E. Sodium nitroprusside
A. Clostridium difficile
B. Salmonella enteritidis
C. Shigella sonnei
D. Staphylococcus aureus
E. Yersinia enterocolitica
Post-antibiotic diarrhea: C. diff
Interesting to recognize that it can be bloody, mucus, and can occur after amoxicillin
Hemoglobin 11.9 g/dL
Leukocyte count 12,200/mm3
Platelet count 240,000/mm3
Leukocyte esterase 3+
Results of blood and urine cultures are pending. Which of the following is the most appropriate pharmacotherapy?
A. Measurement of serum catecholamine concentration
B. Measurement of urine vanillylmandelic acid and homovanillic acid concentrations (wrong choice)
C. X-ray of the abdomen
D. X-ray of the chest
E. Ultrasonography of the abdomen
A. Congestive heart failure
B. Malignant pleural effusion
C. Nephrotic syndrome
D. Traumatic hemothorax
E. Tuberculous pleural effusion
a 4-day-old newborn is brought to the physician b/c of a 2-day history of progressive jaundice. He was born at 36 weeks’ gestation to a 27-year-old woman, gravid2, para 2, following an uncomplicated pregnancy and delivery and weighed 2608 g(5lb 12oz). The newborn’s blood group is O, Rh-positive, and the mother’s blood group is B, Rh-positive. He has been breast-fed since birth and receives 1 to 2 ounces of a supplemental soy milk-based formula every day. His mother says that he has had about seven wet diapers daily, and his stools are yellow and seedy. At discharge 2 days ago, his weight as 2495 g; he now weights 2608 g. His temp is 36.9C, pulse 138/min, respirations 32/min, BP 65/40. Exam shows scleral icterus and jaundice from the face to the lower abdomen. The liver edge is palpated 2 cm below the right costal margin. Laboratory studies at 36 hours of age and now show:
at 36hrs of age Now
hct 54% 52%
Bilirubin, total (mg/dL) 8.2 12.5
Direct (mg/dL) 0.1 0.3
Which of the following is the most likely explanation for these findings?
a) ABO isoimmunization
b) biliary obstruction
d) Erythrocyte enzyme defect
e) physiologic jaundice
a 1 month old infant has had a 12×8 cm, red, raised, well-defined lesion that is lobulated and compressible overlying the buttocks since birth. Examination also shows multiple petechiae and bruises. Which of the following is the most likely explanation for these findings.
b) high-output congestive heart failure
c) impaired tissue growth due to altered vascular supply
d) increased tissue growth due to increased vascular supply
e) thrombocytopenia from platelet sequestration
A healthy 16-year-old girl comes to the physician for an examination prior to participation in school sports. She had chickenpox at age 3, but has no history of serious illness. Her immunizations were up-to-date when she began kindergarten; the only immunization she has received since then is a diphtheria-tetanus toxoid at the age of 10 years for a laceration on her leg. She has been sexually active for the past year w/ two male partners who have used condoms consistently. She is 163cm and weights 54kg; BMI 21. Vital signs are w/in normal limits. Examination shows no abnormalities. Administration of which of the following vaccines is most appropriate at this time?
a) hepatitis B, diphtheria-tetanus-toxoid, HPV
B) HPV, meningococcal, TdaP
c) MMR, TdaP, hepatitis B
d) PCV, PCV-7, IPV, hepatitis B
e) PCV 7, IPV, MMR
f) Td, meningococcal, MMR
an 18-month girl is brought to the emergency department 1 hour after the onset of vomiting and drooling. She had been left alone in the bathroom of her home for a few minutes before the onset of the symptoms. The family keeps nasal decongestants, acetaminophen, ibuprofen, diphenhydramine, and drain cleaner, and insecticide spray in the bathroom. During the past 5 days, she has had an upper respiratory traction infection treated w/ a nasal decongestant containing pseudoephedrine and acetaminophen. She is agitated and drooling. Her temperature is 37C, pulse is 120/min, respirations are 26/min, and BP IS 80/60. Examination shows two small superficial ulcers on the lips and tongue. the remainder of the examination shows no abnormalities. the most likely cause of these findings is ingestion of which of the following?
c) drain cleaner
An 8yo girl is brought to the physician because of a diffuse rash for 24hr. She has had cough, congestion, eye discharge, and fever for 4 days. The rash initially began on her face and chest but has spread to involve her abdomen, back, and lower extremities. Her temprature is 38.9 (102.1F), pulse is 100/min, RR 16/min, and BP is 115/70. Examination shows diffuse red, macular and papular rash involving the face, trunk, and extremities; there are no leasions on the palms or soles. Which of the following is the most likely diagnosis?
c) Id reaction
d) Kawasaki disease
e) Pityriasis rosea
i) Scarlet fever
j) Staph Scaled skin syndrome
A 5yo girl w/ a 1 yr hx of chronic nonproductive cough is brought for a follow-up examination. The cough occurs during the day and night and is not exacerbated by exercise. She has not had chills, diarrhea, or weight loss. Inhaled beta adrenergic agonists, two courses of oral abx, and 10 day course of orapred have not relieved her symptoms. She is at the 50th percentile for height and weight. She appears well. Her temp is 37.5C, pulse 96/min, RR 18/min, and BP 82/60. Examination shows no abnormalities. An x-ray of the chest shows no abnormalities except for linear consolidation in the right middle lobe. Which of the following is the most likely diagnosis?
a) alpha-1 antitrypsin deficiency
d) congenital emphysema
A 9mo old boy has pneumonia for the fourth time. He was born at 28wks with a grade 4 intraventricular hemorrhage and generalized neurologic devastation. Barium swallow shows a grade 4 GERD. Which of the following operative procedures is most likely to decreased the frequency of recurrent pneumonia?
e) vagotomy and pyloroplasty
5)A previously healthy 4-year-old boy is brought to the physician because of a 2-week history of mild itching of his head and scattered areas of hair loss on his scalp. Examination shows several small oval areas of alopecia over the posterior scalp with numerous hairs broken off close to the scalp. Several small, occipital, nontender lymph nodes are palpated. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal organism?
Microsporum could also be yellow-green fluorescent on Wood’s lamp
A 9-year-old girl with type 1 diabetes mellitus is brought to the emergency department because of lethargy, labored breathing, and seven episodes of vomiting over the past 6 hours. Her skin is flushed and warm and she appears severely dehydrated. There is a fruity odor to her breath. She is at the 75th percentile for height and 25th percentile for weight. Her temperature is 37.2°C (99°F), pulse is 110/min, respirations are 24/min, and blood pressure is 100/60 mm Hg. Capillary refill time is 4 seconds, and capillary blood glucose concentration is greater than 500 mg/dL. Which of the following is the most appropriate initial step in management?
A)Intravenous administration of 20 mL/kg of 5% dextrose in water
B) Intravenous administration of 20 mL/kg of 0.9% saline
C) Intravenous administration of 20 mL/kg of lactated Ringer solution with 40 mEq/L of potassium chloride
D) Intravenous administration of 0.1 U/h of regular insulin
E)Continuous intravenous administration of 0.1 U/h of regular insulin
B! Give fluids as first step for DKA
C- too premature to give K
Na+ 135 mEq/L
K+ 4 mEq/L
HCO3- 15 mEq/L
Urea nitrogen 35 mg/dL
Creatinine 0.8 mg/dLHer urine output is 1.5 mL/kg/h. Arterial blood gas analysis on 40% oxygen shows:
Pco2 35 mm Hg
Pao2 100 mm Hg
One hour later, her urine output decreases to less than 0.5 mL/kg/h. A chest x-ray shows hazy lung fields bilaterally and cardiomegaly. Which of the following is the most appropriate next step in management?
A)Intravenous administration of an isotonic fluid bolus
B)Intravenous administration of dopamine
C)Intravenous administration of furosemide
D)Intravenous administration of nitroprusside
E)Increased inhaled oxygen concentration
A 2-month-old boy is brought to the physician because of coughing spells that have progressively worsened over the past 10 days and are frequently followed by vomiting. On examination, he is afebrile and appears healthy until he spontaneously has a coughing spell. Coughing continues for 20 seconds, at which time he appears cyanotic for 10 seconds. No crackles are heard on auscultation of the chest. Which of the following is the most likely diagnosis?
A)Aspiration due to gastroesophageal reflux
C)Congestive heart failure
E)Respiratory syncytial virus bronchiolitis
A previously healthy 4-month-old girl is brought to the emergency department in January because of cough and poor feeding for 2 days. She is still urinating and making tears. She initially had a fever of 38.2°C (100.8°F) but has been afebrile for the past day. She appears mildly ill. Her temperature is 37.5°C (99.5°F), pulse is 140/min, and respirations are 56/min. Examination shows pink tympanic membranes with good mobility. There are mild intercostal retractions, and diffuse bilateral crackles and wheezes are heard. Pulse oximetry on room air shows an oxygen saturation of 84%. Which of the following is the most appropriate next step in management?
A)Arterial blood gas analysis
B)Culture of the pharynx for bacteria
C)Viral culture of respiratory secretions
D)X-rays of the chest
E)X-rays of the neck
F)Administration of an inhaled bronchodilator
G)Administration of oxygen
H)Subcutaneous administration of epinephrine
This is bronchiolitis (hypoxemia, cough, bilateral crackles and wheezes in a young infant)
1. An otherwise healthy 16yo girl is brought to the physician b/c of 6mo of increasing severe pain with menses. Her mother reports that during this time, her daughter has missed 2 days of school during each menstrual period because of severe pelvic cramps associated w/ vomiting. Menses occurs at regular 28day intervals and lasts 4-5 days. Her last menstrual period was 7 days ago. She currently takes acetaminophen, which provides minimal relief of her symptoms. She has had three lifetime sexual partners, and they use condoms inconsistently. PEx shows no abnormalities. Pelvic examination shows a ternder, normal sized uterus and no masses. Which of the following is the most appropriate next step in management?
a) Pregnancy Test
b) Pelvic US
c) Narcotic therapy
A 6yo girl is brought to the physician because of a scaly, pruritic rash on the intertriginous areas of her elvows and knees that worsens in the spring and the fall; it often appears in conjunction with episodes of respiratory distress and wheezing. Tx with which of the following is the most effective short term treatment of the rash?
b) Coal Tar
3. A 6hr old newborn has had cyanosis of her arms and legs since birth. She was born at 38wk gestation following an uncomplicated pregnancy and c-section for breech presentation. She weighed 2090g at birth. She has been breast feeding well. She is alert and is not in acute distress. Her rectal temprature is 36.2C, puse is 112, RR 36, BP 80/45. Pulse ox 96%. Examination shows cyanosis of the upper and lower extremities but no circumoral cyanosis. Cardiopulmonary examination shows no abnormalities. Cap refill is mildly delayed. Which of the following is the most appropriate step in management?
a) Placement of the newborn under warming lights
b) Blood culture
c) Chest x-ray
e) intubation and mechanical ventilation
A previously healthy 4yo boy is brought to the physician because of a 1wk hx of intermittent fever. During the past 3 days, he has had decreased activity and joint pain. Yesterday he developed a red rash on his chest. He attends daycare. He appears pale and is not in acute distress. His temperature is 38.4C, pulse 140, RR 24. Examination shows a petechial rash over the chest. The conjunctivae are pale. There is diffuse adenopathy in the cervical chain. A grade 2/6 systolic murmur is heart. The spleen is palpated 1cm below the left costal margin. There is no swelling or redness of the joints. Lab studies show a Hgb of 6.4g/dL, leukocyte count of 50,000/mm3, and platelet count of 10,000/mm3.
b) Anemia of Chronic Disease
c) Autoimmune hemolytic anemia
d) G6PD deficiency
f) Hereditary spherocytosis
g) Lead poisoning
h) Red blood cell aplasia
i) Sickle cell disease
k) uremia of chronic renal failure
A 4yo boy is hospitalized because of fever, shallow breathing, and unresponsiveness for 3hrs. His temprature is 40C, pulse 160, RR 60 and BP is 60/35. Examination shows purpura over the loewr extremities. He is intubated and mechanically ventilated. Blood cultures grow Neisseria meningitidis. Two days later, an x-ray of the chest shows bilateral patchy infiltrates. Which of the following is the most likely mechanism of these findings?
a) Cholinergic hyperactivity
b) enzymatic deficiency
c) Increased vascular permeability
d) Mucosal inflammation
e) Oxygen toxicity
f) Surfactant deficiency
A previously healthy 8yo boy brought to the emergency department of difficulty breathing 10mins after being stung by a bee. His temp is 36.5C, pulse 130, RR 28 and BP 65/50. Examination shows wheezing, audible stridor, and a generalized urticarial rash. Epi and methlprednisolone are administered. Administration of which of the following is the most appropriate next step?
a) Cromolyn sodium
3*-year-*old boy is brought to the physician for a follow*up examination 2 weeks after being treated for an ear infection. He has had recurrent ear infections, sinusitis, and two episodes of bacterial pneumonia since birth. Over the past year, he has undergone placement of two sets of tympanostomy tubes for otitis media. His mother is HIV negative. He currently takes no medications. He is at the 25th percentile for height and weight. Examination shows no abnormalities except for small anterior cervical lymph nodes. Which of the following is the most likely mechanism of disease?
A) Antibody deficiency
B) Impaired chemotaxis
C) Impaired respiratory burst
D) Splenic dysfunction
E) T-*lymphocyte dysfunction
Hemoglobin 10 g/dL
Mean corpuscular volume 64 μm3
Leukocyte count 6100/mm3
Platelet count 225,000/mm3
Red cell distribution width 10% (N=13%-15%)A blood smear is shown (http://imgur.com/a/tES3u). It has target cells. Which of the following is the most likely explanation for this patient’s anemia?
A) Antibiotic*induced autoimmune hemolysis
B) Decreased synthesis of globin chains
C) Iron deficiency
D) Transient postinfectious bone marrow suppression
E) Vitamin B12 (cobalamin) deficiency
A 10-*day*-old male newborn is admitted to the hospital for treatment of indirect hyperbilirubinemia due to isoimmune hemolysis. He is placed in a room with a 2*-month*-old female infant with dehydration secondary to rotavirus gastroenteritis. Two days later, he develops vomiting and diarrhea, and a stool specimen is positive for rotavirus antigen. This nosocomial infection is most likely caused by failure of caregivers to do which of the following?
A) Dispose of diapers and other waste items properly
B) Observe gown and glove precautions (WRONG)
C) Observe hand*washing techniques
D) Place the patients in a reverse airflow room
E) Restrict visitors to the room
Cl- 84 mEq/L
K+ 4.1 mEq/L
Albumin 2.8 g/dLUrine protein 1+
Pulmonary function tests show a decrease in forced vital capacity from 75% to 30% of predicted value over the past year. An x-*ray of the chest shows marked hyperinflation with coarse nodular infiltrates bilaterally. Which of the following is the most likely explanation for this patient’s edema?
A) Cirrhosis of the liver
B) Cor pulmonale
C) Inferior vena cava obstruction
E) Nephrotic syndrome
F) Protein*losing enteropathy
G) Vitamin E deficiency
the pneumonia. She continues to have fevers and cough, and she now has right-sided chest pain. Her immunizations are up-to-date. She appears ill and is tachypneic.
Her temperature is 38.5°C (101.3°F), pulse is 140/min, and respirations are 45/min. Repeat x-rays of the chest show a large dense consolidation in the right lower lung
field and a fixed right-sided effusion. Which of the following is the most likely causal organism?
A) Enterobacter cloacae
B) Haemophilus influenzae type b
C) Mycobacterium avium-intracellulare
D) Pseudomonas aeruginosa
E) Staphylococcus aureus
shows bilateral papilledema, right abducens palsy, and gait ataxia. Which of the following is the most likely diagnosis?
A) Acoustic neuroma
B) Dandy-Walker syndrome
D) Optic nerve glioma
past 2 months. He has had six to eight loose stools daily for 4 weeks. His temperature is 39°C (102.2°F), pulse is 80/min, and respirations are 30/min. Examination
shows dry skin. There are bilateral 2-cm lymph nodes in the neck, axillae, and groin. The lungs are clear to auscultation. The liver edge is palpated 1 cm below the right
costal margin; the spleen tip is palpated 7 cm below the left costal margin. Laboratory studies show:Hemoglobin 10 g/dL
Leukocyte count 2100/mm3
Segmented neutrophils 80%
Platelet count 180,000/mm3
lgA 340 mg/dL
lgG 2300 mg/dL
lgM 390 mg/dL
Which of the following is the most likely diagnosis?
A) Common variable immunodeficiency
B) HIV infection
C) Selective lgA deficiency
D) Severe combined immunodeficiency
E) Thymic-parathyroid dysplasia (DiGeorge syndrome)
F) X-linked agammaglobulinemia
B! This is acute HIV infection. Be on the lookout if they have lots of nonspecific symptoms over a subacute time course.
Fever, LAD, weight loss, diarrhea, HSM, significant leukopenia
Other common findings: sore throat, oral ulcerations, myalgias/arthralgias, headache, nausea, vomiting
bowel movements. During this period, she has had 6 to 10 urgent, bloody bowel movements daily. Examination shows a swollen, mildly tender left knee joint. Her
hemoglobin concentration is 14.5 g/dl, leukocyte count is 16,000/mm3, and platelet count is 790,000/mm3. Analysis of knee joint aspirate shows straw-colored, slightly
turbid fluid with a leukocyte count of 2000/mm3 (40% segmented neutrophils). Which of the following is the most likely diagnosis?
A) Adenovirus gastroenteritis
B) Chronic nonspecific diarrhea of childhood
D) Henoch-Schonlein purpura
E) Pseudomembranous enterocolitis
F) Ulcerative colitis
Two weeks after a camping trip in New England, a 5-year-old boy develops a 3-cm, red, circular lesion with a clear center, lymphadenopathy, conjunctivitis, myalgia, and nausea. Antibodies to Proteus vulgaris Ox19 are negative. Which of the following is the most likely causal agent?
A. Avoidance of breast-feeding
B. Water supplementation
C. Longer course of phototherapy
D. Antibiotic therapy
E. Exchange transfusion