH = 7.15, CO2 = 28, O2 = 98
Intubation, mechanical ventilation, and iv fluid initiated, but no improvement one hour later. x-ray shows cardiomegaly and pulmonary congestion. Explanation of this condition?a. closure of ductus arteriosus
b. deacreased pulm vascular resistance
c. increased pulm vascular resistance
d. intracardiac right to left shunt
e. opening of ductus arteriosus

a. closure of ductus arteriosus

this pt has hypoplastic left heart disease

3yo comes in for rapid breathing and cant catch his breath. pulse = 100, RR = 30, BP=120/80. lungs clear. slight hyperresonance on right chest. decreased breatah sounds on right. x-ray shows slight overexpansion of right lung compared with left. no infiltrates or effusions. Best management?

a. hyperbaric Oxygen
b. CT of chest
c. bronchoscopy
d. Thoracotomy
e. Tube thoracostomy

c. bronchoscopy (best 1st step in evaluating aspiration)
16yo boy comes for routine health exam. Both maternal and paternal family history includes premature coronary artery disease, HTN, and hyperlipidemia. BMI is 35. Cardiac exam no abnormalities. Fasting serum lipids studies show:
Choldesterol (total): 214; HDL: 32, LDL: 144
Triglycerides: 187
Best step in management?a. reduced calorie diet
b. weight training program
c. Beta-blocking agent therapy
d. cholesterol binding resin therapy
e. stating

a. reduced calorie diet

15 month old girl has a 1 day history of rash and fever for the last 3 days. She got the *MMR 10 days ago*. No acute distress, temp is 101.2 F. She has an erythematous maculopapular rash over the face, trunk, and extremities. Which of the following is the most likely explanation for these findings?

A) arthus reaction from preexisting antibody to rubella virus
B) delayed type hypersensitivity reaction to rubella antigen
C) immune complex disease from vaccine preservatives
D) replication of a live vaccine virus strain
E) viral dissemination in an immunocompromised host

D) replication of a live vaccine virus strain
A previously healthy 3 year old girl brought to physician because of a 2-month history of a right-sided limp. The limp is most obvious when she awakens and gradually becomes less noticeable as she plays. She has no recent history of fever, rash, or other illness and has not been exposed to pets or ticks. Today she appears well but walks with a limp. Temp is 98.2 F. No rash, normal pupils, normal red reflex, normal pharynx, normal cardiac exam. Right knee is swollen and warm but not erythematous or tender. The patient holds the right lower extremity in a slightly flexed position and will not fully extend it when she stands or walks. Laboratory studies show:
ESR 64 mm/hSerum ANA+
Rheumatoid Factor –
ASO titer –
Lyme Ab –

In addition to the administration of naproxen, what’s the best next step?
A) slit lamp exam
B) Bartonella henselae titer
C) Upper GI series
D) Arthroscopy
E) Surgical Aspiration of the right knee

A) slit lamp exam (routine slit lamp exams indicated in juvenile rheumatoid arthritis)

An 18 hour old female newborn is being evaluated bc of jaundice. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery to a 31 year old woman, G2P1. She weighed 3799 g/8 lb 6 oz at birth.* Mother’s blood group is O+*. Newborn has urinated twice but has had no bowel movements. Urine is dark yellow. She has had difficulty latching onto the breast correctly. She is alert. Exam shows jaundice of the face and chest. Abdomen is soft. Liver edge palpated 1 cm below the right costal margin, and the spleen tip is palpated 1 cm below the left costal margin. Serum total bilirubin is 11.1 with direct component of 0.1. What’s the most likely diagnosis?

A) Breast milk jaundice
B) Galacatosemia
C) Hemolytic disease of the newborn
D) Physiologic jaundice of the newborn
E) Sickle cell disease

C) Hemolytic disease of the newborn (ABO incompatibility; can’t be physiological until >24 hrs of life)

An 8 year old girl brought to physician because of pallor and easy fatigability for the past 2 months. Symptoms began after URI. She was adopted, and her family history is unknown. She appears pale, spleen tip palpated 2 cm below left costal margin. Her HCT is 28%, retic count is 4% with *3+ spherocytes*. Splenectomy is most likely to prevent which of the following complications?

A) cholelithiasis
B) esophageal varices
C) overwhelming sepsis
D) painful crises
E) pancreatitis

A) cholelithiasis

For HS, splenectomy is preventives for gallstones

A 10 year old girl is brought to the the emergency department following a generalized tonic clonic seizure. She has a 1 month history of behavior disturbances and a 2 week history of fever, weakness, and painful swelling of the left knee. Her hemoglobin concentration is 9, leukocyte count is 3800, platelet count is 65K. Coomb’s test is positive. UA shows protein and microscopic blood. What’s the most likely diagnosis?

A) Hodgkin disease
B) Henoch Schonlein Purpura
C) Mononucleosis
D) Systemic lupus erythematosus
E) Viral encephalitis

D) Systemic lupus erythematosus

38 week AGA neonate with features of *Down syndrome*, Apgars 6 and 9, AFVSS. Exam reveals hypotonia, pulse ox is 92% on room air. What is the next step?

A) Measure CK and MRI of the brain
B) CXR and blood cultures
C) ECG and karyotype
D) PGE1 and O2 supplementation
E) Surfactant + IV amp/gent

C) ECG and karyotype

A 10 mo girl brought by parents for well child check up. Parents concerned b/c of recent lazy eye development. Born at 38 wks, following an uncomplicated pregnacy and required Oxygen by Nasal cannula for the first day of life. No hx of serious illnes. Vital signs within normal limitis. Examination of the Left eye shows hyphema and esotropia. Conjuctiva is not injectied and there is no discharge. The *left pupil appears white on reflex testing*. The remainder of the exam shows no abnromailties. What is the most likely cause of these findings?

a) congential cataract
b) glaucoma
C) retinoblastoma
D) Retinopathy of prematurity
E) Retintis pigementosa

C) retinoblastoma
2yo has 2week history of irritability, poor appetite, occasional cough, and reluctance to walk. Has had 2kg weight loss since her last exam 6mo ago. No history of reuccrent respiratory illness, constipation, vomiting, or diarrhea. Appears uncomfortable and quiet. 7th%ile for height and 25%ile for weight. Temp = 100.2, Pulse: 140, RR: 24, and BP: 145/100. Bluish discoloration under both eyelids. Cardiac and abdominal exam normal. Labs:
Hgb: 10.5
Leukocyte: 8300 (Neu: 40%, Lymph: 55%)
Plate: 240,000
*Lateral x-ray of chest shows mass in posterior mediastnum*. Diagnosis?A. anthroax
B. Congenital heart disease
C. CF
D. Dermatomyositis
E. Neuroblastoma
F. Pulmonary Sequestration
G. Thymoma
H. TB

E. Neuroblastoma (masses of the POSTERIOR mediastinum are typically neurogenic; rule out thymoma because the mass is not in the ANTERIOR mediastinum)

A previously healthy 7 y.o brought to peds b/c 1 week history of low grade fever and fatigue and a 3 day history of rash and moderate pain and swelling of ankles. Rash first appeared on ankles but has spread over his legs during the past 24 hrs. Tep 38.2. Exam shows palpable petechiae and confluent purpuric areas over lower extremities. Ankles are swollen and mildly tender.

A. ankylosing spondylitis
B. Behcet syndrome
C. dermatomyositis
D. henoch schonlein purpura
E. Juvenile rheumatoid arthiritis
F. Kawasaki
G. Psoriatic arthiritis
H. Reactive arthritis
I. Sarcoidosis
J. Sjogren
K. SLE
L. scleroderma

D. henoch schonlein purpura

Previously healthy 1 month old boy brought to ER 2 hrs after onset of *bilious vomiting*. Less active than usual and feeding poorly. Last bowel 1 day ago. Born at 38 weeks. Appears ill. Tep of 38, pulse 180, resp 60, BP 70/40. *Abdomen firm and distended*. bowel sounds decreased. normal rectal tone. *small amt of stool in rectal vault*. occult blood positive.

A. hirschsprung
B. gastroenteritis
C. hypertrophic pyloric stenosis
D. intussusception
E. midgut vovulus

E. midgut vovulus (bilious vomiting + distended abdomen + blood in stool = malrotation/volvulus

XRAY: corkscrew pattern

typically present w/ “draws up legs”

Previously healthy 9 mo male with Tmax of 40 degrees Celsius, fussiness, and decreased PO intake for past 5 days. No sick contacts. Current temp 39.6. Exam shows cracked, fissured lips, redness of oral mucosa and conjunctiva, and single enlarged cervical LN. Maculopapular rash on trunk and extremities, and dorsal edema of hands. What next?

Acetaminophen
IV Abx
IVIG
IM ceftriaxone
PO Abx
PO corticosteroids
CXR

IVIG

pt has Kawasaki disease
>5 days of fever w/ 4/5 of the following:
conjunctivitis
mucosal changes – strawberry tongue
cervical lymadenopathy
edema
rash

*14 yo female with amenorrhea*. Pubic and axillary hair at 11 yo; breast dev at 12 yo. as tall as a 8yo. decreased femoral pulses, BP is 140/100. Breast Tanner stage 2; Pubic hair Tanner stage 4. Modest. Axilllary hair. Next step?

Measure serum prolactin concentration (wrong)
Karyotype analysis
Measure serum insulin concentration
CXR
EEG

Karyotype analysis

Turner syndrome= primary amenorrha + short stature + coractration of aorta

14 yo male with 3 mos of “dragging” sensation of Left scrotum. 30 weeks GA. Born with Left scrotal hydrocele which resolved. Both testes are descended. Left scrotum hangs lower, left soft tissue mass that feels like *bag of worms*. Mass disappears in supine position. If untreated, what is a complication?

Testicular torsion (wrong)
Distant mets
Incarceration
Infertility
Testicular carcinoma
Torsion of appendix of testis

Infertility

pt presents as varicocele, which is a most common cause of male infertility.

7 yo with 7 days of bloody diarrhea. Generalized fatigue for past 2 days. Afebrile. BP 105/65. Exam shows pallor and scleral icterus. No hepatomegaly. Retic count 12 %. MCV I0. WBC 18. Hb 6. Plts 50. What is the diagnosis?

ALL
Bone marrow suppression
G6PD deficiency
Sickle cell disease
HUS
Iron deficiency
Thalassemia

HUS

hx of bloody diarrhea + low platelets + hemolytic anemia

A 12-hour-old female newborn becomes irritable, has difficulty breathing, and then has a 2-minute generalized tonic-clonic seizure. She was born at 36 weeks’ gestation by cesarean delivery for a breech presentation and weighed 3997 g (8 lb 13 oz). *Her mother had gestational diabetes poorly controlled with diet*; she refused insulin therapy. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Examination shows decreased tone and lethargy. Pulse oximetry shows an oxygen saturation of99%. An ECG shows a *prolonged QT interval*. In addition to measurement of serum glucose concentration, the most appropriate next step is measurement of which of the following serum concentrations?

Bicarb
Bilirubin
Calcium
Mg
TSH

Ca

Mothers /w DM, always check for Ca for neonatal seizures

A 17-year-old girl comes for a precollege physical examination. She is not sexually active. Her menses occur at regular 28-day intervals. She has smoked one-half pack of cigarettes daily for 3 years and drinks 1 oz of alcohol weekly. Her 50-year-old mother was diagnosed with breast cancer 1 year ago. Her father and grandfather died of heart disease during their 30s. Her blood pressure is 130/70 mm Hg while sitting. Which of the following is the most appropriate screening test?”

Serum lipid studies
UA
Mammo
CXR
Stress Test

Serum lipid studies

A* 5-year-old boy* is brought to the physician by his parents because of a painful limp for 3 weeks. He has no history of serious illness or trauma and has not had any other symptoms. Developmental milestones are appropriate for age. On examination, he is unable to bear his full weight on the right and winces when he is asked to stand on his right foot. Flexion and internal rotation of the right hip are decreased. Muscle strength is 4/5 on abduction of the right hip. AP x-rays of the pelvis show a dense, contracted right femoral capital epiphysis. The left femoral capital epiphysis appears normal. Which of the following is the most likely diagnosis

Congenital hip dysplasia
Osgood-Schlatter disease
Diastematomyelia
Femoral anteversion
Proximal focal femoral deficiency
Fibular hemimelia
Septic arthritis of the hip
Jumper’s knee
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Spondylolisthesis of L4 on L5
Metatarsus adductus
Tibial hemimelia

Legg-Calvé-Perthes disease

18 month boy, intermittent ab pain, no vomiting or diarrhea, lethargic. Soft, contender abdomen. Mass palpated in RLQ. decreased bowel sounds. Red stool, occult blood positive. X-ray of abdoment shows no air in ascending or transverse colon. Next step management?

air contrast enema
upper gastrointestinal series
meckel scan
upper endoscopy
laparotomy

air contrast enema

14 y/o boy w/ 1 year history of learning disability, hyperactivity, short attention span, can’t concentrate in homework, generalized tonic clonic seizure at 8 yrs. PE shows nine lesions with coffee stain like appearance on chest and abdomen. Small areas of increased pigmentation in the axillae and small skin tags over chest, abdomen, and back. Diagnosis.

hereditary hemorrhagic telangiectasia
Neurofibromatosis, type 1
sturge-weber syndrome
tuberous sclerosis
von hippel disease

Neurofibromatosis, type 1

9 y/o acute appendicitis brought by adult neighbor to ED. neighbor offers to sign consent form for the operation on behalf of childs parent who cant be reached. management by doc?

A) perform operation because it’s an emergency and no consent is required
B) perform operation, because a responsible adult has given consent
C) perform the operation only if the child gives consent
D) delay the operation until the parent can be contacted, while closely monitoring the child’s status

A) perform operation because it’s an emergency and no consent is required

26 y/o lady gives birth to newborn vaginally 42 weeks gestation. Spontaneous and no complication. Fetal growth restriction was noted by third trimester. Mother didn’t travel, smoke, drink, or use drugs during pregnancy, and no pets in household. Initial exam showed hepatosplenomegaly. X-ray shows *periventricular intracranial calcification*. Most likely agent?

cytomegalovirus
herpes simplex virus 1
parvovirus
rubella virus
treponema pallidum

cytomegalovirus

A 16 y/o boy brought to doc cuz of 2 week history of increasing pain, swelling, and rash over right knee and 1 week of moderate pain and redness in both eyes. Fever of 100F. Eyes have *injected conjunctivae with mucopurulent discharge*. Diffuse, macular, erythematous rash over lower extremities and *marked swelling of the right knee*. Range of motion of the right knee is limited by pain. There is *erythema and edema of the urethral meatus*. Most likely diagnosis?

ankylosing spondylitis
behcet syndrome
dermatomyositis
Henoch schonlein purpora
juvenile rheumatoid arthritis
mucocutaneous lymph node syndrome (kawasaki disease)
psoriatic arthritis
reactive arthritis
sjogren syndrome
SLE
Systemic sclerosis (scleroderma)

reactive arthritis ( has urethritis, conjunctivitis, arthritis)

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