A 10-year-old boy is brought to the emergency department due to low-grade fever over the last 3 days that has not resolved with acetaminophen.  For the last 2 days, the patient has also had a diffuse headache that is now severe and associated with nausea.  Today he is weak and has diffuse myalgias and arthralgias but is able to bear weight and walk with some assistance.  However, he has no photophobia, vomiting, or diarrhea.  The patient returned from a family camping trip in North Carolina a week ago, and no other family members have symptoms.  He has no chronic medical conditions, and his immunizations are up to date.  Temperature is 38.8 C (101.8 F) and pulse is 100/min.  The patient appears lethargic.  Oropharyngeal mucosa and tympanic membranes are normal.  The neck is supple.  The lungs are clear to auscultation.  Cardiac examination reveals no rubs or murmurs.  The abdomen is soft and nontender.  Skin examination shows a macular, erythematous rash and few petechiae on bilateral wrists and ankles.  There are no other skin lesions.  Joints have a full range of motion and no overlying erythema.  Kernig and Brudzinski signs are both negative.  Laboratory results are as follows:

Which of the following is the best therapy option for this patient?

A 5-year-old boy is brought to the office due to fever of 3 days duration.  The fever has not significantly improved with acetaminophen, and the patient has been cranky.  His appetite has decreased, but he is still drinking fluids and has adequate urine output.  He has had nasal congestion but no cough, emesis, or diarrhea.  His older brother currently has upper respiratory tract symptoms.  The patient has no chronic medical conditions, and immunizations are up to date.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 110/min, and respirations are 18/min.  On examination, the child is alert and irritable but consolable.  The conjunctivae are injected without discharge bilaterally.  A few small (0.5 cm) anterior cervical lymph nodes are palpable.  Several erythematous, blanching macules are noted on the trunk and extremities.  The remainder of the examination is unremarkable.

Item 1 of 4

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 4

The patient is brought to the emergency department 2 days later due to continued fever.  Temperature is 39.4 C (102.9 F), blood pressure is 102/74 mm Hg, pulse is 118/min, and respirations are 18/min.  On physical examination, the patient is irritable and difficult to console.  The conjunctivae remain injected without discharge.  The lips appear cracked, and the tongue is red.  There is a diffuse, erythematous, blanching maculopapular rash on the patient’s trunk and extremities with edema of the hands and feet.  The remainder of the examination is unremarkable.  This patient requires additional evaluation with which of the following?

Item 3 of 4

Laboratory results support the suspected diagnosis, and imaging studies are normal.  Which of the following is the best next step in management of this patient?

Item 4 of 4

The patient’s condition improves after treatment is initiated, and preparations are made for discharge.  Which of the following is the greatest risk factor for development of cardiovascular sequalae in this patient?

A 6-year-old boy is brought to the emergency department by his mother because he has refused to walk since this morning.  Two days ago, the patient started having right groin pain after baseball practice, and his mother noticed him “walking funny” yesterday.  She says, “I had to carry him here because he says it hurts too much to walk.”  The mother has witnessed no recent falls or injuries, and the symptoms have not improved with acetaminophen.  The patient has had upper respiratory symptoms for the last 2 weeks and was diagnosed with viral pharyngitis a week ago.  He has no other significant medical history.  Immunizations are up to date.  The patient takes no medications and has no known allergies.  Temperature is 38.6 C (101.5 F).  He appears tired but nontoxic.  The posterior pharynx is clear and without exudates.  The lungs are clear to auscultation.  On examination of the right hip, the patient cries and resists passive movement.  There is decreased range of motion of the right hip.  Laboratory findings show a white blood cell count of 14,000/mm³ and a C-reactive protein of 4.0 mg/L (normal: <3.0).

Item 1 of 2

Which of the following is the best next step in management of this patient’s condition?

Item 2 of 2
The patient undergoes aspiration of the right hip joint.  Synovial fluid analysis shows a white blood cell count of 60,000/mm³ with a neutrophil predominance.  Gram stain and culture are pending.  Immediate initiation of which of the following therapies is most important for improving the long-term outcome of this patient’s condition?

A 16-year-old girl comes to the office due to joint pain lasting several days.  The patient says, “My hands and knees feel stiff when I wake up, and those joints are painful throughout the day.”  The symptoms are improving, but she still has significant discomfort with daily activities.  The patient has never before had such symptoms.  A mildly pruritic rash on her face, arms, and legs developed around the same time as the joint symptoms.  Last week, the patient had an upper respiratory infection with fever and myalgias that resolved quickly without intervention.  She has seasonal allergies for which she uses a glucocorticoid intranasal spray as needed.  She does not use tobacco, alcohol, or illicit drugs.  The patient is not in a relationship and has never been sexually active.  Temperature is 37.2 C (99 F).  She appears well and is sitting comfortably on the examination table.  Cardiopulmonary examination is normal.  Examination of the hands shows mild symmetric swelling of the proximal interphalangeal and metacarpophalangeal joints; there is no warmth or erythema.  Bilateral knees have a full range of motion, mild tenderness to palpation, and no swelling.  Strength and sensation are symmetric and intact throughout, and distal pulses are strong bilaterally.  There is a faint, erythematous, reticular rash on both arms and legs.

Item 1 of 2

Which of the following is the most likely diagnosis for this patient?

Item 2 of 2

Medication is prescribed and the patient returns a month later for follow-up.  The patient says that her symptoms have resolved and she feels “quite good.”  However, she is concerned about the prognosis of her disease and the possibility of recurrent joint problems.  Physical examination reveals complete resolution of the joint swelling.  Which of the following is the best response to this patient’s concern?

A 12-year-old girl is brought to the office for a preventive health maintenance examination.  The patient’s mother has noticed that over the last few months, her daughter “seems to sit sideways” and does not sit up straight when asked.  The patient occasionally takes acetaminophen in the morning due to mild “aches and pains.”  She fractured her left femur in a horse-riding accident at age 8.  Height and weight are at the 75th and 50th percentiles, respectively.  Physical examination shows a well-appearing, nondysmorphic girl.  Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot.  Flexion of the lumbar spine is normal and the patient is able to touch her toes.  Lower extremity strength is normal.  Patellar and Achilles deep tendon reflexes are 2+.  Gait is normal.

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

Posteroanterior and lateral x-rays of the spine are obtained, which reveal a Cobb angle of 5 degrees.  Which of the following is the best next step in management of this patient’s spinal problem?

A 12-year-old boy is brought to the office by his father for an urgent care visit due to right hip pain that has worsened over the past 3 weeks.  The patient initially had “a little bit” of hip pain, but now the pain has spread to his thigh and knee.  He says, “It is so bad that I can barely walk.”  The boy has had no recent injuries, fever, or sore throat.  Aside from the pain in the right lower extremity, he feels well.  He has mild eczema that is managed with emollients.  He is allergic to dust and cats.  The patient’s only hospitalization was for an appendectomy at age 7.  Temperature is 37 C (98.6 F), blood pressure is 114/74 mm Hg, and pulse is 90/min.  He is at the 95th percentile for weight and the 50th percentile for height.  Physical examination reveals an obese boy in moderate pain, with the right hip in an externally rotated position.  There is no warmth, swelling, or tenderness of the right knee or thigh.  The patient has normal Tanner 3 male external genitalia; the testes are descended bilaterally.  Sensation is intact in the lower extremities, and peripheral pulses are 2+ bilaterally.  Dry, red patches are present on the right knee and left elbow.  The remainder of the physical examination is normal.  X-ray of the hips is shown below.

Which of the following is the most appropriate next step in management of this patient’s condition?