Aquifer Peds
A 1-month-old infant who is < 3rd percentile for weight presents to the clinic. He is
breastfed every 2 hours and latches on well. However, he has frequent non-bilious
episodes of vomiting that have been increasing over the past week despite his mother
instituting "reflux precautions." He does not have mucus or blood in his stool. Physical
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exam reveals a small, olive-sized mass in his abdomen. What is the most likely
diagnosis? - -Pyloric stenosis
A 10-day-old boy is brought to the ED by his mother because of fever. Mother describes
that the baby has been "sleepy" and feeding less vigorously than in the previous two
days. She believes his urine output has also decreased. His birth history is notable for
prolonged membrane rupture (about 32 hours), and maternal fever at the time of
delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam,
the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP,
and culture. Attempts are made to obtain CSF and urine for analysis and culture, but
only very small volumes of these fluids are obtained. Volume resuscitation is started.
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Chest x-ray is performed with indeterminate results. What is the most appropriate next
step? - -Send samples for culture and begin parenteral antibiotic treatment
A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a
normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with
scant calcifications on CT. A bone marrow biopsy is performed. Which of the following
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histologic findings on bone marrow biopsy is most consistent with your suspected
diagnosis? - -Small round blue cells with dense nuclei forming small rosettes
A 10-month-old infant is brought to the pediatrics emergency department by her
parents, who say she has been coughing persistently for the past three hours. The
parents were watching a movie at home when they first noticed their daughter coughing.
Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal
flaring, and grunting. Physical examination reveals diminished breath sounds in the right
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lung with normal breath sounds on the left. What other associated physical exam
findings are expected on auscultation? - -Asymmetric wheeze
A 10-year-old boy presents to his pediatrician with a history of hypopigmented
non-pruritic "dots," mostly located on his face and neck. His mother complains that
lesions get worse during the summer when her son plays outside. On exam, they are
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slightly scaly, hypopigmented lesions approximately 0.5 cm in diameter. What is the
most likely etiology of his rash? - -Decreased number of active melanocytes and
decreased number and size of melanosomes
,A 12-month-old previously healthy girl presents with cough and mild subcostal
retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest
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x-ray demonstrates unilateral air trapping. What is the most likely diagnosis? -
-Foreign body aspiration
A 12-year-old boy presents to the ED with reports of anorexia, weight loss, persistent
cough, with nocturnal coughing fits that have been waking him from sleep for the past
three weeks. He reports no fever, chills, myalgia, sore throat, or rhinorrhea. The patient
presented to his primary care clinician one week prior with the same report, and was
treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for
infiltrates at that visit. The patient's symptoms did not improve with this regimen. The
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cough became more frequent, sometimes causing emesis. Which of the following is the
most likely diagnosis? - -Infection w/ Bordetella pertussis in paroxysmal
A 12-year-old female presents to her pediatrician complaining of a headache of gradual
onset x 3 hours, non-provoked and described as a "big rubber band around my whole
head" and a 5 out of 10 on the pain scale. The pain is not throbbing, and there is no
associated photophobia, nausea or vomiting. The patient is afebrile, and there are no
neurologic deficits during physical exam. Her mother states her pain is typically relieved
with ibuprofen, but her mother is concerned that the patient may have migraines
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because she has a few headaches every month after school. The child is otherwise
healthy. What is the most likely cause of her headaches? - -Tension-type
headache
A 12-year-old male with obesity comes to the clinic with a chief concern of right knee
pain. On exam the right knee is neither swollen nor erythematous but he is noted to
have limited ROM of the right hip. In addition, when he lifts his right leg, it externally
rotates. The patient did not have a URI or any trauma preceding the onset of pain. The
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vital signs are normal at the time of the visit and he is well appearing and afebrile. What
is/are the best next step(s) in management? - -AP and lateral x-ray of hip
A 14-month-old female presents to the clinic with a fever of 39.2 C and irritability.
According to mom, the patient was initially sick one week ago with a runny nose and
cough, but these symptoms had resolved. She started pulling at her ear and becoming
increasingly irritable last night. She has had several prior ear infections and was most
recently treated one month ago with amoxicillin. She is up to date on immunizations.
Physical examination reveals a red, opaque, bulging tympanic membrane with bubbles
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and limited mobility of her left ear. The exam of the right ear is normal. Which of the
following is the next step in the management of this patient? - -Amox/Clav
,A 15-month-old male presents to the ED with a 3-day history of vomiting and diarrhea.
His current weight is 11 kg. He was born at 39 weeks, without any perinatal
complications. There is no significant history of travel, sick contacts, or recent changes
in diet. The mother notes that he has had only 2 urine diapers over the last day.
Physical exam is remarkable for an irritable but consolable infant with tachycardia and
normal blood pressure. He is crying with minimal tears and his mucous membranes are
dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds.
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He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the
following statements is true? - -The patient is moderately dehydrated and should
be managed with 50-100ml/kg of oral rehydrating solution over 2-4 hours.
A 15-year-old female is brought to the ER with a chief concern of abdominal pain for
three hours. She rates her pain at 8/10 and describes it as constant and located mainly
in the middle of her abdomen. It is worse with coughing and moving. She had two
episodes of nonbilious, non-bloody vomiting. She is sexually active with her boyfriend of
three months and always uses condoms. Her last menstrual period was two weeks ago.
Vital signs are normal. On exam, she exhibits involuntary guarding, mild rebound
tenderness, and tenderness to palpation between her right anterior superior iliac spine
and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her
right adnexa, but no masses are appreciated and there is no cervical motion
tenderness. Laboratory studies reveal normal complete blood count and c reactive
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protein. Which of the following is the most likely diagnosis in this patient? -
-Appendicitis
A 15-year-old female presents with three hours of abdominal pain and two episodes of
nonbilious, nonbloody vomiting. She rates her pain at 8/10 and describes it as constant,
diffuse, but most severe in her periumbilical region. It is worse with coughing and
moving. She has never had pain like this before and has had no appetite since the pain
started. She is sexually active with her boyfriend of three months, always uses
condoms, and has not been tested for STIs. She is due to start her menstrual cycle next
week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she
exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation
between her right anterior superior iliac spine and umbilicus. On pelvic exam, she
reports tenderness when attempting to palpate her right adnexa, but there are no
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masses and no cervical motion tenderness. Her WBC and CRP are both mildly
elevated. Based on th - -Appendicitis
A 16-month-old male is brought to the urgent care clinic by his father because of a
seizure 30 minutes ago. The child dropped to the floor with loss of consciousness and
, had sporadic twitchy movements of his legs and arms that lasted for five minutes. He
had URI symptoms for the past two days, with a fever to 39.4 C (103 F) today. He is
previously healthy and had normal developmental screening at his last visit. Neither
parent has a seizure disorder, but the child's mother had a single seizure as a young girl
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after developing a high fever with a cold. Which of the following is the most likely
diagnosis in this patient? - -Simple febrile seizure
A 16-year old female presents to the ED with abdominal pain. Upon questioning, the
patient notes that the pain is consistently in the RLQ without radiation. She reports no
dysuria, hematuria, diarrhea, or hematochezia. She has a history of multiple sexual
partners and inconsistent condom use. She does not use any other contraceptive
measures. She believes her last menstrual period was 3 weeks ago, but she is unsure.
She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, pulse
is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her
abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ
without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for
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cervical motion tenderness with some discharge. What is the best NEXT step in
management? - -Pregnancy test
A 16-year-old boy presents to your office requesting clearance to play football. You
begin by taking his medical history. He says that he feels very well, but admits that he
recently experienced one episode of syncope that occurred when he trained really hard
for football tryouts with his friends. He denies any shortness of breath, or chest pain
currently. Family history is significant for an uncle who died of heat stroke at the age of
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30 while playing basketball. Physical examination reveals no abnormalities. What is the
next best step in management? - -Refer to Cardiology
A 16-year-old female presents with acute onset of diffuse abdominal pain with
intermittent sharpness in the epigastrium that radiates to her back. She has had some
episodes of vomiting and has a low grade fever. She is sexually active and has used
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alcohol in the past. Which of the following is most likely to present with epigastric
abdominal pain? - -Pancreatitis
A 16-year-old female with a history of irregular menses presents to the ED with severe
abdominal pain. She has regular unprotected sexual intercourse with multiple male
sexual partners. She has experienced fevers, nausea, vomiting, right shoulder pain and
reports no vaginal bleeding or discharge. Vitals are T 38.0 C, BP 90/60 mmHg, P 120
bpm, R 20 bpm. Qualitative ß-hCG is positive, and hemoglobin is 7 g/dL. Physical exam
reveals that she has difficulty answering questions due to pain. Auscultation of the chest
is notable for tachycardia, a murmur, and clear lungs bilaterally. The abdomen is rigid
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