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Question 1 of 40
1. Question
A 10-year-old boy is brought to the clinic by his adoptive parents due to a worsening cough. The patient has had a productive cough with yellow-green sputum since his parents adopted him at age 7 from a developing country. A tuberculin skin test at the time of immigration revealed a 3-mm induration. The patient’s cough has worsened over the past 3 days, and this morning he had a fever of 38.3 C (101 F). His parents kept him home from school, and he has been resting in bed. The patient has been hospitalized twice in the past year for pneumonia. Temperature is 38.1 C (100.6 F). Height and weight, which were at the 25th percentile 2 years ago, are now at the 5th percentile. The patient is a thin, cooperative child in no acute distress. Auscultation of the lungs reveals scattered bilateral rhonchi and wheezes. Cardiac examination reveals a regular rhythm and no murmurs. The abdomen is soft and nontender with hard stool palpable in the right lower quadrant. Chest x-ray reveals hyperinflation with increased bronchovascular markings throughout and several parallel linear opacities in the bilateral upper lobe parenchyma. Which of the following would most likely establish the diagnosis in this patient?
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Question 2 of 40
2. Question
A newborn girl is evaluated in the nursery for respiratory distress. Approximately 30 minutes after the patient was born, she developed sudden-onset tachypnea and hypoxia for which she is receiving supplemental oxygen by nasal cannula. The infant was born to a 35-year-old woman at 39 weeks gestation via a scheduled cesarean delivery for breech presentation. Membranes ruptured at delivery, revealing clear amniotic fluid. The mother had insulin-controlled gestational diabetes mellitus and tested positive for Group B Streptococcus at 36 weeks gestation. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Temperature is 36.7 C (98 F). Examination shows tachypnea, grunting, nasal flaring, and subcostal and intercostal retractions. Cardiac examination reveals tachycardia without murmurs. Femoral pulses are 2+. Chest x-ray reveals a flattened diaphragm, mild cardiomegaly, and a prominent horizontal fissure on the right side. Which of the following is the most likely outcome of this patient?
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Question 3 of 40
3. Question
A parent calls the office about her 3-year-old son, who started choking and gagging suddenly while playing with a small toy a minute ago. She did not see the boy put anything in his mouth but is now unable to locate the toy. The boy is conscious, but he is no longer gagging and is unable to speak. His lips appear blue. In addition to advising an immediate call to 911, which of the following is the best recommendation?
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Question 4 of 40
4. Question
A 20-month-old girl is brought to the emergency department due to cough and fever. She had nasal congestion and a dry cough yesterday, but the symptoms are worse today. The patient developed fever overnight and the cough is now more forceful. Her father says, “She was coughing so hard that it sounded like she couldn’t breathe.” Her appetite is mildly decreased, but she has been drinking water and juice frequently throughout the day. The patient’s immunizations are up to date, and she takes no medications. Temperature is 38.1 C (100.6 F), pulse is 100/min, and respirations are 28/min. Physical examination demonstrates an awake, alert patient playing with a toy on her father’s lap. When the examiner approaches her, she cries and has an episode of harsh, brassy coughing followed by inspiratory stridor that resolves when she calms down. The nares are patent with clear rhinorrhea, the pharynx has no erythema or exudate, and the tympanic membranes are clear. S1 and S2 are present without murmurs. The lungs are clear to auscultation, but there are mild intercostal retractions. The abdomen is soft and nontender without organomegaly. There are no rashes or lesions. Which of the following is the most appropriate next step in management of this patient?
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Question 5 of 40
5. Question
An 8-year-old girl is brought to the clinic due to a prolonged cough. The patient developed rhinorrhea 6 weeks ago, followed a week later by a cough with occasional expectoration of whitish sputum; the rhinorrhea resolved at that time. For the past 5 weeks, the patient’s cough has continued without improvement throughout the day and night, occasionally awakening her. Use of a humidifier has not relieved her symptoms. The patient has been afebrile and has had no vomiting, abdominal pain, diarrhea, or sick contacts. She takes no daily medications. Immunizations are up to date. Family history is notable for atopic dermatitis in the mother. Height and weight are tracking at the 25th percentile. Temperature is 36.7 C (98 F) and respirations are 24/min. The patient is awake, alert, and playing. Tympanic membranes are normal. The tonsils are normal. The mucous membranes are moist, and the lips are pink. Heart rate and rhythm are normal. The lungs are clear to auscultation bilaterally; no retractions or use of accessory chest muscles is present. Which of the following is the best next step in diagnosis?
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Question 6 of 40
6. Question
A 4-year-old boy is brought to the office due to snoring. For the past 5 months, his mother has heard loud snoring at night, with pauses in his breathing followed by gasping for air. Medical history is significant for 2 episodes of otitis media that resolved with antibiotic therapy. The patient is up to date with vaccinations. He attends day care 5 days a week. His father smokes outside the home. The family has a cat. Height is at the 40th percentile and weight is at the 15th percentile. On physical examination, the patient appears well. The tympanic membranes are clear with no middle ear effusion. The nose is clear with no rhinorrhea. Oral examination shows good dentition and tonsillar hypertrophy. The lungs are clear to auscultation and heart sounds are normal. Which of the following is the best next step in management?
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Question 7 of 40
7. Question
A 3-year-old boy is brought to the clinic by his mother for evaluation of persistent cough for 6 weeks. The patient has a history of asthma and has been using his albuterol inhaler with spacer 4 times a day. The mother reports that the albuterol seemed to help for the first few days, but since then she has not noticed any benefit. The patient also completed a course of oral corticosteroids without improvement in the cough. He has had no fever, rhinorrhea, or congestion. Temperature is 37 C (99 F), blood pressure is 90/44 mm Hg, pulse is 105/min, and respirations are 36/min. Cardiopulmonary examination shows diminished breath sounds and a faint expiratory wheeze throughout the left lung; breath sounds over the right lung are clear. A soft, 1/6 vibratory systolic ejection murmur is heard at the left sternal border. The remainder of the examination is normal. Chest radiograph is shown in the exhibit. Which of the following is the best next step in management of this patient?
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Question 8 of 40
8. Question
The following vignette applies to the next 3 items.
A 6-month-old boy is brought to the emergency department by his mother during the winter due to nasal discharge and cough for the past 3 days. His mother states, “He hasn’t been breastfeeding well today because he’s so congested.” The patient has been voiding less but has had no vomiting, diarrhea, or skin rash. His older brother attends preschool and is recovering from an upper respiratory illness. The patient has no prior illnesses and no known allergies, and all vaccinations are up to date. He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately. Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min. Pulse oximetry shows an oxygen saturation of 93% on room air. Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally. Oral mucous membranes are dry, but capillary refill is <2 seconds. The patient is admitted to the hospital.
Item 1 of 3
Which of the following is the best next step in management of this patient?
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Question 9 of 40
9. Question
Item 2 of 3
Which of the following is the most appropriate method of diagnosing this patient’s condition?
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Question 10 of 40
10. Question
Item 3 of 3
Two days later, the patient remains afebrile. Pulse oximetry has consistently been >97% on room air. Weight has decreased 0.17 kg (6 oz) from admission, but the patient is now breastfeeding well every 3-4 hours. Examination shows crusted rhinorrhea at the nares and no grunting, nasal flaring, or retractions. The lungs are clear to auscultation. The patient is stable for discharge home, but his parents are concerned about his prognosis. The infant is at greatest risk for developing which of the following?
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Question 11 of 40
11. Question
A 5-week-old full-term boy is brought to the emergency department during winter due to intermittent respiratory pauses and cyanosis. He has had rhinorrhea and nasal congestion for the past 2 days. Over the past few weeks, the patient’s father and older sibling have had nasal congestion and rhinorrhea but no fever or cough. The boy has received the hepatitis B vaccination and no other immunizations due to his young age. His temperature is 37.1 C (98.8 F). Physical examination shows bilateral crackles and wheezes and intermittent apnea. Leukocyte count is 9,000 cells/mm3, with 60% lymphocytes and 30% neutrophils. Which of the following is the most likely etiology of this patient’s condition?
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Question 12 of 40
12. Question
A 16-year-old boy comes to the office for follow-up after being seen in the emergency department 5 days earlier due to an acute asthma exacerbation. Two weeks ago, he developed a cough and rhinorrhea. The rhinorrhea resolved after a few days, but the cough worsened and he began wheezing, prompting his visit to the emergency department. In the emergency department, temperature was 36.7 C (98 F) and respirations were 24/min. Pulse oximetry showed 94% on room air. Pulmonary examination revealed scattered expiratory wheezes with slightly diminished breath sounds in all fields. The patient received 2 doses of nebulized albuterol and 60 mg of oral prednisone, after which he felt considerably better and had a normal lung examination; he was then discharged home on an additional 60 mg of prednisone daily for the next 4 days. Today, he feels well and his cardiopulmonary examination is normal. Prior to this illness, he had been treated at home for the last several years with intermittent albuterol. Which of the following is the most appropriate management of this patient?
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Question 13 of 40
13. Question
A 1-month-old boy is brought to clinic by his mother due to concerns about his breathing. The mother states that over the past week she has noticed several episodes in which “he just stops breathing and then takes a lot of quick breaths.” She adds, “He does it many times within a minute and then seems to breathe normally again. It really scares me.” The infant has had no cyanosis, coughing, choking, fevers, or abnormal eye or limb movements. He is exclusively breastfed and is given vitamin D daily. The infant was born at 36 weeks gestation via normal spontaneous vaginal delivery after preterm premature rupture of membranes. He spent a week in the neonatal intensive care unit for temperature instability and feeding difficulties, and was discharged with no remaining medical issues. Family history is notable for a maternal cousin with epilepsy. Temperature is 36.7 C (98 F), blood pressure is 80/50 mm Hg, pulse is 132/min, and respirations are 44/min. Pulse oximetry is 99% on room air. The patient is tracking along the 30th percentiles for weight, length, and head circumference. Physical examination shows a well-nourished infant sleeping in his mother’s arms. The heart has a regular rate and rhythm without murmurs, and the lungs are clear to auscultation without apnea, tachypnea, or increased work of breathing. He has appropriate tone and intact suck, grasp, and Moro reflexes. Plantar reflexes show upgoing toes bilaterally. Which of the following is the most likely diagnosis in this patient?
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Question 14 of 40
14. Question
A 6-week-old boy is being evaluated for an ongoing oxygen requirement. The patient was born at 27 weeks gestation to a 34-year-old mother. The pregnancy was notable for group B Streptococcus infection in the first trimester, and the delivery was complicated by preterm labor. At birth, the infant received surfactant and was intubated due to respiratory distress. He was extubated 2 weeks later and has been stable on 3 L/min supplemental oxygen via nasal cannula. The patient is currently receiving formula feeds and gaining weight appropriately. Temperature is 37.3 C (99.1 F), blood pressure is 70/50 mm Hg, pulse is 140/min, and respirations are 50/min. Examination findings are unchanged since extubation and include coarse crackles bilaterally with mild subcostal retractions. The abdomen is soft with normal bowel sounds. Chest x-ray shows bilateral hazy opacities with normal lung volumes. Which of the following is the greatest risk factor for this patient’s current condition?
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Question 15 of 40
15. Question
A 5-year-old boy is brought to the office for his annual well-child visit. The boy was briefly hospitalized a month ago for an asthma exacerbation, which was treated with albuterol and oral corticosteroids. He has been well since then except for a runny nose and cough for the past 2 days. He takes an inhaled corticosteroid daily and albuterol as needed, most recently 3 weeks ago. The patient lives at home with his mother, who is 38 weeks pregnant, and his father and 2-year-old sister. He recently started kindergarten and is doing well. Temperature is 36.7 C (98 F). The patient is tracking along the 40th and 60th percentiles for weight and height, respectively. Physical examination shows a well-appearing boy who speaks clearly in full sentences, counts to 12, and can hop on one foot. The lungs are clear to auscultation, and the remainder of the examination is unremarkable. He is scheduled to receive the second dose of measles-mumps-rubella (MMR) vaccine today. The parents say, “After his first MMR shot a few years ago, he had a fever up to 39.4 C (103 F), and we almost took him to the emergency department.” Which of the following is the most appropriate next step in management of this patient?
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Question 16 of 40
16. Question
A 2-month-old girl is brought to the office for a well-child checkup. The patient is gaining weight appropriately and has met all developmental milestones. Her mother plans to exclusively breastfeed her until age 6 months. The patient has no medical conditions and is up to date on all recommended vaccinations. She lives with her parents, grandmother, and older brother and will start attending day care next month. No one in the household smokes, and the family has 2 dogs. Family history includes atopic dermatitis in the patient’s father and older brother. The mother wants to know if she can do anything to lower the girl’s risk for developing atopic dermatitis. Which of the following is the most appropriate recommendation for this patient?
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Question 17 of 40
17. Question
A 9-year-old girl is brought to the emergency department due to new-onset seizure. She lost consciousness at school this morning and developed full-body shaking for approximately 5 minutes. The patient has a history of recurrent oral thrush treated with topical and oral medications. She has no other chronic medical conditions or surgical history. Temperature is 37 C (98.6 F), blood pressure is 94/58 mm Hg, pulse is 98/min, and respirations are 18/min. On examination, the patient is alert and interactive. There are several small, white plaques on the buccal mucosa. The remainder of the examination is unremarkable. Laboratory results are as follows:
Complete blood count
Hemoglobin
11.4 g/dL
Platelets
200,000/mm3
Leukocytes
9,000/mm3
Serum chemistry
Sodium
136 mEq/L
Potassium
4.4 mEq/L
Chloride
109 mEq/L
Bicarbonate
20 mEq/L
Blood urea nitrogen
10 mg/dL
Creatinine
0.6 mg/dL
Calcium
6 mg/dL
Glucose
104 mg/dL
Further evaluation shows a parathyroid hormone level of 9.5 pg/mL. This patient’s presentation is most likely due to which of the following?
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Question 18 of 40
18. Question
A 6-year-old boy is brought to the clinic for influenza vaccination in September. He has been healthy and has no nasal congestion, rhinorrhea, or other symptoms. The patient had 2 episodes of otitis media during infancy and has mild intermittent asthma treated with inhaled albuterol as needed. He has no other respiratory problems and takes no other medications. His older brother had cystic fibrosis and recently died at age 10 from a severe influenza infection; the patient’s sweat test was negative. The patient has no medication allergies but has developed a splotchy, itchy red rash to egg-containing products in the past. Eggs have since been excluded from his diet. He has no history of other reactions to egg or to immunizations. Vital signs and physical examination are normal. Which of the following is the best next step in management of this patient?
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Question 19 of 40
19. Question
A 7-month-old boy is brought to the physician by his parents due to irritability and white patches in his mouth. His past medical history is significant for 3 episodes of otitis media and 2 episodes of bronchiolitis that have required hospitalization. He also has a history of chronic loose stools. The child is small for his age and ill-appearing. Head and neck examination shows white patches consistent with oral candidiasis but is otherwise normal. Auscultation of the lungs shows expiratory wheezing. Cardiac examination is within normal limits. Laboratory results are as follows:
Sodium 140 mEq/L Potassium 3.8 mEq/L Chloride 98 mEq/L Bicarbonate 24 mEq/L Calcium 9.6 mg/dL Serum protein electrophoresis shows a very low gamma globulin level. Chest x-ray reveals an absent thymic shadow. Which of the following is the most likely diagnosis?
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Question 20 of 40
20. Question
A 3-year-old boy is brought to the emergency department due to 3 days of cough and increased work of breathing. Prior to this illness, the patient was active in the family garden and playful with his siblings. Nine months ago, a left buttock abscess that grew Staphylococcus aureus was drained; he was also admitted at age 1 due to a hepatic abscess that required incision and drainage and also grew S aureus. Vaccinations are up to date. A maternal uncle died at age 5 due to recurrent infections. Temperature is 38.9 C (102 F), blood pressure is 100/74 mm Hg, pulse is 120/min, and respirations are 30/min. Oxygen saturation is 97% on room air. On examination, the patient appears uncomfortable but is nontoxic. The lungs are aerated throughout with diffusely coarse breath sounds. S1 and S2 are normal without any murmurs, rubs, or gallops. The abdomen is soft and nondistended. Complete blood count is unremarkable except for an elevated leukocyte count of 17,000/mm3 with a neutrophil predominance and a normal lymphocyte count. CT scan of the chest reveals a peribronchial infiltrate with numerous small nodules scattered throughout the lung fields. Additional testing, including a bronchoscopy, is planned. Which of the following is the most likely etiology of this patient’s illness?
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Question 21 of 40
21. Question
A 7-year-old boy is brought to the office due to sudden onset of facial swelling 2 hours ago. He has had no itching or pain other than a sore throat over the last 2 days, for which he has taken acetaminophen. The patient has had similar episodes of facial swelling that resolved spontaneously after a few days. Temperature is 37 C (98.6 F), blood pressure is 100/78 mm Hg, pulse is 95/min, and respirations are 24/min. Examination shows nonpitting edema of the cheeks, lips, and tongue; there is no tenderness or erythema. Which of the following studies is most likely to be abnormal?
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Question 22 of 40
22. Question
A 16-year-old boy is brought to the office by his mother for a routine well visit. The patient has been doing well in school and has not been in the office over the past year for any sick visits. His mother says, “My son has had a girlfriend for the last few months, and I wonder if boys can receive the human papillomavirus vaccine. I am friends with his girlfriend’s mother and heard that she received the vaccine a few years ago.” The patient takes no daily medications and has no known drug allergies. The mother leaves the room for the examination, and the patient says that he is considering vaginal intercourse with his girlfriend. His parents have talked with him about abstinence and the importance of using a condom if having sex. The patient was sexually active with a previous girlfriend and used condoms every time. He is not sexually active with males and has never been tested for sexually transmitted infections. There is no family history of cancer. Physical examination shows no skin lesions, including in the genital area. The penis is circumcised with no visible discharge. The testes are descended bilaterally with no erythema or masses. Counseling about the prevention of pregnancy and sexually transmitted infections is provided. Which of the following is the most appropriate recommendation about the human papillomavirus vaccine in this patient?
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Question 23 of 40
23. Question
A 4-month-old boy is brought to the office for a well-child visit. The boy is rolling over and cooing. He reaches for toys and mouths them frequently. He is breastfed exclusively and takes a multivitamin with iron. Last week, the patient was diagnosed with acute otitis media and croup, which were treated with a 10-day course of amoxicillin and a single dose of dexamethasone. He is currently on day 6 of antibiotics and is no longer irritable or coughing. His last fever was 4 days ago. The patient lives at home with his parents and sister age 3. His sister has a seizure disorder of unclear etiology that is well controlled on antiepileptic medication. Temperature is 36.7 C (98.1 F). Physical examination is normal for his age. The infant is scheduled to receive several immunizations today as part of the recommended schedule. The parents express concern about their son receiving the diphtheria-tetanus-acellular pertussis vaccination. The father says, “After he got his shots the first time, he had a fever of 103 and was so fussy that we had to take him to the urgent care clinic to make sure he was okay. I’m not sure I can go through that again.” Based on this child’s history, which of the following is the most appropriate step regarding DTaP administration in this patient?
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Question 24 of 40
24. Question
A 30-month-old boy is admitted to the hospital due to a 3-day history of fever, cough, and dyspnea. He has a history of recurrent infections, including 4 episodes of cervical lymphadenitis that responded slowly to treatment with clindamycin. Temperature is 38.2 C (100.8 F), blood pressure is 90/60 mm Hg, pulse is 100/min, and respirations are 30/min. The anterior cervical lymph nodes are palpated bilaterally with several firm, 1- to 1.5-cm nodes that are nontender, nonfluctuant, and without overlying erythema. Breath sounds are diminished at the left lower lung base. The abdomen is soft, nontender, and nondistended without hepatosplenomegaly. A chest x-ray reveals a patchy infiltrate in the left lower lobe and a moderately sized pleural effusion. A chest tube is placed, and cloudy fluid is obtained. Laboratory results are as follows:
Pleural fluid analysis
pH
5.5
Glucose
26 mg/dL
Lactate dehydrogenase
1,100 IU
Leukocytes
70,000/mm3
Neutrophils
80%
Lymphocytes
15%
Monocytes
4%
Microscopy of pleural fluid shows numerous, intact gram-negative rods within neutrophils; cultures ultimately grow Burkholderia cepacia. The patient’s condition improves with appropriate treatment. Which of the following is most appropriate for infection prophylaxis for this patient?
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Question 25 of 40
25. Question
A 10-month-old boy is brought to the emergency department for difficulty breathing and vomiting. His mother states her son was playful and in his usual state of health this morning, but 15 minutes after lunch he started to have difficulty breathing. A few minutes later the patient vomited several times and became lethargic. He has not had fever. The patient has no significant medical history, and his immunizations are up to date. Temperature is 35.6 C (96.1 F), blood pressure is 65/38 mm Hg, pulse is 182/min, and respirations are 66/min. Pulse oximetry is 91% on room air. He is drowsy and intermittently whimpers. The pupils are equal and reactive. Oropharyngeal examination is normal. Bilateral wheezing is noted on auscultation of the lungs. Heart sounds are without murmurs or rubs. The abdomen is soft and nontender. What is the most important next step in management of this patient?
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Question 26 of 40
26. Question
A 13-year-old girl is brought to the emergency department by paramedics due to difficulty breathing that started 30 minutes ago. She was at an amusement park with her family when she was stung by a bee on her left ear. The patient experienced shortness of breath; itching; and a raised, red rash on her face and neck minutes after the sting. Medical history includes asthma that is well controlled on budesonide. Blood pressure is 80/40 mm Hg, pulse is 144/min, and respirations are 28/min. Pulse oximetry shows 92% on a nonrebreather mask. The patient is in obvious distress. The oropharynx is patent and without swelling. On auscultation of the lungs, severe bilateral wheezing is present. Heart sounds are rapid without murmurs. There are multiple raised erythematous papules on her face, neck, and upper chest. The patient’s vital signs normalize, and symptoms resolve completely an hour after a single dose of epinephrine and nebulized albuterol. What is the appropriate disposition for this patient?
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Question 27 of 40
27. Question
A 14-year-old boy is brought to the office due to intermittent rhinorrhea, nasal congestion, and nasal itching for the past 2 months. He has also had periodic itchy, watery eyes and an occasional daytime cough. The boy’s symptoms occur usually after he plays with a neighbor’s cat, and they cause the boy to be more tired than usual and have difficulty sleeping. He has had no fever, headache, weight loss, or sick contacts. The patient has atopic dermatitis and was hospitalized for bronchiolitis at age 2. He uses a topical corticosteroid ointment as needed, and his immunizations are up to date. Family history is significant for a younger brother with asthma. Vital signs are within normal limits. Physical examination shows a well-appearing boy with dark, edematous lower eyelids and pale, boggy turbinates with clear rhinorrhea. Lungs are clear to auscultation. Skin examination shows dry, scaly patches in the antecubital fossae bilaterally with associated excoriations. Which of the following is the most effective long-term strategy for relief of this patient’s symptoms?
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Question 28 of 40
28. Question
A 6-year-old boy is brought to the office for the first time for a well-child checkup. The family recently moved to the area, and the boy has been adjusting well and making friends. He started first grade a month ago and soccer last week. The patient is a picky eater and his meals consist of fruit, pasta, crackers, and milk. When asked about his sleep pattern, his mother says, “He sleeps straight through wetting the bed at least twice a week. We tried to potty train him when he was 3 years old, but he’s dry only during the day. Our last doctor recommended a few behavioral changes. We have tried avoiding fluids before bedtime and other changes, but nothing seems to help.” The patient has no dysuria or constipation. He has seasonal allergies for which he takes cetirizine. He is allergic to shellfish and has an epinephrine injector. Immunizations are up to date. Growth is along the 30th percentile for both height and weight. Blood pressure is 96/62 mm Hg. The abdomen is soft, nontender, and nondistended. External genitalia are Tanner stage I with a circumcised penis, normal urethral meatus, and descended testicles bilaterally. The skin is clear with no rashes. Which of the following is the best next step in management of this patient?
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Question 29 of 40
29. Question
A 9-year-old boy is brought to the office for routine follow-up of his chronic renal disease. He has end-stage renal disease due to focal segmental glomerulosclerosis and was started on hemodialysis 3 months ago. The patient has had failure to thrive due to the disease. His nephrologist has recommended renal transplantation, and several family members have offered to donate a kidney. The patient lives with his mother, his maternal uncle, and his 2 siblings. His father died in a car accident 4 years ago. The patient’s blood group is A+. His 7-year-old brother has blood group O–. His 19-year-old sister has blood group A+; she has uncontrolled major depressive disorder and was recently admitted to a psychiatric facility after a suicide attempt. His mother is 38 years old, has asthma, has normal kidney function, and has blood group A+. His uncle is 40 years old and has diabetes mellitus, hypertension, and left ventricular hypertrophy; the uncle has normal kidney function and has blood group A–. Physical examination reveals a boy who appears smaller than his stated age and in no acute distress. Cardiopulmonary examination is normal. Who is the most appropriate potential kidney donor?
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Question 30 of 40
30. Question
A 6-month-old boy is brought to the office by his mother due to fever for 3 days. He has been irritable for the past 2 days. The patient normally drinks 6-oz bottles of expressed breast milk, but he has been taking <3 oz per feed and voiding less frequently than usual. He has had no rash, cough, congestion, vomiting, or diarrhea. The patient takes no medications and has no known allergies. Temperature is 38.9 C (102 F). He is irritable but easily consoled by his mother. Mucous membranes are moist, and tears are present with crying. Tympanic membranes are gray and translucent bilaterally, and the oropharynx is normal. Cardiopulmonary examination is normal. The abdomen is soft, nontender, and nondistended. The penis is uncircumcised. Urine catheterization is performed, and urine dipstick analysis reveals the following:
Specific gravity
1.020
Protein
none
Blood
trace
Leukocyte esterase
moderate
Nitrites
positive
Oral antibiotics are started, and the patient is afebrile within 36 hours. Urine culture yields >50,000 colony-forming units of Escherichia coli. After completion of the therapeutic antibiotic course, which of the following is the best next step in management of this patient?
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Question 31 of 40
31. Question
A 6-year-old boy is brought to the office for chronic bedwetting. He was fully toilet trained for daytime by age 4 but has never consistently stayed dry overnight. In the past 6 months, his parents have tried several behavioral modifications, with fluid intake restricted for 2 hours prior to bedtime and the patient voiding prior to going to sleep. His parents also implemented a reward system, but he still wets the bed frequently. The patient says, “I feel really embarrassed. I want to go to a sleep-away camp next year but my parents won’t let me.” The boy has regular soft bowel movements without stooling accidents. He has no other medical problems and takes no medication. Vital signs are appropriate for age. Physical examination and urinalysis are unremarkable. His mother says, “I’m really tired of washing the sheets every other day. What else do you suggest?” Which of the following is the most appropriate advice regarding this patient’s condition?
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Question 32 of 40
32. Question
A 5-year-old girl is brought to the clinic due to 2 days of dark red urine. The patient was treated for facial impetigo a month ago. Blood pressure is 140/90 mm Hg. Urinalysis reveals hematuria, mild proteinuria, and occasional red blood cell casts. Which of the following glomerular changes are most likely to be present within this patient’s kidneys?
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Question 33 of 40
33. Question
The following vignette applies to the next 3 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 4-year-old boy is brought to the office due to puffy eyes each of the last 3 mornings. The swelling improves slightly throughout the day. He has had no recent illnesses, and medical history is significant only for mild seasonal allergic rhinitis. Temperature is 36.7 C (98 F), blood pressure is 98/70 mm Hg, pulse is 88/min, and respirations are 18/min. Weight is 18.6 kg (41 lb), up 1.6 kg (3.5 lb) from his well child visit 2 months ago. Physical examination reveals periorbital and mild pretibial edema. Laboratory results are as follows:
Serum studies
Sodium
136 mEq/L
Potassium
4 mEq/L
Blood urea nitrogen
10 mg/dL
Creatinine
0.6 mg/dL
Albumin
2.5 g/dL
Total cholesterol
250 mg/dL
C3
normal
Total complement
normal
Urinalysis
Protein
+4
Blood
negative
Glucose
negative
Ketones
negative
Leukocyte esterase
negative
Casts
none
Item 1 of 3
Which of the following is the best next step in the management of this patient?
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Question 34 of 40
34. Question
Item 2 of 3
Which of the following is the most accurate statement about the prognosis of this patient’s disease?
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Question 35 of 40
35. Question
Item 3 of 3
The patient is started on appropriate first-line treatment for this condition. To monitor for adverse medication effects, this patient will require frequent screening with which of the following?
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Question 36 of 40
36. Question
A 12-year-old boy is brought to the emergency department due to cola-colored urine for the past 2 days. In addition, the patient has had decreased urine output and a mild headache. He has no chronic medical conditions but had acute pharyngitis 3 weeks ago that resolved with oral amoxicillin. The patient’s family history is unremarkable. Temperature is 36.8 C (98.2 F), blood pressure is 150/92 mm Hg, pulse is 89/min, and respirations are 15/min. Physical examination shows a tired-appearing boy with edema in the scrotum and bilateral lower extremities. Laboratory results are as follows:
Serum chemistry
Sodium
142 mEq/L
Potassium
4.8 mEq/L
Blood urea nitrogen
26 mg/dL
Creatinine
2.5 mg/dL
Urinalysis
Protein
+2
Blood
gross
White blood cells
1-2/hpf
Red blood cells
20-30/hpf
Casts
red blood cell casts
Complement component C3 levels are low. Which of the following is the most appropriate next step in management of this patient?
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Question 37 of 40
37. Question
The following vignette applies to the next 2 items.
An 8-hour-old boy is evaluated in the neonatal intensive care unit due to respiratory distress. The infant was born at term to a 32-year-old woman, gravida 3 para 2. The mother’s routine serologic screening in the first trimester was unremarkable except for a lack of antibody against rubella. The pregnancy was complicated by oligohydramnios. Antenatal sonography at 19 weeks gestation showed that the fetal kidneys were in the normal position but moderately dilated and that the bladder was also dilated and had a thickened wall. Growth measurements were appropriate for gestational age. The delivery was uncomplicated, but immediately after birth, the infant developed some mild respiratory distress that is now improving. Weight is 3.35 kg (7 lb 6 oz) and respirations are 70/min. The infant is tachypneic but otherwise comfortable, with no grunting or retractions. The bladder is palpable just above the suprapubic ridge. The remainder of the examination is unremarkable.
Item 1 of 2
Which of the following is the most likely diagnosis in this infant?
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Question 38 of 40
38. Question
Item 2 of 2
Which of the following is the best test for confirming this infant’s condition?
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Question 39 of 40
39. Question
A 13-year-old boy comes to the office with his mother because of bed-wetting. The boy was toilet trained for urine during the day and night by age 3. Over the past 2 weeks, he has been wetting his bed every night. His mother has asked him to not drink juice just before bedtime, but he has ignored her. In the past few days, he also has refused to help with household chores and participate in gym class. The patient is developmentally appropriate for age and does not take any medication. Medical history includes oppositional defiant disorder, which is managed with behavioral counseling. Compared to 6 months ago, his height has increased along the 50th percentile, but his weight has remained stable at 44 kg (97 lb). Vital signs are normal. Examination is unremarkable. Which of the following is the best next step in management of this patient?
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Question 40 of 40
40. Question
A 16-year-old boy is brought to the office due to red-tinged urine. Three weeks ago, the patient and his family were traveling abroad when he developed a fever, rhinorrhea, sore throat, and mild cough, which resolved after 3 days. However, when these symptoms resolved, the patient developed 2 days of dark red urine and back pain that resolved spontaneously. He had been asymptomatic for the past 2 weeks, but this morning, his urine was slightly red again. Temperature is 36.8 C (98.2 F), blood pressure is 148/92 mm Hg, and pulse is 72/min. Physical examination is normal. Laboratory results are as follows:
Serum chemistry
Blood urea nitrogen
16 mg/dL
Creatinine
1.1 mg/dL
Urinalysis
Protein
+1
Blood
moderate
Ketones
negative
Leukocyte esterase
negative
Red blood cells
20-30/hpf
Serum complement levels are normal. Which of the following factors is most indicative of a poor prognosis for this patient’s condition?
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