Red flags in pediatric presentations — MCQs

A new mother expresses her concerns because her 1-day-old newborn has been having feeding difficulties. The child vomits after every feeding and has had a continuous cough since shortly after birth. The mother denies any greenish coloration of the vomit and says that it is only composed of whitish milk that the baby just had. The child exhibits these coughing spells during the exam, at which time the physician notices the child’s skin becoming cyanotic. The mother states that the child was born vaginally with no complications, although her records show that she had polyhydramnios during her last ultrasound before the delivery. Which of the following is the most likely cause of the patient’s symptoms?

A 15-year-old boy is brought to the Emergency department by ambulance from school. He started the day with some body aches and joint pain but then had several episodes of vomiting and started complaining of a terrible headache. The school nurse called for emergency services. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. Past medical history is noncontributory. He is a good student and enjoys sports. At the hospital, his blood pressure is 120/80 mm Hg, heart rate is 105/min, respiratory rate is 21/min, and his temperature is 38.9°C (102.0°F). On physical exam, he appears drowsy with neck stiffness and sensitivity to light. Kernig’s sign is positive. An ophthalmic exam is performed followed by a lumbar puncture. An aliquot of cerebrospinal fluid is sent to microbiology. A gram stain shows gram-negative diplococci. A smear is prepared on blood agar and grows round, smooth, convex colonies with clearly defined edges. Which of the following would identify the described pathogen?

A 2-year-old boy presents for a routine checkup. The patient’s mother says that he has been ‘under the weather’ for the past few days. She did not measure his temperature at home but states that he has felt warm. She denies any episodes of diarrhea or vomiting. No significant past medical history or current medications. The patient attends daycare. He is due for a hepatitis A vaccine. The patient was born at term with no prenatal or perinatal complications. The vital signs include: temperature 37.8°C (100.1°F), blood pressure 112/62 mm Hg, pulse 80/min, respiratory rate 18/min, and oxygen saturation 99% on room air. The patient is alert and responsive. The physical exam is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman at 30 weeks 2 days of gestational age is brought into the emergency room following a seizure episode. Her medical records demonstrate poorly controlled gestational hypertension. Following administration of magnesium, she is taken to the operating room for emergency cesarean section. Her newborn daughter’s APGAR scores are 7 and 9 at 1 and 5 minutes, respectively. The newborn is subsequently taken to the NICU for further management and monitoring. Ten days following birth, the baby begins to refuse formula feedings and starts having several episodes of bloody diarrhea despite normal stool patterns previously. Her temperature is 102.2°F (39°C), blood pressure is 84/53 mmHg, pulse is 210/min, respirations are 53/min, and oxygen saturation is 96% on room air. A physical examination demonstrates a baby in mild respiratory distress and moderate abdominal distention. What do you expect to find in this patient?

Four days after delivery, a 1400-g (3-lb 1-oz) newborn has a tonic seizure that lasts for 30 seconds. Over the past 24 hours, he has become increasingly lethargic. He was born at 31 weeks' gestation. Antenatal period was complicated by chorioamnionitis. Apgar scores were 4 and 5 at 1 and 5 minutes, respectively. He appears ill. His pulse is 130/min, respirations are 53/min and irregular, and blood pressure is 67/35 mm Hg. Examination shows a bulging anterior fontanelle. The pupils are equal and react sluggishly to light. Examination shows slow, conjugate back and forth movements of the eyes. Muscle tone is decreased in all extremities. The lungs are clear to auscultation. Which of the following is the most likely underlying cause?

A 5-week-old male infant is brought to the Emergency Department with the complaint of vomiting. His parents state he has been unable to keep normal feedings down for the past week and now has projectile non-bilious vomiting after each meal. He was given a short course of oral erythromycin at 4 days of life for suspected bacterial conjunctivitis. Physical examination is significant for sunken fontanelles and dry mucous membranes. A palpable, ball shaped mass is noted just to the right of the epigastrium. Which of the following conditions is most likely in this patient?

Three days after delivery, a 1100-g (2-lb 7-oz) newborn has a tonic seizure that lasts for 25 seconds. She has become increasingly lethargic over the past 18 hours. She was born at 31 weeks' gestation. Antenatal period was complicated by chorioamnionitis. Apgar scores were 3 and 6 at 1 and 5 minutes, respectively. She appears ill. Her pulse is 123/min, respirations are 50/min and irregular, and blood pressure is 60/30 mm Hg. Examination shows a tense anterior fontanelle. The pupils are equal and react sluggishly to light. Examination shows slow, conjugate back and forth movements of the eyes. Muscle tone is decreased in all extremities. The lungs are clear to auscultation. Which of the following is the most likely diagnosis?

A 55-year-old man presents to his primary care physician for trouble swallowing. The patient claims that he used to struggle when eating food if he did not chew it thoroughly, but now he occasionally struggles with liquids as well. He also complains of a retrosternal burning sensation whenever he eats. He also claims that he feels his throat burns when he lays down or goes to bed. Otherwise, the patient has no other complaints. The patient has a past medical history of obesity, diabetes, constipation, and anxiety. His current medications include insulin, metformin, and lisinopril. On review of systems, the patient endorses a 5 pound weight loss recently. The patient has a 22 pack-year smoking history and drinks alcohol with dinner. His temperature is 99.5°F (37.5°C), blood pressure is 177/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note an overweight man in no current distress. Abdominal exam is within normal limits. Which of the following is the best next step in management?

A 31-year-old man and his wife were referred to a genetic counselor. They are concerned about the chance that their children are likely to inherit certain conditions that run in their families. The wife's father and grandfather are both healthy, but her grandfather cannot see the color red. The husband is unaware if any member of his family has the same condition. The geneticist provides some details about genetic diseases and inheritance patterns, then orders lab tests to analyze the gene mutations carried by both partners. Which of the following are the correct terms regarding the genotype and phenotype of males affected by the condition described?

A 47-year-old man presents to the clinic for an evaluation of intense itching of his right thigh region for the past few days. He states some ‘red bumps’ just began to form. The patient mentions that he was recently at a business conference in Miami. He has a past medical history of hypertension, diabetes type 2, and hyperlipidemia. He takes enalapril, metformin, and atorvastatin. He does not smoke or drink. His vitals are within normal limits today. On physical examination, a linear line with 3 red papules is present along the medial aspect of his right thigh. Additionally, there are small rows of bumps on his left leg and right forearm. Excoriations are also apparent in the same region. Which of the following is the most likely diagnosis?