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1

Smooth, nontender abdominal mass that does not cross midline. Associated with abdominal pain, low-grade fever, HTN, and hematuria. Normal renal function.

A. Gastric duplication cyst
B. Neuroblastoma
C. Polycystic kidney diseawse
D. Rhabdomyosarcoma
E. Wilm's tumor

E. Wilm's tumor

Dx with abdominal ultrasound, confirm with biopsy. CT chest and abdomen to look for mets.

Tx with nephrectomy and post-surgical chemo, possibly radiation

2

A 5-year-old boy presents to the emergency department with two days of abdominal pain and one day of rash. He has not had any vomiting. He had a normal stool today. Medical history is significant for an upper respiratory tract infection one week ago. He is otherwise healthy and takes no medications. Vital signs are normal. On examination he has petechia and purpura on his buttocks and lower extremities. Palpation of the abdomen reveals mild tenderness. The remainder of the exam is normal. Laboratory studies are normal. A clinical diagnosis is made. Which of the following is most important to monitor at this patient’s follow-up visit in two days?

A. BP and urinalysis
B. Platelet count
C. PT/PTT
D. White blood cells and hemoglobin
E. Signs of intracranial hemorrhage

A. BP and urinalysis

This patient likely has Henoch-Schonlein Purpura (HSP). The exact etiology of HSP is unknown, but it is believed to involve an IgA-mediated immune response to infection or other triggers. The incidence is 10 cases per 100,000 children with a peak at ages 4 to 6 years (range of 2 to 17 years). HSP is characterized by a rash consisting of petechiae and palpable purpura. Other findings include a colicky diffuse or periumbilical abdominal pain, arthritis or arthralgia, and renal disease. Given the incidence of renal disease, it is important to check the urine for signs of hematuria or proteinuria; sudden changes in blood pressure can potentially suggest a change in renal function. With abnormal findings, serum BUN and creatinine must be checked.

3

1 week old male with uncomplicated vaginal delivery presents with mom d/t complaint of recurrent epistaxis. VSS. PE reveals murmur and a TTE is ordered which reveals a bicuspid aortic valve and a PDA. Which of the following is most likely also present?

A. coarctation of aorta
B. ostium primum ASD
C. ostium secundum ASD
D. tetralogy of fallot
E. total anomalous pulmonary venous return

A. coarctation of aorta


[Coarctations are often associated with bicuspid aortic valve, PDA, and/or VSD. Due to increase in upper body flow and pressure, epistaxis, headache, LE ischemic sxs, dilated costal arteries, and CHF are commonly found]

4

You dx a pt with ataxia telangiectasia. Which of the following immunologic abnormalities would be expected in this pt?

A. elevated IgA and IgE with reduced levels of IgM
B. IgA deficiency
C. low or absent levels of all immunoglobulins
D. normal immunoglobulins with ineffective neutrophils
E. undetectable IgA levels with elevated IgM and normal IgG

E. undetectable IgA levels with elevated IgM and normal IgG

5

7 y/o female presents to ED with 5 day hx of fever, malaise, and anorexia. PMH includes aortic stenosis. PE reveals loud systolic ejection murmur at cardiac base that radiates to carotids and systolic ejection click. Splenomegaly and petechial eruption on palms and soles also present. Labs reveal WBC 19,000 and ESR of 78. Which of the following is correct regarding most likely dx?

A. Abnormal rheumatoid factor is unusual
B. TTE is most sensitive test for detecting vegetations
C. Gram negative rods are most common cause
D. Ophthalmologic eval is useful in dx
E. Abx should be administered prior to blood culture

D. Ophthalmologic eval is useful in dx

[This is bacterial endocarditis; Roth spots and retinal hemorrhages on ophtho exam can help confirm dx]

6

Pt presents later in life with low urinary excretion of calcium and high urinary excretion of magnesium leading to hypomagnesemia. They also have hypokalemia and hypochloremic metabolic alkalosis

A. Bartter syndrome
B. Gitelman syndrome
C. Goodpasture syndrome
D. Gullner syndrome
E. Liddle syndrome

B. Gitelman syndrome

7

10 y/o brought in with tibial fracture extending from the epiphysis, through the physis, and into the metaphysis. What is salter-harris grade?

A. Grade I
B. Grade II
C. Grade III
D. Grade IV
E. Grade V

D. Grade IV


Grade I = within the physis
Grade II = within the physis and extends into metaphysis
Grade III = in the physis and extends into epiphysis
Grade IV = from epiphysis, through physis, and into metaphysis
Grade V = crush injury of the physis

8

Sickle cell patient presents with abrupt development of nausea, vomiting, and crampy abdominal pain followed by moderate watery diarrhea with specks of blood and mucus. The patient has a pet snake. Most appropriate therapy?

A. Amoxicillin
B. Amoxicillin-clav
C. Cefotaxime
D. Ciprofloxacin
E. Gentamicin

C. Cefotaxime


Pt has acute bacterial gastroenteritis d/t Salmonella -- risk factor is infected domestic animals like dogs, cats, reptiles, and amphibians.

Tx with 3rd gen cephalosporin like cefotaxime, ceftriaxone, or cefixime. Ampicillin may also be used.

9

A previously healthy 4-year-old girl is brought to her clinician because her parents have noticed that she has been less active than usual for the past three weeks. Her father explains that it is difficult to get his daughter out of bed in the mornings and that she no longer plays outside with her older brother. Physical examination is notable for a temperature of 38.4 C, heart rate of 125 bpm, pallor, truncal bruising, and diffuse lymphadenopathy. The remainder of the exam, including a thorough neurologic assessment, is unremarkable. Which of the following is the most likely diagnosis?

A. Aseptic meningitis
B. Kawasaki disease
C. Non-accidental trauma
D. Acute lymphoblastic leukemia
E. Mononucleosis

D. Acute lymphoblastic leukemia

The child presents with evidence of anemia (fatigue, tachycardia, pallor) and thrombocytopenia (unexplained bruising). Failure of two or more hematologic cell lines should always raise suspicion for malignant invasion of the marrow. Furthermore, the child's chief complaint, fatigue, is the most common presenting symptom of acute leukemia. Finally, the incidence of ALL peaks at age 4 years.

10

You are examining a LGA infant born via vaginal delivery at 39 weeks. Pregnancy was complicated by poorly controlled gestational DM requiring insulin therapy. PE of infant reveals asymmetrical Moro reflex with impaired movement of LUE. The left SCM is in spasm. Grasp reflex is intact. Dx?

A. Clavicle fracture
B. Erb-Duchenne palsy
C. Klumpke palsy
D. Shoulder dislocation
E. Torticollis

A. Clavicle fracture

Clavicle fracture results in absent Moro on affected side, along with SCM spasm

11

Which of the following electrolyte abnormalities is most likely in an infant born to a diabetic mother?

A. Hypermagnesemia
B. Hypernatremia
C. Hypocalcemia
D. Hypokalemia
E. Hyponatremia

C. Hypocalcemia


The metabolic/electrolyte abnormalities most frequently observed in infants of diabetic mothers are hypoglycemia, hypocalcemia, and hypomagnesemia]

12

A 6 y/o girl presents with uncomplicated Lymes. Which of the following is most appropriate tx?

A. Oral doxycycline
B. Oral amoxicillin
C. IV penicillin
D. IV ceftriaxone
E. No abx

B. Oral amoxicillin

13

A 4 y/o male presents w/ 2 week history of viral URI sxs and 2-day hx of swelling around eyes. PE reveals normal vitals, moderate periorbital edema, mild scrotal edema, and pedal edema. UA reveals 3+ proteinuria. Which of the following is most accurate regarding the most likely dx?

A. Low serum cholesterol
B. Predisposed to hemorrhage
C. If pt becomes febrile, start empiric abx to cover for encapsulated organisms
D. Refer for diagnostic renal bx
E. Pt will not respond to corticosteroids and requires cyclophosphamide or cyclosporin

C. If pt becomes febrile, start empiric abx to cover for encapsulated organisms

Pts with nephrotic syndrome are at increased risk for infection with encapsulated organisms such as strep pneumo

14

Polymorphous rash with high fever lasting at least 5 days, plus: adenopathy, edema/erythema/peeling of oral cavity, edema/erythema/desquamation of extremities, conjunctivitis. Dx?

A. Kawasaki's disease
B. Roseola
C. Rubella
D. Rubeola
E. Scarlet fever
F. Varicella Zoster

A. Kawasaki's disease

15

Pts with homocystinuria require a methionine-restricted diet, and supplementation with folic acid and pyridoxine. What other medication should be added to the regimen?

A. Propranolol
B. Vitamin C
C. D-penicillamine
D. Aspirin
E. Zinc

D. Aspirin

[due to hypercoagulability]

16

A 6 wk old male presents in September with 2 day hx of cough and increased work of breathing. PMH is significant for uncomplicated vaginal delivery at 38 wks. At 10 days of age, he was treated for conjunctivitis with erythromycin ointment. On PE, he is afebrile, coughing rapidly and has RR of 54. Diffuse wheezes are present throughout lung fields with mild subcostal retractions. Which of the following is the most likely cause?

A. Mycoplasma pneumoniae
B. Chlamydia trachomatis
C. Respiratory syncytial virus
D. Streptococcus pneumoniae
E. Asthma

B. Chlamydia trachomatis

Chlamydia trachomatis is a common cause of afebrile PNA in a child 1-3 months of age. It presents with staccato cough, respiratory distress, and a history of conjunctivitis in 50%. Often presents with tachypnea and wheezing.

17

A 6-week-old infant presents to your office for a check-up. The baby was born full-term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks during feeds because he seems to be trying to catch his breath. He has four to six wet diapers per day and stools three or four times per day. Vital signs: Temperature is 37.6 C (99.7F), respiratory rate is 68 breaths/minute, pulse is 138 beats/minute, blood pressure is 88/58 mmHg, and oxygen saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be LEAST LIKELY to be the cause of the infant's symptoms?

A. Aortic stenosis
B. Atrial septal defect
C. Coarctation of the aorta
D. Patent ductus arteriosus
E. Ventricular septal defect

B. Atrial septal defect



Choice B is correct because atrial septal defects (ASDs) do not cause CHF. ASDs often go undiagnosed for decades due to subtle physical examination findings and/or a lack of appreciable symptoms. Children with ASD's are generally asymptomatic

18

A 13 y/o trauma victim presents unconscious with suspected head injury. On exam, he does not open his eyes to voice or pain. He has decerebrate posturing of the extremities to pain, and he moans with stimulation (you are not able to understand any words). What is his GCS?

A. 4
B. 5
C. 6
D. 7
E. 8

B. 5

Does not open eyes to pain or voice = +1
Decerebrate posturing = +2
Moans to stimulation with incomprehensible words = +2

19

11 day old infant with bilateral eye discharge. PE reveals conjunctival injection, lid swelling, and scant mucopurulent discharge. No rashes or skin lesions present. Most likely pathogen?

A. Chlamydia trachomatis
B. Neisseria gonorrhoeae
C. Staphylococcus aureus
D. Adenovirus
E. Herpes simplex virus

A. Chlamydia trachomatis

This is neonatal conjunctivitis -- MCC is Chlamydia trachomatis. Usually occurs second week of life with mild to moderate lid and conjunctival inflammation, and a small amount of purulent discharge. Tx with 14 days of oral erythromycin

20

Which of the following findings is characteristic of the galactosemias?

A. Elevated creatine kinase
B. Direct hyperbilirubinemia
C. Hyperglycemia
D. Hypertriglyceridemia
E. Hypertrophic cardiomyopathy

B. Direct hyperbilirubinemia

21

Pt presents with polyhydramnios, premature delivery, severe hypokalemia, hypochloremia, metabolic alkalosis, and normal BP

A. Bartter syndrome
B. Gitelman syndrome
C. Goodpasture syndrome
D. Gullner syndrome
E. Liddle syndrome

A. Bartter syndrome

22

Asthma symptoms occurring more than 2 times per week with 3-4 nocturnal awakenings per month. Classification?

A. Exercise-induced
B. Intermittent
C. Mild persistent
D. Moderate persistent
E. Severe persistent

C. Mild persistent

23

Low-pitched, musical or vibratory sound best heard at the left lower sternal border or between the left border and the apex. Louder in supine position and increases with fever and/or anemia. Decreases in upright position.

A. ASD
B. PDA
C. Peripheral pulmonary stenosis
D. Stills murmur
E. Venous hum

D. Stills murmur

Most common innocent murmur, usually heard in children 3-6.

24

A newborn is dx with Trisomy 21. TTE is performed demonstrating a cleft anterior mitral valve leaflet. Which of the following is most likely also present?

A. coarctation of aorta
B. ostium primum ASD
C. ostium secundum ASD
D. tetralogy of fallot
E. total anomalous pulmonary venous return

B. ostium primum ASD


[Ostium primum ASDs are located in the inferior portion of the septum and are associated with clefts in the anterior leaflet of the mitral valve. Ostium secundum ASDs are associated with mitral valve prolapse and regurgitation]

25

A previously healthy and developmentally normal 16-month-old male comes to the urgent care clinic with his father with a chief complaint of his first reported seizure. The child was reported to have dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. The child has had URI symptoms for the past two days, with a fever to 103 degrees F without any changes in mental status. Neither parent has a seizure disorder, but the child's mother reports having a single seizure as a young girl once after developing a high fever after a cold. What is the most likely diagnosis?

A. Epilepsy
B. Simple febrile seizure
C. Complex febrile seizure
D. Absence seizure
E. Cyanotic breath-holding spell

B. Simple febrile seizure

Simple febrile seizures are characterized by < 15 minutes duration, occurring only once in a 24-hour period, and are generalized (in this patient's case, generalized tonic-clonic). A positive family history for febrile seizures in the parents makes it a more likely diagnosis in their children. This particular diagnosis fits this patient the best.

A COMPLEX febrile seizure is characterized by > 15 minute duration, occurring more than once during a 24-hour period, and being focal. Given that this child's seizure was associated with loss of consciousness and tonic-clonic movements lasting five minutes, and occurred only once during a 24-hour period, complex febrile seizure is not the most likely diagnosis.

26

Best empiric treatment for pediatric pneumonia in neonate at risk for sepsis?

A. IV ampicillin + cefotaxime
B. IV azithromycin
C. IV ceftriaxone
D. Oral amoxicillin
E. Oral amoxicillin-clavulanate

A. IV ampicillin + cefotaxime


First-line empiric treatment for pediatric pneumonia should consist of ampicillin to cover Listeria and group B strep AND an amino glycoside like gentamicin OR a 3rd gen cephalosporin like cefotaxime for expanded coverage of gram negative organisms like E.coli

27

A 3 y/o female is dx with cervical adenitis and is discharged home with a 7 day course of amoxicillin-clavulanate. 5 days into therapy, she presents with no decrease in size of the enlarged cervical node. The child’s fevers have also been persistent. PE shows a febrile toddler with conjunctivitis, pharyngitis, right anterior cervical LAD (the node is 2 cm in diameter), and an erythematous macular rash on the chest and back. Which of the following courses of management is most appropriate at this time?

A. Send pt home on oral PCN with presumptive dx of Scarlet fever
B. Perform TST and discharge on oral dicloxacillin, f/u in 48 hrs
C. Admit pt for rule-out sepsis workup that includes evaluation of blood, urine, and CSF cultures for bacterial infection
D. Admit pt for high-dose IVIG
E. Admit pt for high-dose corticosteroid therapy

D. Admit the pt for high-dose IVIG

Dx is Kawasaki disease. Tx is high-dose IVIG and ASA

28

Asthma symptoms that are daily with nocturnal awakenings more than once per week with some limitation in normal activity. Classification?

A. Exercise-induced
B. Intermittent
C. Mild persistent
D. Moderate persistent
E. Severe persistent

D. Moderate persistent

29

Pt with Down syndrome presents with prominent second heart sound, and systolic ejection murmur best appreciated at left upper sternal border. Which of the following is the most likely cause of the cardiac murmur?

A. Coarctation of aorta
B. Complete AV canal defect
C. Mitral valve prolapse
D. Patent ductus arteriosus
E. Pulmonic stenosis

B. Complete AV canal defect

30

A 5-year-old boy is brought to his pediatrician with two days of right ankle pain and rash over both lower extremities. He has not had any fever and is previously healthy. He recovered from an upper respiratory infection two weeks ago. Vital signs are normal. His right ankle is swollen and mildly tender. He has palpable purpura over both lower extremities. Which of the following statements is true about his likely diagnosis?

A. CBC would likely reveal thrombocytopenia
B. This disease is classified as a small vessel vasculitis
C. Urinalysis is not warranted for this patient's work-up
D. Treatment options include IVIG
E. This disease is equally common in girls and boys

B. This disease is classified as a small vessel vasculitis

HSP is classified as a small vessel vasculitis. The exact mechanism of HSP is unknown; however, it is thought to be an IgA-mediated immune response affecting small vessels (skin, GI tract, joints, kidneys). Approximately 50% of cases follow viral or bacterial URIs. Biopsy of affected organs shows leukocytoclastic vasculitis with IgA deposition