If You Pass This Quiz, You Are An Excellent Pediatrician

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| By Catherine Halcomb
Catherine Halcomb
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1. You are speaking to a couple who are expecting their first baby in about 2 weeks. They are concerned about the safety of childhood immunizations and also about "unneeded" medications given to newborns in the hospital. They ask about the purpose of the routine administration of intramuscular vitamin K. You explain to them about hemorrhagic disease of the newborn, stating that the untreated baby can manifest:

Explanation

The correct answer is "A prolonged prothrombin time and a risk of serious hemorrhage in the days following delivery." This explanation states that untreated babies with hemorrhagic disease of the newborn can experience a prolonged prothrombin time, which measures the time it takes for blood to clot. This can lead to a risk of serious hemorrhage, or excessive bleeding, in the days following delivery.

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About This Quiz
If You Pass This Quiz, You Are An Excellent Pediatrician - Quiz

A pediatrician is a medical doctor who sees to the needs of infants, children, adolescents, and young adults. For many young people, a pediatrician is the primary care provider from birth, perhaps through the age of 18. The word pediatrician comes from the Greek word for child.
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2. Blood samples of a 3-day-old full-term infant are sent for screening to identify diseases that would have serious, permanent consequences without prompt and appropriate treatment. Match the disease with the treatment. Biotinidase deficiency (SELECT 1 TREATMENT)

Explanation

Vitamin therapy is the correct treatment for Biotinidase deficiency. Biotinidase deficiency is a rare genetic disorder where the body is unable to properly process biotin, a B-vitamin. Without treatment, this condition can lead to serious neurological problems. Vitamin therapy involves providing the infant with biotin supplements to ensure they receive an adequate amount of the vitamin. This treatment helps to prevent the development of symptoms and allows the infant to grow and develop normally.

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3. Blood samples of a 3-day-old full-term infant are sent for screening to identify diseases that would have serious, permanent consequences without prompt and appropriate treatment. Match the disease with the treatment. Hypothyroidism (SELECT 1 TREATMENT)

Explanation

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, which is important for growth and development. Prompt and appropriate treatment is necessary to prevent serious and permanent consequences. Hormone therapy, in this case, refers to the administration of synthetic thyroid hormone to supplement the deficiency in the body. This treatment helps to restore normal thyroid hormone levels and prevent any potential complications associated with hypothyroidism.

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4. You are asked to see a child in consultation. The family noticed that the child's left arm and leg seemed bigger than those on the right. In addition, the child has aniridia. You examine the family members present, and none of them have aniridia or hemihypertrophy, nor do they know of anyone else in the family with these conditions. You suggest further evaluation of the child for which condition?

Explanation

The child's presentation of hemihypertrophy (one side of the body being larger than the other) and aniridia (absence of the iris in the eye) are both associated with a condition called Beckwith-Wiedemann syndrome. This syndrome is characterized by overgrowth, abnormalities in the abdominal organs, and an increased risk of developing Wilms tumor, a type of kidney cancer. Therefore, further evaluation for Wilms tumor is suggested in this case.

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5. A 15-year-old girl with short stature, neck webbing, and sexual infantilism is found to have coarctation of the aorta. A chromosomal analysis would demonstrate:

Explanation

The presence of short stature, neck webbing, and sexual infantilism in a 15-year-old girl suggests Turner syndrome, which is caused by an XO karyotype. Turner syndrome is characterized by the absence of one X chromosome in females. This chromosomal abnormality leads to various physical and developmental abnormalities, including short stature, webbed neck, and delayed sexual development. The other options listed do not correspond to the clinical features described in the question.

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6. A 2-year-old boy is brought into the emergency room with a complaint of fever for 6 days and development of a limp. On examination, he is found to have an erythematous macular exanthem over his body, ocular conjunctivitis, dry and cracked lips, red throat, and cervical lymphadenopathy. There is a grade II/VI vibratory systolic ejection murmur at the lower left sternal border. A white blood cell count and differential show predominant neutrophils with increased platelets on smear. The most likely diagnosis is:

Explanation

The given clinical presentation of a 2-year-old boy with fever, erythematous macular exanthem, ocular conjunctivitis, dry and cracked lips, red throat, cervical lymphadenopathy, and a grade II/VI vibratory systolic ejection murmur at the lower left sternal border, along with elevated neutrophils and platelets on smear, is consistent with Kawasaki disease. Kawasaki disease is an acute febrile illness that primarily affects young children and is characterized by systemic vasculitis involving medium-sized vessels. It commonly presents with fever, mucocutaneous findings, lymphadenopathy, and cardiovascular involvement, which includes the development of a coronary artery aneurysm.

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7. The next steps in management of the child in the preceding question would be:

Explanation

The next steps in management of the child would involve administering pooled immunoglobulin (IVIG) and high-dose aspirin, along with admitting the child to the hospital. This approach is likely indicated because it suggests a possible diagnosis of Kawasaki disease, which is characterized by fever, conjunctivitis, rash, and mucosal changes. Treatment typically involves IVIG to reduce the risk of coronary artery aneurysms and high-dose aspirin to reduce inflammation. Inpatient admission is necessary to closely monitor the child's response to treatment and manage any potential complications.

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8. The most likely agent responsible for the infant's condition in the preceding question is:

Explanation

The most likely agent responsible for the infant's condition is the Respiratory syncytial virus. This virus is a common cause of respiratory tract infections, especially in infants and young children. It can cause symptoms such as cough, runny nose, fever, and difficulty breathing. RSV is highly contagious and can spread easily through respiratory droplets. It is a leading cause of bronchiolitis and pneumonia in infants, and can be particularly severe in premature babies and those with underlying health conditions.

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9. A 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child?

Explanation

A sweat chloride test is likely to result in the correct diagnosis of this child. The combination of poor weight gain, persistent cough, history of pneumonitis, and large, foul-smelling stools suggests a possible diagnosis of cystic fibrosis (CF). The sweat chloride test is a diagnostic test used to confirm CF, as it measures the amount of chloride in sweat. In individuals with CF, the sweat chloride levels are typically elevated. Therefore, performing a sweat chloride test can help confirm the diagnosis of CF in this infant.

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10. You are awakened in the night by your 2-year-old son, who has developed noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection (URI) for 2 days. The most likely diagnosis is:

Explanation

The most likely diagnosis is viral croup. The symptoms described, such as noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough, are characteristic of viral croup. Viral croup is a common respiratory infection in young children, typically caused by a viral infection that leads to inflammation and swelling of the upper airway. This can result in the characteristic symptoms, including the barking cough. Asthma, epiglottitis, and foreign body in the right mainstem bronchus are less likely given the clinical presentation and history of a mild upper respiratory infection. Bronchiolitis may present with similar symptoms, but viral croup is more likely in this case.

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11. As a doctor in a clinic, you have just given a 10-year-old boy an injection of pollen extract as prescribed by his allergist. You are about to move on to the next patient when the boy starts to complain about a funny feeling in his chest, and his face becomes red and swollen. He then develops severe respiratory distress with wheezing, and as he starts to fall, you catch him and place him on a bed. The least important measure to be instituted immediately would be:

Explanation

The least important measure to be instituted immediately would be the placement of a tourniquet above the injection site. This is because the symptoms described suggest an anaphylactic reaction, which is a severe and potentially life-threatening allergic reaction. In this situation, the priority should be to address the respiratory distress and provide immediate medical intervention. Endotracheal intubation, administration of oxygen, subcutaneous injection of epinephrine, and administration of corticosteroids are all appropriate measures to treat an anaphylactic reaction. A tourniquet may be used in certain situations to control bleeding, but it is not a priority in this case.

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12. An infant can move his head from side to side while following a moving object, can lift his head from a prone position 45° off the examining table, smiles when encouraged, and makes cooing sounds. He cannot maintain a seated position. The most likely age of the infant is:

Explanation

Based on the given information, the infant is able to move his head from side to side while following a moving object, lift his head from a prone position 45° off the examining table, smile when encouraged, and make cooing sounds. These motor and social skills typically develop around the age of 3 months. The fact that the infant cannot maintain a seated position suggests that he is not yet at the age of 6 months or older, where sitting with support becomes more common. Therefore, the most likely age of the infant is 3 months.

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13. A very concerned mother brings a 2-year-old child to your office because of multiple episodes of a brief, shrill cry followed by a prolonged expiration and apnea. You have been following this child in your practice since birth and know that the child is a product of a normal pregnancy and delivery, has been growing and developing normally, and has no acute medical problems. The mother relates that the first episode in question occurred immediately after the mother refused to give the child some juice. The child became cyanotic and unconscious and had generalized clonic jerks. A few moments later the child awakened and had no residual effects. A second episode of identical nature occurred at the grocery store when the father of the child refused to purchase a toy for the child. Your physical examination reveals a totally delightful and normal child. The most likely diagnosis in this case is:

Explanation

Breath-holding spell is the most likely diagnosis in this case. Breath-holding spells are episodes in which a child involuntarily holds their breath, leading to cyanosis (bluish discoloration of the skin) and loss of consciousness. These episodes are often triggered by emotional stress or frustration, such as the child being denied something they want. The child in this case has been growing and developing normally, has no acute medical problems, and appears normal on physical examination, which is consistent with breath-holding spells. Seizure disorder, drug ingestion, hyperactivity with attention deficit, and pervasive development disorder do not explain the specific symptoms described in the case.

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14. The most appropriate course of action in the previous case would be to:

Explanation

The most appropriate course of action in this case would be to reassure the family of the likely benign nature of the problem and offer counseling for appropriate behavior modification. This is because the question mentions a "likely benign nature of the problem," suggesting that the child's condition is not serious. Therefore, it would be appropriate to provide reassurance to the family and offer counseling to help modify the child's behavior.

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15. An infant who sits with only minimal support, attempts to attain a toy beyond reach, and rolls over from the supine to the prone position, but does not have a pincer grasp, is at a developmental level of:

Explanation

An infant who is able to sit with only minimal support, attempt to reach for a toy beyond their reach, and roll over from the supine to the prone position, but does not have a pincer grasp, is at a developmental level of 6 months. At this age, infants are typically able to sit with support, start reaching for objects, and roll over. The absence of a pincer grasp suggests that the infant has not yet developed the fine motor skills required for this milestone, which usually occurs around 9 months of age.

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16. Appropriate treatment for the condition described in the previous question includes:

Explanation

Moisturizers and topical steroids are appropriate treatments for the condition described in the previous question because they can help alleviate symptoms such as dryness, itching, and inflammation. Moisturizers help to hydrate the skin and reduce dryness, while topical steroids have anti-inflammatory properties and can help reduce itching and inflammation. These treatments can provide relief and improve the overall condition of the skin.

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17. You are called by a general practitioner to consult on a patient admitted to the hospital 4 days ago. The patient is a 7-month-old white boy with poor weight gain for the past 3 months, who has not gained weight in the hospital despite seemingly adequate nutrition. His guardian is his maternal aunt, as his mother is in jail for unknown reasons. You take a detailed diet history from the guardian, and the amounts of formula and baby food intake seem appropriate for age. Physical examination reveals an active, alert infant with a strong suck reflex who appears wasted. You note generalized lymphadenopathy with hepatomegaly. In addition, you find a severe case of oral candidiasis that apparently has been resistant to treatment. Which of the following is the most appropriate next step in the evaluation or treatment of this child?

Explanation

The patient's poor weight gain, lack of weight gain despite adequate nutrition, and presence of oral candidiasis that is resistant to treatment are all suggestive of an underlying immunodeficiency. The presence of generalized lymphadenopathy and hepatomegaly further support this suspicion. Congenitally acquired HIV can present with these symptoms, and HIV PCR testing is the most appropriate next step to confirm the diagnosis.

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18. Aunt Mary is helping her family move to a new apartment. During the confusion, 3-year-old Jimmy is noted to be stumbling about, his face flushed and his speech slurred. The contents of Aunt Mary's purse are strewn about on the floor. In the emergency room, Jimmy is found to have a rapid heartbeat, blood pressure of 42/20, and dilated pupils. ECG shows prolonged QRS and QT intervals. Jimmy suddenly starts to convulse. His condition is most likely to be the result of poisoning with:

Explanation

Jimmy's symptoms, such as stumbling, flushed face, slurred speech, dilated pupils, rapid heartbeat, low blood pressure, and prolonged QRS and QT intervals on ECG, are consistent with tricyclic antidepressant poisoning. Tricyclic antidepressants can cause anticholinergic effects, including flushed face, dilated pupils, and dry mouth. They can also cause cardiovascular toxicity, leading to a rapid heartbeat and low blood pressure. Prolonged QRS and QT intervals on ECG are characteristic of tricyclic antidepressant overdose. Convulsions can also occur as a result of tricyclic antidepressant toxicity. Therefore, the most likely cause of Jimmy's condition is poisoning with tricyclic antidepressants.

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19. Universal immunization of infants with a three-dose series of intramuscular, genetically engineered hepatitis B surface antigen vaccine is recommended. Implementation of this recommendation should decrease the incidence of which of the following?

Explanation

Implementation of universal immunization of infants with a three-dose series of hepatitis B vaccine is recommended in order to decrease the incidence of hepatocellular carcinoma. Hepatocellular carcinoma is a type of liver cancer that is commonly caused by chronic hepatitis B infection. By vaccinating infants against hepatitis B, the transmission of the virus can be significantly reduced, leading to a decrease in the incidence of hepatocellular carcinoma.

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20. Many rashes and skin lesions can be found first in the newborn period. For each of the descriptions listed below, select the most likely diagnosis. A newborn's father complains that his son has dandruff, with many waxy flakes of skin on the scalp. When he scrapes the lesions, hair often comes off with the flakes of skin. In addition, the baby has flaking of the eyebrows. (SELECT 1 DIAGNOSIS)

Explanation

The given description of the newborn having dandruff-like flakes of skin on the scalp, flaking of the eyebrows, and hair coming off when the lesions are scraped is consistent with seborrheic dermatitis. Seborrheic dermatitis is a common skin condition in infants that causes flaky, oily, and yellowish scales on the scalp, eyebrows, and other areas of the body. The presence of these symptoms suggests that seborrheic dermatitis is the most likely diagnosis in this case.

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21. For each otherwise normal child presented, choose the sleep disturbance most consistent with the history. A 3-year-old boy awakens every night around 2:00 A.M. screaming incoherently. His parents note that he is agitated, seems awake but unresponsive, and goes back to sleep within a few minutes. He has no memory of the episodes in the morning.

Explanation

The child's symptoms of awakening every night around the same time, screaming incoherently, appearing awake but unresponsive, and having no memory of the episodes in the morning are consistent with night terrors. Night terrors typically occur during non-REM sleep and are characterized by intense fear and agitation. The child's ability to go back to sleep within a few minutes also supports the diagnosis of night terrors, as individuals with nightmares often have difficulty falling back asleep.

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22. For each disorder below, select the dietary deficiency that is likely to be responsible. Enlargement of costochondral junction, craniotabes, and scoliosis (SELECT 1 DEFICIENCY)

Explanation

Enlargement of costochondral junction, craniotabes, and scoliosis are all symptoms associated with rickets, which is caused by a deficiency in vitamin D. Vitamin D is essential for the absorption of calcium and phosphorus, and its deficiency can lead to impaired bone growth and development. The symptoms mentioned in the question, such as enlargement of costochondral junction (enlarged joints between the ribs and the sternum), craniotabes (softening of the skull bones), and scoliosis (abnormal curvature of the spine), are all characteristic features of rickets. Therefore, a deficiency in vitamin D is likely responsible for these symptoms.

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23. Identify the syndrome based on the clinical presentation. A 6-year-old boy weighs 150 lb and has small hands and feet, almond-shaped eyes, and hypogonadism.

Explanation

The correct answer is Prader-Willi syndrome. Prader-Willi syndrome is a genetic disorder characterized by a variety of symptoms including small hands and feet, almond-shaped eyes, and hypogonadism. Individuals with this syndrome often have an insatiable appetite, leading to obesity if not controlled.

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24. For the most likely toxic substance involved in the cases below, match the appropriate treatment. You are called to the delivery room. A newborn infant seems lethargic and has poor tone with only marginal respiratory effort, but his heart rate is above 100 beats per min. The mother had an uncomplicated pregnancy, and delivery was uncomplicated and vaginal 10 min after spontaneous rupture of membranes. The mother received only pain medications while in labor. (SELECT 1 TREATMENT)

Explanation

The correct treatment for the symptoms described in the case is Naloxone (Narcan). The newborn infant is presenting with lethargy, poor tone, and marginal respiratory effort, which are consistent with opioid toxicity. Naloxone is an opioid receptor antagonist that can reverse the effects of opioids and improve respiratory effort. The fact that the mother had an uncomplicated pregnancy and delivery, along with the absence of any other specific information, suggests that opioid toxicity is the most likely cause of the infant's symptoms. Therefore, Naloxone would be the appropriate treatment in this case.

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25. For the most likely toxic substance involved in the cases below, match the appropriate treatment. After helping his father in the yard, a 14-year-old boy complains of weakness and feels like his muscles are twitching. He begins to drool, and then collapses in a generalized tonic clonic seizure. Upon the arrival of EMS, his heart rate is found to be 40 beats per min and his pupils are pinpoint. (SELECT 1 TREATMENT)

Explanation

The symptoms described in the case, such as muscle weakness, twitching, drooling, and collapse followed by a seizure, along with a slow heart rate and pinpoint pupils, suggest the possibility of organophosphate poisoning. Atropine and pralidoxime (2-PAM) are the appropriate treatments for organophosphate poisoning. Atropine helps to counteract the effects of excessive acetylcholine in the body, while pralidoxime reactivates acetylcholinesterase, the enzyme responsible for breaking down acetylcholine. These treatments can help alleviate the symptoms and reverse the toxic effects of organophosphate poisoning.

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26. Excess vitamin intake has been shown to have deleterious effects. Match the vitamin with the toxic effect. Pyridoxine (SELECT 1 EFFECT)

Explanation

Excess intake of pyridoxine, also known as vitamin B6, has been shown to cause sensory neuropathy. Sensory neuropathy is a condition that affects the nerves responsible for transmitting sensory information from the body to the brain. Symptoms of sensory neuropathy include numbness, tingling, and loss of sensation in the extremities. This can lead to difficulties with coordination and balance. Therefore, excessive consumption of pyridoxine can have deleterious effects on the nervous system, specifically causing sensory neuropathy.

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27. Heart failure is possible at any age. Match each clinical condition with the most likely diagnosis. A 14-year-old child has headache, hypertension, edema, and a change in urine output and color. (SELECT 1 DIAGNOSIS)

Explanation

The given symptoms of headache, hypertension, edema, and a change in urine output and color are suggestive of glomerulonephritis. Glomerulonephritis is an inflammation of the glomeruli in the kidneys, which can lead to impaired kidney function and the symptoms described. The other options listed do not typically present with these specific symptoms and are therefore less likely diagnoses in this case.

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28. Heart failure is possible at any age. Match each clinical condition with the most likely diagnosis. A 3-day-old infant was born to a mother with active systemic lupus erythematosus (SLE). (SELECT 1 DIAGNOSIS)

Explanation

Heart block is the most likely diagnosis for a 3-day-old infant born to a mother with active systemic lupus erythematosus (SLE). Systemic lupus erythematosus can cause autoimmune damage to the heart's electrical conduction system, leading to heart block. This condition can occur at any age, including in newborns. Therefore, heart block is a possible diagnosis for this infant.

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29. The Committee on Nutrition of the American Academy of Pediatrics has concluded that children on a normal diet do not need vitamin supplements. There are, however, some clinical situations in which special needs do occur. Match each situation with the appropriate supplement. One-day-old newborn (SELECT 1 SUPPLEMENT)

Explanation

not-available-via-ai

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30. A 3-day-old infant born at 32 weeks' gestation and weighing 1700 g (3 lb, 12 oz) has three episodes of apnea, each lasting 20 to 25 s and occurring after a feeding. During these episodes, the heart rate drops from 140 to 100 beats per min, and the child remains motionless; between episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL and serum calcium is normal. The child's apneic periods most likely are:

Explanation

The correct answer is "Due to an immature respiratory center." This is because the infant is only 3 days old and born prematurely at 32 weeks' gestation. Premature infants often have underdeveloped respiratory centers in the brain, which can lead to episodes of apnea. The fact that the episodes occur after feeding suggests that they may be related to the immaturity of the respiratory center, as the respiratory drive may be temporarily suppressed during digestion. The normal blood sugar and serum calcium levels suggest that hypoglycemia or electrolyte imbalances are not the cause of the apneic episodes. There is no evidence of seizures or underlying pulmonary disease mentioned in the scenario.

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31. Blood samples of a 3-day-old full-term infant are sent for screening to identify diseases that would have serious, permanent consequences without prompt and appropriate treatment. Match the disease with the treatment. Galactosemia (SELECT 1 TREATMENT)

Explanation

Galactosemia is a rare genetic disorder in which the body is unable to break down galactose, a sugar found in milk and dairy products. If left untreated, it can lead to serious health problems such as liver damage, kidney problems, and intellectual disability. The correct treatment for galactosemia is a special diet that eliminates galactose from the infant's diet. This involves avoiding milk, dairy products, and any foods or formulas that contain lactose or galactose. By following a special diet, the infant can avoid the harmful effects of galactosemia and lead a healthy life.

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32. A 1-week-old black infant presents to you for the first time with a large, fairly well-defined, purple lesion over the buttocks bilaterally, as shown in the photograph. The lesion is not palpable, and it is not warm or tender. The mother denies trauma and reports that the lesion has been present since birth. This otherwise well-appearing infant is growing and developing normally and appears normal upon physical examination. The most likely diagnosis in this infant is:

Explanation

This 1-week-old black infant presenting with a large, well-defined, purple lesion over the buttocks bilaterally is most likely diagnosed with a Mongolian spot. Mongolian spots are common in infants with darker skin tones and typically appear as bluish-gray or purple lesions on the lower back or buttocks. They are benign and usually fade over time without any treatment. The absence of trauma, normal growth and development, and the lesion being present since birth all support the diagnosis of a Mongolian spot rather than child abuse, subcutaneous fat necrosis, vitamin K deficiency, or hemophilia.

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33. A newborn infant develops respiratory distress immediately after birth. His abdomen is scaphoid. No breath sounds are heard on the left side of his chest, but they are audible on the right. Immediate intubation is successful with little or no improvement in clinical status. Emergency chest x-ray is shown (A) along with an x-ray 2 h later (B). The most likely explanation for this infant's condition is:

Explanation

The most likely explanation for the infant's condition is a diaphragmatic hernia. This is supported by the scaphoid abdomen, absence of breath sounds on the left side of the chest, and the chest x-ray findings. A diaphragmatic hernia occurs when there is a defect in the diaphragm, allowing abdominal organs to move into the chest cavity. This can cause respiratory distress due to compression of the lungs and displacement of the heart. Immediate intubation may be necessary, but it may not fully resolve the clinical symptoms. The chest x-ray findings, showing abdominal organs in the chest cavity, further support the diagnosis of a diaphragmatic hernia.

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34. A term, 4200-g female infant is delivered via cesarean section because of cephalopelvic disproportion. The amniotic fluid was clear, and the infant cried almost immediately after birth. Within the first 15 min of life, however, the infant's respiratory rate increased to 80 breaths per min, and she began to have intermittent grunting respirations. The infant was transferred to the level 2 nursery and was noted to have an oxygen saturation of 94%. The chest radiograph showed fluid in the fissure, overaeration, and prominent pulmonary vascular markings. The most likely diagnosis in this infant is:

Explanation

The infant in the scenario is experiencing rapid breathing (tachypnea) and intermittent grunting respirations, which are characteristic of transient tachypnea of the newborn (TTN). TTN is a condition that occurs when there is delayed clearance of fetal lung fluid after birth, leading to fluid accumulation in the lungs. This can cause respiratory distress shortly after birth, but it typically resolves within 24-72 hours without any treatment. The chest radiograph findings of fluid in the fissure, overaeration, and prominent pulmonary vascular markings are consistent with TTN. The other options (diaphragmatic hernia, meconium aspiration, pneumonia, and idiopathic respiratory distress syndrome) do not match the clinical presentation and radiographic findings described.

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35. A routine prenatal ultrasound reveals a male fetus with meningomylocele. The 24-year-old primigravid mother is told the infant will require surgery shortly after birth. You counsel her about the etiology of this defect and the risk of further pregnancies being similarly affected, stating that:

Explanation

The correct answer is "Supplementation of maternal diet with folate leads to a decrease in incidence of this condition." This is because neural tube defects, such as meningomylocele, have been shown to be associated with inadequate intake of folate during pregnancy. Supplementation with folate has been proven to decrease the risk of neural tube defects in infants.

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36. An infant born at 35 weeks' gestation to a mother with no prenatal care is noted to be jittery and irritable, and is having difficulty feeding. You note coarse tremors on examination. The nurses report a high-pitched cry and note several episodes of diarrhea and emesis. You suspect the infant is withdrawing from:

Explanation

The symptoms described, such as jitteriness, irritability, difficulty feeding, coarse tremors, high-pitched cry, and episodes of diarrhea and emesis, are consistent with neonatal withdrawal syndrome. This syndrome occurs when a baby is exposed to drugs in utero and experiences withdrawal symptoms after birth. Among the options given, heroin is the most likely cause of these symptoms.

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37. The signs and symptoms of meningitis in an infant can be different than those in an adult. Which of the signs and symptoms of meningitis listed below is more helpful in an adult patient than in a 4-month-old?

Explanation

Brudzinski's sign is a physical examination finding where there is involuntary flexion of the hips and knees when the neck is flexed. This sign is more helpful in an adult patient than in a 4-month-old because it indicates meningeal irritation and inflammation, which is more specific for meningitis in adults. In infants, the fontanelle (soft spot on the top of the head) is not yet closed, and they may not exhibit this sign even if they have meningitis. Therefore, Brudzinski's sign is a more reliable indicator of meningitis in adults compared to infants.

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38. A postterm infant is born at home after a prolonged and difficult labor. The maternal grandmother brings the infant to the hospital at 1 h of life because of fast breathing. Grandmother notes that the child spit up some dark brown particulate fluid shortly after birth. Physical examination reveals an infant in marked respiratory distress. Other findings include both an umbilical cord and flaking skin with a yellow-green hue. Chest radiograph reveals patchy infiltrates bilaterally. What is the diagnosis?

Explanation

The given scenario describes a postterm infant who was born at home after a prolonged and difficult labor. The infant is now presenting with fast breathing and has spit up dark brown particulate fluid shortly after birth. These findings, along with the presence of an umbilical cord and flaking skin with a yellow-green hue, suggest the diagnosis of meconium aspiration. Meconium aspiration occurs when a newborn inhales meconium, which is the baby's first stool, into the lungs during or before delivery. This can cause respiratory distress and lead to patchy infiltrates seen on a chest radiograph.

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39. The same infant is now 7 weeks old. She has been extubated for 2 weeks and still requires oxygen to maintain her saturation above 93%. Her chest radiograph now reveals patchy, fluffy infiltrates with areas of lucency. She requires daily diuretic treatment. What is the diagnosis?

Explanation

The infant in this scenario is 7 weeks old and still requires oxygen to maintain her saturation above 93%. Additionally, her chest radiograph reveals patchy, fluffy infiltrates with areas of lucency, and she requires daily diuretic treatment. These findings are consistent with bronchopulmonary dysplasia, a chronic lung disease that often occurs in premature infants who have required mechanical ventilation and oxygen therapy. This condition is characterized by inflammation and scarring of the lungs, leading to respiratory symptoms and the need for ongoing oxygen support.

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40. Blood samples of a 3-day-old full-term infant are sent for screening to identify diseases that would have serious, permanent consequences without prompt and appropriate treatment. Match the disease with the treatment. Phenylketonuria (SELECT 1 TREATMENT)

Explanation

Phenylketonuria is a genetic disorder that causes a buildup of phenylalanine in the body. This can lead to intellectual disability and other serious health problems if not treated promptly. The correct treatment for phenylketonuria is a special diet that restricts the intake of phenylalanine. By following this diet, the individual can prevent the buildup of phenylalanine and reduce the risk of complications.

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41. For each description of head injury that follows, select the major abnormality with which it is most likely to be associated. Previous premature infant born at 27 weeks' gestation and now 6 months of age presenting with macrocephaly and hydrocephalus on ultrasonogram. (SELECT 1 ABNORMALITY)

Explanation

The given description of a premature infant born at 27 weeks' gestation presenting with macrocephaly and hydrocephalus on ultrasonogram suggests the presence of intraventricular hemorrhage. Intraventricular hemorrhage is a common complication in premature infants and can lead to the accumulation of blood in the ventricles of the brain, causing hydrocephalus and enlargement of the head. This abnormality is the most likely association in this case.

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42. A 10-year-old boy, the star goalie for the Salt Lake City Little League soccer team, had a sore throat about two weeks ago but did not tell anyone because he was afraid he would miss the play-offs. Since several children have been diagnosed with rheumatic fever in the area, his mother is worried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but that the most common finding is:

Explanation

Rheumatic fever is an inflammatory condition that can develop after a streptococcal infection, such as strep throat. It commonly affects the joints, causing arthralgia (joint pain). While other symptoms like carditis (inflammation of the heart), erythema marginatum (a rash with a characteristic appearance), chorea (involuntary movements), and subcutaneous nodules (small lumps under the skin) can also be present, arthralgia is the most common finding in rheumatic fever. Therefore, the correct answer is arthralgia.

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43. In the same patient, of the following manifestations of acute rheumatic fever, which is not relieved by salicylate or steroid therapy?

Explanation

Chorea is a manifestation of acute rheumatic fever that is not relieved by salicylate or steroid therapy. Chorea is characterized by involuntary, jerky movements that are often rapid and purposeless. It is believed to be caused by an autoimmune response triggered by a previous streptococcal infection. While salicylates and steroids can help alleviate other symptoms of acute rheumatic fever such as carditis, arthritis, abdominal pain, and fever, they are not effective in treating chorea. Therefore, chorea remains unaffected by these therapies.

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44. For each of the cases presented below, choose the most likely cardiac diagnosis based on the patient's presentation. A 15-year-old adolescent male presents to the office for a sports physical. In his screening questionnaire, he notes that he occasionally gets short of breath and dizzy during exercise, with occasional chest pain. He lost consciousness once last summer during football practice, but attributed it to the heat. His grandfather died suddenly at age 35 of unknown etiology, but otherwise the family is healthy. (SELECT 1 DIAGNOSIS)

Explanation

Based on the patient's presentation of occasional shortness of breath, dizziness, chest pain, and loss of consciousness during exercise, along with a family history of sudden death at a young age, the most likely cardiac diagnosis is hypertrophic cardiomyopathy. This condition is characterized by abnormal thickening of the heart muscle, which can obstruct blood flow and lead to symptoms such as those described by the patient.

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45. A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyperexpansion of the chest, and easily audible wheezing without rales. The most likely diagnosis is:

Explanation

The most likely diagnosis is bronchiolitis. This is indicated by the symptoms of a runny nose, sneezing, and coughing, which are common in bronchiolitis. The worsening cough, moderate respiratory distress, nasal flaring, hyperexpansion of the chest, and wheezing without rales further support this diagnosis. Bronchiolitis is a viral infection that affects the small airways in the lungs, commonly caused by respiratory syncytial virus (RSV) in infants and young children. It is characterized by inflammation and narrowing of the bronchioles, leading to symptoms such as cough, wheezing, and difficulty breathing.

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46. While waiting for further studies of the patient, it is appropriate to administer:

Explanation

Administering 100% oxygen is appropriate while waiting for further studies of the patient because it helps to improve oxygenation and perfusion to the tissues. This can be beneficial in various medical conditions such as respiratory distress, hypoxemia, and carbon monoxide poisoning. Additionally, providing 100% oxygen can help stabilize the patient's condition and prevent further deterioration while awaiting further diagnostic tests or interventions.

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47. A 6-week-old child develops increased respiratory rate and a nonproductive cough. Physical examination is significant for rales and rhonchi. The past medical history for the child is positive for an eye discharge at 3 weeks of age, which was treated with a topical antibiotic drug. The most likely organism causing this child's condition is:

Explanation

The most likely organism causing this child's condition is Chlamydia trachomatis. This is suggested by the history of eye discharge at 3 weeks of age, which was treated with a topical antibiotic drug. Chlamydia trachomatis is a common cause of respiratory infections in infants, and it can be transmitted during childbirth if the mother has a genital infection. The symptoms of increased respiratory rate, nonproductive cough, rales, and rhonchi are consistent with a respiratory infection caused by Chlamydia trachomatis.

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48. Appropriate therapy for the patient in the previous question includes:

Explanation

Erythromycin is the appropriate therapy for the patient in the previous question because it is a broad-spectrum antibiotic that is effective against a wide range of bacteria. It is commonly used to treat respiratory tract infections, skin and soft tissue infections, and certain sexually transmitted infections. Additionally, erythromycin is safe for use in patients who are allergic to penicillin, which may be a consideration in this case. Acyclovir is an antiviral medication used to treat herpes infections, while ceftriaxone, penicillin G, and nafcillin are antibiotics that are not indicated for the specific condition being treated in the previous question.

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49. Two weeks after a viral syndrome, a 9-year-old girl presents to your clinic with a complaint of several days of drooping of her mouth. In addition to the drooping of the left side of her mouth, you note that she is unable to completely shut her left eye. Her smile is asymmetric, but her examination is otherwise normal. This girl likely has:

Explanation

The girl's symptoms of drooping of the mouth and inability to completely shut her left eye, along with an asymmetric smile, are indicative of Bell palsy. Bell palsy is a condition that causes sudden weakness or paralysis of the muscles on one side of the face, typically due to inflammation of the facial nerve. It is often preceded by a viral infection, such as a viral syndrome, which is consistent with the girl's history. Guillain-Barré syndrome, botulism, cerebral vascular accident, and brainstem tumor would present with different symptoms and are less likely in this case.

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50. The previously healthy 4-year-old child pictured presents to the emergency room with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown occurs with gentle traction. This child most likely has:

Explanation

The child's presentation is consistent with Staphylococcal scalded skin syndrome (SSSS). SSSS is a bacterial infection caused by Staphylococcus aureus that produces an exfoliative toxin. The toxin causes separation of the epidermis from the dermis, resulting in a generalized rash that is worse in flexural and perioral areas. The crusting and fissuring around the eyes, mouth, and nose, along with the desquamation of skin with gentle traction, are characteristic features of SSSS. Epidermolysis bullosa, erythema multiforme, drug eruption, and scarlet fever do not typically present with these specific findings.

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51. After you make the diagnosis in the previous case, you explain the findings to the family and instruct the family to:

Explanation

The correct answer is to ensure that the patient receives antibiotic prophylaxis for dental procedures. This is because the previous case likely involved a diagnosis of infective endocarditis, which is an infection of the heart valves. Antibiotic prophylaxis is recommended for patients with certain heart conditions, such as those with prosthetic heart valves, to prevent bacterial infections during dental procedures. This is important because bacteria from the mouth can enter the bloodstream during dental procedures and potentially infect the heart valves. Therefore, ensuring that the patient receives antibiotic prophylaxis is crucial in preventing complications.

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52. A mother brings an 18-month-old to the emergency center with the concern that the child may have ingested a substance. Which of the following is a contraindication to the use of ipecac in this child:

Explanation

Ingestion of alkali is a contraindication to the use of ipecac in an 18-month-old child because alkali substances can cause severe damage to the esophagus and stomach. Ipecac induces vomiting, which can further irritate and potentially worsen the damage caused by alkali ingestion. Therefore, it is not recommended to use ipecac in this situation.

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53. You are called to the emergency room to see one of your patients. The father of this 3-year-old was spraying the yard with an unknown insecticide. In the emergency room, the child is noted to have bradycardia, muscle fasciculations, meiosis, wheezing, and profound drooling. The most likely agent included in this pesticide is:

Explanation

The symptoms described in the question, such as bradycardia, muscle fasciculations, meiosis, wheezing, and profound drooling, are consistent with organophosphate poisoning. Organophosphates are a class of insecticides that inhibit the activity of the enzyme acetylcholinesterase, leading to an accumulation of acetylcholine in the body. This results in overstimulation of the cholinergic system, leading to the symptoms described. Chlorophenothane (DDT), sodium cyanide, warfarin, and paraquat do not typically cause these specific symptoms.

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54. An infant who appears to be of normal size is noted to be lethargic and somewhat limp after birth. The mother is 28 years old, and this is her fourth delivery. The pregnancy was uncomplicated, with normal fetal monitoring prior to delivery. Labor was rapid, with local anesthesia and intravenous meperidine administered for maternal pain control. Which of the following therapeutic maneuvers is likely to improve this infant's condition most rapidly?

Explanation

The infant's symptoms of lethargy and limpness after birth suggest the possibility of opioid toxicity. The mother received intravenous meperidine for pain control during labor, which is an opioid medication. Administration of naloxone (Narcan) is the appropriate therapeutic maneuver in this situation as it acts as an opioid receptor antagonist, reversing the effects of opioids and improving the infant's condition rapidly. Intravenous infusion of dextrose, administration of vitamin K, and measurement of electrolytes and magnesium levels may be important in certain situations but are not likely to be the most effective interventions in this case. A neurologic consult may be necessary for further evaluation, but it is not the most rapid solution for the infant's condition.

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55. Initial examination of a full-term infant weighing less than 2500 g (5 lb, 8 oz) shows edema over the dorsum of her hands and feet. Which of the following findings would support a diagnosis of Turner syndrome?

Explanation

Redundant skin folds at the nape of the neck is a characteristic finding in Turner syndrome. This condition is caused by the complete or partial absence of one of the X chromosomes in females. The redundant skin folds, also known as webbed neck, are caused by extra skin on the neck. This finding is commonly seen in individuals with Turner syndrome and can help support the diagnosis. The other options listed do not typically correlate with Turner syndrome.

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56. You are advised by the obstetrician that the mother of a baby he has delivered is a carrier of hepatitis B surface antigen (HBsAg positive). The most appropriate action in managing this infant would be to:

Explanation

Administering hepatitis B immune globulin and hepatitis B vaccine to the infant is the most appropriate action in managing this situation. The mother being a carrier of HBsAg means that there is a risk of transmission of hepatitis B to the infant. Administering the immune globulin and vaccine helps to provide passive and active immunity to the infant, reducing the risk of infection. Screening the infant for HBsAg would only confirm if the infection has already occurred, while isolating the infant for enteric transmission is not necessary. Screening the mother for HBeAg would not change the management plan. The statement that transplacentally acquired antibody will prevent infection is incorrect, as it does not provide complete protection.

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57. At the time of delivery, a woman is noted to have a large volume of amniotic fluid. At 6 h of age, her baby begins regurgitating small amounts of mucus and bile-stained fluid. Physical examination of the infant is normal, and an abdominal x-ray is obtained (shown in the following figure). The most likely diagnosis of this infant's disorder is:

Explanation

The given question provides a clinical scenario of a newborn baby who is regurgitating mucus and bile-stained fluid. The physical examination of the infant is normal, and an abdominal x-ray is obtained. The question asks for the most likely diagnosis of the infant's disorder. Duodenal atresia is the most likely diagnosis in this case. Duodenal atresia is a congenital condition characterized by the partial or complete blockage of the duodenum, the first part of the small intestine. It can present with vomiting, distended abdomen, and bile-stained fluid due to the obstruction. The normal physical examination and the abdominal x-ray findings can help confirm this diagnosis.

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58. You are called to the normal newborn nursery to see a baby who was noted to be mildly jaundiced and has a total serum bilirubin concentration of 12 mg/dL at 48 h of age. The baby is a 3500-g boy who was born at term to a 27-year-old O-positive, Coombs-test-negative primigravida 2 h after membranes ruptured. There were no prenatal complications, and the mother had regular prenatal care. Breast-feeding has been well tolerated, and the baby's vitals have been normal. The most appropriate additional diagnostic studies to evaluate the cause of this infant's jaundice are:

Explanation

The most appropriate additional diagnostic studies to evaluate the cause of this infant's jaundice are a complete blood count, direct serum bilirubin, baby blood type and Coombs, and a peripheral smear. These tests can help determine if the jaundice is due to hemolysis, which can be caused by blood type incompatibility or other conditions such as G6PD deficiency. The complete blood count can provide information about the baby's red blood cell count and morphology, while the direct serum bilirubin can measure the level of unconjugated bilirubin in the blood. Baby blood type and Coombs testing can identify any blood type incompatibility or antibodies that may be causing hemolysis. A peripheral smear can further evaluate the morphology of the red blood cells.

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59. Since you are a new intern, you ordered all of the diagnostic studies you could think of instead of just the ones your senior resident told you were most appropriate. The nurse calls to inform you that the infant's studies are back. Both the mother and baby have O-positive blood. The baby's direct serum bilirubin is 0.2 mg/dL, with a repeat total serum bilirubin of 11.8 mg/dL. Urine bilirubin is positive. The mother's white count is 13,000/μL with a differential of 50% polymorphonuclear cells, 45% lymphocytes, and 5% monocytes. The hemoglobin is 17 g/dL, and the platelet count is 278,000/μL. Reticulocyte count is 1.5%. The peripheral smear does not show fragments or abnormal cell shapes. Blood cultures are pending in the laboratory. Liver enzymes and liver ultrasound are normal. G6PD levels and osmotic fragility testing are normal. The most likely diagnosis in this infant is:

Explanation

The most likely diagnosis in this infant is physiologic jaundice. This is supported by the normal liver enzymes and liver ultrasound, as well as the absence of fragments or abnormal cell shapes on the peripheral smear. Physiologic jaundice is a common condition in newborns, caused by the breakdown of red blood cells and the immaturity of the liver in processing bilirubin. In this case, the baby's direct serum bilirubin is within normal range, while the repeat total serum bilirubin is elevated, indicating an increase in bilirubin levels. Additionally, the positive urine bilirubin suggests increased bilirubin excretion. The other options, such as Rh or ABO hemolytic disease, sepsis, congenital spherocytic anemia, and biliary atresia, do not fit with the given clinical findings.

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60. An infant born an hour ago to a mother with severe pregnancy-induced hypertension was floppy at birth and required bag-mask ventilation for several minutes. The infant is now in distress and seemingly agitated, with tachypnea, tachycardia, and hypoxia. Perfusion is poor. Diminished breath sounds are noted on the left side of her chest, and her heart sounds are displaced to the right. What is the best initial step in management?

Explanation

The infant's symptoms, including diminished breath sounds on the left side of the chest, displaced heart sounds to the right, and poor perfusion, suggest a possible tension pneumothorax. Needle aspiration of the chest is the best initial step in management to relieve the pressure and improve ventilation. This procedure involves inserting a needle into the chest to remove air or fluid that may be causing the symptoms. It is a time-sensitive intervention that can be life-saving in this situation.

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61. The parents of a 2-month-old boy are concerned about his risk of coronary artery disease because of the recent death of his 40 year-old maternal uncle from a myocardial infarction. In managing this situation, you would do which of the following?

Explanation

The correct answer is to screen the parents for total cholesterol. This is because coronary artery disease can have a genetic component, and by screening the parents, it can help determine if there is a familial risk for the child. If the parents have high cholesterol levels, it may indicate a higher risk for the child as well. This information can help guide further management and interventions to reduce the child's risk of developing coronary artery disease in the future.

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62. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Administer FIO2 0.4 (SELECT 1 RESULT SET)

Explanation

The correct answer is pH 7.34; PCO2 32; PO2 39; BE 8. This set of arterial blood gas results indicates a normal pH level, slightly elevated PCO2 levels, slightly decreased PO2 levels, and a slightly elevated base excess (BE) level. These results suggest that the patient may be experiencing some respiratory compensation for a metabolic acidosis.

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63. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Place the patient on a ventilator with an FIO2 of 1.0 (SELECT 1 RESULT SET)

Explanation

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64. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Perform tonsillectomy (SELECT 1 RESULT SET)

Explanation

The correct answer is pH 7.36; PCO2 60; PO2 50; BE 7. This set of arterial blood gas results indicates a slightly acidic pH (normal range is 7.35-7.45), elevated PCO2 (indicating respiratory acidosis), decreased PO2 (indicating hypoxemia), and a slightly elevated base excess (indicating a mild metabolic alkalosis). These findings are consistent with the patient undergoing tonsillectomy, as the procedure can cause respiratory acidosis due to airway obstruction and hypoventilation. The decrease in PO2 may be due to impaired gas exchange during the procedure. The mild metabolic alkalosis may be a compensatory response to the respiratory acidosis.

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65. You are counseling an adolescent patient about the long-term management of her asthma while she is away at college. She brought an article she found on the Internet that promotes an herbal supplement purported to be a "safe, natural" treatment for asthma. You recall a recent study in the medical literature showing inhaled steroids to be statistically superior to the advertised herbal supplement at preventing asthma exacerbations at the p <0.05 level. You explain to her that this means that:

Explanation

The correct answer is "The odds are less than 1 in 20 that the differences observed were only a chance variation." This means that the study results are statistically significant, indicating that the inhaled steroids are more effective than the herbal treatment at preventing asthma exacerbations. The p-value of less than 0.05 suggests that the observed differences are unlikely to be due to chance alone. Therefore, it would not be advisable to rely on the herbal treatment as it has not been proven to be as effective as the inhaled steroids.

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66. A 5-year-old boy who was previously healthy has a 1-day history of low-grade fever, colicky abdominal pain, and a skin rash. He is alert but irritable; temperature is 38.6°C (101.5°F). A diffuse, erythematous, maculopapular, and petechial rash is present on his buttocks and lower extremities, as shown in the following figure. There is no localized abdominal tenderness or rebound; bowel sounds are active. Laboratory data demonstrate: Urinalysis: 30 red blood cells per high-powered field, 2+ protein Stool: guaiac positive Platelet count: 135,000/μL These findings are most consistent with:

Explanation

The given clinical presentation of a 5-year-old boy with low-grade fever, colicky abdominal pain, and a skin rash, along with laboratory findings of red blood cells in the urine, positive stool guaiac, and a slightly decreased platelet count, is most consistent with anaphylactoid purpura. Anaphylactoid purpura, also known as Henoch-Schönlein purpura, is a systemic vasculitis that commonly affects children. It typically presents with a purpuric rash, abdominal pain, and joint pain. The presence of blood in the urine and positive stool guaiac are characteristic of the disease. Meningococcemia, child abuse, leukemia, and hemophilia B are not consistent with the given clinical presentation and laboratory findings.

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67. A mother calls you on the telephone and says that her 4-year-old son bit the hand of her 2-year-old son 2 days previously. The area around the laceration has become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F). Your response should be to:

Explanation

The child's symptoms, including redness, swelling, induration, and high fever, suggest that the bite wound has become infected. In cases of infected wounds, surgical debridement and antibiotic treatment are necessary to prevent further complications and promote healing. Admitting the child to the hospital immediately allows for prompt medical intervention and close monitoring of the infection.

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68. A 2-year-old child (A) presents with a four-day history of a rash limited to the feet and ankles. The papular rash is both pruritic and erythematous. The 3-month-old sibling of this patient (B) has similar lesions also involving the head and neck. Appropriate treatment for this condition includes:

Explanation

Permethrin is the appropriate treatment for this condition because the presentation of a papular rash that is both pruritic and erythematous, limited to the feet and ankles in a 2-year-old child, along with similar lesions involving the head and neck in a 3-month-old sibling, suggests scabies. Permethrin is a topical scabicide that is effective in treating scabies infestations. It works by killing the mites that cause scabies and their eggs. Therefore, Permethrin is the correct choice for treating this condition.

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69. New parents ask you how to reduce the chance of their baby suffering from sudden infant death syndrome (SIDS). You tell them to place the child in which of the following for sleep?

Explanation

The correct answer is supine position. Placing the baby on their back to sleep is recommended to reduce the risk of SIDS. This position helps to keep the airway open and decreases the chances of the baby rebreathing their own exhaled carbon dioxide. It is considered the safest sleeping position for infants and has been shown to significantly reduce the incidence of SIDS.

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70. For each otherwise normal child presented, choose the sleep disturbance most consistent with the history. Parents hear over their baby monitor that their 5-year-old girl regularly calls out during the night. When the parents check on her, she is sleeping comfortably and is in no apparent distress.

Explanation

The correct answer is Somniloquy. Somniloquy refers to sleep talking, which is a parasomnia that occurs during non-REM sleep. In this case, the child is calling out during the night but is sleeping comfortably and not in distress. This is consistent with somniloquy, as the child is likely talking during sleep without being aware of it. Night terrors and nightmares typically involve distress and are not consistent with the child's behavior described. Obstructive sleep apnea would involve symptoms such as snoring or pauses in breathing, which are not mentioned in the history. Learned behavior is not a sleep disturbance and does not explain the child's behavior during sleep.

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71. For each otherwise normal child presented, choose the sleep disturbance most consistent with the history. A 4-year-old boy occasionally wakes in the middle of the night crying. When his parents check on him, he seems visibly frightened and tells his parents that dogs were chasing him.

Explanation

The child occasionally wakes up crying and expresses fear of dogs chasing him, which is consistent with nightmares. Nightmares are vivid and disturbing dreams that occur during REM sleep and can cause fear, anxiety, and distress upon waking. Night terrors, on the other hand, are characterized by sudden awakenings with intense fear and confusion, often accompanied by screaming or thrashing, but the child in this case is able to clearly communicate the content of his dreams. Learned behavior, obstructive sleep apnea, and somniloquy (sleep talking) do not fit the description provided.

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72. For each of the injuries listed below, select the age at which it is most likely to occur. Accidental poisoning (SELECT 1 AGE)

Explanation

Accidental poisoning is most likely to occur at the age of 2 years. At this age, children are curious and exploring their environment, which increases the risk of ingesting harmful substances. They are also more mobile and have better hand-eye coordination, making it easier for them to access and consume toxic substances. Additionally, children at this age tend to put objects in their mouths as part of their normal development, further increasing the risk of accidental poisoning.

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73. For each disorder below, select the dietary deficiency that is likely to be responsible. Progressive weight loss, constipation, muscular atrophy, loss of skin turgor, hypothermia, and edema (SELECT 1 DEFICIENCY)

Explanation

The symptoms described in the question, such as progressive weight loss, constipation, muscular atrophy, loss of skin turgor, hypothermia, and edema, are all consistent with caloric deficiency. When the body does not receive enough calories from food, it can lead to weight loss, muscle wasting, and a decrease in body temperature. Additionally, constipation and edema can occur due to a lack of nutrients and fluid imbalance. Therefore, caloric deficiency is likely responsible for the symptoms described.

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74. For each case listed below, match the most likely diagnosis. A 6-year-old boy has developed a limp and has limited mobility of the hip, but denies pain and fever.

Explanation

Legg-Calvé-Perthes disease is the most likely diagnosis for a 6-year-old boy who has developed a limp and limited mobility of the hip, but denies pain and fever. This condition occurs when the blood supply to the femoral head is disrupted, leading to avascular necrosis and collapse of the bone. It typically affects children between the ages of 4 and 10 and is more common in boys. The lack of pain and fever distinguishes it from other possible diagnoses such as osteomyelitis, septic arthritis, and slipped capital femoral epiphysis. Transient synovitis is another possible diagnosis, but it usually presents with pain and resolves spontaneously within a few weeks.

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75. For each case listed below, match the most likely diagnosis. A 3-year-old refuses to walk, is afebrile, had an upper respiratory tract infection a week ago, has right hip pain with movement, and has a normal white blood cell count.

Explanation

The given symptoms of a 3-year-old refusing to walk, having right hip pain with movement, and a normal white blood cell count suggest a diagnosis of transient synovitis. Transient synovitis is a common condition in children where there is inflammation of the hip joint, usually following a viral infection. It is a self-limiting condition that resolves on its own within a few days to weeks. The absence of fever and normal white blood cell count help differentiate it from more serious conditions like septic arthritis or osteomyelitis.

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76. For the most likely toxic substance involved in the cases below, match the appropriate treatment. After a fight with her boyfriend, a 16-year-old girl took "some pills." At presentation she is alert and complains of emesis, diaphoresis, and malaise. Her initial liver function tests, obtained about 12 h postingestion, are elevated. Repeat levels at 24 h show markedly elevated AST and ALT, along with abnormal coagulation studies and an elevated bilirubin. (SELECT 1 TREATMENT)

Explanation

The correct treatment for this case is N-acetylcysteine (Mucomyst). The symptoms described, such as emesis, diaphoresis, and malaise, along with elevated liver function tests and abnormal coagulation studies, suggest liver toxicity. N-acetylcysteine is a specific antidote for acetaminophen overdose, which can cause liver damage. It replenishes glutathione, a key antioxidant in the liver, and helps detoxify the toxic metabolite of acetaminophen. This treatment can prevent or minimize liver damage if administered within a certain time frame after ingestion.

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77. Heart failure is possible at any age. Match each clinical condition with the most likely diagnosis. A 6-month-old child has a loud systolic murmur at the left lower sternal border. (SELECT 1 DIAGNOSIS)

Explanation

A loud systolic murmur at the left lower sternal border in a 6-month-old child is most likely indicative of a ventricular septal defect. A ventricular septal defect is a congenital heart defect where there is an abnormal opening between the two ventricles of the heart. This can cause blood to flow from the left ventricle to the right ventricle, leading to a loud murmur. It is a common cause of heart failure in infants and can occur at any age.

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78. The Committee on Nutrition of the American Academy of Pediatrics has concluded that children on a normal diet do not need vitamin supplements. There are, however, some clinical situations in which special needs do occur. Match each situation with the appropriate supplement. Isoniazid therapy in a pregnant teenager (SELECT 1 SUPPLEMENT)

Explanation

Pregnant teenagers who are undergoing isoniazid therapy may require pyridoxine supplementation. Isoniazid is an antibiotic used to treat tuberculosis, but it can deplete the body's vitamin B6 levels. Pyridoxine, also known as vitamin B6, is essential for various functions in the body, including brain development and metabolism. Therefore, supplementing with pyridoxine can help prevent any deficiencies and support the overall health of the pregnant teenager and her developing baby.

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79. The Committee on Nutrition of the American Academy of Pediatrics has concluded that children on a normal diet do not need vitamin supplements. There are, however, some clinical situations in which special needs do occur. Match each situation with the appropriate supplement. Measles in developing countries (SELECT 1 SUPPLEMENT)

Explanation

Children with measles in developing countries may benefit from vitamin A supplementation. Measles can cause severe vitamin A deficiency, which can lead to complications and increase the risk of mortality. Therefore, providing vitamin A supplements can help improve the nutritional status and overall health of children with measles in these settings.

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80. Match each clinical condition with the most appropriate diagnostic laboratory test. A 3-year-old has had repeated episodes of sinusitis and otitis media. He was recently admitted for osteomyelitis of his femur with Staphylococcus aureus. The family notes that while his first four or five months of life were normal, he has been persistently ill with multiple infections in the ensuing months. The mother notes that her brother had similar problems with infections and died at the age of 3 years from a "lung infection." Physical examination is significant for the absence of lymph nodes and tonsillar tissue. (SELECT 1 TEST)

Explanation

The correct answer is "Serum immunoglobulin levels." This diagnostic laboratory test is appropriate in this case because the patient has a history of recurrent infections and a family history of similar problems. Serum immunoglobulin levels can help determine if the patient has an underlying immunodeficiency disorder, such as selective IgA deficiency or common variable immunodeficiency, which could explain the recurrent infections.

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81. After an uneventful labor and delivery, an infant is born at 32 weeks' gestation weighing 1500 g (3 lb, 5 oz). Respiratory difficulty develops immediately after birth and increases in intensity thereafter. The child's mother (now gravida 3, para 2102) previously lost an infant because of hyaline membrane disease. At 6 h of age, the child's respiratory rate is 60 breaths per min. Examination reveals grunting, intercostal retraction, nasal flaring, and marked cyanosis in room air. Physiologic abnormalities compatible with these data include:

Explanation

The infant's presentation of respiratory difficulty immediately after birth, along with the presence of grunting, intercostal retraction, nasal flaring, and marked cyanosis, suggests a diagnosis of respiratory distress syndrome (RDS), also known as hyaline membrane disease. RDS is commonly seen in premature infants due to the insufficient production of surfactant, leading to decreased lung compliance and reduced lung volume. The right-to-left shunt of blood occurs as a result of the underdeveloped pulmonary vasculature in premature infants. This allows deoxygenated blood to bypass the lungs and mix with oxygenated blood, leading to marked cyanosis. Therefore, the correct answer is decreased lung compliance, reduced lung volume, right-to-left shunt of blood.

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82. You are performing a well-child examination on a new patient, the 1-year-old child shown in the picture. Your next action should be to:

Explanation

The picture shows a child with a noticeable deviation of the eye. This is likely a case of strabismus, which is a misalignment of the eyes. If left untreated, strabismus can lead to a condition called amblyopia, or lazy eye, where the brain favors one eye over the other and central vision fails to develop properly. Therefore, it is important to refer the child to ophthalmology immediately for diagnosis and treatment to prevent long-term vision problems.

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83. You are seeing a 2-month-old infant, brought by her father for a well-child examination. He has concerns about maintaining a safe environment for his child. In providing age-appropriate anticipatory guidance, you tell him that:

Explanation

At 2 months old, infants should only be receiving breast milk or formula. Solid foods should not be introduced until around 4-6 months of age, as their digestive systems are not yet developed enough to handle solid foods. Introducing solid foods too early can increase the risk of digestive issues, allergies, and choking.

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84. You are seeing an established patient, a four-year-old girl brought in by her mother for vaginal itching and irritation. She is toilet trained and has not complained of frequency or urgency, nor has she noted any blood in her urine. Her mother noted she has been afebrile and has not complained of abdominal pain. Mom denies the risk of inappropriate contact; the girl also denies anyone "touching her there." Your physical examination of the perineum is significant for the lack of foul odor or discharge. You do note some erythema of the vulvar area, but the hymenal ring is intact, without evidence of trauma. The appropriate course of action should be to:

Explanation

Based on the information provided, the girl's symptoms of vaginal itching and irritation are most likely due to non-infectious causes. The lack of foul odor or discharge, intact hymenal ring, and absence of trauma suggest that there is no foreign body or infection present. Therefore, the appropriate course of action is to reassure the mother and provide guidance on improving hygiene, such as avoiding bubble baths and using cotton underwear. This approach addresses the most likely cause of the symptoms and is a conservative first step before considering more invasive interventions or referrals.

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85. A five-year-old boy is brought into the emergency room immediately after an unfortunate altercation with a neighbor's immunized Chihuahua that occurred while the child was attempting to dress the dog as a superhero. The fully immunized child has a small, irregular, superficial laceration on his right forearm that has stopped bleeding. His neuromuscular examination is completely normal, and his perfusion is intact. Management should include:

Explanation

In this scenario, the child has a small, superficial laceration on his forearm after an encounter with a neighbor's immunized Chihuahua. The wound has already stopped bleeding, and the child's neuromuscular examination and perfusion are normal. Therefore, the appropriate management would be to perform copious irrigation of the wound. This is important to clean the wound and remove any potential contaminants, reducing the risk of infection. Antimicrobial prophylaxis, tetanus booster immunization, tetanus toxoid in the wound, primary rabies vaccination, and examination of the dog's brain tissue for rabies are not necessary in this case.

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86. Many rashes and skin lesions can be found first in the newborn period. For each of the descriptions listed below, select the most likely diagnosis. A nurse calls you to evaluate an African American baby that seems to have a bacterial skin infection, with many scattered pustules full of a milky fluid. Upon examining a pustule, it easily wipes away, revealing a hyperpigmented spot. (SELECT 1 DIAGNOSIS)

Explanation

Pustular melanosis is the most likely diagnosis because it presents with pustules filled with milky fluid that easily wipe away, revealing a hyperpigmented spot. This condition is commonly seen in African American newborns and is considered a benign condition. Sebaceous nevi, salmon patch, neonatal acne, erythema toxicum, seborrheic dermatitis, and milia do not match the specific characteristics described in the question.

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87. For each disorder below, select the dietary deficiency that is likely to be responsible. Dermatitis, diarrhea, and dementia (SELECT 1 DEFICIENCY)

Explanation

Niacin deficiency is likely to be responsible for the symptoms of dermatitis, diarrhea, and dementia. Niacin, also known as vitamin B3, is essential for the proper functioning of the nervous system and skin health. A deficiency in niacin can lead to a condition called pellagra, which is characterized by dermatitis (skin inflammation), diarrhea, and dementia. Thus, niacin deficiency is the most likely dietary deficiency in this case.

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88. Match each common skin condition with the most appropriate therapy. A 13-year-old girl complains of intense itching of her skin for 2 weeks. You find papules and pustules with a few vesicles distributed over the torso and extremities, but the lesions seem to spare the face. She has areas of lichenification from repeated scratching. The outbreak seems worse on the hands, and you identify raised, linear lesions in the webbing of her hands. (SELECT 1 TREATMENT)

Explanation

The correct answer is Permethrin 5% cream (Elimite) because the description of the skin condition suggests scabies, which is caused by the Sarcoptes scabiei mite. Permethrin is a topical antiparasitic medication that is effective in treating scabies infestations. It works by killing the mites and their eggs, providing relief from itching and eliminating the skin lesions.

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89. Match each common skin condition with the most appropriate therapy. A 10-year-old boy presents with a dry, scaly rash in his antecubital and popliteal fossas, much of it with areas of lichenification. His father notes that this rash always seems to get worse in the winter months. (SELECT 1 TREATMENT)

Explanation

The most appropriate therapy for the 10-year-old boy with a dry, scaly rash in his antecubital and popliteal fossas, along with areas of lichenification, that worsens in the winter months is mild cleansing cream, topical moisturizers, and topical steroids. This treatment can help to moisturize the skin, reduce inflammation, and relieve symptoms associated with the rash.

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90. The nurse from the level II neonatal intensive care nursery calls you to evaluate a baby. The infant, born at 32 weeks' gestation, is now 1 week old and had been doing well on increasing nasogastric feedings. This afternoon, however, the nurse noted that the infant has vomited the last two feedings and seems less active. Your examination reveals a tense and distended abdomen with decreased bowel sounds. As you are evaluating the child, he has a grossly bloody stool. Your management of this infant should include:

Explanation

The correct answer is to stop feeds, begin intravenous fluids, order serial abdominal films, and initiate systemic antibiotics. This is the appropriate management for a baby with a tense and distended abdomen, decreased bowel sounds, and grossly bloody stool. These symptoms suggest a possible gastrointestinal emergency such as necrotizing enterocolitis (NEC), which is a serious condition that requires immediate intervention. Stopping feeds and initiating intravenous fluids help to rest the bowel and prevent further complications. Serial abdominal films can help assess for bowel perforation or other abnormalities. Initiating systemic antibiotics is important to treat any possible infection. Surgical consultation may be needed depending on the findings of the evaluation.

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91. A 1-day-old infant who was born by a difficult forceps delivery is alert and active. She does not move her left arm, however, which she keeps internally rotated by her side with the forearm extended and pronated; she also does not move it during a Moro reflex. The rest of her physical examination is normal. This clinical picture most likely indicates:

Explanation

The clinical picture described suggests left-sided Erb-Duchenne paralysis. This condition is caused by injury to the upper trunk of the brachial plexus, commonly during a difficult forceps delivery. The characteristic presentation includes the arm being internally rotated, extended, and pronated, with a lack of movement during the Moro reflex. The rest of the physical examination being normal helps to rule out other possible causes such as fractures or spinal injury.

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92. A full-term newborn infant is having episodes of cyanosis and apnea, which are worse when he is attempting to feed, but he seems better when he is crying. The most important next step to quickly establish the diagnosis is:

Explanation

Passage of a catheter into the nose is the most important next step to quickly establish the diagnosis because the symptoms described (cyanosis and apnea that worsen during feeding) suggest a possible airway obstruction. By passing a catheter into the nose, the healthcare provider can assess for any anatomical abnormalities or obstructions that may be causing the symptoms. This procedure can help identify the underlying cause of the infant's respiratory distress and guide further management.

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93. The infant in the following pictures (A) and (B) presented with hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash. The most likely diagnosis for this child is:

Explanation

The presence of hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash is consistent with the symptoms of congenital syphilis. Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum, which can be transmitted from an infected mother to her fetus during pregnancy. Congenital syphilis can lead to various complications, including hepatosplenomegaly, anemia, and rash. Therefore, based on the symptoms described, congenital syphilis is the most likely diagnosis for this child.

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94. A previously healthy full-term infant has several episodes of duskiness and apnea during the second day of life. Diagnostic considerations should include which of the following?

Explanation

The correct answer is congenital heart disease. This is because episodes of duskiness and apnea in a previously healthy full-term infant can be indicative of a congenital heart defect. Congenital heart diseases can cause poor oxygenation and inadequate blood flow, leading to symptoms such as cyanosis and apnea. It is important to consider this possibility in order to promptly diagnose and manage any potential cardiac abnormalities in the infant.

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95. A couple expecting their first infant in a few weeks scheduled an appointment in your pediatric clinic to get a head start on child care issues (a prenatal visit). You ask about the pregnancy course, and the mother notes that she was recently told she had oligohydramnios. At delivery of this infant, you plan to evaluate for which of the following conditions?

Explanation

The mother's diagnosis of oligohydramnios, which refers to a low level of amniotic fluid, suggests a potential issue with the kidneys. Renal agenesis, which is the absence of one or both kidneys, is a condition that can cause oligohydramnios. Therefore, at delivery, it would be important to evaluate for renal agenesis in the infant.

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96. A term infant delivered via scheduled cesarean section develops, at 15 min of age, tachypnea, grunting, flaring, and retractions. A chest radiograph reveals well-aerated lungs with fluid in the fissure on the right, prominent pulmonary vascular markings, and flat diaphragms. The child is mildly hypoxic on room air with 89% oxygen saturation. Over the next 6 h she improves and no longer requires oxygen. What is the diagnosis?

Explanation

Transient tachypnea of the newborn is the most likely diagnosis in this case. The infant presented with tachypnea, grunting, flaring, and retractions, which are characteristic signs of respiratory distress. The chest radiograph findings of well-aerated lungs with fluid in the fissure, prominent pulmonary vascular markings, and flat diaphragms are consistent with transient tachypnea of the newborn. This condition is caused by delayed clearance of fetal lung fluid and typically resolves within 48-72 hours after birth. The improvement in the infant's condition over the next 6 hours and no longer requiring oxygen further supports the diagnosis of transient tachypnea of the newborn.

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97. An infant of uncertain dates is born via emergent cesarean section after the mother was critically injured in a motor vehicle accident. Birth weight was 1075 g. The infant has poor respiratory effort and you begin bag-mask ventilation but find it extremely difficult to cause chest wall movement. A chest radiograph reveals diffuse whiteout of both lungs, with an occasional air bronchogram. What is the diagnosis?

Explanation

The correct answer is Respiratory distress syndrome (hyaline membrane disease). This diagnosis is supported by the infant's poor respiratory effort, difficulty in causing chest wall movement during ventilation, and the findings on the chest radiograph of diffuse whiteout of both lungs with occasional air bronchogram. Respiratory distress syndrome is a common condition in premature infants, characterized by a deficiency of surfactant in the lungs, leading to alveolar collapse and impaired gas exchange. This condition typically presents shortly after birth and is more common in infants with low birth weight.

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98. For each description of head injury that follows, select the major abnormality with which it is most likely to be associated. A 1-day-old healthy infant with a superficial swelling over the right parieto-temporal region that does not cross the suture lines. (SELECT 1 ABNORMALITY)

Explanation

A 1-day-old healthy infant with a superficial swelling over the right parieto-temporal region that does not cross the suture lines is most likely associated with a cephalohematoma. A cephalohematoma is a collection of blood beneath the periosteum of the skull, typically caused by birth trauma. It is limited by the suture lines and does not cross them. Other options such as intraventricular hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage typically present with different symptoms and are not consistent with the given description. Caput succedaneum refers to diffuse edema of the scalp and is not associated with a superficial swelling limited to one region.

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99. A 9-month-old infant accidentally ingests an unknown quantity of digitalis. The most important noncardiac manifestation of toxicity in this infant is:

Explanation

The most important noncardiac manifestation of digitalis toxicity in a 9-month-old infant is vomiting. Digitalis is a medication used to treat heart conditions, but it can be toxic if ingested in large amounts. Vomiting is a common symptom of digitalis toxicity and can help remove the drug from the body. Other symptoms of toxicity may include dizziness, visual disturbances, and urticaria, but vomiting is considered the most important noncardiac manifestation in this case.

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100. During a regular checkup on an 8-year-old child, you note a loud first heart sound with a fixed and widely split second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. The mostly likely heart lesion to explain these findings is:

Explanation

The loud first heart sound and fixed and widely split second heart sound at the upper left sternal border that do not change with respirations are consistent with an atrial septal defect. Atrial septal defect is a congenital heart defect where there is a hole in the septum between the atria, allowing blood to flow between them. This abnormal flow of blood can cause the characteristic heart sounds heard in this patient. The fact that the patient is otherwise active and healthy also supports this diagnosis, as many individuals with atrial septal defects are asymptomatic.

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101. During a physical examination for participation in a sport, a 16-year-old girl is noted to have a late apical systolic murmur, which is preceded by a click. The rest of the cardiac examination is normal. She states that her mother also has some type of heart "murmur" but knows nothing else about it. The most likely diagnosis is:

Explanation

The most likely diagnosis in this case is mitral valve prolapse. The late apical systolic murmur, preceded by a click, is a characteristic finding in mitral valve prolapse. Additionally, the fact that the patient's mother also has a heart murmur suggests a possible genetic component to the condition. The rest of the cardiac examination being normal further supports this diagnosis as it is typically an isolated finding in mitral valve prolapse. The other options, such as atrial septal defect, aortic stenosis, tricuspid regurgitation, and ventricular septal defect, do not typically present with the same clinical features as described in the case.

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102. For each of the cases presented below, choose the most likely cardiac diagnosis based on the patient's presentation. You are called to the nursery to evaluate a newborn. The mother has a history of systemic lupus erythematosis and gestational diabetes. The nurses are concerned because the baby has developed petechiae and bruising after his bath. Vital signs have been stable, with a heart rate in the 60s and a respiratory rate in the 40s. You note a large liver, scattered petechiae, and an erytematous rash on the cheeks and the bridge of the nose. (SELECT 1 DIAGNOSIS)

Explanation

Based on the patient's presentation of petechiae, bruising, large liver, scattered petechiae, and an erythematous rash on the cheeks and bridge of the nose, the most likely cardiac diagnosis is congenital heart block. Congenital heart block is commonly associated with maternal autoimmune diseases such as systemic lupus erythematosus. The symptoms observed in the newborn, such as petechiae and bruising, suggest impaired blood clotting due to a slow heart rate.

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103. For each of the cases presented below, choose the most likely cardiac diagnosis based on the patient's presentation. An infant previously diagnosed with a large muscular ventricular septal defect comes to the office with complaints from the mother of fatigue and poor feeding over the past month. You note the child has not gained weight since the previous visit two months ago. The child is apathetic, tachypneic, and has wheezes and crackles on lung auscultation. (SELECT 1 DIAGNOSIS)

Explanation

The infant's presentation of fatigue, poor feeding, failure to gain weight, apathy, tachypnea, and abnormal lung sounds (wheezes and crackles) are consistent with congestive heart failure. Congestive heart failure occurs when the heart is unable to pump blood effectively, leading to fluid accumulation in the lungs and other parts of the body. In this case, the large muscular ventricular septal defect may be causing the heart to work harder and eventually become overwhelmed, resulting in congestive heart failure.

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104. A previously healthy, active 18-month-old child presents with unilateral nasal obstruction and foul-smelling discharge. The child's examination is otherwise unremarkable. The most likely diagnosis is:

Explanation

Based on the given information, the most likely diagnosis is a foreign body. The presence of unilateral nasal obstruction and foul-smelling discharge suggests that there is an object lodged in the child's nose. This is a common occurrence in young children who may insert small objects into their nostrils. The fact that the child's examination is otherwise unremarkable indicates that there are no other significant findings to suggest other diagnoses such as nasal polyps, frontal sinusitis, deviated septum, or choanal atresia.

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105. A 10-year-old has had a "cold" for 14 days. In the 2 days prior to the visit to your office, she has developed a fever to 39°C (102.2°F), purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. The most likely diagnosis is:

Explanation

The most likely diagnosis is maxillary sinusitis. The patient's symptoms, including purulent nasal discharge, facial pain, and a daytime cough, along with the presence of pus in the middle meatus, suggest an infection in the maxillary sinuses. This is further supported by the duration of symptoms (14 days) and the development of a fever. Brain abscess, streptococcal throat infection, sphenoid sinusitis, and middle-ear infection are less likely given the specific presentation of symptoms and findings in the nose.

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106. In patients on theophylline therapy for asthma, certain other drugs change theophylline clearance and raise or lower theophylline levels. Which of the following medications may be safely administered with theophylline?

Explanation

Penicillin may be safely administered with theophylline because it does not change theophylline clearance or affect theophylline levels. This means that there is no significant interaction between penicillin and theophylline, making it a safe option for patients on theophylline therapy for asthma. However, it is important to note that the other medications listed (Erythromycin, Phenytoin, Cimetidine, and Rifampin) can potentially alter theophylline clearance and levels, which may lead to adverse effects or reduced efficacy of theophylline therapy.

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107. A 13-year-old develops fever, malaise, sore throat, and a dry hacking cough over several days. He does not appear to be particularly sick, but his chest examination is significant for diffuse rales and rhonchi. The chest radiograph is shown. The most likely pathogen is:

Explanation

The most likely pathogen in this case is Mycoplasma pneumoniae. This is suggested by the symptoms of fever, malaise, sore throat, and a dry hacking cough, which are characteristic of Mycoplasma pneumonia. The diffuse rales and rhonchi on chest examination further support this diagnosis. Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in adolescents and young adults.

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108. You receive a telephone call from the mother of a 4-year-old child with sickle cell anemia. She tells you that the child is breathing fast, coughing, and has a temperature of 40°C (104°F). The most conservative, prudent approach is to:

Explanation

The symptoms described by the mother, including fast breathing, coughing, and a high temperature, suggest that the child may be experiencing a severe infection. Given that the child has sickle cell anemia, they are at a higher risk for complications from infections. Therefore, the most conservative and prudent approach would be to admit the child to the hospital as an emergency to ensure prompt and appropriate medical care.

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109. The laboratory workup of the patient reveals the following: hemoglobin 5 g/dL; hematocrit 16%; white blood cell count 30,000 μL; and arterial blood, while breathing room air, of pH 7.1, PO2 35 mmHg, and PaCO2 28 mmHg. These values indicate:

Explanation

The laboratory values indicate acidemia, metabolic acidosis, respiratory alkalosis, and hypoxia. Acidemia is indicated by the low pH of 7.1. Metabolic acidosis is suggested by the low hemoglobin and hematocrit levels, which may be due to an underlying condition causing an excess production of acid. Respiratory alkalosis is indicated by the low PaCO2 level, suggesting hyperventilation. Hypoxia is suggested by the low PO2 level. Overall, these values indicate a combination of acid-base disturbances and low oxygen levels in the blood.

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110. A 4-year-old girl is noticed by her grandmother to have a limp and a somewhat swollen left knee. The parents report that the patient occasionally complains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. The condition most likely to be associated with these findings is:

Explanation

The ophthalmologic findings in the photograph show uveitis, which is inflammation of the uvea (middle layer of the eye). Uveitis is a common ocular manifestation of juvenile rheumatoid arthritis (JRA). JRA is an autoimmune disorder that causes chronic inflammation in the joints, and it can also affect other organs, including the eyes. The patient's limp and swollen knee, along with occasional pain, are consistent with joint involvement seen in JRA. Therefore, the correct answer is Juvenile rheumatoid arthritis.

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111. A previously healthy 8-year-old boy has a 3-week history of low-grade fever of unknown source, fatigue, weight loss, myalgia, and headaches. On repeated examinations during this time, he is found to have developed a heart murmur, petechiae, and mild splenomegaly. The most likely diagnosis is:

Explanation

The most likely diagnosis in this case is endocarditis. The symptoms of low-grade fever, fatigue, weight loss, myalgia, and headaches, along with the development of a heart murmur, petechiae, and mild splenomegaly, are suggestive of endocarditis. Endocarditis is an infection of the inner lining of the heart chambers and valves, often caused by bacteria. It can lead to various systemic symptoms and complications, including heart murmurs and splenomegaly. The other options, such as rheumatic fever, Kawasaki disease, scarlet fever, and tuberculosis, do not typically present with the combination of symptoms described in the case.

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112. An 8-hour-old infant develops increased respiratory distress, hypothermia, and hypotension. A CBC demonstrates a WBC of 2500/μL with 80% bands. Which of the following diagnoses is most likely?

Explanation

The correct answer is Group B streptococcal pneumonia because it is a common cause of early-onset neonatal sepsis, which can present with respiratory distress, hypothermia, and hypotension. The low white blood cell count with a high percentage of bands suggests an infection. Gonococcal eye infection and chlamydial pneumonia are less likely in this case because they typically present with conjunctivitis rather than systemic symptoms. Diaphragmatic hernia and transient tachypnea of the newborn would not explain the hypotension and low white blood cell count.

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113. As you are about to step out of a newly delivered mother's room, she mentions that she wants to breast-feed her healthy infant, but that her obstetrician was concerned about one of the medicines she was taking. Which of the woman's medicines, listed below, is clearly contraindicated in breast-feeding?

Explanation

Lithium is contraindicated in breastfeeding because it can pass into breast milk and potentially harm the infant. It is known to cause side effects such as lethargy, poor feeding, and thyroid dysfunction in breastfed infants. Therefore, it is important for the mother to consult with her healthcare provider to find an alternative medication that is safe for breastfeeding while effectively managing her bipolar disorder.

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114. A 2-year-old boy is being followed for congenital cytomegalovirus (CMV) infection. He is deaf and developmentally delayed. The child's mother informs you that she has just become pregnant and is concerned that the new baby will be infected. Which of the following is true?

Explanation

The correct answer is that the mother has antibodies to CMV that are passed to the fetus. This is true because when a pregnant woman is infected with CMV, she produces antibodies that can cross the placenta and provide some level of protection to the fetus. However, it is important to note that even with maternal antibodies, the fetus can still be infected with CMV and may experience complications. Therefore, close monitoring and appropriate management are necessary for the new baby.

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115. At 43 weeks' gestation, a long, thin infant is delivered. The infant is apneic, limp, pale, and covered with "pea soup" amniotic fluid. The first step in the resuscitation of this infant at delivery should be: 

Explanation

The correct answer is suction of the trachea under direct vision. This is the first step in the resuscitation of an infant with signs of meconium aspiration syndrome (MAS). MAS occurs when the fetus passes meconium (the first stool) into the amniotic fluid and then inhales it into the lungs. Suctioning the trachea under direct vision helps to clear the airway of any meconium present, preventing further obstruction and allowing for effective ventilation.

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116. The newborn pictured was born at home and has puffy, tense eyelids; red conjunctivae; a copious amount of purulent ocular discharge; and chemosis 2 days after birth. The most likely diagnosis is:

Explanation

The newborn in the picture is showing symptoms of puffy, tense eyelids, red conjunctivae, a copious amount of purulent ocular discharge, and chemosis 2 days after birth. These symptoms are characteristic of gonococcal ophthalmia, which is caused by the bacteria Neisseria gonorrhoeae. This infection is transmitted from the mother during childbirth and can cause severe eye damage if left untreated. Prompt diagnosis and treatment with antibiotics are necessary to prevent complications.

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117. A term infant is born to a known HIV-positive mother. She has been taking antiretroviral medications for the weeks prior to the delivery of her infant. Routine management of the healthy infant should include:

Explanation

Routine management of a term infant born to an HIV-positive mother who has been taking antiretroviral medications should include a course of zidovudine for the infant. Zidovudine is an antiretroviral medication that can help reduce the risk of perinatal HIV transmission. It is commonly used in infants born to HIV-positive mothers to prevent the transmission of the virus. Other options listed, such as admission to the neonatal intensive care unit, HIV ELISA testing, chest radiographs, and administration of IVIG, are not typically part of routine management for a healthy infant in this situation.

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118. You see the baby shown in the picture for the first time in the nursery as a newborn. You consult plastic and reconstructive surgery as well as the hospital's speech therapist. Understandably, the parents have many questions. Which of the statements listed below is appropriate anticipatory guidance for this family?

Explanation

Recurrent otitis media (middle ear infection) and hearing loss are common complications in babies with cleft palate. This is because the opening in the palate can cause fluid buildup in the middle ear, leading to frequent infections and potential damage to the hearing. It is important for the family to be aware of these potential complications and seek appropriate medical care to prevent and manage them.

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119. A previously healthy 2-year-old black child has developed a chronic cough over the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but none upon expiration. The routine chest radiograph shows no infiltrate, but the heart is shifted slightly to the left. The appropriate next step in making the diagnosis in this patient is to:

Explanation

The correct answer is to obtain inspiratory and expiratory chest radiographs. This is because the patient's symptoms, including chronic cough and abnormal breath sounds on one side, suggest a possible airway obstruction. The decreased air movement during inspiration but none upon expiration indicates a possible obstructive lung disease. Obtaining inspiratory and expiratory chest radiographs can help visualize any possible air trapping or bronchial obstruction. This can aid in the diagnosis of conditions such as foreign body aspiration or bronchiolitis.

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120. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Have patient rebreathe in a paper bag (SELECT 1 RESULT SET)

Explanation

The management procedure of having the patient rebreathe in a paper bag is used to treat respiratory alkalosis, which is characterized by a high pH and low PCO2. In the given answer, the pH is 7.64 (high), PCO2 is 18 (low), PO2 is 94 (normal), and BE is 1 (slightly elevated). These results indicate respiratory alkalosis, which aligns with the management procedure of rebreathing in a paper bag.

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121. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Repeat the test because of obvious laboratory error (SELECT 1 RESULT SET)

Explanation

The correct answer is pH 7.41; PCO2 60; PO2 90; BE 10. This set of arterial blood gas results falls within the normal range for pH, PCO2, PO2, and BE. The pH is slightly alkaline, indicating normal acid-base balance. The PCO2 is within the normal range, indicating normal respiratory function. The PO2 is within the normal range, indicating normal oxygenation. The BE is slightly elevated, indicating a mild metabolic alkalosis. Overall, these results suggest that the patient's respiratory and metabolic function is normal and there is no need to repeat the test due to laboratory error.

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122. The adolescent shown presents with a 14-day history of multiple oval lesions over her back. The rash began with a single lesion over the lower abdomen (A); the other lesions developed over the next days (B). These lesions are slightly pruritic. The likely diagnosis is:

Explanation

The correct answer is Pityriasis rosea. Pityriasis rosea is a common skin condition characterized by oval-shaped lesions that may start with a single lesion and then develop more over time. The lesions are usually slightly itchy and typically appear on the trunk, including the back. Contact dermatitis, seborrheic dermatitis, lichen planus, and psoriasis are all different skin conditions with different clinical presentations and characteristics.

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123. The most appropriate initial therapy for the patient in the previous question is:

Explanation

Observation and topical emollients are the most appropriate initial therapy for the patient in the previous question. This approach involves closely monitoring the patient's condition and using topical emollients to provide relief and moisturize the affected area. It is a conservative treatment option that is often recommended for mild cases of skin conditions, allowing for natural healing to occur. This approach avoids the potential side effects and risks associated with more aggressive treatments such as phototherapy, high-dose topical steroid therapy, systemic antifungal agents, or coal-tar shampoos.

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124. A 16-year-old basketball player complains of pain in his knees. A physical examination reveals, in addition to tenderness, a swollen and prominent tibial tuberosity. Radiographs of the area are unremarkable. The most likely diagnosis is:

Explanation

Osgood-Schlatter disease is the most likely diagnosis for a 16-year-old basketball player complaining of knee pain with tenderness and a swollen and prominent tibial tuberosity. This condition is commonly seen in active adolescents and is characterized by inflammation at the insertion of the patellar tendon on the tibial tuberosity. Radiographs are usually normal in Osgood-Schlatter disease, which supports the unremarkable findings mentioned in the question. Popliteal cyst, slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and gonococcal arthritis are less likely diagnoses in this case.

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125. A 5-year-old boy presents with the severe rash pictured as follows. The rash is pruritic, and it is especially intense in the flexural areas. The mother reports that the symptoms began in infancy (when it also involved the face) and that her 6-month-old child has similar symptoms. The most likely diagnosis of this condition is:

Explanation

The most likely diagnosis for the severe rash in a 5-year-old boy, which is pruritic and especially intense in the flexural areas, is eczema. The fact that the symptoms began in infancy, involved the face, and that the child's 6-month-old sibling has similar symptoms suggests a chronic condition like eczema. Seborrheic dermatitis, superficial candidiasis, psoriasis, and contact dermatitis may also cause rashes, but the presentation and history described in the question are more consistent with eczema.

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126. A 2-year-old boy has been vomiting intermittently for 3 weeks and has been irritable, listless, and anorectic. His use of language has regressed to speaking single words. In your evaluation of this patient, the least likely diagnosis to consider is:

Explanation

Given the patient's symptoms of vomiting, irritability, listlessness, anorexia, and regression in language skills, the least likely diagnosis to consider is food allergy. Food allergies typically present with symptoms such as hives, itching, swelling, wheezing, or anaphylaxis, but not with the symptoms described in the patient. The other options, subdural hematoma, brain tumor, tuberculous meningitis, and lead poisoning, are all more likely causes for the patient's symptoms.

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127. An 8-month-old infant has a 2-day history of diarrhea and poor fluid intake. You diagnose a 10 to 15% dehydration. Which of the following fluids is appropriate to begin immediate resuscitation?

Explanation

Normal saline is the appropriate fluid to begin immediate resuscitation in an 8-month-old infant with 10 to 15% dehydration. Normal saline is an isotonic solution that helps restore fluid and electrolyte balance in the body. It contains a balanced concentration of sodium and chloride, which are important for maintaining proper hydration. D5 1/4 normal saline and D5 1/2 normal saline are not appropriate because they contain dextrose, which can increase osmolarity and worsen diarrhea. Whole blood and D10W are not indicated for resuscitation in this scenario.

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128. In this patient, you decide to give 20 mL/kg of the chosen fluid. A reasonable period of time over which to infuse this fluid is:

Explanation

A reasonable period of time to infuse 20 mL/kg of fluid would be 60 minutes. This is because infusing the fluid over a shorter period of time, such as 2.5 minutes, could lead to fluid overload and potential complications. On the other hand, infusing the fluid over a longer period of time, such as 4 hours, 8 hours, or 24 hours, may not provide the necessary hydration or therapeutic effect in a timely manner. Therefore, infusing the fluid over 60 minutes strikes a balance between delivering the fluid efficiently and minimizing the risk of complications.

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129. A 20-month-old child is brought to the emergency department because of fever and irritability and refusal to move his right lower extremity. Physical examination reveals a swollen and tender right knee that resists passive motion. The most important test to confirm the impression of septic arthritis is:

Explanation

Examination of joint fluid is the most important test to confirm the impression of septic arthritis. Septic arthritis is an infection of the joint space, and examination of joint fluid allows for the direct identification of the causative organism. It also helps in determining the appropriate antibiotic therapy. X-ray of the knee may show signs of joint inflammation but cannot definitively confirm septic arthritis. ESR and CBC are nonspecific tests that may support the diagnosis but cannot confirm it. Blood culture is important but may not always be positive in cases of septic arthritis.

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130. A 16-year-old high school boy sustained an abrasion of the knee after a fall while Rollerblading in the school yard. School records reveal that his last DPT booster was at age 6. In this situation, which of the following is appropriate?

Explanation

The appropriate choice in this situation is to administer an adult tetanus and diphtheria toxoid (Td) vaccine. Tetanus is caused by a bacterial infection that can enter the body through open wounds, such as the abrasion on the knee. The last DPT booster was received at age 6, which means the individual is due for a booster vaccine. The Td vaccine provides protection against both tetanus and diphtheria, making it the appropriate choice in this case.

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131. A mentally retarded 14-year-old boy has a long face, large ears, micropenis, and large testes. Chromosome analysis is likely to demonstrate which of the following?

Explanation

The given symptoms of a long face, large ears, micropenis, and large testes are characteristic features of Fragile X syndrome. This genetic disorder is caused by a mutation in the FMR1 gene on the X chromosome. Chromosome analysis in this case is likely to demonstrate an abnormality in the X chromosome, confirming the diagnosis of Fragile X syndrome. Trisomy 21, Trisomy 18, and Trisomy 13 are all associated with different chromosomal abnormalities and present with different clinical features. William syndrome is caused by a deletion of genetic material on chromosome 7 and does not match the symptoms described.

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132. Many rashes and skin lesions can be found first in the newborn period. For each of the descriptions listed below, select the most likely diagnosis. A 1-week-old child's mother complains that the child has a transient rash that has splotchy areas of erythema with a central clear pustule. Your microscopic examination of the liquid in the pustule reveals eosinophils. (SELECT 1 DIAGNOSIS)

Explanation

The description of a transient rash with splotchy areas of erythema and a central clear pustule, along with eosinophils seen on microscopic examination, is consistent with the diagnosis of erythema toxicum. Erythema toxicum is a common benign rash that appears in the first few days of life and resolves on its own without treatment. It is characterized by erythematous macules or papules with a central pustule, and eosinophils may be present in the pustule fluid.

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133. For each otherwise normal child presented, choose the sleep disturbance most consistent with the history. A 15-month-old toddler continues to wake up crying every night. Her parents give her a nighttime bottle, rock her, and sing to her to help her go back to sleep. Her parents are exhausted and ask you if she is having bad dreams.

Explanation

The toddler's consistent waking up and the parents' actions of giving her a bottle, rocking her, and singing to her suggest that her waking up crying every night is a learned behavior. This means that the toddler has associated these actions with falling back asleep and has learned to wake up and cry in order to receive them. It is not likely that she is having bad dreams or experiencing night terrors or nightmares, as those would typically involve more distress and fear upon waking up. Obstructive sleep apnea and somniloquy (sleep talking) are also less likely explanations in this case.

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134. For each otherwise normal child presented, choose the sleep disturbance most consistent with the history. A 5-year-old child refuses to sleep in his bed, claiming there are monsters in his closet and that he has bad dreams. The parents allow him to sleep with them in their bed to avoid the otherwise inevitable screaming fit. The parents note that the child sleeps soundly, waking only at sunrise.

Explanation

The child's refusal to sleep in his bed and claiming there are monsters in his closet, along with the parents allowing him to sleep with them to avoid a screaming fit, suggests that the child's behavior of not sleeping in his bed is a learned behavior. This means that the child has learned that by refusing to sleep in his bed and expressing fear, he is able to sleep with his parents. The fact that the child sleeps soundly and wakes only at sunrise further supports the idea that this behavior is learned rather than a sleep disorder such as night terrors or nightmares.

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135. For each of the injuries listed below, select the age at which it is most likely to occur. Pedestrian injury (SELECT 1 AGE)

Explanation

Pedestrian injuries are most likely to occur at the age of 6 years. At this age, children are more independent and active, which increases their risk of being involved in accidents as pedestrians. They may not have developed the necessary skills and judgment to navigate traffic safely, making them more vulnerable to injuries. Additionally, children at this age may be less supervised and may not fully understand the dangers of traffic, further increasing their risk.

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136. Identify the syndrome based on the clinical presentation. A 17-year-old boy is well over 6 feet tall and has long slender limbs, hypermobile joints, myopia, and a midsystolic click on physical examination.

Explanation

The clinical presentation described in the question, including a tall stature, long slender limbs, hypermobile joints, myopia, and a midsystolic click, is consistent with Marfan syndrome. Marfan syndrome is a genetic disorder that affects connective tissue, leading to abnormalities in the skeletal, ocular, and cardiovascular systems. This can result in a tall and thin body type, joint hypermobility, nearsightedness (myopia), and a midsystolic click caused by mitral valve prolapse.

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137. Identify the syndrome based on the clinical presentation. A 4-year-old has conductive hearing loss, micrognathia, down-slanting palpebral fissures, abnormally shaped ears, and normal intelligence.

Explanation

The clinical presentation of conductive hearing loss, micrognathia, down-slanting palpebral fissures, abnormally shaped ears, and normal intelligence is consistent with Treacher Collins syndrome. This genetic disorder affects the development of facial bones and structures, leading to characteristic facial features such as underdeveloped cheekbones, small jaw, and abnormal ears. The normal intelligence in this case helps distinguish it from other syndromes that may have similar facial features but are associated with intellectual disabilities.

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138. For the most likely toxic substance involved in the cases below, match the appropriate treatment. Over the last several weeks, a 2-year-old girl has exhibited developmental regression, abnormal sleep patterns, anorexia, irritability, and decreased activity. These symptoms have progressed to acute encephalopathy with vomiting, ataxia, and variable consciousness. The family recently moved, and they are in the process of restoring the interior of their home. (SELECT 1 TREATMENT)

Explanation

The correct answer is Meso-2,3-dimercaptosuccimic acid (DMSA succimer). The symptoms described in the case, such as developmental regression, abnormal sleep patterns, anorexia, irritability, and decreased activity, followed by acute encephalopathy with vomiting, ataxia, and variable consciousness, are consistent with lead poisoning. DMSA succimer is a chelating agent that can be used to treat lead poisoning by binding to and removing lead from the body.

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139. For the most likely toxic substance involved in the cases below, match the appropriate treatment. A 4-year-old girl comes into the emergency room after eating a bottle full of small, chewable pills she found while at her grandfather's house. She has an increased respiratory rate, elevated temperature, and vomiting, and is disoriented. She is intermittently complaining of "a bell is ringing" in her ears. She has a metabolic acidosis on an arterial blood gas. (SELECT 1 TREATMENT)

Explanation

Based on the symptoms described, the most likely toxic substance involved is an overdose of salicylates, such as aspirin. The elevated respiratory rate, elevated temperature, vomiting, disorientation, and "a bell is ringing" sensation in the ears are all consistent with salicylate poisoning. Sodium bicarbonate is the appropriate treatment for salicylate poisoning as it helps to correct the metabolic acidosis caused by the toxic substance.

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140. The normal development of the fetus can be adversely affected by exposure to a number of environmental factors, including infectious agents, physical agents, chemical agents, and maternal metabolic and genetic agents. Match each maternal history of teratogen exposure with the most likely clinical presentation. A 15-year-old mother is taking valproate for absence seizures. (SELECT 1 PRESENTATION)

Explanation

Exposure to valproate during pregnancy has been associated with an increased risk of neural tube defects, including spina bifida. Spina bifida is a congenital condition where the spinal cord does not develop properly, leading to varying degrees of paralysis and other neurological complications. Therefore, it is the most likely clinical presentation in a fetus whose mother has a history of valproate exposure.

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141. The normal development of the fetus can be adversely affected by exposure to a number of environmental factors, including infectious agents, physical agents, chemical agents, and maternal metabolic and genetic agents. Match each maternal history of teratogen exposure with the most likely clinical presentation. A primiparous mother reports drinking two beers a day during the pregnancy. (SELECT 1 PRESENTATION)

Explanation

Excessive alcohol consumption during pregnancy can lead to a condition called Fetal Alcohol Syndrome (FAS). The clinical presentation of FAS includes small palpebral fissures (eye openings), ptosis (drooping eyelids), midfacial hypoplasia (underdevelopment of the middle of the face), and a smooth philtrum (the vertical groove between the nose and upper lip). These physical features are characteristic of FAS and indicate the adverse effects of maternal alcohol exposure on the fetus's development.

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142. Match each common skin condition with the most appropriate therapy. In the late summer, a 5-year-old boy presents with several sores on his arms and legs. The lesions have a honey-colored crust, and there is minimal surrounding erythema. The lesions seem to have spread by the child scratching. (SELECT 1 TREATMENT)

Explanation

The most appropriate therapy for a 5-year-old boy with sores on his arms and legs that have a honey-colored crust and minimal surrounding erythema, and have spread due to scratching, would be topical or oral antibacterial agents. This is because the honey-colored crust suggests a bacterial infection, and the spread of the lesions indicates the need for systemic treatment with oral antibacterial agents or topical application of antibacterial creams or ointments.

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143. The Committee on Nutrition of the American Academy of Pediatrics has concluded that children on a normal diet do not need vitamin supplements. There are, however, some clinical situations in which special needs do occur. Match each situation with the appropriate supplement. Liver disease (SELECT 1 SUPPLEMENT)

Explanation

Children with liver disease may have difficulty absorbing fat-soluble vitamins (vitamins A, D, E, and K) from their diet. Therefore, they may require supplementation of all fat-soluble vitamins to meet their nutritional needs.

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144. A 2-week-old infant has had no immunizations, sleeps 18 hours a day, weighs 3.5 kg, and takes 60 mL of standard infant formula four times a day, but no solid food and no iron or vitamin supplements. Of most concern is:

Explanation

The most concerning factor in this scenario is the caloric intake of the 2-week-old infant. At this age, infants typically require a higher caloric intake to support their rapid growth and development. The fact that the infant is only consuming 60 mL of formula four times a day may indicate inadequate feeding and potential malnutrition. Adequate caloric intake is crucial for proper growth, weight gain, and overall health in infants.

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145. A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed breast milk to provide 120 cal/(kg.d). Over ensuing weeks, the baby is most apt to develop:

Explanation

A premature infant who weighs 950g is at risk for developing hypocalcemia because premature infants have lower calcium stores and are unable to efficiently absorb calcium from breast milk. The baby's weight is used to calculate the required calorie intake, but it does not directly relate to the risk of developing hypocalcemia. Hypernatremia, blood in the stool, hyperphosphatemia, and vitamin D toxicity are not directly related to the baby's weight or the type of feeding.

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146. A primiparous woman whose blood type is O positive gives birth at term to an infant who has A-positive blood and a hematocrit of 55%. A serum bilirubin level obtained at 36 h of age is 12 mg/dL. Which of the following laboratory findings would be characteristic of ABO hemolytic disease?

Explanation

A positive direct Coombs test would be characteristic of ABO hemolytic disease. This test detects antibodies that are attached to the surface of red blood cells, indicating that the mother's antibodies are attacking the infant's red blood cells. This can lead to hemolysis, which is the destruction of red blood cells, and subsequently elevated bilirubin levels. The other laboratory findings mentioned in the options are not specific to ABO hemolytic disease.

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147. The infant pictured as follows was small for gestational age. He also was found to have a ventricular septal defect on cardiac evaluation. This infant appeared to have features consistent with:

Explanation

The infant in the picture is small for gestational age and has a ventricular septal defect, which are both characteristic features of fetal alcohol syndrome. Fetal alcohol syndrome occurs when a mother consumes alcohol during pregnancy, which can lead to growth restriction and heart defects in the baby. Therefore, the features seen in the infant are consistent with fetal alcohol syndrome.

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148. A 19-year-old primiparous woman develops toxemia in her last trimester of pregnancy and during the course of her labor is treated with magnesium sulfate. At 38 weeks' gestation, she delivers a 2100-g infant with Apgar scores of 1 at 1 min and at 5 at 5 min. Laboratory studies at 18 h of age reveal a hematocrit of 79%, platelet count of 100,000/μL, glucose 38 mg/dL, magnesium 2.5 meq/L, and calcium 8.7 mg/dL. Soon after, this the infant has a generalized convulsion. The most likely cause of the infant's seizure is:

Explanation

The infant's high hematocrit level of 79% indicates polycythemia, which is an increased number of red blood cells. This can lead to hyperviscosity of the blood, causing poor circulation and oxygen delivery to the brain. The low Apgar scores at 1 minute and the seizure further support the possibility of hypoxic-ischemic injury due to poor perfusion. Therefore, polycythemia is the most likely cause of the infant's seizure.

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149. A 26-year-old gravida 3 woman has a history of gestational diabetes and a delivery of two previous infants at term that were greater than 4000 grams, each of whom had severe hypoglycemia. Which of the following maneuvers is least likely to reduce the chance of the next child's having hypoglycemia?

Explanation

The correct answer is maternal intravenous loading with 10% glucose beginning 2 to 4 h prior to the expected time of delivery. This maneuver is least likely to reduce the chance of the next child's having hypoglycemia because it only provides a temporary increase in maternal blood glucose levels and does not address the underlying issue of gestational diabetes. Careful control of the maternal blood glucose levels during pregnancy is important to prevent hypoglycemia in the infant. Careful glucose monitoring of the infant, early feedings, and maintenance of the infant in a neutral thermal environment are also important interventions to prevent hypoglycemia.

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150. A well-appearing, 3200-g black infant is noted to have fifth finger polydactyly. The extra digit has no skeletal duplications and is attached to the rest of the hand by a threadlike soft tissue pedicle (see photograph). Appropriate treatment for this condition includes:

Explanation

The appropriate treatment for fifth finger polydactyly with no skeletal duplications and a threadlike soft tissue pedicle is excision of the extra digit. This means that the extra finger should be surgically removed. Chromosomal analysis is not necessary as this condition is not typically associated with chromosomal abnormalities. A skeletal survey is not needed as there are no other skeletal abnormalities mentioned. An echocardiogram and renal ultrasound are also not necessary as they are unrelated to this condition.

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151. A woman gives birth to twins at 38 weeks' gestation. The first twin weighs 2800 g (6 lb, 3 oz) and has a hematocrit of 70%; the second twin weighs 2100 g (4 lb, 10 oz) and has a hematocrit of 40%. Which of the following statements is correct?

Explanation

The first twin is more likely to have hyperbilirubinemia and convulsions because they have a higher hematocrit level of 70%. Hyperbilirubinemia is a condition where there is an excess of bilirubin in the blood, which can lead to jaundice and potentially cause brain damage if not treated. Convulsions can occur as a result of high bilirubin levels affecting the central nervous system. The second twin's lower hematocrit level of 40% does not indicate a higher risk for respiratory distress, cyanosis, congestive heart failure, renal vein thrombosis, or hydramnios.

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152. A newborn infant becomes markedly jaundiced on the second day of life, and a faint petechial eruption first noted at birth is now a generalized purpuric rash. Hematologic studies for hemolytic diseases are negative. Acute management should include which of the following steps?

Explanation

The infant's presentation of marked jaundice and a generalized purpuric rash suggests the possibility of neonatal sepsis, specifically due to Group B Streptococcus (GBS) infection. Isolating the infant from pregnant hospital personnel is important to prevent transmission of GBS to other newborns. This step is crucial in the acute management of the condition.

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153. For each description of head injury that follows, select the major abnormality with which it is most likely to be associated. A 6-month-old comatose infant with multiple broken bones in various stages of healing, bulging anterior fontanelle, and retinal hemorrhages. (SELECT 1 ABNORMALITY)

Explanation

The given description of a 6-month-old comatose infant with multiple broken bones in various stages of healing, bulging anterior fontanelle, and retinal hemorrhages is most likely associated with a subdural hemorrhage. This is because subdural hemorrhage is commonly seen in cases of head trauma, especially in infants who have suffered from abusive head trauma or shaken baby syndrome. The presence of multiple broken bones and retinal hemorrhages further support this association, as they are often seen in cases of severe head trauma.

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154. For the past year, a 12-year-old boy has had recurrent episodes of swelling of his hands and feet, which has been getting worse recently. These episodes occur following exercise and emotional stress, last for two to three days, and resolve spontaneously. The last episode was accompanied by abdominal pain, vomiting, and diarrhea. The results of routine laboratory workup are normal. An older sister and a maternal uncle have had similar episodes but were not told a diagnosis. The most compatible diagnosis is:

Explanation

The most compatible diagnosis in this case is hereditary angioedema. This condition is characterized by recurrent episodes of swelling, which can affect the hands and feet. These episodes are triggered by exercise and emotional stress, which aligns with the patient's symptoms. The abdominal pain, vomiting, and diarrhea experienced during the last episode are also consistent with hereditary angioedema, as gastrointestinal symptoms can occur. The family history of similar episodes in the older sister and maternal uncle further supports this diagnosis.

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155. A child has a history of spiking fevers, which have been as high as 40°C (104°F). She has spindle-shaped swelling of finger joints and complains of upper sternal pain. The most likely diagnosis is:

Explanation

The child's history of spiking fevers, along with the spindle-shaped swelling of finger joints and upper sternal pain, suggests an inflammatory condition rather than an infectious one. Rheumatic fever is a possibility, but it typically presents with other symptoms such as a recent streptococcal infection and carditis. Toxic synovitis is characterized by hip pain and limping, which are not mentioned in the case. Septic arthritis would present with more severe joint pain and systemic symptoms. Osteoarthritis is unlikely in a child. Juvenile rheumatoid arthritis is the most likely diagnosis based on the symptoms described.

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156. A cyanotic newborn is suspected of having congenital heart disease. The ECG shows left axis deviation and left ventricular hypertrophy (LVH). The most likely diagnosis is:

Explanation

Tricuspid atresia is a congenital heart defect characterized by the absence or severe narrowing of the tricuspid valve. This leads to inadequate blood flow between the right atrium and right ventricle. The ECG findings of left axis deviation and left ventricular hypertrophy are consistent with this diagnosis. Left axis deviation occurs because the left ventricle becomes the dominant ventricle in this condition. Left ventricular hypertrophy is a compensatory response to the increased workload on the left side of the heart. Therefore, tricuspid atresia is the most likely diagnosis based on the given information.

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157. A 3-day-old infant with a single second heart sound has had progressively deepening cyanosis since birth but no respiratory distress. Chest radiography demonstrates no cardiomegaly and normal pulmonary vasculature. An electrocardiogram shows an axis of 120° and right ventricular prominence. The congenital cardiac malformation most likely responsible for the cyanosis is:

Explanation

Transposition of the great vessels is the most likely congenital cardiac malformation responsible for the cyanosis in this 3-day-old infant. Transposition of the great vessels occurs when the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to a complete separation of the systemic and pulmonary circulations. This results in cyanosis as deoxygenated blood from the right ventricle is pumped into the systemic circulation. The absence of cardiomegaly and normal pulmonary vasculature on chest radiography, as well as the right ventricular prominence on the electrocardiogram, are consistent with this diagnosis.

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158. For each case presented, select the cardiovascular defect with which the exam findings are most likely to be associated. A 15-year-old adolescent girl comes to your office for a sports physical. Her weight is in the twenty-fifth percentile and her height is above the ninety-fifth percentile. Physical examination reveals a tall, thin girl wearing rather thick glasses. She has a high-arched palate, dental crowding, and a mild scoliosis. Her fingers seem remarkably long and flexible. She has Tanner stage IV development. (SELECT 1 DEFECT)

Explanation

The correct answer is Aortic aneurysm. The physical examination findings of a tall, thin girl with a high-arched palate, dental crowding, mild scoliosis, and long, flexible fingers are consistent with Marfan syndrome, a connective tissue disorder that can lead to the development of aortic aneurysms. The presence of Tanner stage IV development indicates that she is in the late stages of puberty, which is not specific to any particular cardiovascular defect.

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159. For each case presented, select the cardiovascular defect with which the exam findings are most likely to be associated. A happy and friendly 10-year-old girl has prominent, thick lips; a long philtrum; short stature; and mild cognitive impairments. Her mother mentions a 2-week hospital stay after birth for electrolyte problems and poor feeding. (SELECT 1 DEFECT)

Explanation

The exam findings of prominent, thick lips; a long philtrum; short stature; and mild cognitive impairments, along with a history of electrolyte problems and poor feeding after birth, are most likely associated with Supravalvular aortic stenosis.

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160. A 2-year-old girl is playing in the garage, only partially supervised by her father, who is mowing the grass. He finds her in the garage, gagging and vomiting. She smells of gasoline. In a few minutes she stops vomiting, but later that day she develops cough, tachypnea, and subcostal retractions. She is brought to your emergency center. The first step in her management is to:

Explanation

The correct answer is to perform pulse oximetry and arterial blood gas. This is the first step in the management of the 2-year-old girl who has been exposed to gasoline and is now presenting with symptoms such as cough, tachypnea, and subcostal retractions. Performing pulse oximetry and arterial blood gas will help assess her oxygenation and acid-base status, which are important indicators of respiratory distress and potential complications from the gasoline exposure. This information will guide further management decisions and help determine the appropriate course of treatment for the child.

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161. A 3-year-old girl is admitted with the x-ray pictured. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes:

Explanation

The correct answer is treating the 3-year-old patient with isoniazid (INH) and rifampin. The child's x-ray suggests the possibility of tuberculosis (TB), which is supported by her grandfather's symptoms. TB is highly contagious, and the child is at risk of developing active TB due to her close contact with her grandfather. Treating her with INH and rifampin is the appropriate management to prevent the progression of TB. Bronchoscopy and culture of washings for all family members may be necessary to confirm the diagnosis and identify other infected individuals, but it is not the immediate management step. The Mantoux test, isolating the patient, and HIV testing are not indicated based on the information provided.

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162. Although the patient is in respiratory distress, a lack of cyanosis indicates:

Explanation

The lack of cyanosis in a patient in respiratory distress suggests that there is very little indication of hypoxia in a patient with anemia. Cyanosis is the bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. However, in a patient with anemia, the oxygen-carrying capacity of the blood is already reduced due to a low hemoglobin level. Therefore, the absence of cyanosis does not necessarily indicate sufficient oxygenation in these patients.

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163. A 13-year-old boy has a 3-day history of low-grade fever, upper respiratory symptoms, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. Appropriate initial therapy for this patient would be:

Explanation

The patient's symptoms, including high fever, difficulty swallowing, and a fluctuant bulge in the posterior wall of the pharynx, are indicative of a peritonsillar abscess. This is a collection of pus in the tissues surrounding the tonsils. The appropriate initial therapy for this condition is surgical consultation for incision and drainage under general anesthesia. This procedure will help relieve the patient's symptoms and prevent further complications. Narcotic analgesics may provide temporary relief but will not address the underlying issue. A trial of oral penicillin V may be considered after the abscess has been drained. Rapid streptococcal screen and Monospot test are not indicated in this case as the patient's symptoms are consistent with a peritonsillar abscess rather than streptococcal or mononucleosis infection.

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164. A child is brought to your clinic for a routine examine. She can dress with help, can ride a tricycle, knows her own age, and can speak in short sentences. She had difficulty in copying a square. The age of this child is most likely:

Explanation

Based on the given information, the child can dress with help, ride a tricycle, knows her own age, and can speak in short sentences. These are developmental milestones typically achieved by a 3-year-old child. The difficulty in copying a square is also common at this age as it requires more advanced fine motor skills. Therefore, the most likely age of this child is 3 years.

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165. A 4-month-old baby boy has just arrived in the emergency room. He is cold and stiff. History from the parents is that the seemingly healthy infant had been placed in his crib for the night, and when they next saw him, in the morning, he was dead. Physical examination is uninformative. Routine whole-body x-rays are shown. The most likely diagnosis is:

Explanation

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166. The 3-day-old infant pictured has a facial rash. The most likely diagnosis is:

Explanation

Neonatal acne is the most likely diagnosis for the 3-day-old infant's facial rash. Neonatal acne is a common condition that occurs in newborns and is characterized by small, red bumps or pimples on the face. It is caused by hormonal changes and usually resolves on its own within a few weeks or months. Herpes, milia, seborrheic dermatitis, and eczema are less likely diagnoses for a newborn with a facial rash.

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167. Many rashes and skin lesions can be found first in the newborn period. For each of the descriptions listed below, select the most likely diagnosis. The obstetrical resident on call asks you to evaluate an area of a newborn's scalp that seems to have no hair and is scaly and yellowish. (SELECT 1 DIAGNOSIS)

Explanation

Sebaceous nevi are congenital skin lesions that typically appear as hairless, scaly, and yellowish patches on the scalp. This matches the description given in the question, making sebaceous nevi the most likely diagnosis.

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168. For the most likely toxic substance involved in the cases below, match the appropriate treatment. A 2-year-old boy found a bottle of his mother's prenatal vitamins and consumed the majority of them. He now has hematemesis and abdominal pain. He is febrile, and labs reveal a leukocytosis and hyperglycemia. (SELECT 1 TREATMENT)

Explanation

The correct answer, Deferoxamine mesylate, is the appropriate treatment for iron poisoning. In this case, the 2-year-old boy consumed prenatal vitamins which contain iron. The symptoms mentioned, such as hematemesis (vomiting blood), abdominal pain, febrile (having a fever), leukocytosis (increase in white blood cells), and hyperglycemia (high blood sugar), are consistent with iron poisoning. Deferoxamine mesylate is a chelating agent that helps remove excess iron from the body and is the recommended treatment for iron toxicity.

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169. A mother delivers a neonate with meconium staining and Apgar scores of 3 at 1 and 5 min of life. She had no prenatal care and the delivery was by emergency cesarean section for severe fetal bradycardia. Which of the following sequelae could be expected to develop in this intubated neonate with respiratory distress?

Explanation

In this scenario, the neonate was delivered with meconium staining and had low Apgar scores, indicating distress at birth. The emergency cesarean section was performed due to severe fetal bradycardia. These factors suggest that the neonate may have experienced perinatal asphyxia, which can lead to respiratory distress. Respiratory distress can cause a sustained rise in pulmonary arterial pressure, as the lungs may not be able to function properly. This can result in pulmonary hypertension, which is characterized by increased pressure in the pulmonary arteries. Therefore, a sustained rise in pulmonary arterial pressure is a possible sequelae in this intubated neonate with respiratory distress.

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170. The most appropriate next step is to:

Explanation

The correct answer is to begin the baby on oral sodium-L-thyroxine, 10 to 15 mg/(kg.d). This is the most appropriate next step because the baby's abnormal laboratory results suggest a possible hypothyroidism. Sodium-L-thyroxine is the treatment of choice for hypothyroidism in neonates. It is important to start treatment promptly to prevent complications and promote normal growth and development. Repeat testing, obtaining x-rays, and evaluating for symptomatic treatment may be done as part of the overall management plan, but initiating thyroid hormone replacement is the priority. A pediatric endocrinology consultation may also be necessary for further evaluation and management.

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171. The infant in the preceding question immediately develops tachypnea with cyanosis. She improves somewhat on oxygen but has predominantly thoracic breathing movements, and the chest x-ray, which appears to have been taken inadvertently at expiration, seems normal. The procedure most likely to provide a specific etiologic diagnosis is:

Explanation

Ultrasound or fluoroscopy of the chest is the most likely procedure to provide a specific etiologic diagnosis in this case. The infant's symptoms of tachypnea with cyanosis and predominantly thoracic breathing movements suggest a possible respiratory issue. The normal chest x-ray taken at expiration indicates that a static image may not be sufficient to identify the underlying cause. Ultrasound or fluoroscopy can provide real-time imaging of the chest, allowing for a more detailed evaluation of the respiratory system and potential abnormalities such as airway obstruction or lung pathology. This procedure would be more informative in this particular clinical scenario compared to the other options listed.

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172. A full-term infant is born after a normal pregnancy; delivery, however, is complicated by marginal placental separation. At 12 h of age, the child, although appearing to be in good health, passes a bloody meconium stool. For determining the cause of the bleeding, which of the following diagnostic procedures should be performed first?

Explanation

The Apt test is the appropriate diagnostic procedure to perform first in this scenario. The infant's presentation of passing a bloody meconium stool suggests the possibility of maternal-fetal hemorrhage, where fetal blood enters the placenta and mixes with maternal blood. The Apt test is a screening test that detects the presence of fetal hemoglobin in the maternal circulation, indicating maternal-fetal hemorrhage. This test is non-invasive and can provide valuable information for further management and investigation. The other options, such as barium enema, gastric lavage, upper gastrointestinal series, and platelet count, prothrombin time, and partial thromboplastin time, are not specific for determining the cause of the bleeding in this case.

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173. Parents bring a 5-day-old infant to your office. The mother is O negative and was Coombs positive at delivery. The term child weighed 3055 g at birth and had a baseline hemoglobin (16 gm/dL) and a total serum bilirubin (3 mg/dL). He passed a black tarlike stool within the first 24 h of life. He was discharged at 30 h of life with a stable axillary temperature of 36.5°C (97.7°F). Today the infant's weight is 3000 g, his axillary temperature is 35°C (95°F), and he is jaundiced to the chest. Parents report frequent yellow, seedy stool. You redraw labs and find his hemoglobin is now 14 gm/dL, and his total serum bilirubin is 13 mg/dL. The change in which of the following parameters is of most concern?

Explanation

The change in temperature is of most concern because the infant's axillary temperature has decreased from a stable 36.5°C (97.7°F) at discharge to 35°C (95°F) currently. This significant drop in temperature indicates a potential underlying issue, such as an infection or other medical condition, which requires immediate attention and further evaluation.

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174. A 4-year-old girl is brought to the pediatrician's office. Her father reports that she suddenly became pale and stopped running while he had been playfully chasing her. After 30 min, she was no longer pale and wanted to resume the game. She has never had a previous episode or ever been cyanotic. Her physical examination was normal, as were her chest x-ray and echocardiogram. An electrocardiogram showed the pattern seen below, which indicates:

Explanation

Wolff-Parkinson-White syndrome is the correct answer because the electrocardiogram pattern shown indicates the presence of a delta wave, which is characteristic of this syndrome. This syndrome is a congenital condition characterized by the presence of an abnormal electrical pathway between the atria and ventricles, known as the bundle of Kent. This pathway allows for the conduction of electrical impulses to bypass the normal conduction system, leading to episodes of tachycardia. The patient's symptoms of sudden pallor and cessation of activity are consistent with an episode of tachycardia, which resolves on its own. The absence of previous episodes or cyanosis is also typical of Wolff-Parkinson-White syndrome.

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175. A 7-year-old child is brought by her mother for a school physical. His growth parameters show his height to be fiftieth percentile and his weight to be significantly higher than ninety-fifth percentile. His mother complains that he always seems sleepy during the day and that he has started complaining of headaches. His second-grade teacher has commented that he has difficulty staying awake in class. His mother complains that he wakes up the whole house with his snoring at night. The next step in evaluating and managing this condition should be to:

Explanation

The child's symptoms, such as excessive sleepiness during the day, headaches, difficulty staying awake in class, and loud snoring at night, suggest that he may have obstructive sleep apnea (OSA). Polysomnography is the gold standard test for diagnosing OSA. It measures various parameters during sleep, such as brain waves, oxygen levels, heart rate, and breathing patterns, to determine the severity of the condition. Once the diagnosis is confirmed, appropriate management can be initiated, which may include interventions like tonsillectomy and adenoidectomy, CPAP therapy, or other interventions depending on the severity of the condition.

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176. You admitted to the hospital the previous evening a 4-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 h for Staphylococcus aureus. Approximately 20 h into his hospitalization, the nurse calls you because the child has acutely worsened over the last few minutes, with markedly increased work of breathing and increasing oxygen requirement. As you move swiftly to the child's hospital room, you call ahead and order:

Explanation

The correct answer is a large-bore needle and chest tube kit for aspiration of a probable tension pneumothorax. The patient's sudden worsening symptoms, including increased work of breathing and increasing oxygen requirement, suggest the possibility of a tension pneumothorax. A tension pneumothorax occurs when air accumulates in the pleural space and cannot escape, leading to increased pressure on the lungs and compromised breathing. Aspiration of the pneumothorax with a large-bore needle and placement of a chest tube can relieve the pressure and restore normal lung function.

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177. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Perform thoracentesis to remove air under pressure (SELECT 1 RESULT SET)

Explanation

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178. Match each management procedure below with the appropriate set of arterial blood gas results of patients spontaneously breathing room air. Discontinue diuretics, discontinue base, and increase KCl in IV fluids (SELECT 1 RESULT SET)

Explanation

The given set of arterial blood gas results (pH 7.50; PCO2 46; PO2 76; BE 11) indicates a slightly alkaline pH, normal PCO2 levels, slightly elevated PO2 levels, and an elevated base excess (BE). These results suggest that the patient's acid-base balance is slightly alkalotic, with normal carbon dioxide levels and a compensatory increase in bicarbonate levels. This is consistent with the management procedure of discontinuing diuretics, discontinuing base, and increasing KCl in IV fluids, which aims to correct metabolic alkalosis by restoring electrolyte balance and reducing diuresis.

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179. As a city public health officer, you have been charged with the task of screening high-risk children for lead poisoning. The best screen for this purpose is:

Explanation

The best screen for screening high-risk children for lead poisoning is a blood lead level test. Lead poisoning is primarily diagnosed by measuring the level of lead in the blood. This test provides a direct measurement of lead exposure and helps in identifying individuals who have been exposed to high levels of lead. Other screening methods mentioned, such as physical examination, erythrocyte protoporphyrin levels, CBC and blood smear, and environmental history, may provide additional information but are not as reliable or specific for detecting lead poisoning as the blood lead level test.

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180. For each of the injuries listed below, select the age at which it is most likely to occur. Asphyxiation and choking (SELECT 1 AGE)

Explanation

Asphyxiation and choking are most likely to occur at 1 year of age. At this age, infants are more mobile and curious, which increases their chances of coming into contact with small objects that can cause choking. They may also explore their environment by putting objects in their mouths, increasing the risk of asphyxiation if they swallow something that blocks their airway.

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181. For each of the injuries listed below, select the age at which it is most likely to occur. Drowning in a swimming pool (SELECT 1 AGE)

Explanation

Drowning in a swimming pool is most likely to occur at 2 years of age. At this age, children are often curious and mobile, making them more prone to accidents around water. They may lack the necessary skills and awareness to stay safe in a swimming pool, increasing the risk of drowning. It is important to closely supervise young children around water and take appropriate safety measures to prevent accidents.

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182. For each of the injuries listed below, select the age at which it is most likely to occur. Baby-walker injuries (SELECT 1 AGE)

Explanation

Baby-walker injuries are most likely to occur at 6 months of age. This is because babies typically start using baby-walkers around this age, and they may not have developed the necessary coordination and balance skills to safely navigate in the walker. As a result, they may be more prone to accidents and injuries, such as falling or colliding with objects.

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183. For each disorder below, select the dietary deficiency that is likely to be responsible. Congestive heart failure, peripheral neuritis, and psychic disturbances (SELECT 1 DEFICIENCY)

Explanation

Thiamine deficiency is likely to be responsible for the symptoms of congestive heart failure, peripheral neuritis, and psychic disturbances. Thiamine, also known as vitamin B1, plays a crucial role in the metabolism of carbohydrates and is essential for the proper functioning of the nervous system and heart. A deficiency in thiamine can lead to cardiovascular problems, nerve damage, and psychiatric symptoms.

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184. Identify the syndrome based on the clinical presentation. A 2-year-old boy has speech delay but otherwise normal intelligence and development. He has a broad nasal bridge, white forelock, heterochromic irises, and a ventriculoseptal defect diagnosed by echocardiogram. His mother wears a hearing aid and also has a white forelock.

Explanation

The given clinical presentation describes Waardenburg syndrome. This syndrome is characterized by speech delay, normal intelligence and development, broad nasal bridge, white forelock, heterochromic irises, and ventriculoseptal defect. The fact that the boy's mother also has a white forelock further supports the diagnosis, as Waardenburg syndrome is a genetic condition that can be inherited. Prader-Willi syndrome, Marfan syndrome, Treacher Collins syndrome, and Down syndrome do not match the specific clinical features mentioned in the presentation.

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185. For each case listed below, match the most likely diagnosis. An afebrile, obese 14-year-old boy has developed pain at the right knee and a limp.

Explanation

Slipped capital femoral epiphysis is the most likely diagnosis for an afebrile, obese 14-year-old boy who has developed pain at the right knee and a limp. This condition occurs when the ball at the head of the femur slips off the neck of the bone through the growth plate. It is more common in boys who are overweight or going through a growth spurt. Symptoms include pain in the hip, groin, thigh, or knee, and a limp. Prompt diagnosis and treatment are important to prevent further damage to the hip joint.

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186. For each case listed below, match the most likely diagnosis. A 2-year-old refuses to walk, has fever, has significant pain with external rotation of the right leg, and has an elevated white blood cell count.

Explanation

The given symptoms of a 2-year-old refusing to walk, having a fever, significant pain with external rotation of the right leg, and an elevated white blood cell count are indicative of septic arthritis of the hip. Septic arthritis is an infection in the joint, causing inflammation, pain, and limited mobility. The symptoms mentioned align with the presentation of septic arthritis in the hip joint. The other options, such as Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, osteomyelitis, and transient synovitis, do not fully match the given symptoms.

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187. For the most likely toxic substance involved in the cases below, match the appropriate treatment. A 14-year-old male presents after taking a "happy pill" that his friend gave him. He is alert and oriented, but complains of a muscle spasm in his neck, making his head lean on his right shoulder. You also notice he is arching his back in an unusual manner. (SELECT 1 TREATMENT)

Explanation

The symptoms described in the case, including muscle spasm in the neck and arching of the back, are consistent with dystonia, which is a potential side effect of diphenhydramine (Benadryl) overdose. Diphenhydramine is an antihistamine that can cause central nervous system effects at high doses. Treatment for diphenhydramine overdose includes supportive care, such as intravenous fluids and monitoring, and administration of diphenhydramine as an antidote to reverse the symptoms.

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188. Excess vitamin intake has been shown to have deleterious effects. Match the vitamin with the toxic effect. Vitamin D (SELECT 1 EFFECT)

Explanation

Excess intake of Vitamin D can lead to the calcification of the heart.

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189. The normal development of the fetus can be adversely affected by exposure to a number of environmental factors, including infectious agents, physical agents, chemical agents, and maternal metabolic and genetic agents. Match each maternal history of teratogen exposure with the most likely clinical presentation. A multiparous mother has a 1-h glucose tolerance test value of >190 mg/dL and a 3-h glucose tolerance test of >150 mg/dL. (SELECT 1 PRESENTATION)

Explanation

Exposure to high levels of maternal glucose during pregnancy can lead to a condition known as sacral agenesis in the fetus. Sacral agenesis is a congenital malformation characterized by the absence or underdevelopment of the sacrum and lower spine. This can result in various complications, including lower limb paralysis, bowel and bladder dysfunction, and skeletal abnormalities. Therefore, the clinical presentation of sacral agenesis matches with the maternal history of teratogen exposure to high glucose levels during pregnancy.

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190. Match each common skin condition with the most appropriate therapy. A mother complains of "moles" on her child's face for 6 months. You find four flesh-colored, papular lesions, the largest being about a centimeter in diameter. The lesions have a central umbilication. The mother reports no scratching of the lesions. (SELECT 1 TREATMENT)

Explanation

The correct treatment for the given skin condition is the brief application of liquid nitrogen or cantharidin 0.9%, or extrusion of lesion's central plug with a curette. This is because the description of the lesions, including their flesh-colored appearance, central umbilication, and lack of scratching, is consistent with molluscum contagiosum. These treatment options are effective in removing the lesions by freezing them with liquid nitrogen or using cantharidin to cause blistering and subsequent removal. Alternatively, the central plug of the lesion can be extracted using a curette.

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191. The Committee on Nutrition of the American Academy of Pediatrics has concluded that children on a normal diet do not need vitamin supplements. There are, however, some clinical situations in which special needs do occur. Match each situation with the appropriate supplement. Breast-fed infant in Alaska (SELECT 1 SUPPLEMENT)

Explanation

Breastfed infants in Alaska are at risk of vitamin D deficiency due to limited sun exposure, especially during the winter months. Therefore, it is recommended to supplement breastfed infants in Alaska with vitamin D to ensure they meet their nutritional needs.

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192. Match each clinical condition with the most appropriate diagnostic laboratory test. A 1-year-old boy has been admitted three times in the past with abscess formation requiring incision and drainage. He is now admitted for surgical drainage of a hepatic abscess identified on ultrasound. (SELECT 1 TEST)

Explanation

The NBT test is the most appropriate diagnostic laboratory test in this case because the patient has a history of abscess formation, which suggests a possible underlying immunodeficiency. The NBT test is used to evaluate neutrophil function and can help diagnose disorders such as chronic granulomatous disease (CGD), which is characterized by recurrent infections and abscess formation. Therefore, performing an NBT test can help determine if the patient has CGD or another immunodeficiency disorder that may be contributing to their recurrent abscesses.

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193. Match each clinical condition with the most appropriate diagnostic laboratory test. A 5-month-old infant is admitted with severe varicella infection. The lesions cover the infant's entire body, and the infant is beginning to show symptoms of respiratory distress. Past medical history is significant for a history of atopic dermatitis. The family also notes frequent epistaxis; the last episode required nasal packing in the emergency department. (SELECT 1 TEST)

Explanation

The correct answer is platelet count because the patient has a history of frequent epistaxis, which suggests a bleeding disorder. Platelet count is a diagnostic laboratory test that measures the number of platelets in the blood. A low platelet count can indicate a bleeding disorder, such as thrombocytopenia, which could explain the frequent epistaxis and the need for nasal packing. The severe varicella infection and symptoms of respiratory distress are not directly related to platelet count, but the history of atopic dermatitis may indicate an underlying immune system disorder that could affect platelet function.

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194. An infant has fusion of the eyebrows, heterochromic irises, a broad nasal root with lateral displacement of the medial canthi, and a white forelock. Testing should be performed on this child for what associated condition?

Explanation

The given symptoms, including fusion of the eyebrows, heterochromic irises, broad nasal root with lateral displacement of the medial canthi, and a white forelock, are characteristic of a condition called Waardenburg syndrome. One of the common features of Waardenburg syndrome is sensorineural hearing loss or deafness. Therefore, testing should be performed on this child for deafness, as it is associated with Waardenburg syndrome.

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195. A newborn is diagnosed with congenital heart disease. You counsel the family that the incidence of heart disease in future children is:

Explanation

The correct answer is 2 to 6%. Congenital heart disease is a condition that is present at birth and can be caused by a variety of factors, including genetic and environmental factors. The incidence of heart disease in future children of parents with a child diagnosed with congenital heart disease is estimated to be between 2 to 6%. This means that there is a slightly higher risk of heart disease in future children compared to the general population, but it is still relatively low. It is important for the family to be aware of this risk and to discuss it with their healthcare provider.

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196. An ill-appearing 2-week-old girl is brought to the emergency room. She is pale and dyspneic with a respiratory rate of 80 breaths per min. Heart rate is 195 beats per min, heart sounds are distant, and a gallop is heard. There is cardiomegaly by x-ray. An echocardiogram demonstrates poor ventricular function, dilated ventricles, and dilation of the left atrium. An electrocardiogram shows ventricular depolarization complexes that have low voltage. The diagnosis suggested by this clinical picture is:

Explanation

The clinical presentation described in the question, including symptoms such as pallor, dyspnea, tachypnea, tachycardia, distant heart sounds, gallop rhythm, cardiomegaly, poor ventricular function, dilated ventricles, dilation of the left atrium, and low voltage on the electrocardiogram, is consistent with myocarditis. Myocarditis is an inflammation of the myocardium, often caused by viral infections. It can lead to impaired ventricular function and dilation of the heart chambers, as seen in this case. Endocardial fibroelastosis, pericarditis, aberrant left coronary artery arising from pulmonary artery, and glycogen storage disease of the heart do not fully explain the clinical findings.

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197. Appropriate management for the patient in the preceding question includes:

Explanation

Patients with certain heart conditions, such as valvular heart disease, are at risk of developing infective endocarditis (IE) when undergoing dental procedures. Penicillin prophylaxis is recommended to prevent IE in these patients. Cardiac catheterization, avoidance of strenuous activity, beta blockers, and digitalis may be appropriate management options for other cardiac conditions, but they are not specifically indicated for preventing IE in patients undergoing dental procedures.

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198. For each of the cases presented below, choose the most likely cardiac diagnosis based on the patient's presentation. A 15-year-old adolescent female comes to be evaluated for syncopal episodes. Her only other medical problem is congenital deafness. She notes through a signing interpreter that syncopal episodes happen during stressful or emotional situations, and started only within the last year or so. Her mother and father are from the same small farming town and are second cousins. (SELECT 1 DIAGNOSIS)

Explanation

The most likely cardiac diagnosis for the 15-year-old adolescent female with syncopal episodes is Prolonged QT syndrome. This is indicated by the fact that the episodes occur during stressful or emotional situations and started within the last year. Additionally, the patient's parents being second cousins suggests a potential genetic cause for the condition. Prolonged QT syndrome is a genetic disorder that affects the heart's electrical activity, leading to abnormal heart rhythms and fainting spells.

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199. A 13-year-old girl with a history of 2 days of cough and fever has the chest x-ray shown here. The most appropriate treatment is:

Explanation

The chest x-ray shows a consolidation in the right middle lobe, which is indicative of a bacterial infection such as pneumonia. The most appropriate treatment for this would be a prolonged course of ampicillin combined with a β-lactamase inhibitor. Ampicillin is effective against most strains of Streptococcus pneumoniae, the most common cause of community-acquired pneumonia in children. The addition of a β-lactamase inhibitor helps to extend the spectrum of activity to cover β-lactamase-producing organisms. This treatment approach would target the likely bacterial cause of the symptoms and help to resolve the infection.

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200. A tine test administered at a routine visit of a 21⁄2-year-old boy is positive. The child is asymptomatic and thriving; there is no known exposure to tuberculosis. Your initial course of action would be to:

Explanation

The correct answer is to administer a Mantoux (PPD) test. The tine test is not as reliable as the Mantoux test for diagnosing tuberculosis. Since the child is asymptomatic and there is no known exposure to tuberculosis, it is important to confirm the positive tine test result with a more accurate test like the Mantoux test. This will help determine if the child has been exposed to tuberculosis and requires further evaluation or treatment.

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You are speaking to a couple who are expecting their first baby in...
Blood samples of a 3-day-old full-term infant are sent for screening...
Blood samples of a 3-day-old full-term infant are sent for screening...
You are asked to see a child in consultation. The family noticed that...
A 15-year-old girl with short stature, neck webbing, and sexual...
A 2-year-old boy is brought into the emergency room with a complaint...
The next steps in management of the child in the preceding question...
The most likely agent responsible for the infant's condition in the...
A 10-month-old infant has poor weight gain, a persistent cough, and a...
You are awakened in the night by your 2-year-old son, who has...
As a doctor in a clinic, you have just given a 10-year-old boy an...
An infant can move his head from side to side while following a moving...
A very concerned mother brings a 2-year-old child to your office...
The most appropriate course of action in the previous case would be...
An infant who sits with only minimal support, attempts to attain a toy...
Appropriate treatment for the condition described in the previous...
You are called by a general practitioner to consult on a patient...
Aunt Mary is helping her family move to a new apartment. During the...
Universal immunization of infants with a three-dose series of...
Many rashes and skin lesions can be found first in the newborn period....
For each otherwise normal child presented, choose the sleep...
For each disorder below, select the dietary deficiency that is likely...
Identify the syndrome based on the clinical presentation. A...
For the most likely toxic substance involved in the cases below, match...
For the most likely toxic substance involved in the cases below, match...
Excess vitamin intake has been shown to have deleterious effects....
Heart failure is possible at any age. Match each clinical condition...
Heart failure is possible at any age. Match each clinical condition...
The Committee on Nutrition of the American Academy of Pediatrics has...
A 3-day-old infant born at 32 weeks' gestation and weighing 1700 g (3...
Blood samples of a 3-day-old full-term infant are sent for screening...
A 1-week-old black infant presents to you for the first time with a...
A newborn infant develops respiratory distress immediately after...
A term, 4200-g female infant is delivered via cesarean section because...
A routine prenatal ultrasound reveals a male fetus with...
An infant born at 35 weeks' gestation to a mother with no prenatal...
The signs and symptoms of meningitis in an infant can be different...
A postterm infant is born at home after a prolonged and difficult...
The same infant is now 7 weeks old. She has been extubated for 2 weeks...
Blood samples of a 3-day-old full-term infant are sent for screening...
For each description of head injury that follows, select the major...
A 10-year-old boy, the star goalie for the Salt Lake City Little...
In the same patient, of the following manifestations of acute...
For each of the cases presented below, choose the most likely cardiac...
A previously well 1-year-old infant has had a runny nose and has been...
While waiting for further studies of the patient, it is appropriate to...
A 6-week-old child develops increased respiratory rate and a...
Appropriate therapy for the patient in the previous question includes:
Two weeks after a viral syndrome, a 9-year-old girl presents to your...
The previously healthy 4-year-old child pictured presents to the...
After you make the diagnosis in the previous case, you explain the...
A mother brings an 18-month-old to the emergency center with the...
You are called to the emergency room to see one of your patients. The...
An infant who appears to be of normal size is noted to be lethargic...
Initial examination of a full-term infant weighing less than 2500 g (5...
You are advised by the obstetrician that the mother of a baby he has...
At the time of delivery, a woman is noted to have a large volume of...
You are called to the normal newborn nursery to see a baby who was...
Since you are a new intern, you ordered all of the diagnostic studies...
An infant born an hour ago to a mother with severe pregnancy-induced...
The parents of a 2-month-old boy are concerned about his risk of...
Match each management procedure below with the appropriate set of...
Match each management procedure below with the appropriate set of...
Match each management procedure below with the appropriate set of...
You are counseling an adolescent patient about the long-term...
A 5-year-old boy who was previously healthy has a 1-day history of...
A mother calls you on the telephone and says that her 4-year-old son...
A 2-year-old child (A) presents with a four-day history of a rash...
New parents ask you how to reduce the chance of their baby suffering...
For each otherwise normal child presented, choose the sleep...
For each otherwise normal child presented, choose the sleep...
For each of the injuries listed below, select the age at which it is...
For each disorder below, select the dietary deficiency that is likely...
For each case listed below, match the most likely diagnosis. A...
For each case listed below, match the most likely diagnosis. A...
For the most likely toxic substance involved in the cases below, match...
Heart failure is possible at any age. Match each clinical condition...
The Committee on Nutrition of the American Academy of Pediatrics has...
The Committee on Nutrition of the American Academy of Pediatrics has...
Match each clinical condition with the most appropriate diagnostic...
After an uneventful labor and delivery, an infant is born at 32 weeks'...
You are performing a well-child examination on a new patient, the...
You are seeing a 2-month-old infant, brought by her father for a...
You are seeing an established patient, a four-year-old girl brought in...
A five-year-old boy is brought into the emergency room immediately...
Many rashes and skin lesions can be found first in the newborn period....
For each disorder below, select the dietary deficiency that is likely...
Match each common skin condition with the most appropriate...
Match each common skin condition with the most appropriate...
The nurse from the level II neonatal intensive care nursery calls you...
A 1-day-old infant who was born by a difficult forceps delivery is...
A full-term newborn infant is having episodes of cyanosis and apnea,...
The infant in the following pictures (A) and (B) presented with...
A previously healthy full-term infant has several episodes of...
A couple expecting their first infant in a few weeks scheduled an...
A term infant delivered via scheduled cesarean section develops, at 15...
An infant of uncertain dates is born via emergent cesarean section...
For each description of head injury that follows, select the major...
A 9-month-old infant accidentally ingests an unknown quantity of...
During a regular checkup on an 8-year-old child, you note a loud first...
During a physical examination for participation in a sport, a...
For each of the cases presented below, choose the most likely cardiac...
For each of the cases presented below, choose the most likely cardiac...
A previously healthy, active 18-month-old child presents with...
A 10-year-old has had a "cold" for 14 days. In the 2...
In patients on theophylline therapy for asthma, certain other drugs...
A 13-year-old develops fever, malaise, sore throat, and a dry hacking...
You receive a telephone call from the mother of a 4-year-old child...
The laboratory workup of the patient reveals the following: hemoglobin...
A 4-year-old girl is noticed by her grandmother to have a limp and a...
A previously healthy 8-year-old boy has a 3-week history of low-grade...
An 8-hour-old infant develops increased respiratory distress,...
As you are about to step out of a newly delivered mother's room, she...
A 2-year-old boy is being followed for congenital cytomegalovirus...
At 43 weeks' gestation, a long, thin infant is delivered. The infant...
The newborn pictured was born at home and has puffy, tense eyelids;...
A term infant is born to a known HIV-positive mother. She has been...
You see the baby shown in the picture for the first time in the...
A previously healthy 2-year-old black child has developed a chronic...
Match each management procedure below with the appropriate set of...
Match each management procedure below with the appropriate set of...
The adolescent shown presents with a 14-day history of multiple oval...
The most appropriate initial therapy for the patient in the previous...
A 16-year-old basketball player complains of pain in his knees. A...
A 5-year-old boy presents with the severe rash pictured as follows....
A 2-year-old boy has been vomiting intermittently for 3 weeks and has...
An 8-month-old infant has a 2-day history of diarrhea and poor fluid...
In this patient, you decide to give 20 mL/kg of the chosen fluid. A...
A 20-month-old child is brought to the emergency department because of...
A 16-year-old high school boy sustained an abrasion of the knee after...
A mentally retarded 14-year-old boy has a long face, large ears,...
Many rashes and skin lesions can be found first in the newborn period....
For each otherwise normal child presented, choose the sleep...
For each otherwise normal child presented, choose the sleep...
For each of the injuries listed below, select the age at which it is...
Identify the syndrome based on the clinical presentation. A...
Identify the syndrome based on the clinical presentation. A...
For the most likely toxic substance involved in the cases below, match...
For the most likely toxic substance involved in the cases below, match...
The normal development of the fetus can be adversely affected by...
The normal development of the fetus can be adversely affected by...
Match each common skin condition with the most appropriate...
The Committee on Nutrition of the American Academy of Pediatrics has...
A 2-week-old infant has had no immunizations, sleeps 18 hours a day,...
A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed...
A primiparous woman whose blood type is O positive gives birth at term...
The infant pictured as follows was small for gestational age. He also...
A 19-year-old primiparous woman develops toxemia in her last trimester...
A 26-year-old gravida 3 woman has a history of gestational diabetes...
A well-appearing, 3200-g black infant is noted to have fifth finger...
A woman gives birth to twins at 38 weeks' gestation. The first twin...
A newborn infant becomes markedly jaundiced on the second day of life,...
For each description of head injury that follows, select the major...
For the past year, a 12-year-old boy has had recurrent episodes of...
A child has a history of spiking fevers, which have been as high as...
A cyanotic newborn is suspected of having congenital heart disease....
A 3-day-old infant with a single second heart sound has had...
For each case presented, select the cardiovascular defect with which...
For each case presented, select the cardiovascular defect with which...
A 2-year-old girl is playing in the garage, only partially supervised...
A 3-year-old girl is admitted with the x-ray pictured. The child lives...
Although the patient is in respiratory distress, a lack of cyanosis...
A 13-year-old boy has a 3-day history of low-grade fever, upper...
A child is brought to your clinic for a routine examine. She can dress...
A 4-month-old baby boy has just arrived in the emergency room. He is...
The 3-day-old infant pictured has a facial rash. The most likely...
Many rashes and skin lesions can be found first in the newborn period....
For the most likely toxic substance involved in the cases below, match...
A mother delivers a neonate with meconium staining and Apgar scores of...
The most appropriate next step is to:
The infant in the preceding question immediately develops tachypnea...
A full-term infant is born after a normal pregnancy; delivery,...
Parents bring a 5-day-old infant to your office. The mother is O...
A 4-year-old girl is brought to the pediatrician's office. Her father...
A 7-year-old child is brought by her mother for a school physical. His...
You admitted to the hospital the previous evening a 4-year-old boy who...
Match each management procedure below with the appropriate set of...
Match each management procedure below with the appropriate set of...
As a city public health officer, you have been charged with the task...
For each of the injuries listed below, select the age at which it is...
For each of the injuries listed below, select the age at which it is...
For each of the injuries listed below, select the age at which it is...
For each disorder below, select the dietary deficiency that is likely...
Identify the syndrome based on the clinical presentation. A...
For each case listed below, match the most likely diagnosis. An...
For each case listed below, match the most likely diagnosis. A...
For the most likely toxic substance involved in the cases below, match...
Excess vitamin intake has been shown to have deleterious effects....
The normal development of the fetus can be adversely affected by...
Match each common skin condition with the most appropriate...
The Committee on Nutrition of the American Academy of Pediatrics has...
Match each clinical condition with the most appropriate diagnostic...
Match each clinical condition with the most appropriate diagnostic...
An infant has fusion of the eyebrows, heterochromic irises, a broad...
A newborn is diagnosed with congenital heart disease. You counsel the...
An ill-appearing 2-week-old girl is brought to the emergency room. She...
Appropriate management for the patient in the preceding question...
For each of the cases presented below, choose the most likely cardiac...
A 13-year-old girl with a history of 2 days of cough and fever has the...
A tine test administered at a routine visit of a 21⁄2-year-old...
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