Paedi MCQ A

Question 1

A 6-week-old boy, born by vaginal delivery after an uncomplicated term gestation, has experienced cough and “fast breathing” for 2 days.
His mother relates that he has a 1-week history of nasal congestion and watery eye discharge, but no fever or change in appetite. He has a temperature of 99.4°F (37.4°C) and a respiratory rate of 44 breaths/min.
He has nasal congestion, clear rhinorrhea, erythematous conjunctivae bilaterally, and watery, right eye discharge. His lungs demonstrate scattered crackles without wheezes. Which of the following is the most
likely pathogen?
A. C trachomatis
B. L monocytogenes
C. Respiratory syncytial virus
D. Rhinovirus
E. S pneumoniae

Answer 1

A

Question 2

A 2-year-old girl has increased work of breathing. Her father notes she has had cough and subjective fever over the past 3 days. She has been complaining that her “belly hurts” and has experienced one episode of posttussive emesis but no diarrhea. Her immunizations are current,
and she is otherwise healthy. Her temperature is 102°F (38.9°C). She is somnolent but easily aroused. Respirations are 28 breaths/min, and her examination is remarkable for decreased breath sounds at the left base posteriorly with prominent crackles. Which of the following acute interventions is the next best step in your evaluation?
A. Blood culture
B. Chest radiography
C. Pulse oximetry
D. Sputum culture
E. Viral nasal swab

Answer 2

C

Question 3

You are evaluating a previously healthy 8-year-old boy with subjective fever, sore throat, and cough over the past week. There has been no rhinorrhea, emesis or diarrhea, and his appetite is unchanged. According to your clinic records, his immunizations are current and his weight was at the 25th percentile on his examination 6 months ago. Today he is noted at the 10th percentile for weight. He is afebrile, with clear nares and posterior oropharynx, and a normal respiratory effort. He has bilateral
cervical and right supraclavicular lymphadenopathy. Chest auscultation
is notable for diminished breath sounds at the left base. Beyond obtaining a chest radiograph, which of the following is the best next step in your evaluation?
A. Rapid strep throat swab
B. Viral nasal swab
C. PPD placement
D. Lymph node biopsy
E. Bordetella pertussis direct fluorescent antibody testing

Answer 3

C

Question 4

Students attending a school built in 1951 are at risk for which of the following?
A. Arsenic
B. Asbestos
C. Dichlorodiphenyltrichloroethane (DDT)
D. Mercury
E. Polychlorinated biphenyls (PCBs)

Answer 4

B

Question 5

A 5-year-old girl developed high fever, ear pain, and vomiting 1 week ago. She was diagnosed with OM and started on amoxicillin-clavulanate.
On the third day of this medication she continued with findings of OM, fever, and pain. She received ceftriaxone intramuscularly and switched to oral cefuroxime. Now, 48 hours later, she has fever, pain, and no improvement in her OM; otherwise she is doing well. Which of the following is the most logical next step in her management?
A. Addition of intranasal topical steroids to the oral cefuroxime
B. Adenoidectomy
C. High-dose oral amoxicillin
D. Oral trimethoprim-sulfamethoxazole
E. Tympanocentesis and culture of middle ear fluid

Answer 5

E

Question 6

A 1-month-old boy has a fever to 102.7°F (39.3°C), is irritable, has diarrhea, and has not been eating well. On examination he has an immobile red TM that has pus behind it. Which of the following is the most appropriate course of action?
A. Admission to the hospital with complete sepsis evaluation
B. Intramuscular ceftriaxone and close outpatient follow-up
C. Oral amoxicillin-clavulanate
D. Oral cefuroxime
E. High-dose oral amoxicillin

Answer 6

A

Question 7

A girl is born via stat cesarean section to a 34-year-old mother whose pregnancy was complicated by hypertension and abnormal fetal heart monitoring. At delivery she is covered in thick, green meconium and is limp, apneic, and bradycardic. Which of the following is the best first step in her resuscitation?
A. Administer IV bicarbonate.
B. Administer IV naloxone.
C. Initiate bag-and-mask ventilation.
D. Initiate chest compressions immediately.
E. Intubate with an endotracheal tube and suction meconium from
the trachea.

Answer 7

E

Question 8

A term male is delivered vaginally to a 22-year-old mother. Immediately after birth he is noted to have a scaphoid abdomen, cyanosis, and respiratory distress. Heart sounds are heard on the right side of the chest, and the breath sounds seem to be diminished on the left side. Which of the
following is the most appropriate next step in his resuscitation?
A. Administer IV bicarbonate.
B. Administer IV naloxone.
C. Initiate bag-and-mask intubation.
D. Initiate chest compressions immediately.
E. Intubate with an endotracheal tube.

Answer 8

E

Question 9

A term infant is born vaginally after an uncomplicated pregnancy. She appears normal but has respiratory distress when she stops crying.
When crying she is pink; when not she makes vigorous respiratory efforts but becomes dusky. Which of the following is the likely explanation for her symptoms?
A. Choanal atresia
B. Diaphragmatic hernia
C. Meconium aspiration
D. Neonatal narcosis
E. Pneumothorax

Answer 9

A

Question 10

A 14-month-old child has lower-extremity bowing, a waddling gait, genu varum, and is at the fifth percentile for height. Laboratory data include low–normal serum calcium, moderately low serum phosphate,
and elevated serum alkaline phosphatase levels, hyperphosphaturia, and normal parathyroid levels. Which of the following is the most likely diagnosis?
A. Fanconi syndrome
B. Genetic primary hypophosphatemia
C. Malabsorption of vitamin D
D. Phosphate malabsorption
E. Renal osteodystrophy

Answer 10

B

Question 11

An 8-month-old African-American baby arrives to the emergency department with his mother with the complaint of decreased left arm movement. He is the product of a normal term pregnancy, has had no medical problems, and was in good health when his mother dropped him off at the day care center. Upper arm radiographs show a left
humerus spiral fracture. Which of the following is the most appropriate next step in management?
A. Admit the child and call child protective services.
B. Obtain serum 1,25(OH)2D levels.
C. Order serum alkaline phosphatase levels.
D. Obtain stool for analysis for fat-soluble vitamins.
E. Send chromosome sample for osteogenesis imperfecti analysis.

Answer 11

A

Question 12

The diet of a 3-year-old child with cystic fibrosis should be supplemented with which of the following?
A. Folate
B. Sodium
C. Vitamin C
D. Vitamin B12
E. Vitamin D

Answer 12

E

Question 13

A 14-year-old adolescent female from another state was followed for 7 years for a history of insulin-dependent diabetes mellitus. At your clinic her hemoglobin A1C is 14.9%. This laboratory test indicates
which of the following?
A. Her glucose control is poor.
B. She does not have insulin-dependent diabetes.
C. She has entered the “honeymoon phase” of her diabetes.
D. She has an underlying infection.
E. She is demonstrating the Somogyi phenomenon.

Answer 13

A

Question 14

Six months after being diagnosed with what appears to be insulindependent diabetes, the 5-year-old in the case presentation has a significant decrease in his insulin requirement. Which of the following is the most likely explanation?
A. His diagnosis of insulin-dependent diabetes was incorrect.
B. He had a chronic infection that is now under control.
C. He has followed his diabetes diet so well that he requires less
insulin.
D. He is demonstrating the Somogyi phenomenon.
E. He has entered the “honeymoon phase” of his diabetes.

Answer 14

E

Question 15

A 15-year-old adolescent female has experienced abdominal pain, vomiting, and lethargy for 3 days. Her chest and throat examinations are clear, but her abdominal examination is significant for right lower
quadrant pain. Rectal examination is equivocal for pain, and her pelvic
examination is remarkable for pain upon movement of her cervix.
Laboratory data include a white blood cell count of 18,000/mm3, serum glucose level of 145 mg/dL, and serum bicarbonate level of 21 mEq/dL. Her urinalysis is remarkable for 1+ white blood cells, 1+ glucose, and 1+ ketones. Which of the following is the most likely diagnosis?
A. Appendicitis
B. Diabetic ketoacidosis (DKA)
C. Gastroenteritis
D. Pelvic inflammatory disease (PID)
E. Right lower lobe pneumonia

Answer 15

D

Question 16

A 16-year-old obese adolescent female has enuresis, frequent urination, a white vaginal discharge, and a dark rash around her neck. Her serum glucose level is 250 mg/dL, and her urinalysis is positive for 2+ glucose but is
otherwise negative. Which of the following is the most likely diagnosis?
A. Chemical vaginitis
B. Chlamydia cervicitis
C. Psoriasis
D. Type II diabetes
E. Urinary tract infection (UTI)

Answer 16

D

Question 17

A healthy, well-developed 6-year-old child arrives as a new patient to your clinic. His immunization card reveals that he received an immunization at birth and some when he was 2 months old, but none since.
Which of the following statements about him is correct?
A. He should receive the live oral poliovirus vaccine rather than the
inactivated (injectable) poliovirus vaccine (IPV).
B. The pertussis vaccine is contraindicated at his age and is replaced
with the tetanus-diphtheria vaccine.
C. He is too old to receive the H influenzae type b vaccine.
D. His vaccinations at birth and 2 months are repeated because too
much time has elapsed for them to be effective.
E. He is too young for the varicella vaccine.

Answer 17

C

Question 18

Appropriate advice for a mother of a 2-week-old child here for a “wellchild” visit includes which of the following?
A. By age 1 month the child should be sleeping through the night.
B. Children should be able to roll over by age 2 months and to sit by
age 4 months.
C. Half-strength fruit juices can be initiated at age 2 months.
D. Potty training should begin at age 1 year.
E. Sleep in the supine position is recommended.

Answer 18

E

Question 19

During a “well-child” visit, the parents of a healthy 5-month-old offer a great amount of information. Which of the following bits of information is of most concern?
A. A diet that includes baby cereal, five different baby vegetables,
and one baby fruit
B. Consuming 32 oz of infant formula per day
C. Intermittent tugging on the ears
D. Limited eye contact with parents
E. Rolling from front to back but not back to front

Answer 19

D

Question 20

A 2-day-old infant has significant nasal and rectal bleeding. He was delivered by a midwife at home; the pregnancy was without complications. His Apgar scores were 9 at 1 minute and 9 at 5 minutes. He has breast-fed well and has not required a health-care professional visit since birth. Which of the following vitamin deficiencies might explain his condition?
A. Vitamin A
B. Vitamin B1
C. Vitamin C
D. Vitamin D
E. Vitamin K

Answer 20

E

Question 21

An exclusively breast-fed infant with poor routine care is switched at 6 months of age to whole milk and table foods. Screening laboratories at 9 months of age demonstrate the hemoglobin and hematocrit to be 8 mg/dL and 25%, respectively, and the lead level to be less than 2 μg/dL.
A follow-up complete blood count (CBC) 2 weeks later shows the hemoglobin to be at 7.8 mg/dL, the hematocrit 25%, the mean corpuscular volume (MCV) 62%, and the platelet count to be 750,000/mm3.
Which of the following would be the next step in the management of this child?
A. Order a hemoglobin electrophoresis.
B. Obtain a bone marrow aspiration.
C. Initiate iron supplementation.
D. Refer to a pediatric hematologist.
E. Initiate soybean-based formula.

Answer 21

C

Question 22

A 3-week-old is admitted for failure to thrive, diarrhea, and a sepsis like picture. He does well on intravenous fluids; when begun on routine infant formula with iron, his symptoms return. It is Saturday and the state health department laboratory is closed. You should begin feeds with which of the following?
A. Amino acid–based formula (Nutramigen or Pregestimil)
B. Low-phenylalanine formula (Lofenalac or Phenex-1)
C. Low-iron, routine infant formula (Similac with low iron or Enfamil
with low iron)
D. Low-isoleucine, low-leucine, low-valine infant formula (Ketonex-1
or MSUD 1)
E. Soy-based formula (ProSobee or Isomil)

Answer 22

E

Question 23

An institutionalized male juvenile delinquent upon close examination has severe nodulocystic acne, mild pectus excavatum, large teeth, prominent glabella, and relatively long face and fingers. His family says he has poor fine motor skills (such as penmanship), an explosive temper, and a low–normal IQ.
Diagnosis.

Answer 23

XYY male

Question 24

A tall, thin 14-year-old adolescent male has no signs of puberty. He was delayed in his speech development and always has done less well in school than his siblings. He is shy, and teachers report his activity is immature. Physical examination reveals breast development, and long limbs with a decreased upper segment–lower segment ratio. He has small testes and phallus.
Diagnosis.

Answer 24

Klinefelter syndrome (XXY)

Question 25

A 15-year-old adolescent female with primary amenorrhea is noted to be well below the fifth percentile for height. She has hypertension, a low posterior hairline, prominent and low-set ears, and excessive
nuchal skin.
Diagnosis.

Answer 25

Turner syndrome (XO)

Question 26

A 15-year-old adolescent female has a 1-month history of urinary frequency
without dysuria and recent onset of an itchy rash beneath both breasts. She has been gaining weight over the past year and regularly complains of fatigue. She is afebrile with a weight greater than the 99th percentile and has an erythematous, macular rash beneath both breasts characterized by satellite lesions. Urinalysis is significant for 2+
glucosuria, but no pyuria. Which of the following is the most likely diagnosis?
A. Diabetes mellitus
B. Fanconi syndrome
C. Human immunodeficiency virus
D. Occult malignancy
E. Severe combined immunodeficiency (SCID)

Question 27

A mother notes her 6-week-old son’s umbilical cord is still attached. His activity and intake are normal; there has been no illness or fever. Delivery was at term without problems. His examination is notable for
a cord without evidence of separation and a shallow, 0.5-cm ulceration at the occiput without discharge or surrounding erythema. Mother declares that the “sore,” caused by a scalp probe, has been slowly healing since birth and was deemed unremarkable at his 2-week checkup. Which of the following is consistent with this child’s likely diagnosis?
A. Defective humoral response
B. Functional leukocyte adherence glycoproteins
C. Marked neutrophilia
D. Normal wound healing
E. Purulent abscess formation

Answer 27

A

Question 28

A 6-month-old girl is seen after an emergency room visit for decreased
intake, emesis, and watery diarrhea for the past 3 days. She was diagnosed yesterday with “stomach flu” and given IV fluids. She is doing better today with improved intake and resolution of her emesis and diarrhea. The father is concerned about her thrush since birth (despite multiple courses of an oral antifungal) and that she has been hospitalized twice for pneumonia over the past 4 months. Her weight has dropped from the 50th percentile on her 4-month visit to the 5th percentile today. She has no findings consistent with dehydration, but she does appear to have some extremity muscle wasting. Her examination is remarkable for buccal mucosal exudates and hyperactive
bowel sounds. Vital signs and the remainder of her examination are normal. You suspect severe combined immunodeficiency (SCID).
Which of the following is consistent with the diagnosis?
A. Autosomal dominant inheritance
B. Persistent lymphocytosis
C. Defective cellular immunity
D. Normal vaccine immune response
E. No curative therapy

Answer 28

C

Question 29

A 6-month-old girl is seen after an emergency room visit for decreased
intake, emesis, and watery diarrhea for the past 3 days. She was diagnosed yesterday with “stomach flu” and given IV fluids. She is doing better today with improved intake and resolution of her emesis and diarrhea. The father is concerned about her thrush since birth (despite multiple courses of an oral antifungal) and that she has been hospitalized twice for pneumonia over the past 4 months. Her weight has dropped from the 50th percentile on her 4-month visit to the 5th percentile today. She has no findings consistent with dehydration, but she does appear to have some extremity muscle wasting. Her examination is remarkable for buccal mucosal exudates and hyperactive
bowel sounds. Vital signs and the remainder of her examination are normal. You suspect severe combined immunodeficiency (SCID).
Which of the following is consistent with the diagnosis?
A. Autosomal dominant inheritance
B. Persistent lymphocytosis
C. Defective cellular immunity
D. Normal vaccine immune response
E. No curative therapy

Answer 29

C

Question 30

You are called urgently to examine a term, 2-hour-old newborn who has had temperature instability, difficulty with feeding, and a suspected seizure. He has atypical facies (wide-set eyes, a prominent nose, and a small mandible), a cleft palate, and a holosystolic murmur. Stat laboratory tests and chest radiograph reveal marked hypocalcemia, a boot-shaped heart, and no apparent thymus. Which of the following
is the most likely diagnosis?
A. Ataxia–telangiectasia
B. DiGeorge syndrome
C. Hyper-IgE syndrome
D. SCID
E. Wiskott-Aldrich syndrome

Answer 30

B

Question 31

A small-for-gestational age infant is born to a 35-year-old woman. He has low-set and malformed ears, microcephaly, rocker-bottom feet, inguinal hernias, cleft lip or palate, and micrognathia. Chromosomal
analysis is likely to reveal which of the following?
A. Down syndrome (trisomy 21)
B. Edwards syndrome (trisomy 18)
C. Holt-Oram syndrome
D. Patau syndrome (trisomy 13)
E. Turner syndrome

Answer 31

B

Question 32

A small-for-gestational age, dysmorphic newborn infant has microcephaly
and sloping forehead, cutis aplasia (missing portion of the skin and hair) of the scalp, polydactyly, microphthalmia, and omphalocele. Which of the following is the most likely diagnosis?
A. Down syndrome (trisomy 21)
B. Edwards syndrome (trisomy 18)
C. Holt-Oram syndrome
D. Patau syndrome (trisomy 13)
E. Turner syndrome

Answer 32

D

Question 33

The parents of an 8-year-old DS boy arrive for his annual well-child visit. He wants to participate in sports, including the Special
Olympics. Until further evaluation can be completed, which of the following sports would you suggest as being safe?
A. Diving
B. Football
C. Tennis
D. Tumbling
E. Wrestling

Answer 33

C

Question 34

Parents bring their 16-year-old daughter for a “well-child” checkup. She looks normal on examination. As part of your routine care you
plan a urinalysis. The father pulls you aside and asks you to secretly run a urine drug screen (UDS) on his daughter. Which of the following is the most appropriate course of action?
A. Explore the reasons for the request with the parents and the adolescent,
and perform a UDS with the adolescent’s permission if the
history warrants.
B. Perform the UDS as requested, but have the family and the girl
return for the results.
C. Perform the UDS in the manner requested.
D. Refer the adolescent to a psychiatrist for further evaluation.
E. Tell the family to bring the adolescent back for a UDS when she
is exhibiting signs or symptoms such as euphoria or ataxia.

Answer 34

A

Question 35

Parents bring their 6-month-old son to see you. He is symmetrically less than the fifth percentile for height, weight, and head circumference. He was born at 30 weeks’ gestation and weighed 1000 g. He was
a planned pregnancy, and his mother’s prenatal course was uneventful until an automobile accident initiated the labor. He was ventilated for 3 days in the intensive care unit (ICU) but otherwise did well without
ongoing problems. He was discharged at 8 weeks of life. Which of the following is the mostly likely explanation for his small size?
A. Chromosomal abnormality
B. Protein-calorie malnutrition
C. Normal ex-premie infant growth
D. Malabsorption secondary to short gut syndrome
E. Congenital hypothyroidism

Answer 35

C

Question 36

A 13-month-old child is noted to be at the 25th percentile for weight, the 10th percentile for height, and less than the 5th percentile for head circumference. She was born at term. She was noted to have a small head at birth, to be developmentally delayed throughout her life, and to have required cataract surgery shortly after birth. She currently takes phenobarbital for seizures. Which of the following would most likely explain this child’s small size?
A. Congenital cytomegalovirus (CMV) infection
B. Down syndrome
C. Glycogen storage disease type II
D. Congenital hypothyroidism
E. Craniopharyngioma

Answer 36

A

Question 37

A 2-year-old boy had been slightly less than the 50th percentile for weight, height, and head circumference, but in the last 6 months he has fallen to slightly less than the 25th percentile for weight. The pregnancy was normal, his development is as expected, and the family reports no psychosocial problems. The mother says that he is now a finicky eater (wants only macaroni and cheese at all meals), but she insists that he eat a variety of foods. The meals are marked by much
frustration for everyone. His examination is normal. Which of the following is the best next step in his care?
A. Sweat chloride testing
B. Examination of the eyes for retinal hemorrhages
C. Reassurance and counseling for family about childhood normal
developmental stage
D. Testing of stool for parasites
E. Magnetic resonance imaging (MRI) of the brain

Answer 37

C

Question 38

A 4-month-old child has poor weight gain. Her current weight is less
than the 5th percentile, height about the 10th percentile, and head
circumference at the 50th percentile. The planned pregnancy resulted
in a normal, spontaneous, vaginal delivery; mother and child were discharged after a 48-hour hospitalization. Feeding is via breast and bottle; the quantity seems sufficient. The child has had no illness. The examination is unremarkable except for the child’s small size. Screening laboratory shows the hemoglobin and hematocrit are 11 mg/dL
and 33%, respectively, with a platelet count of 198,000/mm3. Serum electrolyte levels are sodium 140, chloride 105, potassium 3.5, bicarbonate 17, blood urea nitrogen 15, and creatinine 0.3. Liver function tests are normal. Urinalysis reveals a pH of 8 with occasional epithelial cells but no white blood cells, bacteria, protein, ketones, or reducing substances. Which of the following is the most appropriate therapy for this child?
A. Transfusion with packed red blood cells (PRBCs)
B. Intravenous (IV) infusion of potassium chloride
C. Sweat chloride analysis
D. Growth hormone determination
E. Oral supplementation with bicarbonate

Answer 38

E

Question 39

The parents of a 2-year-old girl, recent immigrants from Guatemala,
bring their child to you for the first time. The child was born at term
after an uncomplicated pregnancy and delivery, and her neonatal
course was uneventful. She sat without support at 6 months of age,
pulled to a stand at 10 months, and walked at 14 months. She has a
10-word vocabulary, is able to drink from a cup, and feeds herself with
a spoon. A previous child in the family died at age 5 years from “heart
trouble.” On physical examination, you note lower extremity contractures,
hand stiffness, somewhat coarse facial features, and hepatosplenomegaly.
The child’s growth is within normal limits, and her examination is otherwise
normal. Which of the following is the most appropriate next step to
diagnose this child’s condition?
A. Abdominal computerized tomography (CT)
B. Brain magnetic resonance imaging (MRI)
C. Chromosomal analysis
D. Tests for a storage disorder
E. Thyroid function studies

Answer 39

D

Question 40

A term infant delivered vaginally develops vomiting and abdominal
distention at age 10 hours. No stool passage has been noted. An
abdominal radiograph shows distended bowel loops and a “bubbly”
pattern in a portion of intestine; the colon is narrow. Which of the following
should you tell the parents?
A. You would like to consult a pediatric surgeon because you suspect
that their child has Hirschsprung disease.
B. The child most likely has necrotizing enterocolitis, a condition
more commonly seen in premature infants. Therefore you question
the child’s supposed gestational age.
C. You are concerned about the possibility of meconium ileus and
would like to obtain some family history.
D. You believe that the child simply is constipated and would like to
change to a soy-based formula to see whether the baby tolerates
this better.
E. The child’s symptoms and radiograph findings most likely are normal.

Answer 40

C