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Question 1 of 39
1. Question
The following vignette applies to the next 2 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 6-month-old boy is brought to the emergency department due to poor feeding. His mother says, “My son normally nurses every 3 hours, but for the past 24 hours, he hasn’t been latching or sucking well when I offer him the breast. A few days ago, his eyelids started to appear droopy, and they do not open fully today. He also was previously able to roll and sit by himself, but, today, he is only lying down and not doing anything.” The patient normally stools 2 or 3 times per day but has not stooled for 7 days, despite the family giving him small amounts of prune juice. He was born at 40 weeks gestation by vaginal delivery after an uncomplicated pregnancy. Vaccinations are up to date, and the patient takes no medications. He lives on a large farm with his parents and grandfather. Temperature is 36.7 C (98.1 F), pulse is 128/min, and respirations are 30/min. Pulse oximetry shows 99% on room air. Physical examination demonstrates a hypotonic infant lying with arms and legs splayed outward on the examination table. He has bilateral ptosis and poor suck. Gag reflex is intact.
Item 1 of 2
Which of the following is the most likely mechanism of this patient’s condition?CorrectIncorrect -
Question 2 of 39
2. Question
Item 2 of 2
The patient is admitted to the intensive care unit for close observation. On admission, temperature is 36.8 C (98.2 F), blood pressure is 88/45 mm Hg, pulse is 135/min, and respirations are 28/min. Pulse oximetry is 99% on room air. The examination is otherwise unchanged from the initial evaluation. Arterial blood gas on room air is as follows:pH
7.39
PaO2
98 mm Hg
PaCO2
40 mm Hg
HCO3−
24 mEq/L
Which of the following is the most appropriate immediate step in management of this patient?
CorrectIncorrect -
Question 3 of 39
3. Question
A 2-year-old girl is brought to the office by her parents for a routine well-child visit. The patient speaks >100 words and can use 2-word phrases. She can go up and down stairs and draw a line. The patient takes no medications and has no allergies. Immunizations are up to date. She lives with her parents, grandparents, and 5-year-old brother in a home built in 2003. Height and weight are in the 50th percentile. Physical examination is normal. She is playing with brightly-painted wooden dolls on the floor of the examination room, and her mother says, “These dolls actually used to be her grandmother’s when she was a child.” Capillary blood collection shows a hemoglobin level of 11 g/dL and a lead level of 11 µg/dL (normal: <5). A venous lead level of 12 µg/dL is confirmed the next day. In addition to education about lead exposure and toxicity prevention, which of the following is the best next step in management of this patient?
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Question 4 of 39
4. Question
The following vignette applies to the next 2 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.
An 18-month-old boy is brought to the office for a well-child visit. The family relocated to the area 5 months ago. The patient speaks 15-20 words and runs well. His diet has variety and includes whole milk, fruits, vegetables, and meat. He has no fatigue, vomiting, constipation, or abdominal pain. The patient has no chronic medical conditions and takes no daily medications. Vaccinations are up to date. He lives with his parents and 5-month-old sister in a home built in 1938 that is currently undergoing renovations. A lead level performed at age 12 months was 4 μg/dL (normal: <5). Examination shows a playful and active boy. Cardiac, pulmonary, and abdominal examinations are unremarkable. Capillary blood sample shows a hemoglobin level of 12 mg/dL and lead level of 35 μg/dL.
Item 1 of 2
Which of the following is the best next step in management of this patient?
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Question 5 of 39
5. Question
Item 2 of 2
A venous blood sample confirms a lead level of 35 μg/dL. The parents are concerned about potential consequences of lead toxicity. Which of the following complications is this child at greatest risk of developing?
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Question 6 of 39
6. Question
A 3-year-old boy is brought to the office for a routine visit. The patient is doing well, and his parents have no concerns. Review of systems is unremarkable. He was recently adopted from China; his medical and family history is unknown. The patient takes no daily medications and has received all recommended immunizations. His adoptive parents are schoolteachers, and the family lives in a newly built home. Vital signs are appropriate for age, and BMI is at the 40th percentile. Examination shows a quiet and alert boy. Cardiac, pulmonary, and abdominal examinations are unremarkable. Complete blood count and serum electrolytes are normal. Venous lead level is 60 µg/dL (normal: <5). X-ray of the abdomen reveals no lead-containing foreign bodies. Lead toxicity and exposure are discussed with the family. Which of the following is the best next step in management of this patient?
CorrectIncorrect -
Question 7 of 39
7. Question
A 3-year-old Caucasian boy is brought to your office by his mother with complaints of irritability and decreased appetite. The mother says that the boy seems weak and has been less active over the last several weeks. The patient regularly spends some time outside the house under the supervision of his older brother, and the brother saw him eating cement and woodwork several times. The patient’s past medical history is insignificant. He has no known allergies. All his vaccinations are up-to-date. He received iron and vitamin D supplements. His vital signs are stable. Physical examination reveals a non-distended abdomen with periumbilical tenderness. What is the best next step in the management of this patient?
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Question 8 of 39
8. Question
A 3-year-old, previously healthy boy is brought to the emergency department due to accidental drug ingestion. His mother found him playing with his grandfather’s pill bottles earlier today, and later, he developed nausea and vomited twice. The patient also began breathing rapidly and appeared ill. His grandfather recently had a myocardial infarction and takes multiple medications. On physical examination, the patient is mildly lethargic, tachypneic, and tachycardic. The abdomen is soft and nontender. The extremities are warm and capillary refill time is normal. Laboratory studies reveal high anion gap metabolic acidosis. Treatment with intravenous sodium bicarbonate infusion is begun. This therapy is most likely to provide a beneficial effect via which of the following mechanisms?
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Question 9 of 39
9. Question
A 5-week-old girl is brought to the emergency department for worsening “coughing spells” and a cyanotic episode. Evaluation reveals a positive nasopharyngeal PCR for pertussis. The patient is admitted to the hospital for monitoring and started on clarithromycin. Medical history is notable for neonatal seizures that resolved within the first week of life, and she continues to take daily phenobarbital with no recurrent seizures. During hospitalization, vital signs remain appropriate for age, and the patient continues to have occasional, but less forceful, coughing spells with no further cyanotic episodes. She tolerates formula every 2-4 hours. However, on day 3, the parents note that the patient is difficult to wake for a feed. She has had no seizures or fever. Vital signs are normal. Examination shows a sleeping infant who is poorly arousable with decreased tone and a weak suck. The anterior fontanelle is flat. The remainder of the examination is unremarkable. Which of the following is the most likely cause of this patient’s new symptoms?
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Question 10 of 39
10. Question
A 4-year-old boy is brought to the emergency department by his mother for vomiting and diarrhea. His mother says, “He started complaining of a stomachache after playing at the neighbor’s farm, but I thought he was just hungry after playing outside all afternoon.” The child subsequently had several episodes of emesis and diarrhea. His mother has also noticed that he seems to be sweating excessively and drooling. He has no medical conditions and takes no daily medications. The patient lives with his parents and uncle. His uncle has sickle cell disease, for which he takes ibuprofen and oxycodone as needed for pain crises. Temperature is 37.2 C (99 F), blood pressure is 90/60 mm Hg, pulse is 50/min, and respirations are 36/min. Pulse oximetry is 94% on room air. Physical examination shows an ill-appearing child moaning on the stretcher and clutching his abdomen. Significant diaphoresis and bilateral tearing are noted, and his pupils are constricted. Cardiac examination reveals a regular rhythm with bradycardia and no murmurs, and respiratory exam is notable for tachypnea, bilateral wheezing, and mild subcostal retractions. Oxygen via facemask is administered. Which of the following medications should also be administered?
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Question 11 of 39
11. 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 7-year-old boy is brought to the emergency department by his parents due to left eye swelling and redness. The patient has had left eye pain for 2 days and the pain worsened today. He has no symptoms in his right eye. He has allergic rhinitis, for which he takes intranasal steroids. The patient developed sinusitis approximately 3 weeks ago and was treated with amoxicillin-clavulanate. He has no other medical conditions and has had no surgeries. The patient’s mother was diagnosed with left leg deep vein thrombosis after a recent transatlantic flight. Temperature is 39.2 C (102.5 F), blood pressure is 102/70 mm Hg, pulse is 94/min, and respirations are 18/min. The left eyelid is erythematous, tender, and swollen. The conjunctiva is hyperemic. Movement of the left eye causes pain. Visual acuity and pupillary reaction are normal bilaterally. Purulent mucus is draining from the nose, and nasal turbinates are swollen and erythematous. Examination of the right eye is unremarkable, and facial sensation is intact.
Item 1 of 3
Which of the following findings is most concerning in this patient?
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Question 12 of 39
12. Question
Item 2 of 3
Laboratory results are as follows:
Hemoglobin
15.4 g/dL
Leukocytes
15,000/mm3
Platelets
246,000/mm3
Which of the following is the best next step in management of this patient?
CorrectIncorrect -
Question 13 of 39
13. Question
Item 3 of 3
CT scan reveals inflammation of extraocular muscles, fat stranding, and mild anterior displacement of the globe. No fluid collections are identified. Which of the following is the best next step in management of this patient?
CorrectIncorrect -
Question 14 of 39
14. Question
The following vignette applies to the next 3 items.
A 13-year-old boy is brought to clinic by his parents due to copious, purulent discharge from his right eye. The patient’s eye was crusted shut this morning. His father was able to open the eye by wiping it with a damp washcloth. The patient went to school but was sent home by the school nurse. He has not had ocular pain, visual changes, or fever. He lives at home with his parents and older sister, none of whom have similar symptoms. The patient has mild myopia and wears contact lenses. He takes loratadine daily for seasonal allergies. Vital signs are within normal limits. Examination shows conjunctival erythema and yellow exudate in the right eye. The conjunctiva of the left eye is also erythematous, but there are no secretions. Visual acuity testing with the patient’s contacts removed shows 20/80 vision in both eyes, consistent with his well-child examination at age 12.
Item 1 of 3
Which of the following is the most appropriate pharmacotherapy?
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Question 15 of 39
15. Question
Item 2 of 3
The mother is very concerned about possible complications of the disease. Which of the following complications is most likely to occur with this patient’s condition?
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Question 16 of 39
16. Question
Item 3 of 3
The parents administer the treatment as prescribed. After 2 days of treatment, the initial symptoms have not improved, and the child now says, “The light really bothers me, and it feels like there is something really painful in my eye.” Which of the following is the most appropriate next step in treatment?
CorrectIncorrect -
Question 17 of 39
17. Question
A 10-day-old girl is brought to the emergency department due to 2 days of bilateral eye redness and drainage. The parents say, “Her eyes were a little watery yesterday, but today, the discharge is a bit thicker.” The patient was born at 39 weeks gestation via vaginal delivery to a 24-year-old woman, gravida 2 para 2. During the first trimester, the pregnancy was complicated by maternal gonococcal infection that was treated successfully. The patient received topical erythromycin ointment shortly after delivery. She had an uncomplicated nursery course and, at age 3 days, was discharged with her mother. The patient has been breastfeeding, voiding, and stooling normally. Her brother, age 2, had an upper respiratory tract infection last week; her parents have not been sick. Vital signs are appropriate for age. On examination, the pupils are equal, round, and reactive to light. Mild eyelid swelling, conjunctival injection, and a small amount of mucopurulent discharge are present bilaterally. The remainder of the examination is normal. Which of the following is the most likely route of transmission of this patient’s infection?
CorrectIncorrect -
Question 18 of 39
18. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to the Next Item, you will not be able to add or change an answer.
An 11-year-old boy is brought to the clinic by his parents due to eye redness and discharge. He has had a sore throat for 4 days and right eye redness for 2 days. The boy says, “It sometimes feels like my eye is burning!” This morning, both eyes were crusted shut. His father used a moist towel to open the patient’s eyelids and saw that the left eye was also red. The boy has had no eye pain, visual changes, or itching. He has a history of eczema for which he uses topical moisturizers at night. The patient lives with his parents, 2 younger sisters, 7 dogs, 3 cats, and a turtle. No one in his family has similar symptoms. Temperature is 37.4 C (99.4 F). Physical examination reveals conjunctival injection and clear mucoid discharge in both eyes. Mild rhinorrhea and pharyngeal erythema are also present. The lungs are clear to auscultation, and the remainder of the examination is normal.
Item 1 of 2
Which of the following is the most likely diagnosis?
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Question 19 of 39
19. Question
Item 2 of 2
The patient’s diagnosis is discussed with the family. The mother says, “I’ve heard that this condition is very contagious, and I don’t want him to get his classmates sick. When can he return to school?” Which of the following is the most appropriate response?
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Question 20 of 39
20. Question
A 3-day-old girl is brought to the emergency department due to profuse eye discharge. The infant’s right eye began to have clear drainage and redness yesterday evening. The parents wiped the drainage away with a moist cloth. This morning, both eyes were involved and the discharge was heavy and purulent. The patient is breastfeeding well and voiding and stooling normally. She was born at term via vaginal delivery to a 24-year-old primigravida. The parents elected for an all-natural birth process and declined routine prenatal laboratory testing. The mother opted for unmedicated labor and delivery at a birthing center, and the infant received no medications postpartum. The mother and infant were discharged approximately 4 hours after delivery. Temperature is 36.9 C (98.4 F). On physical examination, bilateral eyelid swelling is seen. When the eyelids are opened, thick, purulent discharge is expressed. The remainder of the examination is unremarkable. Which of the following peripartum interventions would most likely have prevented this patient’s condition?
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Question 21 of 39
21. Question
A 15-month-old boy is brought to the office for a well-child visit. His parents are concerned that he is not yet walking. He can pull himself up to stand and take steps while holding on to furniture but has not yet taken any steps unassisted. The patient says 5 words and can follow simple commands, such as “Clap your hands!” or “Wave bye-bye!” He is also able to pick up small items and food with his thumb and pointer finger and tries to use a spoon when feeding. The boy is up to date with all vaccinations. He has no known allergies and takes no medications. He was born via uncomplicated vaginal delivery at 37 weeks gestation. The patient was breastfed exclusively, with vitamin D supplementation, until age 6 months and has since had a varied diet. Gross motor milestones include rolling over at age 6 months and sitting unassisted at age 8 months. Height and weight are at the 40th percentile. Physical examination shows a nondysmorphic and active boy. He pulls himself up to stand and cruises around the examination room while holding on to chairs or his mother. During the examination, he cries and clings to his mother. The remainder of the examination is unremarkable. What is the best next step in management of this patient?
CorrectIncorrect -
Question 22 of 39
22. Question
A 3-year-old boy is brought to the office by his parents for evaluation of lower extremity weakness. His mother states, “He used to be able to play soccer with his older sisters for hours, but for the past several months, he stops playing after 10 minutes because his legs feel tired.” The patient has also been “clumsy” recently and frequently trips while walking. He has no joint pain, incontinence, constipation, numbness, or systemic fatigue. Language development is slightly delayed, and he learned to walk at age 18 months. He has had no chronic medical conditions or surgeries. The patient takes no medications and has received all recommended vaccinations. His aunt has Hashimoto thyroiditis; family history is otherwise noncontributory. Vital signs are normal for age. Physical examination shows a cooperative boy without dysmorphia. Both calves appear large in circumference compared to the thighs. Strength is 3/5 in the bilateral quadriceps and 4/5 in the calves. Sensation is intact. Achilles deep tendon reflexes are hyporeflexic. The patient walks with a waddling gait. Which of the following is the best next step in management of this patient?
CorrectIncorrect -
Question 23 of 39
23. Question
The following vignette applies to the next 2 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.
An 18-hour-old girl is undergoing a routine examination in the newborn nursery. The patient has urinated 4 times and passed meconium. She was born via uncomplicated vaginal delivery at 41 weeks to a 23-year-old primipara. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Birth weight and length are at the 25th percentile for gestation. Temperature is 37.2 C (99 F). The patient is initially asleep but easily roused. Examination shows open and soft fontanelles, posteriorly rotated ears, and a small maxilla. The soft palate has a high arch, but no submucosal cleft is felt on palpation. The neck is short and webbed, without masses. Auscultation reveals a regular heart rate and rhythm with no murmurs. There is good air entry in all fields with no grunting, retractions, or nasal flaring. External genitalia are normal. The hands and feet are moderately edematous. Crease lines on both hands are normal. Pulses are 2+ in all extremities.
Item 1 of 2
Which of the following is the most likely long-term outcome for patients with this condition?
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Question 24 of 39
24. Question
Item 2 of 2
The mother is concerned about the recurrence risk of this condition in subsequent pregnancies. Which of the following is the best response?
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Question 25 of 39
25. Question
A 4-month-old girl undergoes an autopsy after passing away at home. The infant was found supine and unresponsive in her crib after a nap. There was no loose bedding in the crib or smoke exposure in the home. The infant was exclusively breastfed and used a pacifier overnight. The only ongoing medical condition was gastroesophageal reflux disease, which led to frequent spits up and was managed with behavioral measures alone. Medical history was otherwise notable for prematurity of 30 weeks gestation due to preterm labor and a prolonged neonatal intensive care unit stay due to apnea of prematurity. The mother was age 41 at conception, and pregnancy was complicated by depression treated with fluoxetine. The infant was developmentally appropriate based on corrected age for gestation. Gross examination was unremarkable other than mottled skin, and autopsy findings are inconclusive. Which of the following was the greatest risk factor for this infant’s condition?
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Question 26 of 39
26. Question
A 7-year-old boy is brought to the emergency department due to rash, abdominal pain, and nausea. The rash first appeared 2 days ago. According to his father, a few initial red, round lesions on the back of both thighs now seem to have “merged together” and spread “all over his legs and buttocks.” The rash is not itchy or painful. The abdominal pain and nausea began today and have been intermittent. The boy’s appetite is decreased but he has no vomiting or diarrhea. His last bowel movement was yesterday and appeared normal. Other than an upper respiratory infection last week, the patient has been healthy and takes no medications. He went to a family barbeque last week and ate a hamburger and hot dog. Vaccinations are up to date and he has no allergies. His temperature is 36.7 C (98 F), blood pressure is 110/65 mm Hg, and pulse is 105/min. On physical examination, his abdomen is soft, nondistended, and mildly tender to palpation in the periumbilical region. Skin examination shows a non-blanching purple rash on his lower extremities and buttocks. Stool guaiac is positive. Which of the following is the most likely diagnosis in this patient?
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Question 27 of 39
27. Question
A 16-year-old boy is brought to the office for evaluation of attention deficit hyperactivity disorder. The parents state that the patient has always been impulsive and that teachers are concerned about his inattentiveness and poor grades. He also has mild intellectual disability. Review of medical records shows a history of gross motor and speech delay, for which the patient received physical and speech therapies during childhood. Height is at the 70th percentile, and weight is at the 50th percentile. Physical examination is notable for a long and narrow face, a prominent mandible, and large testes. There is hyperlaxity of the finger and thumb joints. This patient’s condition is most likely due to which of the following?
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Question 28 of 39
28. Question
A 3-day-old boy is seen in the nursery due to vomiting. He has had 2 episodes of nonprojectile vomiting of green fluid and has developed abdominal distension over the last hour. The patient is breastfed and initially nursed every 2 hours but is now nursing less frequently. The infant passed a small amount of meconium immediately after delivery but has passed no other stool. He is voiding adequately. The patient was delivered vaginally at 38 weeks gestation without complications. Apgars were 8 and 9 at 1 and 5 minutes, respectively. Temperature is 36.7 C (98 F). On examination, the infant is asleep but easily roused. The anterior fontanelle is open and flat, and the mucous membranes are moist. Cardiac examination is normal. The lungs are clear to auscultation bilaterally. The abdomen is distended with hypoactive bowel sounds. The liver and spleen are not palpable. Abdominal x-ray findings include dilated, gas-filled loops of small bowel; absent air-fluid levels; and a “ground-glass” mass in the right side of the abdomen. Further history-taking should focus on which of the following factors?
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Question 29 of 39
29. Question
A seven-year-old female is being evaluated in the pediatric clinic for short stature. Her medical records reveal that she was small at birth. When she was approximately two years of age, her parents noticed that she was not growing as much as her peers. Her height and weight are below the 5th percentile on the normal growth chart. Her projected height is more than 2 standard deviations below her mid-parental height. She has short fourth metacarpal bones bilaterally and multiple nuchal folds. Her carrying angles in the upper extremities are increased. A diagnosis of Turner syndrome is suspected. Karyotyping is performed and the result is 45, XO. At this time, which of the following is necessary in the management of this patient?
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Question 30 of 39
30. Question
A 4-month-old boy is brought to the office by his parents for a well-child visit. Their only concern is that the infant spits up a few times a day after breastfeeding. These episodes are occurring less frequently than before, and the emesis is not bilious or projectile. He is sometimes fussy after spitting up but is easily consolable. The patient was born at 37 weeks gestation by spontaneous vaginal delivery and has no chronic medical conditions. Vaccinations are up to date. His weight and length growth charts are shown in image 1, and the head circumference growth chart is shown in image 2. On physical examination, the patient is alert and smiling. The anterior fontanelle is soft and flat, and there are no craniofacial anomalies. Cardiac examination is normal. The abdomen is soft and nontender. He is able to roll from his stomach to his back and hold his head steady without support. Which of the following is the best next step in the management of this patient?
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Question 31 of 39
31. Question
A 3-year-old boy is brought to the office due to ear drainage. His mother reports that he was well until the previous day, when he developed a fever of 38.9 C (102 F), accompanied by crankiness, decreased appetite, and frequent crying. He was given acetaminophen for his symptoms, but they did not improve. Today his mother put him in his room for a nap; when she returned, thick white liquid was leaking from his right ear. Since waking from his nap, he has not been cranky, but the drainage has persisted. Temperature is 38.3 C (101 F), pulse is 114/min, and respirations are 18/min. On physical examination, he appears alert and active. The pupils are equal and reactive; the nasal turbinates are clear, and there is no erythema or exudate in the pharynx. The left tympanic membrane is normal, but the right tympanic membrane is not visible due to copious purulent drainage in the canal. The pinna appears normal and there is no tenderness on manipulation of the ear. The neck is supple without lymphadenopathy. Cardiopulmonary examination is within normal limits. What is the most likely explanation for this patient’s findings?
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Question 32 of 39
32. Question
A 2-year-old boy is brought to the emergency department due to irritability and intermittent fever for the past 2 days following a week of upper respiratory symptoms. Medical history is significant for Dandy-Walker malformation. A ventriculoperitoneal shunt was placed during his initial neonatal intensive care unit hospitalization after birth. Immunizations are up to date. Height, weight, and head circumference are at the 40th percentile. Temperature is 38.2 C (100.8 F). On examination, the patient is awake and interactive. Pupils are equal and reactive with no papilledema on funduscopy. There is clear rhinorrhea. The right tympanic membrane has clear fluid behind it; the left tympanic membrane is bulging and erythematous. The oropharynx is mildly inflamed. There is no cervical adenopathy. The abdomen is soft and nontender. Cranial nerve examination is normal. Kernig and Brudzinski signs are negative. CT scan of the head reveals no evidence of hydrocephalus or ventricular debris. X-ray of the shunt shows normal placement with no evidence of discontinuity. Which of the following is the best next step in management of this patient?
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Question 33 of 39
33. Question
A 13-year-old girl comes to the physician for evaluation of her third episode of maxillary sinusitis during the past 7 months. She complains of fever, headache, nasal congestion, and facial pain that began 3 days ago. Except for previous sinusitis episodes, her medical history is unremarkable. The patient has no known allergies. Her family history is unremarkable, but both parents smoke cigarettes. On examination, she has maxillary sinus tenderness and purulent nasal discharge. The remainder of the examination is normal. Computed tomography scan demonstrates mucosal thickening, opacification, and air-fluid levels in the maxillary sinuses. Which of the following should the physician say to the patient’s parents?
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Question 34 of 39
34. Question
An 8-month-old boy is brought to the office due to recurrent episodes of otitis media, including 2 episodes of acute otitis media in the past 3 months. One episode was in his left ear; the second was in his right ear 2 weeks ago and resolved after a course of amoxicillin. He was born by spontaneous vaginal delivery at 38 weeks gestation and has had no other medical problems. He lives with his mother and 3-year-old brother, both of whom are in good health. There are no pets or carpets in the house. His mother smokes a pack of cigarettes a day but only outdoors. The patient does not attend day care. He eats solid foods twice a day and breastfeeds every 3 hours, including overnight when he falls asleep while feeding. His growth and developmental milestones are age-appropriate. On physical examination, he is awake, alert, and playful. His head is normocephalic. Pupils are equal and reactive to light and accommodation. The nares are clear; there is no erythema of the pharynx; the tympanic membranes are clear without erythema or effusion. Cardiopulmonary examination is normal. The mother is concerned that the recurrent infections will affect his hearing and asks for advice on avoiding future episodes. Which of the following is the most appropriate intervention in management of this patient?
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Question 35 of 39
35. Question
A 7-year-old girl is brought to the office for a routine health maintenance examination. While in the waiting room, she develops a nosebleed. An assistant pinches the patient’s nasal alae against the nasal septum for 10 minutes while the girl is seated and leaning forward. This slows, but does not stop, the flow of blood. Prior to the appointment, the patient was at a summer camp playing outside in hot, dry weather. She has had no recent facial trauma, unusual bruising, or gingival bleeding. Blood pressure is 100/70 mm Hg and pulse is 94/min. On examination, the patient is sitting in a chair, awake, alert, and in no distress. A continuous trickle of blood from her left naris obscures the mucosa. She has no oropharyngeal lesions. Which of the following is the best next step in management of this patient’s condition?
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Question 36 of 39
36. Question
A newborn girl is being evaluated in the nursery. She was born at term to a 23-year-old primigravida via spontaneous vaginal delivery. Vital signs are normal. Examination of the patient shows an isolated cleft lip. Anterior fontanelle is open and soft. The ears appear to be in normal position, and the neck is supple. Cardiopulmonary examination is unremarkable. Abdominal examination shows no organomegaly. The patient has normal external genitalia. Examination of the extremities shows normal digits. Examination of the back shows intact skin with no dimpling. The mother states that her maternal uncle had an isolated cleft lip and cleft palate, which were surgically corrected. Both parents have no known medical conditions. The parents ask about the cause of this anomaly. This patient’s clinical findings are most likely a result of which of the following?
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Question 37 of 39
37. Question
The following vignette applies to the next 2 items. The items in this 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 2-year-old boy is brought to the clinic by his parents due to worsening right ear pain. His mother states, “He started tugging at his ear 3 days ago and had a fever, but I could not take time off from work to bring him in.” This morning, the pain increased, and his father notes that “his ear seems more prominent, like it’s sticking out from his head.” The patient has been less active than normal but has had no vomiting, diarrhea, or rash. He had an episode of acute otitis media 2 months ago that resolved with oral antibiotics. Immunizations are up to date, and he takes no daily medications. Temperature is 40 C (104 F), blood pressure is 100/40 mm Hg, pulse is 132/min, and respirations are 30/min. Examination shows a tired, irritable boy who screams with any attempt to examine his ear. Swelling, erythema, and tenderness to palpation are noted posterior to the right ear. Otoscopy reveals an erythematous and bulging tympanic membrane with loss of normal landmarks and light reflex.
Item 1 of 2
Involvement of which of the following structures is most likely responsible for this patient’s presentation?CorrectIncorrect -
Question 38 of 39
38. Question
Item 2 of 2
CT scan of the temporal bones is obtained which reveals fluid in the mastoid air cells with erosion of bony septa. Which of the following is the most appropriate step in management?CorrectIncorrect -
Question 39 of 39
39. Question
A 10-year-old girl is brought to the emergency department due to right ear pain. She was participating in a martial arts competition this afternoon when her opponent struck her on the right side of the head. The patient has had no discharge from the ear canal and no hearing loss, rhinorrhea, or vertigo. She has no chronic medical conditions and takes no medications. Blood pressure is 110/70 mm Hg and pulse is 92/min. The patient is awake, alert, and appears in moderate pain. The face has normal contours with no point tenderness. The pupils are equal and reactive to light; extraocular movements are intact. There is erythema and a 2.5-cm (1-in) hematoma overlying the superior antihelix of the right pinna. The right pinna is tender to light touch, and manipulation of the pinna is painful. Scant dried blood is noted at the external auditory meatus. Bilateral tympanic membranes are clear. The mastoid process is nontender and has no bruising. The patient’s parents ask if there is anything else that needs to be done for the hematoma. Which of the following is the most appropriate statement regarding management of this patient?
CorrectIncorrect