Preventive Pediatrics
A family with 2 children, aged 2 and 5 years, is planning a camping trip in the New England area. One of the parents calls the pediatrician’s office to ask about the best repellent to use to prevent tick bites.
Of the following, the BEST option to recommend is:
A.oral garlic
B.topical catnip oil
C.topical N,N-diethyl-meta-toluamide (DEET)
D.topical oil of lemon eucalyptus
C.topical N,N-diethyl-meta-toluamide (DEET)
A 6-year-old girl is seen for a health supervision visit. She has been healthy, and her growth and development have been normal. She is doing well in first grade. Her parents divorced when she was 4 years old. Her father, who resides in a neighboring state, is unemployed and has a history of substance use (alcohol and marijuana). The girl lives with her mother, a pharmacist who recently remarried; her stepparent is employed full time as a physician. They live in a single-family home with one pet dog; the mother’s parents live a few houses away. The girl is not exposed to environmental tobacco smoke.
Of the following, the factor MOST associated with an increased risk of maltreatment of this child is
A.her current age
B.living with an unrelated adult
C.maternal education level
D.proximity of the grandparents
B.living with an unrelated adult
A 12-month-old boy is seen in the emergency department for cough, fever, and decreased oral intake for the past 2 days. He has had the normal number of wet diapers and no diarrhea. He has a history of hypoplastic left heart syndrome (HLHS), which was initially palliated with a Norwood-type repair and at 5 months of age with a bidirectional Glenn procedure (cavopulmonary anastomosis). The boy has been doing well since his last surgery and receives consistent cardiologic follow-up. The cardiologist had no concerns at the last clinic visit. His vital signs are as follows: temperature, 38 °C; heart rate, 170 beats/min; respiratory rate, 50 breaths/min; blood pressure, 95/50 mm Hg; and oxygen saturation, 67% in room air (average of 80%-85% since last surgery).
He is alert and interactive, with mildly increased work of breathing without acute distress. On lung auscultation, air movement is adequate and equal bilaterally, with mild wheezing and without stridor. He has well-healed surgical scars. Capillary refill time is 2 to 3 seconds. The remainder of his examination findings are normal.
Of the following, the BEST next step in this boy’s management is
A.blood culture and empiric antibiotics
B.chest radiography
C.peripheral intravenous saline bolus
D.supplemental oxygen
D.supplemental oxygen
A 12-year-old girl is brought to an urgent care clinic with abdominal pain, weight loss, and intermittent vomiting. Her symptoms have been progressive over the past 3 months. She has no previous medical history. The family moved from out of state earlier this year, and her parents report she has had difficulty with making new friends. She eats a vegan diet and takes a daily multivitamin. Her diet is well balanced, although her intake has diminished over the past 3 months. On physical examination, the girl is underweight. She has patchy areas of hair loss and irregularly broken hairs. A firm mass is noted on palpation of the epigastric region. The remainder of her examination findings are normal. Abdominal radiography confirms the presence of a large mass in the stomach. Based on her presentation and examination findings, a bezoar is suspected.
Of the following, this child is MOST likely to have a
A.lactobezoar
B.pharmacobezoar
C.phytobezoar
D.trichobezoar
D.trichobezoar
A 12-year-old child is seen in the office after exposure 4 days ago to a cousin who was diagnosed with measles the day after exposure. The child underwent a hematopoietic stem cell transplant 4 months ago for Hodgkin lymphoma and is currently receiving immunosuppressive therapy. His parents are concerned about his risk of contracting measles. His weight is 40 kg. He is afebrile, and his physical examination findings are unremarkable. The boy received his measles mumps rubella vaccine at ages 15 months and 4 years.
Of the following, the BEST next measures in this child’s care are
A.intramuscular measles immunoglobulin and home quarantine for 21 days
B.intramuscular measles immunoglobulin and home quarantine for 28 days
C.intravenous measles immunoglobulin and home quarantine for 21 days
D.intravenous measles immunoglobulin and home quarantine for 28 days
D.intravenous measles immunoglobulin and home quarantine for 28 days
An 18-month-old child is seen for a health supervision visit. Her mother is very concerned about exposure to environmental toxins. She specifically asks how she can protect her child from pesticides, because she has read that young children are more at risk of experiencing detrimental effects than are adults. The family lives in a suburban community, and both parents work indoors. During the visit, the physician provides focused education about the risks of pesticides and age-appropriate anticipatory guidance.
Of the following, this child’s GREATEST risk of experiencing a pesticide exposure is from:
A.eating conventionally grown fruits and vegetables
B.local airborne pest eradication
C.oral flea prevention treatment of the family pet
D.topical application of insect repellents
A.eating conventionally grown fruits and vegetables
A 2-year-old girl is admitted to the hospital for vomiting after every meal. Her mother reports that the child has had a persistent cough and intermittent constipation. The girl was recently discharged from another hospital after evaluation for the same concern, without a definitive diagnosis. Her mother is concerned that there may be something wrong with the girl’s esophagus. She states that her daughter needs further testing and that her nursing coworker shares her concern.
During rounds the next day, the child appears well. She is eating breakfast without difficulty; she states that she feels “good” and that nothing hurts. Her mother adds that the child has pain most of the day at home.
Of the following, the BEST next step in this child’s care is to
A.order a videofluoroscopic swallowing study
B.place the child in a room equipped for covert video surveillance
C.review the child’s medical records
D.schedule a forensic interview with the child
C.review the child’s medical records
A 17-year-old boy is seen in the emergency department for 7 days of episodic fevers, fatigue, and occasional chills. He has a history of tetralogy of Fallot for which he underwent complete repair as an infant and primary percutaneous pulmonary valve placement 1 year ago. He follows up regularly with a cardiologist; his last appointment was 6 months ago. The boy was seen by his primary care physician 2 days ago at which time crackles were heard during his pulmonary examination and he was prescribed azithromycin for presumed pneumonia. His symptoms have persisted despite initiation of antibiotic treatment. He takes 81 mg/d of aspirin and no other regular medications and has been taking acetaminophen as needed for fever. He has had no recent illnesses and was in his usual state of health before the initiation of symptoms.
The adolescent is febrile, has mild tachycardia, and has normal blood pressure. Physical examination reveals clear lung fields with no increased work of breathing, a III/VI systolic ejection murmur, a II/IV diastolic murmur, no hepatomegaly, and normal perfusion. The remainder of his examination findings are normal.
Of the following, the BEST next step in this adolescent’s evaluation is to
A.administer a normal saline bolus and alternate ibuprofen and acetaminophen for fever control
B.complete the current antibiotic regimen
C.obtain a chest radiograph to determine whether to continue the current antibiotic
D.obtain at least 2 independent blood cultures
D.obtain at least 2 independent blood cultures
A 2-month-old term infant was seen in the clinic for a health supervision visit. He has been exclusively fed a standard cow milk protein formula. His parents reported frequent large-volume spit-ups immediately following each feed. He displayed no evidence of pain or discomfort during these episodes. At that visit, both his weight and length were at the 25th percentile for age. They were counseled regarding appropriate feeding volumes, and a recommendation was made to thicken the feeds using oatmeal, barley, or a multigrain infant cereal, which they have followed.
At his 4-month visit, his parents report similar symptoms. His weight is at the 10th percentile, and his length is at the 25th percentile for age. He is meeting all developmental milestones.
Of the following, the BEST next step in management is
A.initiation of a histamine-2 receptor antagonist
B.initiation of a proton pump inhibitor
C.referral to a pediatric gastroenterologist
D.trial of an extensively hydrolyzed protein-based formula
D.trial of an extensively hydrolyzed protein-based formula
A 4-year-old child with acute lymphoblastic leukemia is hospitalized because of fever and diarrhea that started 2 days ago. He has had 10 episodes of diarrhea per day, without blood or mucus. He is currently receiving induction chemotherapy, and his absolute neutrophil count is 200 cells/µL (0.20 × 109/L). Tests detected Clostridioides difficile in his stool. A hospital infection prevention specialist reports that the rate of C difficile infections on the pediatric inpatient unit has increased over the past 2 months.
Of the following, the MOST effective strategy for limiting the spread of this infection is
A.environmental cleaning using ultraviolet disinfection
B.environmental cleaning using vaporized hydrogen peroxide
C.hand hygiene using alcohol sanitizer, along with use of gowns and gloves
D.hand hygiene using soap and water, along with use of gowns and gloves
D.hand hygiene using soap and water, along with use of gowns and gloves
A 13-year-old adolescent is seen for a health supervision visit. She currently does not exercise, and her body mass index is at the 24th percentile for her age. The family is looking for guidance on how to incorporate movement into her daily routine. The pediatrician provides the family with the current US Department of Health and Human Services physical activity guidelines.
Of the following, the BEST option for an exercise prescription for this adolescent is:
A.60 minutes of high-intensity aerobic activity daily
B.60 minutes of high-intensity aerobic activity 4 days per week, with 3 days per week of no activity
C.60 minutes of moderate aerobic activity daily, including 3 days per week of light activity and bone strengthening
D.60 minutes of moderate aerobic activity daily, including 3 days per week of vigorous activity, bone strengthening, and muscular strengthening
D.
60 minutes of moderate aerobic activity daily, including 3 days per week of vigorous activity, bone strengthening, and muscular strengthening
A 3-year-old boy is brought to the emergency department after his preschool teacher noticed bruising on his lower extremities. On the basis of the teacher’s concerns about the bruising, school staff made a report to child protective services, and a social worker advised the parents to bring him to the emergency department for evaluation. The child appears well. His mother reports that he has been in good health, with normal growth and development. Aside from the bruises on his legs (Figure 1), the boy’s physical examination findings are unremarkable.
Of the following, the BEST next step in this child’s evaluation is to
A.arrange for a forensic interview
B.gather a history from the parent(s)
C.obtain laboratory testing
D.obtain a skeletal survey
B.gather a history from the parent(s)
An 18-month-old girl diagnosed with left-sided cervical lymphadenitis is admitted to the general pediatrics inpatient unit. She initially presented to the emergency department 6 days ago with 4 days of fever, an erythematous truncal rash, and left cervical tenderness. Computed tomography of the neck confirmed a phlegmon in the left anterior cervical lymph node chain. She was evaluated by an otolaryngologist and given ampicillin-sulbactam. Her fever and rash have persisted despite 2 days of antibiotic treatment, and her neck findings are unchanged. Today she developed bilateral nonpurulent conjunctivitis and oropharyngeal erythema. The remainder of her physical examination findings are normal. Laboratory evaluation demonstrates an elevated C-reactive protein level, mild transaminitis, hypoalbuminemia, and hyponatremia. Her complete metabolic profile and complete blood cell count are otherwise normal.
Echocardiography is performed because of a concern for Kawasaki disease. Although the findings were somewhat limited because of patient movement, this imaging demonstrates a structurally and functionally normal heart with mild mitral regurgitation and a small pericardial effusion. The dimensions of the proximal coronary arteries are normal.
Of the following, the BEST next step in this child’s management is to
A.administer intravenous immunoglobulin and oral aspirin and repeat echocardiography in 2 to 3 days
B.broaden the antibiotic coverage and have the otolaryngologist reevaluate the child
C.continue the current treatment plan and monitor for additional diagnostic criteria
D.initiate evaluation for an underlying systemic inflammatory condition
A.administer intravenous immunoglobulin and oral aspirin and repeat echocardiography in 2 to 3 days
A 10-year-old girl is seen in the clinic for evaluation of chronic abdominal pain for more than 6 months. The abdominal pain began shortly after a gastrointestinal illness, with vomiting and diarrhea that lasted about 1 week. Since that time, the child has experienced periumbilical abdominal pain most days of the week. Eating does not make the pain worse or better. She has soft, nonbloody stools daily. Her height and weight have remained at the 25th percentile for age. Her vital signs are within normal limits and physical examination findings are unremarkable. The girl’s abdomen is not distended or tender to palpation; she has no hepatosplenomegaly or palpable abdominal masses. She has a normal external genitourinary examination and is at sexual maturity stage 1.
Of the following, the BEST next step in this girl’s care is to
A.obtain abdominal ultrasonography
B.order a fecal calprotectin concentration
C.place a referral for self-hypnosis training
D.prescribe sertraline at 12.5 mg/day
C.place a referral for self-hypnosis training
A 3-year-old is undergoing evaluation for a cat bite to the right hand sustained 1 hour ago. The child’s temperature is 37.3 °C, heart rate is 110 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 90/60 mm Hg. They have no known allergies. Physical examination of the right hand reveals 2 small puncture wounds on the thenar eminence, with mild surrounding swelling and tenderness. There are no red streaks extending proximally from the wound, and there is no bony tenderness. The child has a full range of motion of all fingers. The puncture wounds are cleansed and irrigated appropriately in the office.
Of the following, the BEST next step in management is to prescribe
A.amoxicillin-clavulanate
B.cephalexin
C.ciprofloxacin
D.doxycycline
A.amoxicillin-clavulanate
A 4-year-old child who required a splenectomy 2 weeks ago after sustaining severe abdominal trauma in an automobile crash is undergoing evaluation. He started receiving oral penicillin prophylaxis just before being discharged from the hospital. This is his first follow-up visit in the medical home setting after splenectomy. His primary care practitioner provides specific caregiver education and anticipatory guidance related to his splenectomy status. This includes recommendations for prevention of invasive infections and management of febrile illness.
Of the following, the MOST appropriate additional guidance to be provided to the child’s caregiver(s) is to
A.discontinue penicillin prophylaxis after 6 months
B.keep him home from school/day care whenever there is a viral gastroenteritis outbreak
C.recommend against use of live vaccines in light of his splenectomy
D.recommend vaccinations against encapsulated organisms and annual influenza vaccination
D.recommend vaccinations against encapsulated organisms and annual influenza vaccination
A 4-week-old girl is brought to the office by her mother for a scheduled weight check. Her birth history is unremarkable. The mother reported difficulty with formula feeding at her 2-week appointment and today reports that the infant continues to be fussy while feeding as well as crying intermittently throughout the day and night. The mother states, “I thought she would be sleeping through the night by now.” The infant lives in a home with her mother, stepfather, and twin brother.
The infant’s weight has increased appropriately from the last visit. There are skin changes on her left cheek (Figure). On inquiry, the mother reports no history of trauma.
Of the following, the BEST next step in this infant’s management is to
A.counsel the family regarding age-appropriate infant behavior
B.make a report to child protective services
C.order laboratory testing for hematologic disorders
D.schedule a follow-up visit for the next day
B.make a report to child protective services
A 15-year-old boy is being monitored for elevated blood pressure that was incidentally discovered at a health supervision visit. He is otherwise healthy and plays baseball for the high school team. He takes no medications or over-the-counter supplements. There is a family history of hypertension in his mother and several of her relatives. His body mass index is at the 80th percentile for age. Blood pressure measurements during the past 4 months have all been in the stage 1 hypertension range. The results of basic laboratory evaluation were unremarkable, and recent echocardiography did not demonstrate left ventricular hypertrophy. During the past 4 months, he has made lifestyle changes, including dietary changes and exercising at a gym.
Of the following, the BEST next step in this adolescent’s management is to
A.continue to monitor blood pressures
B.obtain renal ultrasonography
C.restrict from competitive sports
D.start treatment with antihypertensive medication
D.start treatment with antihypertensive medication
A 14-month-old boy with a history of failure to thrive that has lasted several months is evaluated in the emergency department for 1 week of vomiting and upper leg rash and 2 days of swelling of his eyelids and extremities. His emesis is nonbilious and nonbloody and occurs once daily. The boy’s diet consists of almond milk (16 oz daily) and small amounts of mashed avocados and bananas. He receives outpatient speech-language and physical therapy services. Few growth data are available; however, there is a documented weight loss of 6 oz (0.17 kg) over the past 6 weeks.
On physical examination, the boy is irritable but consolable. His weight is 8.4 kg (4th percentile for age), length is 71 cm (less than 1st percentile for age), and weight for length is at the 30th percentile for age. His abdomen is distended but soft, without hepatosplenomegaly. There is periorbital edema and symmetrical pitting edema of his extremities. Red/orange erosions coalescing into larger plaques are present over his upper medial thighs and diapered area.
Of the following, the BEST next step in this boy’s treatment is
A.hospitalization and daily administration of 50% of his estimated calorie needs
B.hospitalization and daily administration of 100% of his estimated calorie needs
C.outpatient monitoring with daily weight checks and increasing his caloric intake by 50%
D.outpatient monitoring with weekly weight checks and administration of an appetite stimulant
A.hospitalization and daily administration of 50% of his estimated calorie needs
A previously healthy 18-month-old child is seen in the office for vomiting and profuse watery diarrhea which began 3 days ago. The child has been having about 10 diarrheal stools daily, without blood or mucus. He attends day care and 3 weeks ago returned from a family vacation trip to Puerto Rico, where he played with a pet turtle. His immunizations were delayed until 6 months of age during the COVID-19 pandemic. On physical examination, the boy’s temperature is 39.5 °C, heart rate is 120 beats/minute, respiratory rate is 40 breaths/min, and blood pressure is 92/62 mm Hg. He has dry mucous membranes, decreased skin turgor, and a capillary refill time of 3 seconds. His bowel sounds are hyperactive. The remainder of his examination findings are normal.
Of the following, the MOST likely etiology of this child’s illness is
A.enterotoxigenic Escherichia coli
B.rotavirus
C.Salmonella
D.SARS-CoV-2
B.rotavirus
A 10-year-old girl is seen for a health supervision visit. The girl’s mother has noticed that she frequently talks back when asked to do her chores and she has been spending more time in her room using her phone in the evenings after dinner. The girl no longer wants to spend weekends doing family activities, preferring to spend time with friends instead. These new behaviors have been accompanied by a decline in her grades at school. On physical examination, the girl appears well. Her breast development is at 3 and pubic hair is at 2 on the sexual maturity rating scale.
Among the recent behaviors observed by the girl’s mother, the one that MOST warrants intervention is
A.declining grades at school
B.isolating in her room in the evenings
C.no longer spending time with family on weekends
D.sexual maturity ratings for age
A.declining grades at school
A 6-year-old boy is seen for a health supervision visit. There is a note in the chart that his mother has concerns about her boyfriend’s behavior around her son. Prior to the physical examination, she steps out to use the restroom. While she is gone, the boy says that someone at home gave him money to keep a secret about seeing his private area. He then points to his buttocks and says, “He touched me there last night.”
Of the following, the MOST appropriate question to ask the boy is
A.“Did this happen once or more than once?”
B.“Do you know why this happened?”
C.“Was it your mother’s boyfriend who touched you?”
D.“What happened next?”
D.“What happened next?”
An 8-month-old infant new to the practice, is seen in the office for a health supervision visit. The infant has no significant medical history, and the parents have no specific concerns. The infant’s vital signs and growth parameters are normal, and oxygen saturation in room air is 99%. On physical examination, there is a harsh, III/VI systolic ejection murmur heard at the left sternal border, which radiates to the left upper sternal border, softly to both axillae, and there is a midsystolic click.
Of the following, this infant’s MOST likely diagnosis is
A.mitral valve regurgitation
B.patent ductus arteriosus
C.pulmonary valve stenosis
D.ventricular septal defect
C.pulmonary valve stenosis
A 7-year-old child is seen for evaluation of an 8-month history of regurgitation, which occurs frequently after eating. The child regurgitates then either rechews and swallows or spits out stomach contents. The regurgitation does not occur at night. There is no associated nausea or retching. A 4-week trial of proton pump inhibitor therapy did not improve his symptoms. The child’s weight, height, and body mass index are at the 50th percentile for age. His physical examination findings are normal.
Of the following, the BEST treatment option for this child is (a)
A.carbonated beverage intake
B.diaphragmatic breathing
C.gluten-free diet
D.histamine-2 receptor antagonist
B.diaphragmatic breathing
A 5-year-old child is undergoing evaluation for a sore throat, runny nose, and cough of 2 days’ duration. On physical examination, the child appears well. He has a temperature of 39 °C, a heart rate of 90 beats/min, a respiratory rate of 18 breaths/min, and an oxygen saturation of 100% in room air. He has rhinorrhea and pharyngeal redness with enlarged tonsils. The remainder of his examination findings are normal. He has had recurrent episodes of pharyngitis over the past 2 months, for which he has received multiple courses of antibiotics after testing positive for group A Streptococcus. He is currently on day 8 of a 10-day course of amoxicillin.
Of the following, the MOST appropriate care for this child is to
A.obtain respiratory viral testing
B.obtain a throat culture
C.prescribe amoxicillin-clavulanate
D.prescribe clindamycin
A.obtain respiratory viral testing