History Taking and Performing Physical Examination
A 2-month-old male presents with poor feeding and irritability. The mother reports that over the past two days, he has become more difficult to console, feeds less frequently, and sleeps more. He was born at term via uncomplicated vaginal delivery and is exclusively breastfed. On physical exam, he appears lethargic, has a bulging fontanelle, and a high-pitched cry.
Which additional historical detail is most critical to assess first?
A. Recent travel history
B. Birth weight and growth trajectory
C. Maternal history of HSV or STIs
D. Timing of last vaccinations
E. Contact with siblings who attend daycare
Correct Answer: C. Maternal history of HSV or STIs
Explanation:
Bulging fontanelle, lethargy, and high-pitched cry in a 2-month-old suggest meningitis or encephalitis, and HSV is a key neonatal pathogen. A maternal history of HSV or STIs would increase suspicion for neonatal HSV encephalitis, which is life-threatening if not treated early.
A 6-week-old female is brought in with a rectal temperature of 101.5°F. She is feeding adequately and appears well on exam. No source of infection is identified on history or physical exam.
Which of the following diagnostic tests is most appropriate to include in the initial workup?
A. Rapid strep test
B. Chest X-ray
C. Urinalysis with urine culture
D. Serum RSV and influenza testing
E. Stool culture
Correct Answer: C. Urinalysis with urine culture
Explanation:
In infants under 2–3 months, urinary tract infections are a common and often occult source of fever. A urinalysis with culture via catheterized specimen is a standard part of the fever workup in this age group, regardless of exam findings.
A 3-year-old is brought in with a 2-day history of low-grade fever, nasal congestion, and a barking cough. Parents report that his breathing becomes noisy at night. On exam, he has inspiratory stridor at rest and mild intercostal retractions.
What is the most likely diagnosis?
A. Epiglottitis
B. Foreign body aspiration
C. Croup (laryngotracheitis)
D. Asthma exacerbation
E. Bronchiolitis
Correct Answer: C. Croup (laryngotracheitis)
Explanation: The classic presentation of croup includes a barking cough, inspiratory stridor, and preceding viral symptoms. Epiglottitis presents more severely with drooling and tripod positioning.
Immunization Delay in a Toddler
A 15-month-old presents for a well-child visit. His mother reports that he received his 2- and 4-month vaccines on schedule but missed his 6-month visit due to travel. He has had no vaccines since then.
What is the best approach to catch up on his immunizations?
A. Restart the entire vaccine series from the beginning
B. Repeat the 2- and 4-month vaccines before moving forward
C. Administer only the 15-month vaccines today and recheck in 6 months
D. Continue the vaccine series from where it was interrupted
E. Delay all vaccines until antibody titers are drawn
Correct Answer: D. Continue the vaccine series from where it was interrupted
Explanation: The CDC catch-up schedule allows continuation without restarting. Previous valid doses remain effective.
A 1-month-old presents with poor feeding, irritability, and a rectal temperature of 38.4°C. On exam, the infant is lethargic with delayed capillary refill.
What is the most appropriate next step in management?
A. Send home with close follow-up
B. Administer oral antibiotics and monitor
C. Order outpatient blood work and urinalysis
D. Admit for IV antibiotics and full sepsis workup
E. Observe in office for 1 hour
Correct Answer: D. Admit for IV antibiotics and full sepsis workup
Explanation: Any febrile infant under 28–60 days requires hospitalization, blood/urine/CSF cultures, and empiric IV antibiotics due to risk of serious bacterial infection.
A 6-month-old weighing 7 kg presents with a fever. The parent asks how much acetaminophen to give at home. The concentration is 160 mg/5 mL.
What is the appropriate single dose?
A. 1 mL
B. 2 mL
C. 3 mL
D. 4 mL
E. 5 mL
Correct Answer: C. 3 mL
Explanation: The standard dose is 10–15 mg/kg. At 15 mg/kg × 7 kg = 105 mg. 105 mg ÷ 160 mg × 5 mL = ~3.3 mL. Rounding to 3 mL is a safe and typical dosing approximation.
A term newborn becomes cyanotic during feeding but improves when crying. Cardiac exam reveals a harsh systolic murmur and a single second heart sound.
Which physiological mechanism best explains this presentation?
A. Decreased systemic vascular resistance
B. Pulmonary overcirculation
C. Right-to-left shunt due to right ventricular outflow obstruction
D. Patent ductus arteriosus with left-to-right flow
E. Incomplete closure of the foramen ovale
Correct Answer: C. Right-to-left shunt due to right ventricular outflow obstruction
Explanation: This presentation is consistent with Tetralogy of Fallot, where obstruction of right ventricular outflow causes deoxygenated blood to shunt into the systemic circulation, especially during feeding or agitation when systemic resistance drops.
A 3-year-old female presents with a 2-day history of cough and wheezing. Her father reports that she has no significant past medical history and no known allergies. On exam, she is afebrile, alert, and has diffuse wheezes without rales. Respiratory rate is 34 breaths/min. Oxygen saturation is 97% on room air.
Which additional physical exam finding would be most important to assess for severity?
A. Presence of nasal flaring
B. Capillary refill time
C. Presence of a murmur
D. Bowel sounds
E. Pupillary light reflex
Correct Answer: A. Presence of nasal flaring
Explanation:
Nasal flaring indicates increased work of breathing in pediatric patients. In the context of wheezing, it helps determine if the child is compensating or decompensating, guiding urgency of intervention.
A 13-year-old girl presents with heavy menstrual bleeding since menarche 3 months ago. Her periods last 9–10 days with large clots. She appears pale and fatigued. Her physical exam is otherwise unremarkable.
Which of the following initial laboratory studies is most appropriate?
A. Pelvic ultrasound
B. Iron panel and serum ferritin
C. Complete blood count with platelet count
D. Prothrombin time and activated partial thromboplastin time
E. Hormonal panel (FSH, LH, estradiol)
Correct Answer: C. Complete blood count with platelet count
Explanation:
Heavy menstrual bleeding in adolescents may be due to anovulatory cycles or a bleeding disorder such as von Willebrand disease. A CBC with platelets is essential to assess for anemia and thrombocytopenia, which can help identify the severity and possible etiology.
A 5-year-old with New-Onset Limp and Night Pain
A 5-year-old presents with a limp that has progressed over 2 weeks. The pain is worse at night and not relieved with ibuprofen. He has no recent injury. Physical exam reveals mild thigh tenderness but no swelling or erythema. Labs show mild anemia.
What is the most likely diagnosis?
A. Osteomyelitis
B. Growing pains
C. Acute lymphoblastic leukemia
D. Transient synovitis
E. Juvenile idiopathic arthritis
Correct Answer: C. Acute lymphoblastic leukemia
Explanation: Night pain, limp, systemic signs (anemia), and lack of trauma suggest leukemia with bone marrow involvement rather than isolated joint or bone pathology.
You are seeing a healthy 2-month-old for a routine well-baby visit. The parent reports that the baby sometimes naps in the car seat because it helps him sleep better.
What advice is most appropriate?
A. It's safe if the seat is secured and supervised
B. Use car seat only for travel and always place baby flat on the back for sleep
C. Side-sleeping is better than prone sleeping
D. Elevate the head of the crib to help with reflux
E. Co-sleeping is safest if parents are non-smokers
Correct Answer: B. Use car seat only for travel and always place baby flat on the back for sleep
Explanation: The AAP recommends infants sleep on a flat surface on their back, in a crib or bassinet. Car seats are not safe sleep environments.
A 7-year-old with known peanut allergy accidentally ingests a cookie containing peanuts. He develops wheezing, urticaria, and lip swelling. Vitals show tachycardia and mild hypotension.
What is the most appropriate first-line treatment?
A. Diphenhydramine orally
B. Albuterol nebulizer
C. Epinephrine intramuscularly
D. IV fluids
E. Methylprednisolone IV
Correct Answer: C. Epinephrine intramuscularly
Explanation: IM epinephrine is the treatment of choice for anaphylaxis and should be administered promptly. Antihistamines and steroids are adjunctive.
A 6-year-old with mild persistent asthma uses albuterol more than twice a week and has nighttime symptoms twice a month. He is not on any controller medications.
What is the most appropriate next step in therapy?
A. Continue albuterol as needed
B. Start a leukotriene receptor antagonist
C. Start a low-dose inhaled corticosteroid
D. Start an oral steroid taper
E. Begin combination ICS/LABA
Correct Answer: C. Start a low-dose inhaled corticosteroid
Explanation: Mild persistent asthma requires a controller medication. A low-dose inhaled corticosteroid is the first-line treatment at this stage, per national guidelines.
A preterm infant is placed in a crib without supplemental heat. After 20 minutes, the infant is found to be hypothermic.
What physiological limitation most contributes to this infant’s hypothermia?
A. Immature renal concentrating ability
B. High surface area-to-volume ratio and limited brown fat stores
C. Low surfactant production
D. Poor glycogen storage
E. Incomplete myelination of peripheral nerves
Correct Answer: B. High surface area-to-volume ratio and limited brown fat stores
Explanation: Preterm infants lose heat rapidly due to a large surface area relative to mass and decreased insulating fat. Brown fat helps with non-shivering thermogenesis, which is underdeveloped in preemies.
A 9-year-old boy presents with abdominal pain localized to the right lower quadrant. He says it started around the belly button but has since moved. He feels nauseated and hasn’t eaten all day. On exam, he has localized tenderness over McBurney’s point and mild rebound tenderness.
What is the most specific physical exam maneuver to support the suspected diagnosis?
A. Murphy’s sign
B. Chandelier sign
C. Obturator sign
D. Carnett’s sign
E. Heel drop test
Correct Answer: C. Obturator sign
Explanation:
The obturator sign tests for irritation of the obturator internus muscle and supports appendicitis, especially if the appendix is pelvic. It's more specific than Rovsing’s or rebound alone in atypical presentations.
A 2-year-old boy is brought to the ED after a generalized tonic-clonic seizure that lasted 3 minutes. He is now alert and afebrile. Parents report he had a similar event two months ago. No family history of epilepsy.
Which diagnostic test is the most appropriate next step?
A. Head CT without contrast
B. Lumbar puncture
C. Electroencephalogram (EEG)
D. Blood glucose
E. MRI brain with contrast
Correct Answer: C. Electroencephalogram (EEG)
Explanation:
In a previously healthy child with recurrent afebrile seizures, the next step is EEG to assess for seizure disorder patterns and determine the type of epilepsy. Neuroimaging may be indicated later but is not the immediate next best test in this case.
A 10-month-old with Cough and Wheezing
A 10-month-old presents with a 3-day history of rhinorrhea, low-grade fever, and cough. Parents note increasing work of breathing. On exam, the infant is tachypneic with nasal flaring and diffuse wheezing and crackles. O2 sat is 92% on room air.
What is the most likely diagnosis?
A. Asthma
B. Bronchiolitis
C. Viral pneumonia
D. Cystic fibrosis
E. Pertussis
Correct Answer: B. Bronchiolitis
Explanation: Bronchiolitis is the most common cause of wheezing in infants, often due to RSV. Asthma is less likely before 12 months, and pertussis typically features paroxysmal cough without wheezing.
A 14-year-old male presents for a sports physical. He is healthy and asymptomatic. Family history reveals that his uncle died suddenly at age 32 while playing basketball.
What is the most appropriate next step?
A. Reassure and clear for sports
B. Perform an exercise treadmill test
C. Obtain an echocardiogram
D. Refer for genetic testing
E. Advise against sports participation permanently
Correct Answer: C. Obtain an echocardiogram
Explanation: Family history of sudden cardiac death raises concern for hypertrophic cardiomyopathy. Screening with ECG or echo is appropriate before clearing for sports.
Otitis Media With Effusion (OME)
A 4-year-old is seen for a failed hearing screen. Otoscopy reveals dull, retracted tympanic membranes with fluid levels. No fever or pain. He has failed two prior hearing screens over 3 months.
What is the most appropriate intervention?
A. Prescribe amoxicillin for 10 days
B. Reassure and observe for another 3 months
C. Refer for tympanostomy tube placement
D. Recommend decongestants and allergy testing
E. Order sinus CT
Correct Answer: C. Refer for tympanostomy tube placement
Explanation: Chronic OME (>3 months) with hearing loss warrants ENT referral for potential tube placement to improve hearing and prevent language delays.
A 10-year-old tests positive for group A strep on a rapid antigen test. He has no allergies and is otherwise healthy. He can swallow pills.
What is the preferred antibiotic and duration?
A. Azithromycin 500 QD for 3 days
B. Penicillin VK 250mg BID for 10 days
C. Amoxicillin 500 BID for 10 days
D. Cephalexin 500 TID for 3 days
E. Clindamycin 300 QID for 10 days
Correct Answer: B. Pen VK 250 mg BID x 10 days
Explanation: Amoxicillin QD or penicillin BID for 10 days is the standard treatment for streptococcal pharyngitis to prevent complications like rheumatic fever.
A term infant is born to a mother with poorly controlled gestational diabetes. Within the first hour of life, the baby becomes jittery and irritable. A bedside glucose check shows 32 mg/dL.
Which mechanism best explains this finding?
A. Hepatic glycogen deficiency
B. Congenital adrenal hyperplasia
C. Hyperinsulinemia secondary to maternal hyperglycemia
D. Galactose-1-phosphate uridyltransferase deficiency
E. Delayed closure of the ductus venosus
Correct Answer: C. Hyperinsulinemia secondary to maternal hyperglycemia
Explanation: Infants of diabetic mothers experience islet cell hyperplasia due to chronic maternal hyperglycemia in utero. After birth, maternal glucose supply ceases, but insulin remains high, causing hypoglycemia.
A 13-year-old male presents with knee pain that has been worsening over the past week. He denies any trauma. He is overweight and walks with an antalgic gait. On exam, there is limited internal rotation of the hip on the affected side.
Which historical question is most critical for guiding your diagnosis?
A. Recent participation in sports
B. Presence of fevers or chills
C. History of recent viral illness
D. Pain localization to hip vs. knee
E. Family history of rheumatologic disease
Correct Answer: D. Pain localization to hip vs. knee
Explanation:
This vignette suggests slipped capital femoral epiphysis (SCFE), where pain is often referred to the knee. Clarifying the origin of pain can help distinguish between local vs. referred symptoms and guide imaging.
A 10-year-old girl presents with periumbilical pain that migrated to the right lower quadrant. She has nausea and decreased appetite. Her WBC count is 13,000/μL with a left shift. Exam shows tenderness at McBurney’s point.
Which diagnostic test would most effectively confirm the suspected diagnosis?
A. Abdominal X-ray
B. CT abdomen and pelvis with IV contrast
C. MRI abdomen
D. Abdominal ultrasound
E. Plain KUB (kidneys-ureters-bladder) film
Correct Answer: D. Abdominal ultrasound
Explanation:
In children, abdominal ultrasound is the preferred first-line test for suspected appendicitis due to its safety (no radiation), good sensitivity, and accessibility. CT may be used if the ultrasound is inconclusive or if the child is obese.
A 15-year-old girl reports several weeks of fatigue and feeling cold. Her diet is mostly vegetarian. On exam, she is pale with brittle nails and a smooth tongue. Lab results show microcytic anemia.
What is the most likely diagnosis?
A. Iron deficiency anemia
B. Thalassemia trait
C. Anorexia nervosa
D. Acute leukemia
E. Hypothyroidism
Correct Answer: A. Iron deficiency anemia
Explanation: A classic presentation in adolescent females with poor iron intake. Smooth tongue and nail changes reflect chronic iron deficiency. Thalassemia would typically show microcytosis without iron deficiency signs.
A 9-month-old infant is seen for a routine visit. The family lives in a rural area that uses well water. The child has two teeth and does not use fluoride toothpaste.
What is the best preventive measure?
A. No fluoride is needed until age 2
B. Begin fluoride supplementation orally
C. Prescribe fluoride mouth rinse
D. Recommend flossing after each feed
E. Start brushing with baking soda
Correct Answer: B. Begin fluoride supplementation orally
Explanation: If local water lacks fluoride and the child has teeth, oral fluoride supplementation is recommended starting at 6 months.
An 8-year-old boy is diagnosed with ADHD. Parents report concerns about school performance but prefer to avoid medication if possible. He has no other medical or psychiatric diagnoses.
What is the most appropriate initial intervention?
A. Begin stimulant medication
B. Refer for cognitive behavioral therapy
C. Initiate school-based behavioral interventions
D. Order neuroimaging to assess for structural brain abnormalities
E. Recommend dietary changes only
Correct Answer: C. Initiate school-based behavioral interventions
Explanation: For school-aged children with mild-to-moderate ADHD symptoms, behavioral therapy is first-line if parents decline medication. Collaboration with the school is essential.
A 16-year-old girl with severe nodulocystic acne has failed topical and oral antibiotics. Her dermatologist recommends isotretinoin.
What is the most important initial action before prescribing?
A. Order a CBC and LFTs
B. Discuss benzoyl peroxide use
C. Refer for counseling
D. Confirm two forms of contraception or recent negative pregnancy tests
E. Start with a low dose and titrate up
Correct Answer: D. Confirm two forms of contraception or recent negative pregnancy tests
Explanation: Isotretinoin is highly teratogenic. Under iPLEDGE, female patients of childbearing potential must have two negative pregnancy tests and commit to using two forms of contraception.
A healthy newborn becomes visibly jaundiced at 18 hours of life. Total bilirubin is 13 mg/dL.
What is the most likely underlying mechanism?
A. Delayed meconium passage
B. Overproduction of direct bilirubin due to infection
C. Physiologic breakdown of fetal hemoglobin with immature liver conjugation
D. Hepatic obstruction
E. Crigler-Najjar syndrome
Correct Answer: C. Physiologic breakdown of fetal hemoglobin with immature liver conjugation
Explanation: Physiologic jaundice typically begins after 24 hours, but early onset near that window with a modest elevation is usually due to normal breakdown of fetal hemoglobin and limited UDP-glucuronosyltransferase activity.
A 6-year-old boy is brought to the clinic for a limp that has worsened over the past 10 days. His parents report he occasionally refuses to walk in the morning and says his legs feel tired. They deny any recent trauma. He has also been more fatigued than usual and seems pale. No fever is reported. On physical exam, he walks slowly with a wide-based gait. Mild tenderness is noted over both shins without joint swelling, and petechiae are visible on his lower legs.
Which historical or physical exam finding most raises suspicion for a serious underlying condition?
A. Morning limp without trauma
B. Fatigue and pallor
C. Wide-based gait
D. Absence of fever
E. Pain localized to the tibia
Correct Answer: B. Fatigue and pallor
Explanation:
While limping without trauma is concerning, the combination of fatigue, pallor, and petechiae should immediately raise red flags for hematologic malignancy, particularly acute lymphoblastic leukemia (ALL). Bone pain (often mistaken for joint pain), fatigue, pallor, and bruising or petechiae reflect bone marrow failure and infiltration, and are critical clues not to miss.
A 5-year-old child presents with fatigue, pallor, and bruising. Physical exam reveals petechiae on the lower limbs and mild hepatosplenomegaly. Parents deny recent infections, medications, or trauma.
Which laboratory finding would be most concerning for leukemia?
A. Isolated low hemoglobin with normal WBC and platelet counts
B. Platelet count of 110,000/μL with normal WBC and hemoglobin
C. Pancytopenia with peripheral blasts
D. Elevated ESR and CRP
E. Microcytic anemia with high RDW
Correct Answer: C. Pancytopenia with peripheral blasts
Explanation:
Pancytopenia with peripheral blasts is a hallmark of acute leukemia, such as ALL. This pattern reflects bone marrow infiltration and failure. Early diagnosis is critical and often confirmed with bone marrow biopsy.
. A 7-year-old with Itchy Rash and Allergies
A 7-year-old has a chronic, itchy rash on the antecubital and popliteal fossae. He has a history of asthma and allergic rhinitis. Exam shows lichenified, excoriated plaques in flexural areas.
What is the most likely diagnosis?
A. Contact dermatitis
B. Psoriasis
C. Atopic dermatitis
D. Scabies
E. Seborrheic dermatitis
Correct Answer: C. Atopic dermatitis
Explanation: Eczema commonly affects flexural areas in school-aged children and is associated with a personal or family history of atopy (asthma, allergies).
Car Seat Safety for a Toddler
A 2-year-old child is brought in for a routine visit. The parents proudly report that he now rides forward-facing in his car seat.
What is the most appropriate guidance?
A. Forward-facing is fine after age 1
B. Return to rear-facing until age 3
C. Continue forward-facing with a booster
D. Rear-facing is preferred until at least age 2 or until exceeding height/weight limits
E. Seatbelt use is appropriate for short trips
Correct Answer: D. Rear-facing is preferred until at least age 2 or until exceeding height/weight limits
Explanation: The AAP recommends rear-facing car seats until age 2 or until the child outgrows the seat’s limits, as this position offers better head and neck protection.
A 6-week-old girl is brought for a routine check-up. On physical exam, you note a positive Ortolani maneuver on the left. There is asymmetry of the thigh folds and limited abduction of the left hip.
What is the most appropriate next step in management?
A. Reassure the parents and recheck in 1 month
B. Order bilateral hip radiographs
C. Refer to pediatric orthopedics and order a hip ultrasound
D. Begin Pavlik harness in office
E. Delay intervention until the child is walking
Correct Answer: C. Refer to pediatric orthopedics and order a hip ultrasound
Explanation: A positive Ortolani or Barlow exam is a red flag for DDH. Ultrasound is preferred before 6 months of age due to incomplete ossification of the femoral head. Prompt referral to orthopedics is indicated.
A 3-year-old girl presents with ear discomfort and a low-grade fever that began 24 hours ago. Her parents report that she is otherwise acting normally, eating well, and her ear pain has improved with over-the-counter acetaminophen. On exam, her right tympanic membrane is erythematous and bulging.
What is the most appropriate next step in management?
A. Amoxicillin
B. Azithromycin
C. Cephalexin
D. Augmentin
E. Watchful waiting with close follow-up
Correct Answer: E. Watchful waiting with close follow-up
Explanation: In children over 2 years old with unilateral, non-severe acute otitis media and symptom improvement with analgesics, watchful waiting is appropriate. This approach supports antimicrobial stewardship while ensuring appropriate follow-up if symptoms worsen or fail to improve within 48–72 hours.
A 12-year-old girl reports a recent increase in height and foot size. She has started breast development but has not yet had her first menstrual period.
Which hormone is primarily responsible for initiating this pubertal growth spurt?
A. Progesterone
B. Estrogen
C. Growth hormone
D. Cortisol
E. Follicle-stimulating hormone
Correct Answer: C. Growth hormone
Explanation: Growth hormone, along with IGF-1, is the primary driver of the pubertal growth spurt. Estrogen contributes later by promoting epiphyseal plate closure, but GH initiates the linear growth acceleration.