A 15-month-old boy is brought to the pediatrician’s office by his mother due to abnormal muscle tone and an inability to walk. He was able to control his head at 5 months of age, roll at 8 months of age, sit at 11 months of age, and develop hand preference at 13 months of age. On physical exam, he is observed to asymmetrically crawl. He has a velocity-dependent increase in tone and 3+ biceps and patellar reflexes. His startle, asymmetric tonic neck, and Babinski reflexes are present. Which of the following is the most common risk factor for developing this patient’s clinical presentation?
Q62
A 10-year-old boy is brought to the emergency department by his mother due to frequent vomiting, abdominal pain, and weakness. Over the last 5 days, has been noted to have polydipsia and polyuria. Family history is irrelevant. His temperature is 37.1°C (98.7°F), blood pressure is 100/70 mm Hg, and pulse is 110/min. Physical examination reveals no response to verbal commands, sunken eyes, poor skin turgor, and rapid deep respirations. Laboratory results are shown:
Random plasma glucose 420 mg/dL
Serum beta-hydroxybutyrate elevated
Fasting C-peptide undetectable
Antiglutamic acid decarboxylase (GAD) antibodies positive
This patient's condition occurs as a result of which of the following?
Q63
An exclusively breast-fed, 4-month-old boy is brought to the physician by his mother for a routine examination. He was born at term and delivery was uncomplicated. He received all standard treatment and testing prior to being discharged from the hospital. Examination shows no abnormalities. Without receiving additional supplementation at this time, this infant is at greatest risk of developing which of the following conditions?
Q64
A 5-year-old boy is brought in by his mother with reports of trouble at school. Teachers report that for the last 6 months he has been having difficulty finishing tasks, is easily distracted, frequently does not listen, commonly fails to finish schoolwork, has not been able to complete any of the class projects this year, and frequently loses school books and supplies. Teachers also say that he constantly fidgets, often leaves his seat without permission, has trouble being quiet, talks excessively, frequently interrupts his classmates when trying to answer questions, and has difficulty waiting in line. The mother states that she has also been noticing similar behaviors at home and that his symptoms have been affecting him negatively academically and socially. The patient has no significant past medical history. The patient is in the 90th percentile for height and weight and has been meeting all the developmental milestones. He is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following medications is a first-line treatment for this patient’s most likely diagnosis?
Q65
An 8-month-old child presents with a history of poor growth and a chronic cough. He was born to a 21-year-old woman at 41 weeks of gestation. Soon after birth, he developed respiratory distress and was admitted to the neonatal intensive care unit where he was mechanically ventilated for 24 hours. He was initially breastfed, but due to frequent vomiting and loose bowel movements, he was formula fed thereafter. Despite this change, he continued to have loose, large, greasy, foul-smelling stools and failure to thrive. When physically examined, his temperature is 37.0°C (98.6°F), heart rate is 120/min, and blood pressure is 80/60 mm Hg. Oxygen saturation is 97% on room air and the baby's weight is 6.7 kg (14.8 lb, < 5th percentile). HEENT examination is significant for bilateral otitis media and mild nasal congestion. Normal breath sounds with mild wheezing and rales are heard. Which condition best explains this patient's clinical presentation?
Q66
A 14-year-old boy presents with a 1-month history of gradual onset of pain immediately below his right kneecap. He has recently started playing basketball for the junior varsity team at his school, and he is very excited for the season to begin. Unfortunately, the pain in his knee is exacerbated by all the jumping activity during practice. The patient reports similar pain when climbing up and down the stairs. He denies any previous history of knee injury. Physical examination reveals full range of motion of his knee, but the pain is reproduced when the knee is extended against resistance. Which of the following is the most likely diagnosis?
Q67
A 7-year-old boy is brought to the emergency department because of abdominal pain, nausea, and vomiting one day after he was a passenger in a low-velocity motor vehicle accident in which he was wearing an adult seatbelt. He has no personal or family history of serious illness. His temperature is 37.1°C (98.8°F), pulse is 107/min, respirations are 20/min, and blood pressure is 98/65 mm Hg. Physical examination shows dry mucous membranes. The upper abdomen is distended and tender to palpation. The remainder of the examination shows no abnormalities. A CT scan of the abdomen shows a large gastric bubble with mild gastric distention. Which of the following is the most appropriate next step in management?
Q68
A 7-year-old boy presents with right hip pain for the past 2 days. He reports gradual onset of pain and states it hurts to walk. He had a recent cold last week but is otherwise healthy. His temperature is 98.2°F (36.8°C), blood pressure is 107/70 mm Hg, pulse is 90/min, respiratory rate is 19/min, and oxygen saturation is 98% on room air. Physical exam reveals no swelling or warmth surrounding the joint. The patient is sitting with the right hip flexed, abducted, and externally rotated. Passive range of motion of the hip causes discomfort. The patient is able to ambulate but states it hurts. An initial radiograph of the hip is unremarkable. The patient's CRP is 0.10 mg/L. Which of the following is the best next step in management of this patient?
Q69
A 3-month-old African American boy presents to his pediatrician’s office for his routine well visit. He was born full-term from an uncomplicated vaginal delivery. He is exclusively breastfeeding and not receiving any medications or supplements. Today, his parents report no issues or concerns with their child. He is lifting his head for brief periods and smiling. He has received only 2 hepatitis B vaccines. Which of the following is the correct advice for this patient’s parents?
Q70
A 9-year-old girl is brought to the physician by her father because of multiple episodes of staring and facial grimacing that have occurred over the past 3 weeks. There are no precipitating factors for these episodes and they last for several minutes. She does not respond to her family members during these episodes. One week ago, her brother witnessed an episode in which she woke up while sleeping, stared, and made hand gestures. She does not remember any of these episodes but does recall having a vague muddy taste in her mouth prior to the onset of these symptoms. After the episode, she feels lethargic and is confused. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?
Growth/Development US Medical PG Practice Questions and MCQs
Question 61: A 15-month-old boy is brought to the pediatrician’s office by his mother due to abnormal muscle tone and an inability to walk. He was able to control his head at 5 months of age, roll at 8 months of age, sit at 11 months of age, and develop hand preference at 13 months of age. On physical exam, he is observed to asymmetrically crawl. He has a velocity-dependent increase in tone and 3+ biceps and patellar reflexes. His startle, asymmetric tonic neck, and Babinski reflexes are present. Which of the following is the most common risk factor for developing this patient’s clinical presentation?
A. Intrauterine growth restriction
B. Prematurity (Correct Answer)
C. Perinatal hypoxic injury
D. Multiparity
E. Stroke
Explanation: ***Prematurity***
- **Cerebral palsy (CP)** is characterized by **delayed motor milestones**, **abnormal muscle tone (spasticity)**, **hyperreflexia**, and **persistent primitive reflexes** beyond the expected age.
- **Prematurity** (especially birth before 32 weeks' gestation) is the **most common risk factor** for CP overall, accounting for approximately 40-50% of cases.
- The developing brain of premature infants is particularly vulnerable to periventricular leukomalacia (PVL) and intraventricular hemorrhage (IVH), which can lead to various CP subtypes.
- While this patient's **early hand preference** and **asymmetric crawling** suggest hemiplegic CP (often associated with stroke), the question asks for the most common risk factor **epidemiologically**, not the most likely cause in this specific case.
*Intrauterine growth restriction*
- While **IUGR** can be associated with developmental delays and is a risk factor for CP, it is less common than prematurity as the primary risk factor.
- IUGR alone without complications (like prematurity or hypoxia) accounts for a smaller proportion of CP cases.
*Perinatal hypoxic injury*
- **Perinatal hypoxic-ischemic encephalopathy (HIE)** can cause CP, especially severe cases resulting in basal ganglia or watershed area damage.
- However, with modern obstetric monitoring and intervention, severe perinatal hypoxia accounts for only ~10% of CP cases—less common than prematurity.
*Multiparity*
- **Multiparity** (having multiple previous births) is generally not considered a direct or common risk factor for cerebral palsy.
- Any slight associations are typically due to confounding factors like increased risk of preterm birth in subsequent pregnancies, rather than multiparity itself.
*Stroke*
- **Perinatal stroke** can cause CP, typically presenting as **hemiplegic CP** with early hand preference and asymmetric motor findings—features seen in this patient.
- While stroke is a significant cause of hemiplegic CP specifically, it accounts for a smaller proportion of overall CP cases compared to prematurity, which causes various CP subtypes and is more prevalent.
Question 62: A 10-year-old boy is brought to the emergency department by his mother due to frequent vomiting, abdominal pain, and weakness. Over the last 5 days, has been noted to have polydipsia and polyuria. Family history is irrelevant. His temperature is 37.1°C (98.7°F), blood pressure is 100/70 mm Hg, and pulse is 110/min. Physical examination reveals no response to verbal commands, sunken eyes, poor skin turgor, and rapid deep respirations. Laboratory results are shown:
Random plasma glucose 420 mg/dL
Serum beta-hydroxybutyrate elevated
Fasting C-peptide undetectable
Antiglutamic acid decarboxylase (GAD) antibodies positive
This patient's condition occurs as a result of which of the following?
A. Insulin resistance
B. Starvation
C. Immune-mediated destruction of pancreatic beta cells (Correct Answer)
D. Defective synthesis or release of arginine vasopressin
E. Salicylate poisoning
Explanation: ***Immune-mediated destruction of pancreatic beta cells***
- The diagnosis of **Type 1 Diabetes Mellitus (T1DM)** is strongly supported by the patient's age (10 years old), rapid onset of symptoms (frequent vomiting, abdominal pain, weakness, polydipsia, polyuria), **random plasma glucose of 420 mg/dL**, elevated **serum beta-hydroxybutyrate** (indicating **diabetic ketoacidosis**), and specifically, the **positive antiglutamic acid decarboxylase (GAD) antibodies** and **undetectable fasting C-peptide**.
- **Antiglutamic acid decarboxylase (GAD) antibodies** are a common marker for autoimmune destruction of **pancreatic beta cells**, which leads to **absolute insulin deficiency**. **C-peptide** is a byproduct of insulin synthesis; its absence indicates the pancreas is not producing insulin.
*Insulin resistance*
- **Insulin resistance** is characteristic of **Type 2 Diabetes Mellitus (T2DM)**, which typically presents in older individuals, often with **obesity**, and is not associated with **positive GAD antibodies** or **undetectable C-peptide**.
- In **insulin resistance**, the body produces insulin, often in high amounts initially, but the cells do not respond effectively, leading to hyperglycemia.
*Starvation*
- While **starvation** can lead to **ketogenesis** and signs like weakness, it would typically result in **hypoglycemia** or normal glucose levels, not profound hyperglycemia (420 mg/dL).
- The presence of **polydipsia**, **polyuria**, and positive **GAD antibodies** rules out starvation as the primary cause.
*Defective synthesis or release of arginine vasopressin*
- This describes **diabetes insipidus**, a condition characterized by **polyuria** and **polydipsia** due to impaired water reabsorption by the kidneys.
- However, **diabetes insipidus** is not associated with **hyperglycemia**, **ketosis**, or **positive GAD antibodies** and therefore does not fit the overall clinical picture.
*Salicylate poisoning*
- **Salicylate poisoning** can cause metabolic acidosis (often with a respiratory alkalosis component), vomiting, and altered mental status.
- However, it does not explain the profound **hyperglycemia** and is not associated with **positive GAD antibodies** or undetectable **C-peptide**.
Question 63: An exclusively breast-fed, 4-month-old boy is brought to the physician by his mother for a routine examination. He was born at term and delivery was uncomplicated. He received all standard treatment and testing prior to being discharged from the hospital. Examination shows no abnormalities. Without receiving additional supplementation at this time, this infant is at greatest risk of developing which of the following conditions?
A. Intracranial bleed
B. Microcytic anemia (Correct Answer)
C. Rickets
D. Scaly dermatitis
E. Peripheral neuropathy
Explanation: ***Microcytic anemia***
- Exclusively breastfed infants are at risk for **iron deficiency anemia** because breast milk contains low levels of iron (~0.3 mg/L), and newborn iron stores are typically depleted by **4-6 months of age**.
- At 4 months, iron stores are beginning to deplete, and iron supplementation is typically initiated around this time; without supplementation, the infant is at greatest risk for developing **microcytic anemia** due to impaired hemoglobin synthesis.
- Iron deficiency causes red blood cells to be small (microcytic) and pale (hypochromic).
*Intracranial bleed*
- An intracranial bleed in an otherwise healthy infant is most commonly associated with **vitamin K deficiency bleeding (VKDB)**.
- However, the infant received **standard treatment** at birth, which includes vitamin K prophylaxis (typically 1 mg IM), making this highly unlikely.
*Rickets*
- Rickets is caused by **vitamin D deficiency**, leading to impaired bone mineralization.
- While breast milk is deficient in vitamin D, the **AAP recommends vitamin D supplementation (400 IU/day)** for all breastfed infants starting shortly after birth, which is part of standard care and would prevent rickets.
- No bone abnormalities are noted on examination.
*Scaly dermatitis*
- Scaly dermatitis, such as **seborrheic dermatitis (cradle cap)**, is common and physiological in infants but is not directly linked to a specific nutritional deficiency from exclusive breastfeeding.
- Severe, generalized scaly dermatitis could indicate **zinc deficiency** or **essential fatty acid deficiency**, but this is rare in otherwise healthy, exclusively breastfed term infants.
*Peripheral neuropathy*
- Peripheral neuropathy in infants can be caused by genetic, metabolic, or toxic conditions.
- It is **not** a common complication associated with exclusive breastfeeding in an otherwise healthy term infant.
Question 64: A 5-year-old boy is brought in by his mother with reports of trouble at school. Teachers report that for the last 6 months he has been having difficulty finishing tasks, is easily distracted, frequently does not listen, commonly fails to finish schoolwork, has not been able to complete any of the class projects this year, and frequently loses school books and supplies. Teachers also say that he constantly fidgets, often leaves his seat without permission, has trouble being quiet, talks excessively, frequently interrupts his classmates when trying to answer questions, and has difficulty waiting in line. The mother states that she has also been noticing similar behaviors at home and that his symptoms have been affecting him negatively academically and socially. The patient has no significant past medical history. The patient is in the 90th percentile for height and weight and has been meeting all the developmental milestones. He is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following medications is a first-line treatment for this patient’s most likely diagnosis?
A. Clonidine
B. Guanfacine
C. Atomoxetine
D. Methylphenidate (Correct Answer)
E. Haloperidol
Explanation: ***Methylphenidate***
- The patient exhibits core symptoms of **ADHD** (hyperactivity, impulsivity, and inattention) for at least 6 months, across multiple settings, and causing significant impairment. **Methylphenidate** is a **first-line stimulant medication** for treating ADHD.
- As a **stimulant**, methylphenidate increases levels of **dopamine** and **norepinephrine** in the brain, improving focus and reducing hyperactivity.
*Clonidine*
- **Clonidine** is an **alpha-2 adrenergic agonist** that can be used to treat ADHD, particularly for managing **hyperactivity, impulsivity, and tics**.
- It is typically considered a **second-line agent** or an adjunct therapy when stimulants are not effective or are contraindicated.
*Guanfacine*
- **Guanfacine** is another **alpha-2 adrenergic agonist** often used for ADHD, especially for children who cannot tolerate stimulants or have significant **hyperactivity/impulsivity**.
- Like clonidine, it is generally considered a **non-stimulant alternative** but not typically the first-line choice over stimulants.
*Atomoxetine*
- **Atomoxetine** is a **norepinephrine reuptake inhibitor** and a non-stimulant medication for ADHD.
- It is a **first-line non-stimulant option** but stimulants like methylphenidate are generally preferred as first-line due to their higher efficacy and faster onset of action.
*Haloperidol*
- **Haloperidol** is a **first-generation antipsychotic** primarily used to treat **psychotic disorders** like schizophrenia, severe agitation, and Tourette's syndrome.
- It is **not indicated** for the treatment of ADHD and would be inappropriate given the patient's symptoms.
Question 65: An 8-month-old child presents with a history of poor growth and a chronic cough. He was born to a 21-year-old woman at 41 weeks of gestation. Soon after birth, he developed respiratory distress and was admitted to the neonatal intensive care unit where he was mechanically ventilated for 24 hours. He was initially breastfed, but due to frequent vomiting and loose bowel movements, he was formula fed thereafter. Despite this change, he continued to have loose, large, greasy, foul-smelling stools and failure to thrive. When physically examined, his temperature is 37.0°C (98.6°F), heart rate is 120/min, and blood pressure is 80/60 mm Hg. Oxygen saturation is 97% on room air and the baby's weight is 6.7 kg (14.8 lb, < 5th percentile). HEENT examination is significant for bilateral otitis media and mild nasal congestion. Normal breath sounds with mild wheezing and rales are heard. Which condition best explains this patient's clinical presentation?
A. Celiac disease
B. Shwachman-Diamond syndrome
C. Cow's milk protein allergy
D. Giardiasis
E. Cystic fibrosis (Correct Answer)
Explanation: ***Cystic fibrosis***
- The constellation of **poor growth**, **chronic cough**, **respiratory distress** in the neonatal period needing ventilation, **recurrent infections** (otitis media), and classic gastrointestinal symptoms of **greasy, foul-smelling stools** and **failure to thrive** is highly suggestive of cystic fibrosis.
- The gastrointestinal symptoms are due to **pancreatic exocrine insufficiency**, where thick mucus blocks pancreatic ducts, preventing digestive enzymes from reaching the intestine, leading to **malabsorption of fats** and fat-soluble vitamins.
*Celiac disease*
- While celiac disease also presents with **malabsorption** and **failure to thrive**, it typically manifests after the introduction of **gluten-containing foods**, usually around 6-12 months of age.
- It does not explain the early **respiratory issues** or the recurrent infections seen in this patient.
*Shwachman-Diamond syndrome*
- This syndrome presents with **pancreatic exocrine insufficiency** and **bone marrow dysfunction** (neutropenia leading to recurrent infections), which could explain some symptoms.
- However, it typically lacks the prominent **respiratory findings** and chronic cough that are a hallmark of cystic fibrosis.
*Cow's milk protein allergy*
- This allergy often causes **vomiting, loose stools, and poor growth**, especially after formula feeding.
- However, it does not account for the **chronic cough**, **respiratory distress at birth**, or the **greasy, foul-smelling nature of the stools**, which points more specifically to fat malabsorption.
*Giardiasis*
- This parasitic infection can cause **diarrhea, abdominal cramps, and malabsorption**, leading to **poor growth**, especially in children in daycare settings.
- It would not explain the **neonatal respiratory distress**, **chronic cough**, or recurrent upper respiratory infections described in the patient.
Question 66: A 14-year-old boy presents with a 1-month history of gradual onset of pain immediately below his right kneecap. He has recently started playing basketball for the junior varsity team at his school, and he is very excited for the season to begin. Unfortunately, the pain in his knee is exacerbated by all the jumping activity during practice. The patient reports similar pain when climbing up and down the stairs. He denies any previous history of knee injury. Physical examination reveals full range of motion of his knee, but the pain is reproduced when the knee is extended against resistance. Which of the following is the most likely diagnosis?
A. Prepatellar bursitis
B. Meniscal tear
C. Osgood-Schlatter disease (Correct Answer)
D. Patellofemoral syndrome
E. Shearing injury of the anterior cruciate ligament (ACL)
Explanation: ***Osgood-Schlatter disease***
- This condition presents with **gradual onset of pain below the kneecap**, worsened by activities involving quadriceps contraction like **jumping** and **climbing stairs** in a young, active adolescent.
- Pain on **resisted knee extension** and a history of growth spurts in highly active adolescents (basketball player) are classic features, pointing to stress on the **tibial tubercle apophysis**.
*Prepatellar bursitis*
- Characterized by **inflammation of the prepatellar bursa**, located directly **over the kneecap**, not below it.
- Typical causes include **direct trauma** or prolonged kneeling, leading to localized swelling and tenderness over the patella itself.
*Meniscal tear*
- Often results from a **sudden twisting injury** to the knee, causing immediate pain, swelling, and sometimes mechanical symptoms like **locking or clicking**.
- The pain is usually localized to the **joint line** and is not typically exacerbated by resisted knee extension in the absence of a pre-existing tear.
*Patellofemoral syndrome*
- Also known as "runner's knee," this condition causes **anterior knee pain**, often described as a **dull ache behind or around the kneecap**.
- While it can be worsened by activity, the pain is usually **diffuse** rather than localized immediately below the kneecap, and typically does not involve distinct tenderness at the tibial tubercle.
*Shearing injury of the anterior cruciate ligament (ACL)*
- An **ACL injury** typically results from a **sudden, forceful hyperextension or twisting injury**, often with an audible "pop," leading to immediate pain, swelling, and instability.
- This patient's **gradual onset of pain** with full range of motion against resistance and without a specific injury mechanism makes an ACL shearing injury unlikely.
Question 67: A 7-year-old boy is brought to the emergency department because of abdominal pain, nausea, and vomiting one day after he was a passenger in a low-velocity motor vehicle accident in which he was wearing an adult seatbelt. He has no personal or family history of serious illness. His temperature is 37.1°C (98.8°F), pulse is 107/min, respirations are 20/min, and blood pressure is 98/65 mm Hg. Physical examination shows dry mucous membranes. The upper abdomen is distended and tender to palpation. The remainder of the examination shows no abnormalities. A CT scan of the abdomen shows a large gastric bubble with mild gastric distention. Which of the following is the most appropriate next step in management?
A. Focused assessment with sonography for trauma
B. Emergent laparotomy
C. Nasogastric decompression and total parenteral nutrition (Correct Answer)
D. Esophagogastroduodenoscopy
E. Oral rehydration therapy and early refeeding
Explanation: ***Nasogastric decompression and total parenteral nutrition***
- The patient's symptoms (abdominal pain, nausea, vomiting, distended and tender upper abdomen, gastric distention on CT) following a motor vehicle accident, especially with an adult seatbelt, suggest a **duodenal hematoma**. This injury commonly occurs from compression of the duodenum against the spine and causes a partial or complete obstruction.
- **Nasogastric decompression** is crucial to relieve gastric distention and prevent further vomiting, while **total parenteral nutrition (TPN)** provides adequate nutritional support during the healing process, as oral intake will be restricted for several days to weeks. Most duodenal hematomas resolve with conservative management.
*Focused assessment with sonography for trauma*
- While FAST is a rapid screening tool for the detection of **free fluid** in the abdomen after trauma, the CT scan already confirmed gastric distention without mentioning significant free fluid or other major organ injury requiring immediate surgical intervention.
- FAST would be most useful in identifying conditions like **hemoperitoneum** or **pericardial effusion**, which are not the primary concern given the patient's presentation and CT findings indicating an obstructive process.
*Emergent laparotomy*
- **Emergent laparotomy** is typically reserved for signs of **unstable vital signs**, **peritoneal signs** (e.g., rigid abdomen, rebound tenderness), or evidence of **bowel perforation** or significant intra-abdominal bleeding not responsive to resuscitation.
- The patient's vital signs are relatively stable, and there are no clear indications of bowel perforation or massive internal hemorrhage that would warrant immediate surgical exploration.
*Esophagogastroduodenoscopy*
- **Esophagogastroduodenoscopy (EGD)** is an invasive procedure that could risk further injury to an already compromised or swollen duodenum, especially in the presence of a hematoma causing obstruction.
- EGD is primarily used for diagnosing mucosal lesions, ulcers, or sources of upper GI bleeding, not for the initial management of a suspected duodenal hematoma causing obstruction after trauma.
*Oral rehydration therapy and early refeeding*
- The patient has significant abdominal pain, nausea, vomiting, and gastric distention, indicating a **mechanical obstruction** in the duodenum.
- Attempting **oral rehydration** and early refeeding would likely worsen the patient's symptoms and could lead to further complications like aspiration, as the gastric outlet is obstructed.
Question 68: A 7-year-old boy presents with right hip pain for the past 2 days. He reports gradual onset of pain and states it hurts to walk. He had a recent cold last week but is otherwise healthy. His temperature is 98.2°F (36.8°C), blood pressure is 107/70 mm Hg, pulse is 90/min, respiratory rate is 19/min, and oxygen saturation is 98% on room air. Physical exam reveals no swelling or warmth surrounding the joint. The patient is sitting with the right hip flexed, abducted, and externally rotated. Passive range of motion of the hip causes discomfort. The patient is able to ambulate but states it hurts. An initial radiograph of the hip is unremarkable. The patient's CRP is 0.10 mg/L. Which of the following is the best next step in management of this patient?
A. Vancomycin and piperacillin-tazobactam
B. Ibuprofen (Correct Answer)
C. Arthrocentesis
D. MRI
E. Prednisone
Explanation: ***Ibuprofen***
- This presentation (recent viral illness, **afebrile**, hip pain, unremarkable X-ray, normal inflammatory markers) is highly suggestive of **transient synovitis**, a self-limiting inflammatory condition of the hip.
- Management of **transient synovitis** primarily involves supportive care with **NSAIDs** like ibuprofen for pain and inflammation.
*Vancomycin and piperacillin-tazobactam*
- This aggressive **antibiotic regimen** is indicated for suspected **septic arthritis**, which is less likely given the **normal temperature**, normal CRP, and gradual onset of symptoms.
- **Septic arthritis** typically presents with more acute onset, higher fever, and elevated inflammatory markers.
*Arthrocentesis*
- **Arthrocentesis** (joint aspiration) is crucial for differentiating **septic arthritis** from other causes of hip pain in children by analyzing synovial fluid.
- However, given the clinical picture (afebrile, gradual onset, normal CRP, unremarkable X-ray), the likelihood of septic arthritis is low, making arthrocentesis not the immediate next step.
*MRI*
- An **MRI** would be useful in cases where the diagnosis is unclear or to rule out other conditions like **osteomyelitis** or **Perthes disease**.
- Given the classic presentation of **transient synovitis**, an MRI is generally not the initial step in management unless symptoms persist or worsen despite conservative treatment.
*Prednisone*
- **Corticosteroids** like prednisone are used for inflammatory conditions, but they are generally reserved for more severe or chronic inflammatory arthropathies.
- For **transient synovitis**, **NSAIDs** are usually sufficient, and corticosteroids are not typically indicated as a first-line treatment.
Question 69: A 3-month-old African American boy presents to his pediatrician’s office for his routine well visit. He was born full-term from an uncomplicated vaginal delivery. He is exclusively breastfeeding and not receiving any medications or supplements. Today, his parents report no issues or concerns with their child. He is lifting his head for brief periods and smiling. He has received only 2 hepatitis B vaccines. Which of the following is the correct advice for this patient’s parents?
A. He should be sleeping more.
B. He should have his serum lead level checked to screen for lead intoxication.
C. He should start vitamin D supplementation. (Correct Answer)
D. He should start rice cereal.
E. He needs a 3rd hepatitis B vaccine.
Explanation: ***He should start vitamin D supplementation.***
- **Exclusively breastfed** infants, regardless of maternal vitamin D intake, require **vitamin D supplementation** due to insufficient amounts in breast milk.
- The recommended daily dose is **400 IU** starting from the first few days of life, to prevent **rickets** and promote bone health.
- **African American infants** have an additional risk factor due to increased skin melanin content, which reduces cutaneous vitamin D synthesis from sunlight exposure.
*He should be sleeping more.*
- A 3-month-old infant typically sleeps between **14-17 hours per day**, with **waking periods to feed** and interact.
- The case description does not indicate any concerns with the child's sleep patterns, and **developmental milestones** like lifting his head and smiling are being met.
*He should have his serum lead level checked to screen for lead intoxication.*
- **Lead screening** is not routinely recommended for all infants unless specific **risk factors** are present, such as living in an older home with lead paint, or having siblings with elevated lead levels.
- There are no reported risk factors for lead exposure in this patient's history.
*He should start rice cereal.*
- Introduction of solid foods, such as rice cereal, is typically recommended around **6 months of age**, when the infant shows signs of **developmental readiness**.
- These signs include **head control**, sitting with support, and showing interest in food.
*He needs a 3rd hepatitis B vaccine.*
- The **third dose of the hepatitis B vaccine** is typically administered between **6 and 18 months of age**.
- At 3 months old, the infant is not yet due for his third dose.
Question 70: A 9-year-old girl is brought to the physician by her father because of multiple episodes of staring and facial grimacing that have occurred over the past 3 weeks. There are no precipitating factors for these episodes and they last for several minutes. She does not respond to her family members during these episodes. One week ago, her brother witnessed an episode in which she woke up while sleeping, stared, and made hand gestures. She does not remember any of these episodes but does recall having a vague muddy taste in her mouth prior to the onset of these symptoms. After the episode, she feels lethargic and is confused. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?
A. Generalized tonic-clonic seizures
B. Atonic seizure
C. Myoclonic seizure
D. Breath-holding spell
E. Focal impaired awareness seizure (Correct Answer)
Explanation: ---
***Focal impaired awareness seizure***
- The patient's **staring, facial grimacing, unresponsiveness**, and subsequent **confusion and lethargy** are characteristic of a **focal impaired awareness seizure** (previously termed complex partial seizure).
- The **"muddy taste" pre-episode** is an **aura**, indicating a focal onset from a specific brain region (likely temporal lobe), and the **hand gestures** during an episode represent **automatisms**, commonly seen in focal seizures affecting the temporal lobe.
- **Impaired awareness** during the episode (unresponsiveness to family) and **post-ictal confusion** are hallmark features of this seizure type.
*Generalized tonic-clonic seizures*
- **Generalized tonic-clonic seizures** involve a loss of consciousness followed by widespread tonic (stiffening) and clonic (jerking) movements of all limbs, which are not described here.
- While post-ictal confusion can occur, the **focal onset symptoms** (aura, automatisms) and absence of the characteristic bilateral motor phases differentiate this from a generalized tonic-clonic seizure.
*Atonic seizure*
- **Atonic seizures** are characterized by a sudden, brief loss of muscle tone, leading to a "drop attack," which is not consistent with the described staring, grimacing, and automatisms.
- These are brief (seconds), not lasting several minutes, and lack the complex motor behaviors or auras observed in this case.
*Myoclonic seizure*
- **Myoclonic seizures** present as sudden, brief, shock-like jerks of a muscle or muscle group, typically without significant loss of consciousness.
- The prolonged duration, complete unresponsiveness, and complex behaviors like grimacing and hand gestures are not typical features of myoclonic seizures.
*Breath-holding spell*
- **Breath-holding spells** are typically triggered by emotional distress (e.g., anger, fear) in young children (peak age 6-18 months, rarely after age 6) and involve a brief period of crying followed by apnea, cyanosis, and sometimes loss of consciousness.
- These episodes are **triggered events** (not spontaneous), do not involve complex automatisms, auras, or prolonged post-episode confusion like those described.
