I Can See Clearly Now
Beat It!
Paging Dr. Kaicker
The knee bone's connected to the hip bone
A Picture is Worth ...
100
A 2-year-old boy presents to your office with a 2-day history of swelling of the right eye. He has been otherwise well. There are scattered insect bites on his body, including one about 2 cm lateral to the affected eye. There is no discharge, and the bite appears to be healing. The boy's right eyelids are swollen and seem tender to palpation. Of the following, the MOST concerning additional ophthalmologic finding for this boy is: A. decreased extraocular movements B. hyperemia of the palpebral conjunctiva C. photophobia D. purulent exudates E. subconjunctival hemorrhage
A. decreased extraocular movements
100
During a routine health supervision visit, the mother of one of your patients informs you that she is 28 weeks pregnant and that fetal echocardiography has revealed tetralogy of Fallot in an otherwise normal fetus. She asks you about the prognosis for children who have this condition. Of the following, the MOST appropriate response is that: A. cardiac catheterization techniques may help avoid surgery B. complete repair is associated with an excellent result, with less than 5 % mortality C. surgery most likely will be undertaken before the child is discharged after birth D. tetralogy of Fallot rarely is associated with chromosomal abnormalities E. the usual surgical approach is palliative and requires three stages
B. complete repair is associated with an excellent result, with less than 5 % mortality
100
Which of the following is the least common finding in a new pediatric leukemia patient? A. Bone pain B. Fevers C. Hepatosplenomegaly D. Platelets < 50,000 E. WBC > 100,000
E. WBC > 100,000
100
This painless bone mass looks like "sclerotic destruction of bone with new born formation in a sunburst pattern" on Xray.
Osteosarcoma
100
Daily Double: A 12-year-old boy is brought to the emergency department by emergency medical services after sustaining a lower leg injury sliding into home plate during a baseball game. He tells you that he thinks his leg twisted when he slid. He reports that he had immediate pain in his right ankle and has been unable to walk since the injury occurred. Prior to transport, the paramedics splinted his right lower leg. On physical examination, he has significant swelling and ecchymosis around his distal tibia and fibula. Following the administration of analgesia, radiographs are obtained (See Picture). 1. What is the injury (be specific)? 2. Of the following, the MOST likely complication of this injury is: A. avascular necrosis of the distal tibia B. osteochondritis desiccans C. osteomyelitis D. tibial growth arrest E. unicameral bone cyst
1. Salter Harris Type IV fracture 2. D. tibial growth arrest
200
You are treating a former extremely low-gestational age newborn (ELGAN) who was born at 26 weeks' gestation weighing 700 g. She is now 4 weeks old. Her nurse asks when the eye examination for retinopathy of prematurity (ROP) will be performed and what risk for significant visual impairment exists in this infant. Of the following, the BEST time to obtain the first ROP screening eye examination in this infant is: A. 4 weeks after discharge from the hospital B. 4 weeks after weaning from oxygen C. 5 weeks after birth D. 5 weeks after the expected delivery date E. 5 weeks after weaning from the ventilator
C. 5 weeks after birth
200
Yesterday, you received a call from the newborn nursery that they were referring to you a term infant who was being discharged at 4 days of age. The female newborn's birthweight was 3.3 kg and the delivery was by repeat cesarean section. Findings on physical examination at discharge, including heart rate, respiratory rate, and blood pressure, were normal. Her lungs were clear, and no murmurs were noted. She was breastfeeding without difficulty. Today, her mother calls to tell you that she is difficult to awaken, pale, and breathing much more rapidly than she was in the hospital nursery. She has had one wet diaper in the last 12 hours. When you meet them in the emergency department, you note that the infant has cool extremities, weak pulses, and lethargy. Of the following, the MOST likely cause of this newborn's condition is A. aortic coarctation B. atrioventricular septal (canal) defect C. tetralogy of Fallot D. transposition of the great arteries E. ventricular septal defect
A. aortic coarctation **Bonus Question $200
200
An 8-week-old breastfed boy is brought to the clinic for his health supervision visit. His mother thinks he may be more pale than her other children, but he has otherwise been healthy. Findings on physical examination and vital signs are normal. He does not appear pale to you. A complete blood count reveals hemoglobin of 9 g/dL (90 g/L) and a mean cell volume of 85 fL. The remainder of the complete blood count is normal. Of the following, the MOST appropriate recommendation for this infant is to A. administer a daily multivitamin and folic acid B. admit the infant for a packed red blood cell transfusion C. measure serum iron and transferrin concentrations D. reassure the mother that the anemia will resolve E. switch feeding to an iron-fortified infant formula
D. reassure the mother that the anemia will resolve
200
This painful bone lesion appears as a radiolucent nidus on Xray with surrounding sclerotic bone and responds to aspirin but not tylenol
Osteoid osteoma
200
The mother of a 10-month-old child who has mild hypotonia brings him to the office after he has an unprovoked seizure. On physical examination, you note several hypopigmented macules on the trunk (See Picture). Magnetic resonance imaging of the brain reveals several thickened areas of cerebral cortex, with abnormal signal and abnormalities along the walls of the lateral ventricles. Of the following, the MOST likely diagnosis is A. incontinentia pigmenti B. neurofibromatosis type 1 C. Sturge-Weber syndrome D. tuberous sclerosis E. von Hippel-Lindau syndrome
D. tuberous sclerosis
300
A 16-year-old baseball player is brought to the emergency department after being hit in the left eye by a pitched ball. He complains of severe pain and decreased vision in his left eye. His heart rate is 120 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 140/86 mm Hg. Physical examination reveals an agitated boy who has marked swelling around his left orbit but no palpable deformities along the orbital ridge. His extraocular movements are intact bilaterally. His right pupil is 3 mm and briskly reactive, but his left pupil is 5 mm and sluggishly reactive. Closer inspection of the left eye reveals findings shown in picture. Of the following, the MOST appropriate next step is to A. administer antibiotic eyedrops B. administer ibuprofen for analgesia C. instruct the boy to lay flat in bed D. place an eye shield over the left eye E. sedate the boy with ketamine
D. place an eye shield over the left eye
300
Which of the following is a commonly associated finding with hypertrophic cardiomyopathy? A. A systolic murmur heard best at the apex and LLSB which increases in intensity when moving from an upright to a supine position B. A systolic murmur heard best at the LUSB, which increases in intensity with the Valsalva maneuver C. A diastolic murmur heard best at the LUSB while standing D. A harsh murmur present during systole and diastole heard best at the right and left second ICS E. A midsystolic click heard best when sitting and leaning forward.
B. A systolic murmur heard best at the LUSB, which increases in intensity with the Valsalva maneuver
300
In which condition do you see Howell-Jolly bodies on peripheral smear?
Post-Splenectomy or functional asplenia
300
This painless bone lesion presents as a lytic lesion with surrounding periosteal reaction and can be found in the long bones, pelvis, and ribs.
Ewing's Sarcoma
300
You are camping with a group of boys at a rural campground in the southeastern United States when one of the campers is bitten by a snake. His tent mates kill the snake (See picture). The victim is crying and guarding his right hand. On examination of the boy's hand, you note several small, erythematous abrasions but no swelling or ecchymosis. Of the following, the MOST appropriate course of action is to: A. apply a tourniquet above the bite B. apply ice to the wound C. incise and suction the wound D. provide local wound care E. transport the boy to the hospital for antivenom
D. provide local wound care Bonus Question: What else is important in the immediate management of this patient?
400
At what age does visual fixation occur in the newborn?
Age 6-9 weeks
400
Left axis deviation on the electrocardiogram is seen in which two conditions: A. VSD and aortic stenosis B. Aortic stenosis and PDA C. Pulmonary atresia and tricuspid atresia D. Tricuspid atresia and VSD E. Tricuspid atresia and AV canal defect
E. Tricuspid atresia and AV canal defect *Bonus question $800
400
Which of the following is the most dangerous? A. ANC = 100 that is virus-induced B. ANC = 500 that is chemotherapy-induced C. ANC = 0 that is due to autoimmune neutropenia D. ANC = 100 that is due to Kostmann syndrome E. ANC = 50 that is due to cyclic neutropenia
D. ANC = 100 that is due to Kostmann syndrome
400
Intoeing at age 6 months -2 years is due to?
Internal Tibial Torsion **Bonus Question: $400
400
A 14-year-old girl presents for evaluation of areas of skin thickening, tightness, and discoloration that developed 2 months ago. Physical examination reveals shiny, hypopigmented patches with brown borders on the leg and ankle. The affected skin is immobile, firm, and has a "bound-down" feeling. See Picture. Of the following, the MOST likely diagnosis is: A. lichen sclerosus et atrophicus B. linear scleroderma C. pityriasis alba D. progressive systemic sclerosis E. vitiligo
B. linear scleroderma
500
A 13 y.o. male is brought to the ED with a dramatic decrease in visual acuity. He reports that he thinks a metal sliver went into his eye during shop class, when he experienced severe pain in his left eye while trying to pry open a metal lock with a screwdriver. He tried washing it out but the pain persisted. Physical exam reveals a severely erythematous left eye with ring abscess and corneal deterioration on slit lamp exam. Which of the following is the most likely pathogen to cause these symptoms? A. Bacillus cereus B. Acanthamoeba C. Bartonella henselae D. Staphylococcus epidermidis E. Streptococcus oralis
A. Bacillus cereus
500
Included in your rounds today is a 36-hour-old boy who was born at term by normal, spontaneous vaginal delivery. His respiratory rate is 80 breaths/min and heart rate is 168/min. He has easily palpable, bounding pulses in all four extremities, and his blood pressure is 72/30 mm Hg. Precordial examination reveals a lift and a 3/6 systolic ejection murmur at the upper left sternal border. You also note a murmur over the anterior fontanelle. Of the following, the MOST likely diagnosis is A. aortic coarctation with congestive heart failure B. aortic insufficiency C. large ventricular septal defect with congestive heart failure D. left-to-right extracardiac shunting with congestive heart failure E. right-to-left extracardiac shunting with right heart failure
D. left-to-right extracardiac shunting with congestive heart failure
500
An African-American mother brings her 4-week-old daughter to the emergency department because of progressive shortness of breath and pallor. She had mild anemia and jaundice shortly after birth, which was believed to be due to ABO incompatibility (mother is type O-, infant is type A-). She required phototherapy for 1 day and was discharged without further complications. Her respiratory rate today is 65 breaths/min and heart rate is 170 beats/min. She appears pale and mildly icteric and has mild-to-moderate respiratory distress. Complete blood count reveals a hemoglobin of 5 mg/dL (50 g/L) and a mean cell volume of 95 fL. Of the following, the MOST likely cause of this child's severe anemia is A. ABO incompatibility B. Diamond-Blackfan anemia C. hemoglobin SS disease D. iron deficiency E. physiologic anemia of infancy
A. ABO incompatibility
500
This painless benign bone lesion appears as a sharply marginated eccentric lucency in the femoral metaphyseal cortex and generally regresses without treatment.
Fibroma (fibrous cortical defect)
500
A 16-year-old girl who has moderate persistent asthma presents to the emergency department with coughing, wheezing, and increasing dyspnea. She states that she was feeling fine until she was exposed to cologne that one of her classmates was wearing. An ambulance was called after her symptoms did not improve following administration of two puffs of her beta2 agonist inhaler. On physical examination, the teenager has a respiratory rate of 30 breaths/min, heart rate of 90 beats/min, and pulse oximetry of 98% on room air. She has difficulty completing a sentence and points to her neck, saying it is "hard to get air in." PFTs are as pictured. Of the following, the MOST likely cause for this patient's symptoms is: A. allergic rhinitis B. asthma exacerbation C. habit cough D. sinusitis E. vocal cord dysfunction
E. vocal cord dysfunction
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