Day 19 Flashcards
Q1- A 6-year-old boy is seen for routine examination by his doctor, but his parents have stated that lately he becomes short of breath while playing with his friends, and has a bluish hue to his lips when coming back from playing. The boy’s teacher also says he finds the boy squatting while playing outside during recess. Which of the following is the most likely diagnosis?
A-Atrial septal defect B-Patent foramen ovale C-Hypertrophic obstructive cardiomyopathy D-Tetralogy of Fallot E-Restrictive cardiomyopathy
Ans: D. The history of exercise intolerance and squatting while playing outside (tetspells) is pathognomonic for tetralogy of Fallot. The remainder of choices do not present with tet spells such as squatting during exertion.
Q2- A 3-month-old female infant is brought in because her parents say she will not eat anymore. Upon physical examination, a loud pansystolic murmur is appreciated. The child also appears small for her age, but her records show no maternal or delivery complications.
Which of the following is the most likely finding on EKG?
A-Right ventricular hypertrophy B-Right bundle branch block C-ST segment elevation D-QT interval elongation E-P wave inversion
Ans: A. The key to this case is understanding that a child who was otherwise healthy but presents with a holosystolic murmur and symptoms of failure to thrive most likely has a VSD. Right ventricular hypertrophy occurs from blood shunting from the high pressure left system to the low pressure right system. This could later lead to Eisenmenger syndrome (ES). ES is defined as the process in which a left-to-right shunt caused by a VSD reverses into a right-to-left shunt due to hypertrophy of the right ventricle.
Q3- A 17-year-old boy who just flew from Australia and landed in New York presents in the ED with facial drooping, altered mental status, and left side paralysis. He took some diphenhydramine to get through the flight. Physical exam reveals a swollen left calf muscle.
Which of the following is the most likely process underlying this patient’s stroke?
A-Emboli from his carotid artery B-Emboli from his middle cerebral artery C-Trauma brain injury D-Paradoxical emboli from deep leg veins E-Medication side effect
Ans: D. The patient most likely has thrown a clot to his brain. The clot was formed in the setting of venous stasis and was able to travel to his brain via a patent ASD.Without the ASD, this clot would have embolized to the pulmonary circulation. Choices(A) and (B) are incorrect because he is too young for such advanced vascular disease;(C) is incorrect because there is no history of trauma; diphenhydramine does not cause emboli, ruling out choice (E).
Q4- A 14 -year-boy is brought in after his mother found him unconscious. He quickly awoke on the ride to the hospital and was without confusion. The mother states he did not lose urinary continence and there were no episodes of shaking. His medical history is significant for hearing loss since birth, and the mother mentions he has an uncle who died suddenly from a “heart condition.” His blood pressure is 123/75 and does not change with standing, heart rate is 76, and his mucous membranes are wet. What is the most likely diagnosis?
A-Seizure B-Long QT syndrome C- Orthostatic hypotension D- Stroke E-Vertigo
Ans: B. This patient has the hallmark findings of long QT syndrome. Although there are 13 different varieties of long QT syndrome, for the USMLE a combination of hearing loss, syncope, normal vitals and exam, and family history of sudden cardiac death is all you need to clinch the diagnosis. Seizure is incorrect, as the child was not disoriented or post-ictal after the syncopal episode. Orthostatics were normal, ruling out orthostatic hypotension. Both stroke and vertigo are unlikely in a 12-year-old boy.
Q5- Upon her first feeding, a 1-day-old child begins to choke and exhales milk bubbles from her nose, then appears to be in significant respiratory distress. CXR reveals an air bubble in the upper esophagus and no gas pattern in the remainder of the GI tract. A coiled NGT is also seen.
What is the most common complication of this condition?
A-Meningitis B-Pneumonia V-Dental caries D-Dyspepsia E-Belching
Ans: B. The signs described both on physical exam and radiological exam point towards an esophageal atresia with a tracheoesophageal fistula. Aspiration pneumonia is a severe and common complication of this condition as food contents are aspirated via the fistula in the respiratory system. Aspiration leads to abscess formation from anaerobic proliferation. Dental caries cannot form because the child is only 1 day old and therefore does not have teeth. Food cannot reach the stomach, so there is no possibility for either dyspepsia or belching
Q6- 1-month-old child is fed, after which he has vomitus that is forceful and winds up across the nursery. The vomitus is nonbloody and nonbilious. Physical examination reveals a palpable mass in the abdomen. An upper GI series is ordered.
Which of the following is the most likely finding on this radiologic exam?
A-String sign B-Doughnut sign C-Bird’s beak sign D-Steeple sign E-Murphy sign
Ans: A. Projectile vomiting and palpable abdominal mass is characteristic of pyloric stenosis. String sign is seen on upper GI series (barium is swallowed and its passage is watched under fluoroscopy). Doughnut sign is seen during intussusceptions. Bird’s beak is seen in achalasia, steeple sign is seen during croup, and the Murphy sign is not ever a radiological sign, but rather a physical exam sign with right upper quadrant tenderness that causes cessation of breathing.
Q7- 1-day-old child is given her first feeding; at which time she begins to have very dark green vomiting. On physical examination, the child has oblique eye fissures with epicanthic skin folds and a single palmar crease. A holosystolic murmur is also heard. CXR reveals a double bubble sign.
Which of the following is the most likely diagnosis?
A-Biliary atresia B-Duodenal atresia C-Volvulus D-Intussusception E-Pyloric stenosis
Ans: B. The child’s bilious vomiting on the first day of life is the prototypic finding in children with this condition. Furthermore, the description of Down syndrome-like characteristics such as eye shape, simian crease, and congenital murmur also points to duodenal atresia. Volvulus and intussusception would present with symptoms of obstruction such as distension and failure to pass flatus and stool, and do not have vomiting as a presenting symptom. Biliary atresia would not have any bilious vomiting, nor would pyloric stenosis. Pyloric stenosis has a projectile vomitus.
Q8- A 1-year-old child is having his diaper changed when his father notices the stool looks like a purple jelly. He quickly rushes to the ED and reports that the previous night, the child was very irritable, complained of pain, and had an episode of vomiting. On physical exam the child seems lethargic and a firm sausage-shaped mass is palpated.
Which of the following is the most likely diagnosis?
A-Biliary atresia B-Duodenal atresia C-Volvulus D-Intussusception E-Pyloric stenosis
Ans: D. Intussusception presents with currant jelly stool, sausage-shaped mass, neurologic signs, and abdominal pains. The remaining choices do not fit this description.
Q9- A 16-month-old boy is brought in by his mother after she notices bright red blood in his diaper. The mother states the child has not been crying more than usual and has not had any changes in feeding habits. His examination is within normal limits except for a mild mass palpated in the middle left quadrant, and his vital signs are stable. Labs show a normal hematocrit. What is the most accurate test for this condition?
A-Colonoscopy B-Flexible sigmoidoscopy C- CT scan D-Meckel’s scan E-Repeat hemoglobin
Ans: D. When presented with painless bright red blood per rectum in a male child under age 2, you must consider Meckel’s diverticulum. A technetium-99m (99mTc) pertechnetate scan, also called a Meckel scan, is the most accurate test for this presentation. Endoscopy is not indicated in this condition, and CT scan has low yield for diagnosis. Rechecking the hemoglobin will not be of any value, as the amount of bleeding is not drastic enough to cause a modest decrease.
Q10 -An 11-month-old girl is brought from daycare to the ED for severe diarrhea and a fever of 103°F. The parents are still not present, but the daycare provider states that the girl has been lethargic, has not been eating, and has had several episodes of diarrhea. The last episode was bloody and contained mucus. Physical exam reveals a child who is listless and drowsy. Her skin shows sign of tenting. Laboratory findings show marked leuokocytosis, elevated BUN and creatinine, and markedly decreased bicarbonate and elevated hematocrit.
Which of the following is the most appropriate next step in management of this patient?
A-CT of the abdomen and pelvis B-Discharge home C-Fluid resuscitation D-Stool ova and parasite (O&P) analysis E-Empiric antibiotic delivery
Ans: C. The child is severely dehydrated as demonstrated by acute renal failure secondary to hypovolemia, skin tenting, and hemoconcentration The most appropriate next step is aggressive IV fluid rehydration and electrolyte replenishment. At this time, no other test or therapy is important; this child is unstable and could be on the brink of hypovolemeic shock. Radiologic imaging delays the administration of fluids and discharging the child home could result in fatal consequences. Antibiotic coverage is not the most appropriate next step because antibiotics can take 12 to 24 hours to become effective. Antibiotics are needed, but fluids work faster and are needed more urgently at this time.
Q11-A 4-day-old preterm female neonate is noted by the resident to have increased gastric residual volume and abdominal distension. On rectal exam the stool is heme positive. Lactate is 2.9 mg/dL. A supine x-ray of the abdomen shows air in the bowel wall but no free air in the peritoneum. What is the best next step in management of this condition?
A-Call surgical consult B-Start antibiotics C-CT scan of the abdomen D- 0.9% normal saline bolus E-Ringer lactate maintenance fluids
Ans: B. When there is confirmed evidence of necrotizing enterocolitis, start antibiotics; the antibiotics of choice are vancomycin, gentamicin, and metronidazole. This is adjunct with serial abdominal x-rays to exclude perforation. Calling a consult is always the wrong answer on the USMLE, and a CT scan of the abdomen is not necessary, as x-ray can diagnose the findings. Although starting fluids is correct, it is not the best next step compared with initiating antimicrobial therapy.
Q12- A 10.5-pound infant is born to a mother with Type I diabetes. Upon examination of the newborn, he is shaking and a holosystolic murmur is heard over the precordium. The baby’s right arm is adducted and internally rotated. His lab findings show elevated bilirubin. Which of the following is the most appropriate next step in management?
A-IV insulin B-Blood sugar level C-Serum calcium levels D-Serums TSH E-CT head and neck
Ans: B. Infants of diabetic mothers (IDMs) are born macrosomic, with plethora, and can be very jittery. The newborn usually has dramatically high circulating levels of glucose, but upon delivery, maternal glucose is no longer available. This child is still producing high levels of insulin, and thus his blood sugar levels have dropped. Cardiac anomalies are common, as in this child, who most likely has a VSD. When we think ofdiabetes, our first thought is insulin treatment. This is the most common wrong answer, since it would further exacerbate these newborns’ problems.
Q13-A 2-year-old girl who resides in England is brought in for a routine visit. The parents state that they are worried because their daughter appears to walk abnormally and falls a great deal when she tries to play with her older brother. The child’s delivery was unremarkable. The parents state that she does not like milk and withdrew from both breastfeeding and cow’s milk quite early. Physical exam reveals a very unsteady gait and bowing of the tibia, and x-ray reveals a beading of the ribs and genu varum.
What is the most likely diagnosis?
A-Rickets B-Kartagener syndrome C-Coarctation of the aorta D-Traumatic fracture E-Cerebellar injury
Ans: A. Vitamin D-deficient rickets is a disorder caused by a lack of vitamin D and calcium. This child’s risk factors include living in a sunless environment and low milk intake. The child displays classic signs including a “rachitic rosary” of the ribs on CXR and bowing of tibia. Kartagener syndrome is characterized by infertility and situs inversus. Coarctation has rib notching on the CXR; traumatic injury would show a clearer break of the tibia; and cerebellar injury would present with ataxia rather than simply an unsteady gait.
Q14-A 7-month-old infant is brought in by his mother after what she describes as a seizure. The child has had a fever of 103°F for the last 3 days and has been very irritable lately. He appears unresponsive but is breathing. Physical examination reveals a markedly delayed capillary refill and a blood pressure of 80/20.
What is the most likely diagnosis?
A-Febrile seizure B-Absence seizure C-Dog bite D-Cocaine withdrawal E-Epilepsy
Ans: A. This child has febrile seizure secondary to sepsis. The real take-home message with this case is to evaluate the child for the underlying cause of the sepsis. Understanding he has had a febrile seizure is only the surface of the case. A full sepsis evaluation must be ordered, which includes CBC with differential blood and urine cultures, urinalysis, chest x-ray, and lumbar puncture (if irritability or lethargy is mentioned = meningitis). Dog bites do not present with seizures. Cocaine withdrawal does not have seizures.
Q15-A 4-year-old child is brought in for a severe cough, fever, and runny nose. The cough sounds like a bark and she is in obvious respiratory distress. Upon physical examination, she refuses to lie flat. CXR shows a positive steeple sign.
What is the most appropriate next step in management?
A-Intubate
B-Racemic epinephrine
C-Empiric antibiotics
D-CT neck
Ans: B. This child presents with classic signs of croup, an inflammation that is quite literally choking off the upper airway. The seallike barking cough with URI-like symptoms gives it away. This is a medical emergency. To prevent asphyxiation and probable tracheostomy, administer racemic epinephrine to decrease swelling. Do not waste time with radiology. There is no medical evidence suggesting that intubation, antibiotics, or antipyretics decrease mortality.
