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
f. increased intracranial pressure
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
G) Vasovagal episode
H) Ventricular tachyarrhythmia
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
Hep B core Ab +
Hep B surface ag +
Hep B surface ab –
Hep B virus – not immune
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
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
“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
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%
Platelet count 240,000/mm3
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
Use of only disposable diapers at the day-care center
Well water filtration
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??
B. Gardnerella Vaginitis
C Haemophilus ducrey
F. Neisseria Gonorrhea
G. Treponema pallidum
H. Trichomonas vaginalis
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
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?
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.
pneumococcal vaccination after 5
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.
B. IV antibiotics
D. IM ceftriaxone
E. Oral antibiotics
F. Oral corticosteroid
G. Xray chest
no abnormalities of pharynx,
no exudate of white count
normal WBC count
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.
specific gravity: 1.015
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?
renal digital subtraction angiography
ct scan of abdomen
renal dimercaptosuccinic acid sca
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?
coartation of aorta
Renal artery thrombosis
strawberry hemangioma, vs cherry hemangioma
-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
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
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
– barking cough hoarsness too
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
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?
C) Cardiac enzymes
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
E) IV fluid bolus
F) Partial exchange transfusion
G) No intervention necessary
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
C) CT of head and neck
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?
b. measure serum alpha-fetorotein
c. measure serum beta-hCG
d. x-ray of abdomen
e. CT scan of pelvice
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
e. Tube thoracostomy
Choldesterol (total): 214; HDL: 32, LDL: 144
Best step in management?a. reduced calorie diet
b. weight training program
c. Beta-blocking agent therapy
d. cholesterol binding resin therapy
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
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
E) Surgical Aspiration of the right knee
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
C) Hemolytic disease of the newborn
D) Physiologic jaundice of the newborn
E) Sickle cell disease
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?
B) esophageal varices
C) overwhelming sepsis
D) painful crises
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
D) Systemic lupus erythematosus
E) Viral encephalitis
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
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
D) Retinopathy of prematurity
E) Retintis pigementosa
Leukocyte: 8300 (Neu: 40%, Lymph: 55%)
*Lateral x-ray of chest shows mass in posterior mediastnum*. Diagnosis?A. anthroax
B. Congenital heart disease
F. Pulmonary Sequestration
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
D. henoch schonlein purpura
E. Juvenile rheumatoid arthiritis
G. Psoriatic arthiritis
H. Reactive arthritis
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.
C. hypertrophic pyloric stenosis
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?
pt has Kawasaki disease
>5 days of fever w/ 4/5 of the following:
mucosal changes – strawberry tongue
*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)
Measure serum insulin concentration
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)
Torsion of appendix of testis
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?
Bone marrow suppression
Sickle cell disease
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?
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
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
Proximal focal femoral deficiency
Septic arthritis of the hip
Slipped capital femoral epiphysis
Spondylolisthesis of L4 on L5
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
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
von hippel disease
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
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?
herpes simplex virus 1
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?
Henoch schonlein purpora
juvenile rheumatoid arthritis
mucocutaneous lymph node syndrome (kawasaki disease)
Systemic sclerosis (scleroderma)