Section 3 Pediatrics
SETTING 1: COMMUNITY-BASED HEALTH CENTER
You work at a community-based health facility where patients seeking both routine and urgent care are encountered. Many patients are members of low-income groups; many are ethnic minorit
Several industrial parks and local businesses send their employees to the health center for treatment of on-the-job injuries and employee health screening. There is a facility that provides x-ray fil
but CT and MRI scans must be arranged at other facilities. Laboratory services are available.
1. The left pupil of a 12-month-old girl has been noted to be white by the parents. Recently, she has been rubbing that eye and squinting when exposed to bright light. A full ophthalmic exam i
performed, but the retina is poorly visualized even after dilation of the pupil. A massive outpouring of white blood cells is seen in the anterior chamber, and fibrous strands are noted to exten
from the iris to the lens consistent with uveitis. The remainder of her physical exam is normal. Which of the following is the most appropriate first step in the management of this patient?
A. CT scan of the orbits
B. The avoidance of steroid eye drops
C. Blood samples for acute and convalescent titers of CMV, toxoplasmosis, syphilis, and toxocara
D. The avoidance of dilating eye drops
E. Titers of anti-nuclear antibody (ANA)
2. A 5-year-old boy is brought into the clinic with a history of “ white spots on his face” for 2 weeks. The lesions are nonpruritic and appear to have a fine scaly uniform texture (Figure 3-2)
Under Wood’s light exam there is no specific fluorescence. The mother thinks they have become worse since the return from his camping trip. Which of the following is the most appropriat
management option?
A. Dermatology referral
B. Griseofulvin
C. Low-potency topical corticosteroid
D. Topical selenium sulfide
E. Diphenhydramine (Benadryl)
Figure 3-2 • Image Courtesy of the Phoenix Children’s Hospital, Phoenix, Arizona.
3. A 2-year-old boy comes to your clinic for a checkup. He is well except that he walks with a slight in-toed gait. When you place him prone on the examination table with his knees flexed an
measure the angle formed by the axis of the thigh and the axis of the foot, you note that the foot is internally rotated. You diagnose internal tibial torsion. The best management for thi
condition at this age is:
A. Refer to a pediatric orthopedic surgeon for serial casting
B. Obtain leg radiographs to measure the thigh-foot angle
C. Suggest high-top, straight last shoes with arch supports
D. Send patient to be fitted for a Denis-Brown bar
E. Reassure parents that no treatment is needed at this age
4. You are seeing a 12-year-old girl in the clinic because she has ptosis and muscle weakness after repetitive use. You suspect a diagnosis of myasthenia gravis. The best next test to confirm th
diagnosis would be:
A. EMG
B. EEG
C. Anti-acetylcholine receptor antibodies assay in the serum
, D. Muscle biopsy
E. Serum creatine phosphokinase (CPK) level
5. You are seeing a 9-month-old boy for a well-child exam. This is his first visit to the clinic since the age of 2 months because his parents are homeless and have been living in multipl
shelters. He has been bottle fed and reportedly began solids around 6 months of age. The mother does not report any excessive spitting-up, feeding problems, or undercurrent illnesses. O
exam, he is alert and interactive, but markedly thin. The rest of the physical exam is normal. His growth chart reveals that his head circumference and length have dropped from the 90th to th
75th percentile, while his weight has dropped from the 75th to less than the 25th percentile. CBC, lead level, urinalysis, CMP, thyroid function, HIV, and sweat tests are all normal. The bes
next step in management would be:
A. Contrast head MRI
B. Contrast head CT
C. Nuclear medicine gastric emptying study
D. Colonoscopy with biopsies
E. Hospitalization for observed feedings and calorie count
6. You are seeing a 12-year-old obese female in your clinic for the first time. The mother reports that her daughter had a low glucose as a newborn and was very floppy. She had feeding difficultie
and grew poorly, requiring nutritional supplements as an infant; she is now overweight. Her mother reports that she is obsessed with food, hides food, and sneaks into the refrigerator at night
She is very behind in school and is in special education classes. On physical examination, she has blue, almond-shaped eyes, and blond hair. She has very small hands and feet. Her speech i
nasal in quality. She is quite obese, with her weight above the 99th percentile, and is short for her age. Due to your suspicions, you order a chromosomal evaluation. The result shows a
abnormality of chromosome 15. Which of the following is accurate counseling about this patient’s syndrome?
A. Hypotonia is progressive, leading to respiratory failure
B. Mental retardation is uncommon
C. Ataxia is commonly seen in older children
D. Obesity and sleep apnea are common in older patients
E. Cardiac and skeletal defects are common
7. A 6-year-old boy who is in first grade is brought to your clinic because his parents are quite upset about his encopresis. The patient had been successfully toilet trained at 3 years of age, bu
the mother reports the boy now goes several days without having a bowel movement. His stools are so large in size that there is pain with bowel movements. About three times a week, th
patient has loose stool that leaks into his underwear. This is causing great problems with teasing at school. On physical examination, you find a large amount of stool in the rectum. The bes
next step in the management of this patient is:
A. Institute a low-fiber diet
B. Prescribe enemas or laxatives to evacuate retained stool
C. Have child sit on toilet for at least 30 minutes (or until bowel movement) daily
D. Order a barium enema
E. Refer patient to a child psychiatrist
8. A 3-year-old boy is seen in your clinic because of an apparent ataxia that has been progressive for the past year. Recently he has also developed “ bloodshot” eyes, which is not associated wit
eye drainage. His other significant history shows that he suffers from rather severe and resistant sinopulmonary infections and otitis media. Examination reveals bilateral telangiectasis of th
conjunctiva. You are concerned about an immunodeficiency syndrome. Which of the following is the most accurate information to give to the family?
A. This condition is transmitted as an autosomal dominant trait; therefore a parent should have this condition, or it is a result of a genetic mutation
B. Agammaglobulinemia frequently accompanies this condition
C. Thymus hypoplasia is associated with this condition
D. The ataxia which occurs is usually a static condition and not progressive
E. T-cell function is abnormal, and therefore lymphoproliferative disorders are usually of very low incidence
9. A 2-month-old boy is seen at a clinic well-child checkup and is noted to have a head size greater than the 95th percentile. His height and weight are both near the 50th percentile. His hea
control is poor, and his anterior fontanelle is also quite large. His cranial sutures are slightly separated. A head ultrasound is ordered (Figure 3-9). Which one of the following statement
applies to this patient?
A. The ultrasound examination reveals hydranencephaly
B. The ultrasound is most consistent with a Dandy-Walker cyst
C. A ventricle peritoneal shunt would offer no benefit to this patient
D. This abnormality is generally associated with myelomeningocele
E. This benign condition needs only long-term observation
Figure 3-9 • Image Courtesy of the Department of Radiology, Phoenix Children’s Hospital, Phoenix, Arizona.
10. A 3-year-old girl presents with a history of coke-colored urine and periorbital edema. She has previously been well, but was noted to have URI symptoms and a sore throat with fever about
weeks ago. These symptoms appeared to resolve spontaneously. Her presumed diagnosis is poststreptococcal glomerulonephritis (PSGN). Which one of the following statements is consisten
with this diagnosis?
A. Thinning of the glomerular basement membrane
B. Late development of hypertension
, C. Elevated serum antistreptolysin O (ASO) titer, but a negative anti-DNAase titer
D. Decreased renal tubular function
E. A low serum C3 complement
11. You are seeing a term infant in the clinic for the first time. The infant was born to a mother who abused cocaine throughout her pregnancy. Which of the following is an associated complicatio
of in-utero cocaine exposure that you might expect in this patient?
A. Ventricular septal defect
B. Postterm delivery
C. Hydrocephalus
D. Placenta previa
E. Hearing loss
12. A 6-year-old child is being seen in your clinic for the evaluation of scalp itching. On further exam you notice that the boy’s hair reveals evidence of head lice. Which of the following would b
appropriate advice for this boy’s parents?
A. Head lice are highly contagious as they can jump from person to person
B. Head lice carry contagious diseases
C. Infestation can often occur after sharing clothing or helmets
D. The one-time application of permethrin 1% is inadequate treatment
E. The child should be allowed to return to school once all nits are gone
13. An 8-year-old male is being evaluated in your clinic for obesity. He is in the second grade and has otherwise been healthy and developing appropriately. His body mass index is 32. Which o
the following most likely applies to this patient’s obesity?
A. His exam is likely to yield normal findings
B. Sleep apnea is a potential complication
C. TSH levels are expected to be abnormal
D. A dietary history will be noncontributory
E. The patient is at a decreased risk for slipped capital femoral epiphysis
14. A 21/2-year-old male being seen in the clinic develops an urticarial rash and facial swelling after tasting peanut butter for the first time. He has had no previous history of urticaria, but does hav
a history of mild atopic dermatitis. Treatment with diphenhydramine improves the symptoms and they gradually clear with continued diphenhydramine administration. The parents ar
extremely anxious and have a number of questions. Which of the following would be correct information to give to the family?
A. Peanut allergy will be lifelong
B. Peanut allergy is more common in adults than in children
C. Risk factors for peanut allergy include a history of atopy
D. The prevalence of peanut allergy is decreasing
E. Peanut allergy is an IgA-mediated phenomenon
15. A 2-month-old with jaundice is seen in your clinic for the first time. The total and direct bilirubin levels are elevated and you are concerned about the possibility of biliary atresia. Which of th
following statements about your suspected diagnosis is true?
A. The condition is usually due to obliteration of the entire extrahepatic biliary tree
B. Biliary atresia is much more common than neonatal hepatitis
C. In biliary atresia, an abdominal ultrasound often shows a large gall bladder
D. A liver biopsy cannot differentiate biliary atresia from neonatal hepatitis
E. Success of the Kasai procedure is highest if performed after 6 months of life
16. An 18-month-old boy is seen in the clinic for a checkup. You note that he has severe dental decay. The mother is concerned about her son’s caries but has heard “ many different things abou
cavities.” Which of the following is accurate information to tell this child’s mother?
A. Caries are caused by an overgrowth of Staphylococcus aureus
B. Dental bacterial colonization occurs when a baby is born
C. The most likely source of bacterial colonization is the mother’s oral flora
D. Children of mothers with high rates of caries are not at greater-than-average risk for developing caries
E. Dental decay is equally common in rich and poor families
17. A 6-year-old girl is brought to your clinic because of poor weight gain, chronic cough, and intermittent diarrhea. She has a history of asthma and over the last 2 years she has had four bouts o
pneumonia that required hospitalization and antibiotic treatment. She takes an inhaled steroid daily, but is on no other medication. What would you do next?
A. Refer the patient to a nutritionist for a calorie count
B. Start a leukotriene inhibitor for better asthma control
C. Obtain a CT scan of the sinuses
D. Order a sweat chloride test
E. Refer the patient to a gastroenterologist to rule out Crohn disease
18. A 2-month-old baby comes to your clinic for a checkup. The mother is concerned that the baby has had noisy breathing since shortly after birth. The baby is taking the bottle well and has bee
gaining weight adequately. On physical examination the baby looks comfortable but has some intermittent inspiratory stridor, which is worsened in the supine position. Which statement abou
this condition is most accurate?
A. It is a common cause of expiratory wheezing in young infants
B. Symptoms usually appear around 6 months when chest muscles are getting stronger
C. The airway noise is due to collapse of the supraglottic structures during inspiration
D. Even in severe cases of upper airway obstruction, bronchoscopy is not necessary
E. Because symptoms rarely resolve spontaneously, most infants require tracheostomy
19. 14-year-old girl is seen at your clinic because of significant pain and swelling of her knees and ankles for the past 2 weeks. She has also had intermittent fevers. There is no family history o
arthritis. A rheumatoid factor (RF) is negative, an ASO titer is negative, her sedimentation rate is 80, and an ANA is significantly positive. Which one of the following statements is accurat
regarding this girl’s illness?
A. There is sufficient evidence in the information given to make the diagnosis of systemic lupus erythematosus (SLE)
B. The positive ANA has a low sensitivity but a high positive predictive value for the diagnosis of SLE
C. The presence of a malar rash and a positive anti-DNA antibody test in addition to the findings described will make the diagnosis of SLE
D. In children and adolescents with SLE, renal disease is uncommon and does not usually contribute to long-term morbidity as it does in adults
E. Lupus patients usually produce a variety of anti-nuclear antibodies, but it is unusual to find other autoantibodies
20. A 7-year-old boy is referred to you because he is found to have problems concentrating in school. His teacher also notes that his cognition is near the bottom of the class. You take a thoroug
history and determine that the patient has been exposed to lead in the home. A blood lead level is 30 µg/dL (normal is <10 µg/dL). The next most appropriate step in managing this patien
includes:
A. Immediate chelation therapy with bronchoalveolar lavage (BAL) and 2,3-dimercaptosuccinic acid (DMSA)
B. Removal from the source of exposure
C. Admission to the hospital for observation and repeat lead levels
, D. Calling child welfare to apprehend the child
E. Performing x-rays of the long bones
21. A 12-year-old girl is seen in your clinic for a preschool checkup. She is found to have a blood pressure of 135/90. She is at the 75th percentile for height and weight. Her femoral pulses ar
good. She has no cardiac murmurs. Her examination is normal. A urinalysis is also normal. You confirm the blood pressure readings several times in your clinic, and the blood pressure
remain about the same. You also check that the cuff size is normal. You consult the tables for normal blood pressure and find that, for her height and age, the 95th percentile for systolic is 12
and for diastolic is 82. Your next step would be:
A. Prescribe a mild diuretic
B. Place her on a low-sodium diet
C. Obtain a renal ultrasound
D. Advise her that this blood pressure is at the upper limits of normal for her age
E. Use a home blood pressure monitor for 24 to 48 hours
22. 9-year-old boy is seen in your clinic with a skin rash he’s had for the past 2 days. The rash is mostly on his trunk, and seems to come and go. The rash is red and slightly raised, appears t
migrate, and is nonpruritic. He gives a history of having had a sore throat about 2 weeks ago, and has had some low-grade fevers and joint pains. An ASO titer is 1:625. Which one group o
findings would confirm the diagnosis of acute rheumatic fever?
A. Arthralgia, no fever, and a rash resembling erythema multiforme
B. Subcutaneous nodules, fever, and arthralgia
C. Erythema multiforme, arthralgia, and prolonged PR interval
D. Arthralgia, fever, no rash, and erythrocyte sedimentation rate (ESR) = 120
E. Arthritis, no fever, and ESR = 10
23. A 13-year-old slender early adolescent girl has been complaining of right hip discomfort for several weeks. An examination reveals significant discomfort when that hip is rotated, and she prefer
to keep her hip slightly flexed and externally rotated. Which one of the following is the most accurate information to give to the family?
A. Endocrine dysfunction need not be considered as causative factor in slipped capital femoral epiphysis
B. Slipped capital femoral epiphysis occurs most often in obese adolescent girls
C. About 50% of cases of slipped capital femoral epiphysis in girls occur after puberty
D. A simple anterior-posterior (AP) pelvis x-ray may not demonstrate a slipped capital femoral epiphysis
E. Slipped capital femoral epiphysis is not commonly bilateral
24. A 2-year-old boy presents to the clinic and has pallor on exam. His mother states that he drinks 45 ounces of cow’s milk a day. A CBC reveals a hemoglobin of 8.2 and a mean corpuscula
volume (MCV) of 65. Which of the following indices is compatible with this patient’s diagnosis?
A. Decreased red blood cell distribution width (RDW)
B. Increased serum ferritin
C. Increased total iron binding capacity (TIBC)
D. Increased reticulocyte count
E. Increased serum iron level
25. A 15-month-old boy is seen in your clinic because of vomiting and diarrhea. He had two episodes of vomiting earlier today, but now he is able to drink small amounts of fluid without emesis
On physical examination, you find the baby to be mildly dehydrated, but the remainder of the examination is completely within normal limits. Rather than hospitalizing the baby for IV fluids
you decide to treat with oral rehydration solution at home. The composition of the oral rehydration solution should be:
A. 20–30 mEq of sodium per liter; 2% glucose
B. 40–50 mEq of sodium per liter; no glucose
C. 50–90 mEq of sodium per liter; no glucose
D. 50–90 mEq of sodium per liter; 10% to 12% glucose
E. 50–90 mEq of sodium per liter; 2% glucose
26. A 6-year-old boy is brought to your clinic because of fever and a painful, swollen eye. His mother thinks he may have been bitten by a mosquito on his face yesterday. The inflamed, tens
eyelid swelling, which was first noted about 18 hours ago, has progressed so that you are not able to examine the globe adequately. You order a CT scan of the orbit (Figure 3-26). How wil
you manage this patient?
A. Admit to the hospital for observation and pain control
B. Administer subcutaneous epinephrine and initiate oral corticosteroids
C. Begin oral administration of amoxicillin and see patient in clinic tomorrow
D. Start oral antihistamine and application of ice directly to the eye every 4 to 6 hours
E. Admit patient to the hospital to start IV antibiotics and obtain surgical consultation
SETTING 1: COMMUNITY-BASED HEALTH CENTER
You work at a community-based health facility where patients seeking both routine and urgent care are encountered. Many patients are members of low-income groups; many are ethnic minorit
Several industrial parks and local businesses send their employees to the health center for treatment of on-the-job injuries and employee health screening. There is a facility that provides x-ray fil
but CT and MRI scans must be arranged at other facilities. Laboratory services are available.
1. The left pupil of a 12-month-old girl has been noted to be white by the parents. Recently, she has been rubbing that eye and squinting when exposed to bright light. A full ophthalmic exam i
performed, but the retina is poorly visualized even after dilation of the pupil. A massive outpouring of white blood cells is seen in the anterior chamber, and fibrous strands are noted to exten
from the iris to the lens consistent with uveitis. The remainder of her physical exam is normal. Which of the following is the most appropriate first step in the management of this patient?
A. CT scan of the orbits
B. The avoidance of steroid eye drops
C. Blood samples for acute and convalescent titers of CMV, toxoplasmosis, syphilis, and toxocara
D. The avoidance of dilating eye drops
E. Titers of anti-nuclear antibody (ANA)
2. A 5-year-old boy is brought into the clinic with a history of “ white spots on his face” for 2 weeks. The lesions are nonpruritic and appear to have a fine scaly uniform texture (Figure 3-2)
Under Wood’s light exam there is no specific fluorescence. The mother thinks they have become worse since the return from his camping trip. Which of the following is the most appropriat
management option?
A. Dermatology referral
B. Griseofulvin
C. Low-potency topical corticosteroid
D. Topical selenium sulfide
E. Diphenhydramine (Benadryl)
Figure 3-2 • Image Courtesy of the Phoenix Children’s Hospital, Phoenix, Arizona.
3. A 2-year-old boy comes to your clinic for a checkup. He is well except that he walks with a slight in-toed gait. When you place him prone on the examination table with his knees flexed an
measure the angle formed by the axis of the thigh and the axis of the foot, you note that the foot is internally rotated. You diagnose internal tibial torsion. The best management for thi
condition at this age is:
A. Refer to a pediatric orthopedic surgeon for serial casting
B. Obtain leg radiographs to measure the thigh-foot angle
C. Suggest high-top, straight last shoes with arch supports
D. Send patient to be fitted for a Denis-Brown bar
E. Reassure parents that no treatment is needed at this age
4. You are seeing a 12-year-old girl in the clinic because she has ptosis and muscle weakness after repetitive use. You suspect a diagnosis of myasthenia gravis. The best next test to confirm th
diagnosis would be:
A. EMG
B. EEG
C. Anti-acetylcholine receptor antibodies assay in the serum
, D. Muscle biopsy
E. Serum creatine phosphokinase (CPK) level
5. You are seeing a 9-month-old boy for a well-child exam. This is his first visit to the clinic since the age of 2 months because his parents are homeless and have been living in multipl
shelters. He has been bottle fed and reportedly began solids around 6 months of age. The mother does not report any excessive spitting-up, feeding problems, or undercurrent illnesses. O
exam, he is alert and interactive, but markedly thin. The rest of the physical exam is normal. His growth chart reveals that his head circumference and length have dropped from the 90th to th
75th percentile, while his weight has dropped from the 75th to less than the 25th percentile. CBC, lead level, urinalysis, CMP, thyroid function, HIV, and sweat tests are all normal. The bes
next step in management would be:
A. Contrast head MRI
B. Contrast head CT
C. Nuclear medicine gastric emptying study
D. Colonoscopy with biopsies
E. Hospitalization for observed feedings and calorie count
6. You are seeing a 12-year-old obese female in your clinic for the first time. The mother reports that her daughter had a low glucose as a newborn and was very floppy. She had feeding difficultie
and grew poorly, requiring nutritional supplements as an infant; she is now overweight. Her mother reports that she is obsessed with food, hides food, and sneaks into the refrigerator at night
She is very behind in school and is in special education classes. On physical examination, she has blue, almond-shaped eyes, and blond hair. She has very small hands and feet. Her speech i
nasal in quality. She is quite obese, with her weight above the 99th percentile, and is short for her age. Due to your suspicions, you order a chromosomal evaluation. The result shows a
abnormality of chromosome 15. Which of the following is accurate counseling about this patient’s syndrome?
A. Hypotonia is progressive, leading to respiratory failure
B. Mental retardation is uncommon
C. Ataxia is commonly seen in older children
D. Obesity and sleep apnea are common in older patients
E. Cardiac and skeletal defects are common
7. A 6-year-old boy who is in first grade is brought to your clinic because his parents are quite upset about his encopresis. The patient had been successfully toilet trained at 3 years of age, bu
the mother reports the boy now goes several days without having a bowel movement. His stools are so large in size that there is pain with bowel movements. About three times a week, th
patient has loose stool that leaks into his underwear. This is causing great problems with teasing at school. On physical examination, you find a large amount of stool in the rectum. The bes
next step in the management of this patient is:
A. Institute a low-fiber diet
B. Prescribe enemas or laxatives to evacuate retained stool
C. Have child sit on toilet for at least 30 minutes (or until bowel movement) daily
D. Order a barium enema
E. Refer patient to a child psychiatrist
8. A 3-year-old boy is seen in your clinic because of an apparent ataxia that has been progressive for the past year. Recently he has also developed “ bloodshot” eyes, which is not associated wit
eye drainage. His other significant history shows that he suffers from rather severe and resistant sinopulmonary infections and otitis media. Examination reveals bilateral telangiectasis of th
conjunctiva. You are concerned about an immunodeficiency syndrome. Which of the following is the most accurate information to give to the family?
A. This condition is transmitted as an autosomal dominant trait; therefore a parent should have this condition, or it is a result of a genetic mutation
B. Agammaglobulinemia frequently accompanies this condition
C. Thymus hypoplasia is associated with this condition
D. The ataxia which occurs is usually a static condition and not progressive
E. T-cell function is abnormal, and therefore lymphoproliferative disorders are usually of very low incidence
9. A 2-month-old boy is seen at a clinic well-child checkup and is noted to have a head size greater than the 95th percentile. His height and weight are both near the 50th percentile. His hea
control is poor, and his anterior fontanelle is also quite large. His cranial sutures are slightly separated. A head ultrasound is ordered (Figure 3-9). Which one of the following statement
applies to this patient?
A. The ultrasound examination reveals hydranencephaly
B. The ultrasound is most consistent with a Dandy-Walker cyst
C. A ventricle peritoneal shunt would offer no benefit to this patient
D. This abnormality is generally associated with myelomeningocele
E. This benign condition needs only long-term observation
Figure 3-9 • Image Courtesy of the Department of Radiology, Phoenix Children’s Hospital, Phoenix, Arizona.
10. A 3-year-old girl presents with a history of coke-colored urine and periorbital edema. She has previously been well, but was noted to have URI symptoms and a sore throat with fever about
weeks ago. These symptoms appeared to resolve spontaneously. Her presumed diagnosis is poststreptococcal glomerulonephritis (PSGN). Which one of the following statements is consisten
with this diagnosis?
A. Thinning of the glomerular basement membrane
B. Late development of hypertension
, C. Elevated serum antistreptolysin O (ASO) titer, but a negative anti-DNAase titer
D. Decreased renal tubular function
E. A low serum C3 complement
11. You are seeing a term infant in the clinic for the first time. The infant was born to a mother who abused cocaine throughout her pregnancy. Which of the following is an associated complicatio
of in-utero cocaine exposure that you might expect in this patient?
A. Ventricular septal defect
B. Postterm delivery
C. Hydrocephalus
D. Placenta previa
E. Hearing loss
12. A 6-year-old child is being seen in your clinic for the evaluation of scalp itching. On further exam you notice that the boy’s hair reveals evidence of head lice. Which of the following would b
appropriate advice for this boy’s parents?
A. Head lice are highly contagious as they can jump from person to person
B. Head lice carry contagious diseases
C. Infestation can often occur after sharing clothing or helmets
D. The one-time application of permethrin 1% is inadequate treatment
E. The child should be allowed to return to school once all nits are gone
13. An 8-year-old male is being evaluated in your clinic for obesity. He is in the second grade and has otherwise been healthy and developing appropriately. His body mass index is 32. Which o
the following most likely applies to this patient’s obesity?
A. His exam is likely to yield normal findings
B. Sleep apnea is a potential complication
C. TSH levels are expected to be abnormal
D. A dietary history will be noncontributory
E. The patient is at a decreased risk for slipped capital femoral epiphysis
14. A 21/2-year-old male being seen in the clinic develops an urticarial rash and facial swelling after tasting peanut butter for the first time. He has had no previous history of urticaria, but does hav
a history of mild atopic dermatitis. Treatment with diphenhydramine improves the symptoms and they gradually clear with continued diphenhydramine administration. The parents ar
extremely anxious and have a number of questions. Which of the following would be correct information to give to the family?
A. Peanut allergy will be lifelong
B. Peanut allergy is more common in adults than in children
C. Risk factors for peanut allergy include a history of atopy
D. The prevalence of peanut allergy is decreasing
E. Peanut allergy is an IgA-mediated phenomenon
15. A 2-month-old with jaundice is seen in your clinic for the first time. The total and direct bilirubin levels are elevated and you are concerned about the possibility of biliary atresia. Which of th
following statements about your suspected diagnosis is true?
A. The condition is usually due to obliteration of the entire extrahepatic biliary tree
B. Biliary atresia is much more common than neonatal hepatitis
C. In biliary atresia, an abdominal ultrasound often shows a large gall bladder
D. A liver biopsy cannot differentiate biliary atresia from neonatal hepatitis
E. Success of the Kasai procedure is highest if performed after 6 months of life
16. An 18-month-old boy is seen in the clinic for a checkup. You note that he has severe dental decay. The mother is concerned about her son’s caries but has heard “ many different things abou
cavities.” Which of the following is accurate information to tell this child’s mother?
A. Caries are caused by an overgrowth of Staphylococcus aureus
B. Dental bacterial colonization occurs when a baby is born
C. The most likely source of bacterial colonization is the mother’s oral flora
D. Children of mothers with high rates of caries are not at greater-than-average risk for developing caries
E. Dental decay is equally common in rich and poor families
17. A 6-year-old girl is brought to your clinic because of poor weight gain, chronic cough, and intermittent diarrhea. She has a history of asthma and over the last 2 years she has had four bouts o
pneumonia that required hospitalization and antibiotic treatment. She takes an inhaled steroid daily, but is on no other medication. What would you do next?
A. Refer the patient to a nutritionist for a calorie count
B. Start a leukotriene inhibitor for better asthma control
C. Obtain a CT scan of the sinuses
D. Order a sweat chloride test
E. Refer the patient to a gastroenterologist to rule out Crohn disease
18. A 2-month-old baby comes to your clinic for a checkup. The mother is concerned that the baby has had noisy breathing since shortly after birth. The baby is taking the bottle well and has bee
gaining weight adequately. On physical examination the baby looks comfortable but has some intermittent inspiratory stridor, which is worsened in the supine position. Which statement abou
this condition is most accurate?
A. It is a common cause of expiratory wheezing in young infants
B. Symptoms usually appear around 6 months when chest muscles are getting stronger
C. The airway noise is due to collapse of the supraglottic structures during inspiration
D. Even in severe cases of upper airway obstruction, bronchoscopy is not necessary
E. Because symptoms rarely resolve spontaneously, most infants require tracheostomy
19. 14-year-old girl is seen at your clinic because of significant pain and swelling of her knees and ankles for the past 2 weeks. She has also had intermittent fevers. There is no family history o
arthritis. A rheumatoid factor (RF) is negative, an ASO titer is negative, her sedimentation rate is 80, and an ANA is significantly positive. Which one of the following statements is accurat
regarding this girl’s illness?
A. There is sufficient evidence in the information given to make the diagnosis of systemic lupus erythematosus (SLE)
B. The positive ANA has a low sensitivity but a high positive predictive value for the diagnosis of SLE
C. The presence of a malar rash and a positive anti-DNA antibody test in addition to the findings described will make the diagnosis of SLE
D. In children and adolescents with SLE, renal disease is uncommon and does not usually contribute to long-term morbidity as it does in adults
E. Lupus patients usually produce a variety of anti-nuclear antibodies, but it is unusual to find other autoantibodies
20. A 7-year-old boy is referred to you because he is found to have problems concentrating in school. His teacher also notes that his cognition is near the bottom of the class. You take a thoroug
history and determine that the patient has been exposed to lead in the home. A blood lead level is 30 µg/dL (normal is <10 µg/dL). The next most appropriate step in managing this patien
includes:
A. Immediate chelation therapy with bronchoalveolar lavage (BAL) and 2,3-dimercaptosuccinic acid (DMSA)
B. Removal from the source of exposure
C. Admission to the hospital for observation and repeat lead levels
, D. Calling child welfare to apprehend the child
E. Performing x-rays of the long bones
21. A 12-year-old girl is seen in your clinic for a preschool checkup. She is found to have a blood pressure of 135/90. She is at the 75th percentile for height and weight. Her femoral pulses ar
good. She has no cardiac murmurs. Her examination is normal. A urinalysis is also normal. You confirm the blood pressure readings several times in your clinic, and the blood pressure
remain about the same. You also check that the cuff size is normal. You consult the tables for normal blood pressure and find that, for her height and age, the 95th percentile for systolic is 12
and for diastolic is 82. Your next step would be:
A. Prescribe a mild diuretic
B. Place her on a low-sodium diet
C. Obtain a renal ultrasound
D. Advise her that this blood pressure is at the upper limits of normal for her age
E. Use a home blood pressure monitor for 24 to 48 hours
22. 9-year-old boy is seen in your clinic with a skin rash he’s had for the past 2 days. The rash is mostly on his trunk, and seems to come and go. The rash is red and slightly raised, appears t
migrate, and is nonpruritic. He gives a history of having had a sore throat about 2 weeks ago, and has had some low-grade fevers and joint pains. An ASO titer is 1:625. Which one group o
findings would confirm the diagnosis of acute rheumatic fever?
A. Arthralgia, no fever, and a rash resembling erythema multiforme
B. Subcutaneous nodules, fever, and arthralgia
C. Erythema multiforme, arthralgia, and prolonged PR interval
D. Arthralgia, fever, no rash, and erythrocyte sedimentation rate (ESR) = 120
E. Arthritis, no fever, and ESR = 10
23. A 13-year-old slender early adolescent girl has been complaining of right hip discomfort for several weeks. An examination reveals significant discomfort when that hip is rotated, and she prefer
to keep her hip slightly flexed and externally rotated. Which one of the following is the most accurate information to give to the family?
A. Endocrine dysfunction need not be considered as causative factor in slipped capital femoral epiphysis
B. Slipped capital femoral epiphysis occurs most often in obese adolescent girls
C. About 50% of cases of slipped capital femoral epiphysis in girls occur after puberty
D. A simple anterior-posterior (AP) pelvis x-ray may not demonstrate a slipped capital femoral epiphysis
E. Slipped capital femoral epiphysis is not commonly bilateral
24. A 2-year-old boy presents to the clinic and has pallor on exam. His mother states that he drinks 45 ounces of cow’s milk a day. A CBC reveals a hemoglobin of 8.2 and a mean corpuscula
volume (MCV) of 65. Which of the following indices is compatible with this patient’s diagnosis?
A. Decreased red blood cell distribution width (RDW)
B. Increased serum ferritin
C. Increased total iron binding capacity (TIBC)
D. Increased reticulocyte count
E. Increased serum iron level
25. A 15-month-old boy is seen in your clinic because of vomiting and diarrhea. He had two episodes of vomiting earlier today, but now he is able to drink small amounts of fluid without emesis
On physical examination, you find the baby to be mildly dehydrated, but the remainder of the examination is completely within normal limits. Rather than hospitalizing the baby for IV fluids
you decide to treat with oral rehydration solution at home. The composition of the oral rehydration solution should be:
A. 20–30 mEq of sodium per liter; 2% glucose
B. 40–50 mEq of sodium per liter; no glucose
C. 50–90 mEq of sodium per liter; no glucose
D. 50–90 mEq of sodium per liter; 10% to 12% glucose
E. 50–90 mEq of sodium per liter; 2% glucose
26. A 6-year-old boy is brought to your clinic because of fever and a painful, swollen eye. His mother thinks he may have been bitten by a mosquito on his face yesterday. The inflamed, tens
eyelid swelling, which was first noted about 18 hours ago, has progressed so that you are not able to examine the globe adequately. You order a CT scan of the orbit (Figure 3-26). How wil
you manage this patient?
A. Admit to the hospital for observation and pain control
B. Administer subcutaneous epinephrine and initiate oral corticosteroids
C. Begin oral administration of amoxicillin and see patient in clinic tomorrow
D. Start oral antihistamine and application of ice directly to the eye every 4 to 6 hours
E. Admit patient to the hospital to start IV antibiotics and obtain surgical consultation
