A mother brings her six-month-old son to see you in the emergency department in January. The child
had an uneventful prenatal course, and growth and development have been normal to this point. The child is
primarily breast fed, but his mother did begin to introduce solids at 4 months of age. The child now presents
with emesis and diarrhea of two days duration. She has noted no blood in his stools. In addition, the patient has
had several episodes of emesis, and does not seem to have tolerated any oral intake. You inquire about urine
output, and the patient s mother reports one wet diaper yesterday and none today. She denies any fevers. The
patient does attend day care, and according to his mother, there have been several other children there with a
On physical examination, heart rate is 165, and the remainder of the vital signs are within normal limits. Weight
is 6.3 kg. The patient weighed 7 kg at his pediatrician s office earlier this week. The patient is crying but
consolable with the examination. He appears ill and listless. Eyes appear sunken and lips are dry. The patient
is not producing tears with his crying. Anterior fontanel is sunken. The patient s lungs are clear, and
auscultation of the heart reveals no murmurs. Capillary refill is 3-4 seconds, but skin turgor appears normal.
Examination of the rectal area reveals redness and excoriation.
Given the patient s history, you suspect gastroenteritis. You give the pts mother a bottle of oral rehydration
solution and instruct her to give the child a teaspoon every 5 minutes. While explaining the instructions to his
mother, the child drinks several ounces from his bottle and promptly vomits on you.
Of the following, the next best step in this patient s management is:
E. Place a peripheral IV and give 140 ml of normal saline (saline 0.9 %) as a bolus
The next best step in this patient's management is to place a peripheral IV and give 140 ml of normal saline (saline 0.9%) as a bolus. This patient is presenting with signs of dehydration, including decreased urine output, sunken fontanel, dry lips, and poor skin turgor. These findings indicate a need for immediate fluid resuscitation. The recommended initial fluid bolus for pediatric patients is 20 ml/kg, and in this case, the patient's weight is 6.3 kg, so 140 ml of normal saline is appropriate. The other options, such as trying infant formula or giving antibiotics, are not indicated at this time. Stool cultures and other investigations may be considered later if the patient's condition does not improve.
A 8-year-old female presents to the emergency department with a seizure. On initial evaluation, the
patient appears to be post-ictal, but is otherwise okay. Initial vital signs are significant for blood pressure of
180/110. She has never had a seizure before. On further questioning, the patient s parents report that she had
several episodes of coca-cola colored urine a few days ago, and was seen by her doctor and given an
antibiotic for presumed urinary tract infection. Over the last few days prior to her presentation, she has been
complaining of headaches and ankle swelling. Otherwise the patient has been fine. She has never been
hospitalized, takes no medications, and she has no known allergies. She is in 3rd grade, and plays soccer in a
local league. She is very seldom ill, and with the exception of a sore throat 2 weeks ago, she has had no other
recent illnesses. CT of the head is normal.
What is the most likely diagnosis?
B. Post-infectious glomerulonephritis
The most likely diagnosis in this case is post-infectious glomerulonephritis. The patient's history of recent episodes of coca-cola colored urine, headaches, and ankle swelling, along with a recent urinary tract infection and normal CT scan, are consistent with the presentation of post-infectious glomerulonephritis. This condition is characterized by inflammation of the glomeruli in the kidneys following an infection, often caused by streptococcal bacteria. It can present with symptoms such as hematuria, hypertension, and edema.
What would be the most likely urinalysis and laboratory findings in the patient in the previous question?
A. Red blood cell casts, 2+ protein, pyruria, and RBCs too numerous to count
The most likely urinalysis and laboratory findings in the patient would include red blood cell casts, 2+ protein, pyuria, and RBCs too numerous to count. This combination of findings suggests a significant amount of blood in the urine, as indicated by the presence of red blood cell casts and numerous RBCs. The presence of protein and pyuria also indicates inflammation or infection in the urinary tract. The high protein level (2+) suggests kidney damage or dysfunction. Overall, these findings are consistent with a severe renal condition.
A 3-year-old boy is seen in the emergency room with edema and shortness of breath. He was
previously healthy, but his mother has noted worsening edema over the past 2 weeks and over the past 2 days
he appears increasingly dyspneic. Physical examination reveals mild tachypnea, periorbital edema, decreased
lung sounds in the bilateral bases, and pitting edema of bilateral lower extremities. CXR reveals bilateral pleural
effusions. BMP and CBC are normal. Urinalysis reveals 3+ protein. Serum albumin is markedly decreased with
a value of 2 g/dl. A 24-hour urine collection reveals 3 grams of protein.
Light microscopy of a kidney biopsy would most likely reveal:
D. Normal findings
The given clinical presentation suggests nephrotic syndrome, which is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia. In this case, the decreased serum albumin and significant proteinuria indicate glomerular dysfunction. However, the normal findings in the BMP, CBC, and kidney biopsy suggest that the underlying cause is likely minimal change disease (MCD), the most common cause of nephrotic syndrome in children. MCD is characterized by normal findings on light microscopy, while electron microscopy may reveal effacement of podocyte foot processes. Therefore, the correct answer is "Normal findings."
After consultation with a pediatric nephrologist, what would be the most appropriate combination of
medications for the treatment of the patient in the previous question?
C. Prednisone, furosemide, albumin
The most appropriate combination of medications for the treatment of the patient in the previous question would be prednisone, furosemide, and albumin. Prednisone is a corticosteroid that helps reduce inflammation and suppress the immune system. Furosemide is a diuretic that helps remove excess fluid from the body. Albumin is a protein that helps maintain blood volume and prevent fluid from leaking out of blood vessels. This combination of medications would help manage the patient's condition and address the underlying issues causing their symptoms.
A 15-year-old boy is seen in the ER for evaluation after fall from a tree. He fell a short distance and had no
loss of consciousness. His parents brought him in for evaluation of a small laceration to his knee. During
physical examination, his blood pressure is noted to be 148/90 using a large adult blood pressure cuff that
completely encircles his right upper arm. His weight is 110 kilograms. His laceration is easily repaired and his
physical examination is otherwise normal. He has no other physical complaints or concerns.
You speak with the patient and his parents about his blood pressure. They relate that his blood pressure has
been high on other occasions at the pediatrician's office. In fact, on the advice of the pediatrician, they have
been checking his blood pressure at home and have recorded several readings in 150/90 range. Additionally,
they report that since the last visit to the pediatrician two months ago, the boy's weight has increased by 2
kilograms. His height is currently at the 75 %ile for age. Calculation of the patient's body mass index (BMI)
reveals a value of 32.
Of the following, which of the following is the BEST initial course of action for this patient?
C. Caloric restricion and exercise program
The patient is a 15-year-old boy who has a high blood pressure reading, elevated weight, and a high BMI. These findings suggest that the patient is overweight or obese, which is a common cause of hypertension in adolescents. The best initial course of action in this case would be to recommend a caloric restriction and exercise program to help the patient lose weight and improve his blood pressure. This approach is recommended as the first-line treatment for hypertension in overweight or obese individuals, and pharmacologic therapy is typically reserved for cases where lifestyle modifications are ineffective.
A previously healthy 4-month-old male infant presents to the emergency room with decreased PO intake,
increased fussiness, and fever. His parents state that he has not been taking feeds well for the past two
days and has a decreased number of wet diapers daily. He has had no vomiting. Fever at home was 101.4
rectally this morning. He has become increasingly more irritable and seems to cry each time he urinates. The
parents have not noticed any blood in the urine or on the diaper.
Physical examination reveals heart rate of 155, BP 90/50, sunken anterior fontanel and sticky oral mucous
membranes. Blood cultures and a catheterized urine specimen are obtained for culture and urinalysis.
Urinalysis reveals presence of leukocyte esterase and nitrites. Microscopic urine evaluation shows greater
than 50 WBC/HPF. You diagnose urinary track infection (UTI) with dehydration and admit the patient for
intravenous fluid and antibiotic therapy.
After initiation of therapy, the patient s clinical picture rapidly improves, and urine culture shows greater than
100,000 CFU of Escherichia coli.
After initiating appropriate antibiotic therapy, the MOST appropriate next step in the the management of this
D. Renal ultrasound with initiation of IV antibiotic therapy; prophylactic antibiotics until a VCUG
(voiding cystourethrogram) is obtained
The correct answer is renal ultrasound with initiation of IV antibiotic therapy; prophylactic antibiotics until a VCUG (voiding cystourethrogram) is obtained. This is the most appropriate next step in the management of this patient because the presence of leukocyte esterase, nitrites, and greater than 50 WBC/HPF in the urine indicates a urinary tract infection (UTI). The patient's symptoms, such as decreased PO intake, increased fussiness, and fever, along with physical examination findings of sunken anterior fontanel and sticky oral mucous membranes, suggest dehydration. The rapid improvement in the patient's clinical picture after initiation of antibiotic therapy confirms the diagnosis of UTI. Renal ultrasound is necessary to evaluate for urinary tract obstruction, and a VCUG is needed to further assess the urinary system. Prophylactic antibiotics should be given until the VCUG is obtained to prevent recurrent UTIs.
A previously healthy 5-year-old child is brought urgently to the ED for evaluation. He has had bloody diarrhea for the past day. He has become increasingly listless over the past several hours and his parents are very
concerned. He has no known medical problems.
The patient has not traveled anywhere recently and owns no pets. Several days ago, his family ate out at a fish
restaurant. The patient had a hamburger because he does not like fish. No one else in the family is ill.
Physical examination reveals a very ill-appearing child. He is at least moderately dehydrated. Laboratory
analysis is significant for hemoglobin of 7.2 g/dl, platelets of 30,000, BUN 80 and creatinine 2.3. Serum
potassium level is 5.6. Peripheral blood smear is shown below.
Based on the MOST LIKELY diagnosis, WHICH of the following therapies would be contraindicated at this
B. Parenteral (IV) antibiotic therapy upon hospital admission
The patient's presentation, with bloody diarrhea, listlessness, and laboratory findings of anemia, thrombocytopenia, and renal dysfunction, is consistent with hemolytic uremic syndrome (HUS). HUS is most commonly caused by infection with Shiga toxin-producing Escherichia coli (STEC), often acquired through contaminated food. Antibiotic therapy is contraindicated in HUS caused by STEC infection because it can increase the release of Shiga toxin and worsen the disease. Supportive care, including hydration, monitoring of fluid status, and transfusion of packed red blood cells for symptomatic anemia, is important in managing HUS. Dialysis may be indicated if there is severe renal dysfunction. Telemetry monitoring is not specifically contraindicated in this situation.