Exam 2: Pediatric

A 9-year-old boy is brought to the office by his mother due to behavioral changes.  The mother says, "He has always been an active child and can be loud at times; however, over the past few months, he has been more irritable.  He usually gets along well with his classmates but got into a fight with one last week."  The mother also notes that the patient gets upset in the mornings because he does not want to go to school.  Since starting third grade 6 months ago, his academic performance has declined, and he has been making below average grades.  A progress report from his teacher states that he does not participate in group activities and is unable to complete class assignments on time.  When interviewed privately, the patient reports that his classmates call him a baby because he uses his fingers to count and reads slowly.  He has no significant medical history.  Vital signs are within normal limits; height and weight curves are tracking consistently.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

A 13-month-old boy is brought to the clinic for a well-child visit.  The patient has been walking since age 10 months.  He can say "mama" and "dada."  Solid food intake consists of homegrown baby food, including small portions of fruits, vegetables, eggs, and grains once a day.  He breastfeeds 8-10 times a day.  The patient was born full-term and has no chronic medical conditions.  He takes no medications or vitamins.  He has a cousin with achondroplasia.  On examination, the anterior fontanel is wide open.  The skull bones are pliable to palpation.  Bony prominences are palpated at the costochondral junctions bilaterally.  Bilateral legs appear bowed; the left leg appears more bowed than the right.  The remainder of his examination is normal.  Which of the following is the most likely cause of this patient's findings?

A 17-year-old boy comes to the office for evaluation of right thigh pain.  The patient had severe pain and swelling in the thigh after being kicked by another player during a soccer match 4 weeks ago.  His symptoms resolved completely in 2 weeks.  However, a week later, he had recurrent pain in the same area associated with decreased range of motion.  He has no other symptoms.  Medical history is unremarkable, and the patient does not use illicit drugs.  Vital signs are normal.  The right thigh circumference is 2 cm greater than that of the left, with an indurated, mobile, 3-cm mass anteriorly.  The pain is reproduced by passive flexion of the knee.  There is no overlying skin erythema.  Strength and sensation in the affected limb are normal.  Peripheral pulses are normal.  The left thigh is normal, and examination findings in the right and left lower legs are normal and symmetric.  What is the most likely cause of this patient's condition?

A 11-year-old girl is brought to the office due to a 2-day history of rapid-onset, abnormal movements of the body.  The abnormal movements began bilaterally in the upper limbs, followed by the trunk and then lower extremities.  As a result, the patient has had difficulty performing daily activities such as bathing and eating.  However, she has no abnormal movements during sleep.  Vital signs are normal.  Examination shows a restless child with irregular, jerky movements involving the entire body and generalized hypotonia.  Mental status examination, cranial nerves, and sensations are normal.  Which of the following is the best next step in diagnosis?

An 8-year-old boy is brought to the office for evaluation of bilateral leg and back pain.  His pain started yesterday and has gradually worsened.  He has had no relief with ibuprofen, acetaminophen, and warm packs.  The patient's medical history is notable for sickle cell disease, and he has had 5 prior hospitalizations for similar pain episodes in his back and legs.  Hydroxyurea has been prescribed, but the prescription has not been filled due to lack of insurance.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 132/min, and respirations are 20/min.  Physical examination shows an uncomfortable-appearing boy with conjunctival pallor.  Palpation of the bilateral legs and back shows tenderness, although no erythema or swelling is noted.  Laboratory results are as follows: What finding is most likely to be present on this patient's peripheral smear?

A 10-year-old boy is brought to the office by his grandmother for a new patient visit.  The boy has a known diagnosis of HIV infection acquired perinatally from his mother and has been taking highly active antiretroviral medications since infancy.  The grandmother is the patient's legal guardian; his mother died from complications of AIDS several years ago.  While the patient is having his vital signs measured, the grandmother explains that she has not revealed the diagnosis to the patient because she wants "to let him live a normal childhood."  Although the patient has been compliant with his HIV medications, he believes they are vitamins.  Vital signs are normal.  Weight is at the 45th percentile for age.  Cardiopulmonary and abdominal examinations are unremarkable.  Viral load is undetectable with a CD4 lymphocyte count of 780 cells/mm³.  Speaking privately with the pediatrician after the examination, the grandmother reiterates that she does not want to disclose the patient's diagnosis.  Which of the following is the most appropriate response?

A 5-year-old boy comes to the office with his parents due to bed-wetting.  He had difficulty toilet training for urination as a toddler and has never achieved consistent dryness during the day or night.  The patient has a soft stool every day and has had no episodes of fecal incontinence.  Compared to other children his age, he tires easily, requiring a nap after playing outside.  The patient was adopted from an overseas orphanage 2 months ago, and medical history is significant for frequent urinary tract infections.  Temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 16/min.  Height and weight are at the 25th and 5th percentiles, respectively.  Physical examination shows no abnormalities.  Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

A 16-year-old boy is brought to the office by his mother for follow-up after sustaining a ligament injury while playing football 4 weeks ago.  The patient has been using a splint and going to physical therapy twice weekly.  His pain has decreased, and he is hoping to return to football practice.  Medical history is significant for asthma managed with as-needed albuterol and prior treatment of gonorrhea, which he acquired a year earlier after an unprotected sexual encounter.  Physical examination of the ankle reveals no pain, tenderness, or swelling and there is full range of motion.  At the end of the visit the mother mentions that the family is moving to a new neighborhood and will be changing medical providers.  She asks for a copy of her son's medical record to take to the new practice.  Which of the following is the best response to the mother's request?

A 6-week-old boy is seen in the office for routine follow-up after discharge from the neonatal intensive care unit.  He was born at 31 weeks gestation to a 41-year-old woman via cesarean delivery for preeclampsia with severe features and breech presentation.  The hospital course included brief oxygen supplementation via continuous positive airway pressure and nasal cannula and phototherapy for jaundice.  The patient is now breastfeeding every 3 hours and gaining weight appropriately.  Maternal prenatal laboratory studies were normal.  Weight today is 3 kg (6.6 lb).  Examination is unremarkable.  The parents inquire about upcoming vaccines for their infant.  Which of the following is the most accurate statement regarding immunization scheduling for this patient?

A 13-year-old girl is brought to the office for evaluation of sunburn.  She and her family just returned from a 4-day vacation to the Bahamas.  While there, the patient applied sun protection factor 50 sunscreen every morning about 30 minutes before walking to the beach.  She specifically bought "water-resistant" sunscreen so that she could swim.  After 2 days, however, she developed painful redness on her face and shoulders that has started to peel.  The patient is otherwise healthy and takes no daily medications.  Her parents say that "everybody tans easily" in their family, and there is no family history of skin cancer.  Physical examination shows a well-appearing adolescent with tender, blanching erythema on the face, shoulders, and arms.  There is no edema or vesicles.  Appropriate supportive care measures for treatment of her sunburn are discussed with the family.  Which of the following is the most appropriate preventive recommendation to provide this patient?

A 28-year-old woman comes to the office due to weakness.  The patient, who is 8 weeks postpartum, reports intermittent weakness of the upper and lower extremities.  She says, "My arms feel weak after carrying the baby for a few minutes, and I can't lift him until I rest for some time.  Yesterday evening, I couldn't even get off of the toilet, but today, I feel fine."  The patient has also had episodes of blurry vision.  Her pregnancy was complicated by gestational diabetes, but she has no chronic medical conditions.  The patient's only medication is a daily multivitamin.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 120/68 mm Hg and pulse is 74/min.  Physical examination shows normal pupils and extraocular movements.  Jugular venous pressure is not elevated, and chest auscultation reveals no abnormalities.  There is no extremity edema.  Deep tendon reflexes and muscle strength of the bilateral upper and lower extremities are normal.  Which of the following is the most likely diagnosis?

A 14-year-old boy is brought to the office due to a breast lump.  For the last 2 months, he has felt a mass under his right nipple.  The patient has no medical conditions and smokes 1 or 2 cigarettes per day.  He takes no medications and does not use alcohol or illicit drugs.  His grandmother developed breast cancer at age 64.  The patient's height and weight are at the 60th and 40th percentiles, respectively.  Physical examination reveals tender, glandular, right subareolar breast tissue that is 3 cm (1.2 in) in diameter.  There is no overlying erythema or warmth, and no discharge can be expressed from the nipple.  The left chest wall is flat without palpable breast tissue.  He has Tanner 3 genitalia, including normal testicular volume.  What is the most appropriate next step in the management of this patient?

A 37-year-old woman comes to the office due to frequent tearfulness.  The patient describes herself as "a happy person" at baseline but says that "about 6 months ago, I began to have more sad days than happy days."  She frequently goes a week without leaving home and has to force herself to eat and clean.  The patient's father committed suicide at age 41, and her paternal grandfather is said to have died of a "mental disease" at age 49.  The patient tearfully admits to thoughts of suicide but has no plans or intent.  Temperature is 36.9 C (98.4 F), blood pressure is 121/77 mm Hg, pulse is 68/min, and respirations are 14/min.  The patient has no subjective memory issues.  She scores 25/30 on the Montreal Cognitive Assessment (normal: ≥26), losing points on measures of executive function.  She appears restless during the examination, shifting frequently in her chair.  The patient repeatedly raises her right arm in an abrupt, twisting motion that ends with smoothing her hair.  Extraocular movement testing shows delayed initiation of voluntary saccades.  Deep tendon reflexes are 3+ in both upper and lower extremities.  The patient's disease is primarily associated with degeneration of which of the following neuronal cell groups?

A 3-year-old boy with DiGeorge syndrome is brought to the emergency department after a 5-minute, generalized tonic-clonic seizure.  For the past week, the patient has been increasingly tired and has had severe morning headaches, which have not been relieved by acetaminophen or ibuprofen.  He has been dragging his right leg for several days while walking.  His appetite has decreased, and he has been vomiting after waking up in the morning.  The patient's family recently emigrated from a developing country to obtain care for his unrepaired tetralogy of Fallot.  The patient has speech delay and a history of recurrent pneumonias and sinus infections.  Temperature is 38.3 C (101 F).  Physical examination shows a tired-appearing child with dysmorphic facial features.  The right lower extremity exhibits decreased strength and the ankle deep tendon reflex is hyperreflexic; the left lower extremity is normal.  There is no truncal ataxia.  Which of the following is the most likely cause of this patient's symptoms?

A 7-year-old girl is brought to the emergency department with a painful swollen eye.  She awoke this morning with left eye swelling, which has progressively worsened throughout the day.  The patient has seasonal allergies for which she takes an over-the-counter antihistamine.  She has no other significant medical history.  Temperature is 39.1 C (102.4 F).  Examination of the left eye shows tender, swollen, erythematous eyelids and a small abrasion below the eyelid.  There is mild conjunctival injection but no drainage.  Extraocular movements are normal and do not cause pain.  Visual acuity is 20/20 bilaterally.  Funduscopic examination is normal, and examination of the right eye is unremarkable.  Facial sensation is intact.  Which of the following is the most likely diagnosis in this patient?

A 5-day-old neonate is brought to the hospital due to poor feeding, sweating, pallor, and respiratory distress.  The symptoms are exacerbated with feedings.  There has been no loss of consciousness or cyanosis during these episodes.  She has no fever or cough.  The girl was born at 38 weeks gestation via an uncomplicated vaginal delivery.  On examination, temperature is 36.7 C (98 F), pulse is 165/min, and respirations are 75/min.  Oxygen saturation on room air is 97% in the right hand and 95% in the left foot.  She has nasal flaring and retractions.  Bilateral fine crackles are present.  A gallop is heard over the precordium; there is no murmur.  The liver edge is palpable 3 cm below the right costal margin.  Extremities are pale and cold.  Brachial pulses are strong and femoral pulses are weak.  What is the most likely cause of her symptoms?

A 33-year-old woman comes to the office with severe bilateral facial pain for the past several days.  She reports sharp, shooting pain that is confined to her cheeks and jaw, lasts several seconds, and occurs 10-20 times a day.  The pain is sometimes triggered by a cold breeze, brushing of her teeth, or chewing.  The patient has been taking ibuprofen for the pain without much relief.  She has never experienced this condition before, but 6 months ago she had numbness of her right hand that lasted about 2 weeks.  Four weeks ago, she was treated for acute sinusitis.  The patient is a primary school teacher and does not use tobacco, alcohol, or illicit drugs.  Her temperature is 36.7 C (98 F), blood pressure is 118/82 mm Hg, pulse is 72/min, and respirations are 14/min.  On physical examination, a similar pain is elicited by lightly touching the patient's cheeks.  Otherwise, neurologic examination demonstrates no focal deficits.  Which of the following is the most likely cause of this patient's symptoms?

A 4-month-old boy is brought to the office by his mother due to noisy breathing.  Approximately a month ago, his mother first noticed a squeaky noise when he was crying or lying in his crib.  The noise has become progressively louder and persistent.  The patient was recently placed in a day care after his mother returned to work; she attributed the noisy breathing to a viral infection, but it has failed to resolve.  He is breastfed but is fed formula at day care.  The mother reports no episodes of difficulty breathing or bluish discoloration during feeding, but he often spits up a small amount after feeds.  The patient was born at full term without complications and is up to date with vaccinations.  He is afebrile; height and weight are at the 60th percentile.  On physical examination, the patient appears well and smiles at the examiner.  When the patient is placed supine on the examination table, inspiratory stridor is heard, which resolves quickly when he is placed in the prone position.  No cyanosis is noted.  The remainder of the examination shows no abnormalities.  Which of the following is the most likely diagnosis?

A 38-year-old, right-handed woman is brought to the emergency department after a brief seizure witnessed by her husband.  The patient has never before had a seizure but has had headaches for several weeks.  Her husband says that she has acted strangely for several months.  The patient used to be quite social, but lately, she is not motivated to participate in any social activities and has lost interest in everyday activities.  She will not talk unless directly spoken to and has impaired memory.  The patient has no significant medical or psychiatric history.  There is no family history of neurologic disorders.  Temperature is 36 C (96.8 F), blood pressure is 130/78 mm Hg, and pulse is 86/min.  On examination, the patient is somnolent but wakes to voice and follows commands.  The pupils are equal and reactive.  Funduscopy reveals bilateral papilledema.  Bilateral upper and lower extremity muscle strength is normal.  Neuroimaging is most likely to reveal which of the following findings in this patient?

A 5-day-old girl is brought to the emergency department for evaluation of vaginal discharge.  Her mother has noticed white vaginal discharge mixed with a small amount of blood since yesterday.  The girl does not appear to be in pain and has been voiding and stooling adequately.  She is exclusively breastfed every 2-3 hours.  The mother mentions that she was treated "with a shot and a pill" for a sexually transmitted disease early in her pregnancy and subsequently tested negative.  The girl was born via forceps-assisted vaginal delivery due to protracted labor at 38 weeks gestation.  Temperature is 36.7 C (98 F).  Physical examination reveals a thin, white, odorless vaginal discharge with blood streaking.  The external genitalia are otherwise unremarkable, and the abdomen is soft and nontender without palpable masses.  What is the most likely cause of this patient's vaginal discharge?