NR603 Advanced Clinical
Diagnosis & Practice Across
the Lifespan 2025/2026
Practice Questions
Question 1
A 6-month-old infant presents with fever, irritability, and a bulging fontanelle. Lumbar puncture
reveals CSF with 500 WBCs/μL (90% neutrophils), glucose 20 mg/dL, and protein 150 mg/dL.
What is the most likely diagnosis?
A. Viral meningitis B. Bacterial meningitis C. Tuberculous meningitis D. Fungal meningitis
Correct Answer: B
Rationale: Diagnostic reasoning: CSF neutrophilic pleocytosis, hypoglycorrhachia, and elevated
protein are hallmark for bacterial infection in pediatric meningitis. Differential: Viral
(lymphocytes, normal glucose), TB/fungal (lymphocytes, very low glucose). Evidence-based
management: Empiric ceftriaxone 100 mg/kg/day IV + vancomycin 60 mg/kg/day IV per AAP
2025; add dexamethasone 0.15 mg/kg q6h for 4 days if <2 months or Hib suspected; blood/CSF
cultures guide de-escalation.
Question 2
A 2-year-old child has recurrent wheezing, nocturnal cough, and family history of atopy.
Spirometry shows FEV1/FVC 70%. What is the next step?
A. Chest X-ray B. Trial of albuterol MDI C. Allergy testing D. Sweat chloride test
Correct Answer: B
Rationale: Diagnostic reasoning: Episodic reversible airway obstruction with atopy suggests
asthma; FEV1/FVC <80% indicates obstruction. Differential: Viral URI (acute), foreign body
(unilateral), CF (failure to thrive). Evidence-based management: GINA 2025: Albuterol 2-6
puffs q4-6h PRN for 2 weeks; if >2 episodes/year, start low-dose ICS (fluticasone 88 mcg BID);
allergy referral if persistent.
,Question 3
A 4-year-old with ADHD symptoms (inattention, hyperactivity) scores high on Vanderbilt scale.
No contraindications. What is first-line pharmacotherapy?
A. Clonidine B. Methylphenidate C. Atomoxetine D. Guanfacine
Correct Answer: B
Rationale: Diagnostic reasoning: Vanderbilt meets DSM-5 criteria for ADHD (6+ symptoms ≥6
months, impairment). Differential: Anxiety (worry-focused), learning disorder (academic only).
Evidence-based management: AACAP 2025: Osmotic-release methylphenidate 18 mg daily
(titrate 18 mg/week to 54 mg); monitor HR/BP monthly, height q3 months; parent training
adjunct.
Question 4
An 8-year-old girl has short stature (below 3rd percentile), delayed bone age. Labs: IGF-1 low,
GH stimulation test peak <5 ng/mL. Diagnosis?
A. Constitutional delay B. GH deficiency C. Hypothyroidism D. Turner syndrome
Correct Answer: B
Rationale: Diagnostic reasoning: Low IGF-1 and subnormal GH peak confirm deficiency; bone
age < chronological. Differential: Constitutional (mid-parental height normal), Turner (karyotype
45X). Evidence-based management: Endocrine Society 2025: Pituitary MRI, recombinant GH
0.025-0.035 mg/kg/day SQ; monitor IGF-1 q3-6 months, bone age annually.
Question 5
A 10-year-old boy with type 1 DM presents with ketoacidosis (pH 7.1, glucose 450).
Management priority?
A. IV insulin bolus B. Fluid resuscitation C. Bicarbonate infusion D. Potassium replacement
Correct Answer: B
Rationale: Diagnostic reasoning: DKA (anion gap >12, ketones +) in new T1DM from insulin
deficiency. Differential: Sepsis (fever), starvation (mild acidosis). Evidence-based management:
ISPAD 2025: 10 mL/kg NS bolus, then 1.5x maintenance over 48 hrs; insulin infusion 0.1
U/kg/hr after fluids start; K+ 40 mEq/L if <3.3 mEq/L.
Question 6
,A 12-year-old with acne vulgaris (comedones, papules) on face/shoulders. Mild severity. Initial
treatment?
A. Oral isotretinoin B. Topical benzoyl peroxide C. Oral doxycycline D. Topical retinoid only
Correct Answer: B
Rationale: Diagnostic reasoning: Mild acne (<20 inflammatory lesions). Differential: Rosacea
(telangiectasia), folliculitis (pustules). Evidence-based management: AAD 2025: Benzoyl
peroxide 4% gel daily; add adapalene 0.1% if comedonal; follow-up 8 weeks, escalate to topical
dapsone if persistent.
Question 7
A 3-year-old with failure to thrive (weight <5th percentile), steatorrhea, anemia. Sweat chloride
65 mmol/L. Diagnosis?
A. Celiac disease B. Cystic fibrosis C. Milk protein allergy D. Gastroesophageal reflux
Correct Answer: B
Rationale: Diagnostic reasoning: Abnormal sweat test (>60 mmol/L) with malabsorption
confirms CF. Differential: Celiac (anti-tTG +), GERD (no steatorrhea). Evidence-based
management: CF Foundation 2025: CFTR genotyping, pancreatic enzymes 500-2500 U
lipase/kg/meal; elexacaftor/tezacaftor/ivacaftor if F508del.
Question 8
A 7-year-old with acute otitis media (bulging TM, pain). No high-risk features. Management?
A. Observation B. Amoxicillin C. Tympanocentesis D. Decongestants
Correct Answer: B
Rationale: Diagnostic reasoning: Otoscopic findings meet AAP AOM criteria. Differential:
Otitis externa (canal erythema). Evidence-based management: AAP 2025: Amoxicillin 80
mg/kg/day divided BID x10 days; observation option if >2 years/mild; recheck 48-72 hrs if no
improvement.
Question 9
A 5-year-old with strabismus, amblyopia risk. Next step?
A. Patching B. Glasses only C. Surgery D. Observation
, Correct Answer: A
Rationale: Diagnostic reasoning: Convergent strabismus with VA difference >2 lines.
Differential: Pseudostrabismus (light reflex). Evidence-based management: AAPOS 2025:
Atropine 1% or patching 2 hrs/day for non-dominant eye; full correction if anisometropia;
orthoptist follow-up.
Question 10
A 9-month-old with iron deficiency anemia (Hb 9 g/dL, ferritin <12). Cause?
A. Excessive milk intake B. Lead poisoning C. Thalassemia D. Hookworm
Correct Answer: A
Rationale: Diagnostic reasoning: Cow's milk excess displaces iron-rich foods. Differential: Lead
(microcytic, high RDW). Evidence-based management: AAP 2025: Ferrous sulfate 3 mg/kg/day;
limit milk 24 oz/day, iron-fortified cereal; recheck Hb in 4 weeks.
Question 11
A 14-year-old girl with dysmenorrhea (severe cramps). No pathology on exam. Treatment?
A. OCPs B. NSAIDs C. Hysterectomy D. Antibiotics
Correct Answer: B
Rationale: Diagnostic reasoning: Primary dysmenorrhea (onset post-menarche, no pelvic
disease). Differential: Secondary (endometriosis, ultrasound). Evidence-based management:
ACOG 2025: Ibuprofen 400-600 mg q6h starting menses onset x1-3 days; add OCPs if
refractory.
Question 12
A 1-year-old with rash (sandpaper-like), strawberry tongue, fever 3 days. Scarlet fever?
A. Yes, treat with PCN B. Viral exanthem C. Kawasaki D. Measles
Correct Answer: A
Rationale: Diagnostic reasoning: Pastia lines, sandpaper rash, strawberry tongue = GAS scarlet
fever. Differential: Kawasaki (conjunctivitis). Evidence-based management: IDSA 2025:
Penicillin V 250 mg BID x10 days; supportive (acetaminophen); ASO titer follow-up.
Diagnosis & Practice Across
the Lifespan 2025/2026
Practice Questions
Question 1
A 6-month-old infant presents with fever, irritability, and a bulging fontanelle. Lumbar puncture
reveals CSF with 500 WBCs/μL (90% neutrophils), glucose 20 mg/dL, and protein 150 mg/dL.
What is the most likely diagnosis?
A. Viral meningitis B. Bacterial meningitis C. Tuberculous meningitis D. Fungal meningitis
Correct Answer: B
Rationale: Diagnostic reasoning: CSF neutrophilic pleocytosis, hypoglycorrhachia, and elevated
protein are hallmark for bacterial infection in pediatric meningitis. Differential: Viral
(lymphocytes, normal glucose), TB/fungal (lymphocytes, very low glucose). Evidence-based
management: Empiric ceftriaxone 100 mg/kg/day IV + vancomycin 60 mg/kg/day IV per AAP
2025; add dexamethasone 0.15 mg/kg q6h for 4 days if <2 months or Hib suspected; blood/CSF
cultures guide de-escalation.
Question 2
A 2-year-old child has recurrent wheezing, nocturnal cough, and family history of atopy.
Spirometry shows FEV1/FVC 70%. What is the next step?
A. Chest X-ray B. Trial of albuterol MDI C. Allergy testing D. Sweat chloride test
Correct Answer: B
Rationale: Diagnostic reasoning: Episodic reversible airway obstruction with atopy suggests
asthma; FEV1/FVC <80% indicates obstruction. Differential: Viral URI (acute), foreign body
(unilateral), CF (failure to thrive). Evidence-based management: GINA 2025: Albuterol 2-6
puffs q4-6h PRN for 2 weeks; if >2 episodes/year, start low-dose ICS (fluticasone 88 mcg BID);
allergy referral if persistent.
,Question 3
A 4-year-old with ADHD symptoms (inattention, hyperactivity) scores high on Vanderbilt scale.
No contraindications. What is first-line pharmacotherapy?
A. Clonidine B. Methylphenidate C. Atomoxetine D. Guanfacine
Correct Answer: B
Rationale: Diagnostic reasoning: Vanderbilt meets DSM-5 criteria for ADHD (6+ symptoms ≥6
months, impairment). Differential: Anxiety (worry-focused), learning disorder (academic only).
Evidence-based management: AACAP 2025: Osmotic-release methylphenidate 18 mg daily
(titrate 18 mg/week to 54 mg); monitor HR/BP monthly, height q3 months; parent training
adjunct.
Question 4
An 8-year-old girl has short stature (below 3rd percentile), delayed bone age. Labs: IGF-1 low,
GH stimulation test peak <5 ng/mL. Diagnosis?
A. Constitutional delay B. GH deficiency C. Hypothyroidism D. Turner syndrome
Correct Answer: B
Rationale: Diagnostic reasoning: Low IGF-1 and subnormal GH peak confirm deficiency; bone
age < chronological. Differential: Constitutional (mid-parental height normal), Turner (karyotype
45X). Evidence-based management: Endocrine Society 2025: Pituitary MRI, recombinant GH
0.025-0.035 mg/kg/day SQ; monitor IGF-1 q3-6 months, bone age annually.
Question 5
A 10-year-old boy with type 1 DM presents with ketoacidosis (pH 7.1, glucose 450).
Management priority?
A. IV insulin bolus B. Fluid resuscitation C. Bicarbonate infusion D. Potassium replacement
Correct Answer: B
Rationale: Diagnostic reasoning: DKA (anion gap >12, ketones +) in new T1DM from insulin
deficiency. Differential: Sepsis (fever), starvation (mild acidosis). Evidence-based management:
ISPAD 2025: 10 mL/kg NS bolus, then 1.5x maintenance over 48 hrs; insulin infusion 0.1
U/kg/hr after fluids start; K+ 40 mEq/L if <3.3 mEq/L.
Question 6
,A 12-year-old with acne vulgaris (comedones, papules) on face/shoulders. Mild severity. Initial
treatment?
A. Oral isotretinoin B. Topical benzoyl peroxide C. Oral doxycycline D. Topical retinoid only
Correct Answer: B
Rationale: Diagnostic reasoning: Mild acne (<20 inflammatory lesions). Differential: Rosacea
(telangiectasia), folliculitis (pustules). Evidence-based management: AAD 2025: Benzoyl
peroxide 4% gel daily; add adapalene 0.1% if comedonal; follow-up 8 weeks, escalate to topical
dapsone if persistent.
Question 7
A 3-year-old with failure to thrive (weight <5th percentile), steatorrhea, anemia. Sweat chloride
65 mmol/L. Diagnosis?
A. Celiac disease B. Cystic fibrosis C. Milk protein allergy D. Gastroesophageal reflux
Correct Answer: B
Rationale: Diagnostic reasoning: Abnormal sweat test (>60 mmol/L) with malabsorption
confirms CF. Differential: Celiac (anti-tTG +), GERD (no steatorrhea). Evidence-based
management: CF Foundation 2025: CFTR genotyping, pancreatic enzymes 500-2500 U
lipase/kg/meal; elexacaftor/tezacaftor/ivacaftor if F508del.
Question 8
A 7-year-old with acute otitis media (bulging TM, pain). No high-risk features. Management?
A. Observation B. Amoxicillin C. Tympanocentesis D. Decongestants
Correct Answer: B
Rationale: Diagnostic reasoning: Otoscopic findings meet AAP AOM criteria. Differential:
Otitis externa (canal erythema). Evidence-based management: AAP 2025: Amoxicillin 80
mg/kg/day divided BID x10 days; observation option if >2 years/mild; recheck 48-72 hrs if no
improvement.
Question 9
A 5-year-old with strabismus, amblyopia risk. Next step?
A. Patching B. Glasses only C. Surgery D. Observation
, Correct Answer: A
Rationale: Diagnostic reasoning: Convergent strabismus with VA difference >2 lines.
Differential: Pseudostrabismus (light reflex). Evidence-based management: AAPOS 2025:
Atropine 1% or patching 2 hrs/day for non-dominant eye; full correction if anisometropia;
orthoptist follow-up.
Question 10
A 9-month-old with iron deficiency anemia (Hb 9 g/dL, ferritin <12). Cause?
A. Excessive milk intake B. Lead poisoning C. Thalassemia D. Hookworm
Correct Answer: A
Rationale: Diagnostic reasoning: Cow's milk excess displaces iron-rich foods. Differential: Lead
(microcytic, high RDW). Evidence-based management: AAP 2025: Ferrous sulfate 3 mg/kg/day;
limit milk 24 oz/day, iron-fortified cereal; recheck Hb in 4 weeks.
Question 11
A 14-year-old girl with dysmenorrhea (severe cramps). No pathology on exam. Treatment?
A. OCPs B. NSAIDs C. Hysterectomy D. Antibiotics
Correct Answer: B
Rationale: Diagnostic reasoning: Primary dysmenorrhea (onset post-menarche, no pelvic
disease). Differential: Secondary (endometriosis, ultrasound). Evidence-based management:
ACOG 2025: Ibuprofen 400-600 mg q6h starting menses onset x1-3 days; add OCPs if
refractory.
Question 12
A 1-year-old with rash (sandpaper-like), strawberry tongue, fever 3 days. Scarlet fever?
A. Yes, treat with PCN B. Viral exanthem C. Kawasaki D. Measles
Correct Answer: A
Rationale: Diagnostic reasoning: Pastia lines, sandpaper rash, strawberry tongue = GAS scarlet
fever. Differential: Kawasaki (conjunctivitis). Evidence-based management: IDSA 2025:
Penicillin V 250 mg BID x10 days; supportive (acetaminophen); ASO titer follow-up.
