A 5-year-old boy is brought to the emergency department by his grandmother because of difficulty breathing. Over the past two hours, the grandmother has noticed his voice getting progressively hoarser and occasionally muffled, with persistent drooling. He has not had a cough. The child recently immigrated from Africa, and the grandmother is unsure if his immunizations are up-to-date. He appears uncomfortable and is sitting up and leaning forward with his chin hyperextended. His temperature is 39.5°C (103.1°F), pulse is 110/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pulmonary examination shows inspiratory stridor and scattered rhonchi throughout both lung fields, along with poor air movement. Which of the following is the most appropriate next step in management?
Q82
A 10-year-old boy with bronchial asthma is brought to the physician by his mother because of a generalized rash for 2 days. He has also had a fever and sore throat for 4 days. The rash involves his whole body and is not pruritic. His only medication is a fluticasone-salmeterol combination inhaler. He has not received any routine childhood vaccinations. His temperature is 38.5°C (101.3°F) and pulse is 102/min. Examination shows dry mucous membranes and a flushed face except around his mouth. A diffuse, maculopapular, erythematous rash that blanches with pressure is seen over the trunk along with a confluence of petechiae in the axilla. Oropharyngeal examination shows pharyngeal erythema with a red beefy tongue. His hemoglobin is 13.5 mg/dL, leukocyte count is 11,200/mm3 (75% segmented neutrophils, 22% lymphocytes), and platelet count is 220,000/mm3. The clinical presentation is consistent with scarlet fever. Which of the following is the most likely sequela of this condition?
Q83
A 12-year-old girl is brought to the emergency department by her parents due to severe shortness of breath that started 20 minutes ago. She has a history of asthma and her current treatment regime includes a beta-agonist inhaler as well as a medium-dose corticosteroid inhaler. Her mother tells the physician that her daughter was playing outside with her friends when she suddenly started experiencing difficulty breathing and used her inhaler without improvement. On examination, she is struggling to breathe and with subcostal and intercostal retractions. She is leaning forward, and gasping for air and refuses to lie down on the examination table. Her blood pressure is 130/92 mm Hg, the respirations are 27/min, the pulse is 110/min and O2 saturation is 87%. There is prominent expiratory wheezes in all lung fields. The patient is put on a nonrebreather mask with 100% oxygen. An arterial blood gas is collected and sent for analysis. Which of the following is the most appropriate next step in the management of this patient?
Q84
A 15-month-old girl is brought to the physician because of the sudden appearance of a rash on her trunk that started 6 hours ago and subsequently spread to her extremities. Four days ago, she was taken to the emergency department because of a high fever and vomiting. She was treated with acetaminophen and discharged the next day. The fever persisted for several days and abated just prior to appearance of the rash. Physical examination shows a rose-colored, blanching, maculopapular rash, and postauricular lymphadenopathy. Which of the following is the most likely diagnosis?
Q85
A 9-year-old boy presents to the emergency department with a 12-hour history of severe vomiting and increased sleepiness. He experienced high fever and muscle pain about 5 days prior to presentation, and his parents gave him aspirin to control the fever at that time. On presentation, he is found to be afebrile though he is still somnolent and difficult to arouse. Physical exam reveals hepatomegaly and laboratory testing shows the following results:
Alanine aminotransferase: 85 U/L
Aspartate aminotransferase: 78 U/L
Which of the following is the most likely cause of this patient's neurologic changes?
Q86
A previously healthy 10-year-old boy is brought to the emergency department 15 minutes after he had a seizure. His mother reports that he complained of sudden nausea and seeing “shiny lights,” after which the corner of his mouth and then his face began twitching. Next, he let out a loud scream, dropped to the floor unconscious, and began to jerk his arms and legs as well for about two minutes. On the way to the hospital, the boy regained consciousness, but was confused and could not speak clearly for about five minutes. He had a fever and sore throat one week ago which improved after treatment with acetaminophen. He appears lethargic and cannot recall what happened during the episode. His vital signs are within normal limits. He is oriented to time, place, and person. Deep tendon reflexes are 2+ bilaterally. There is muscular pain at attempts to elicit deep tendon reflexes. Physical and neurologic examinations show no other abnormalities. Which of the following is the most likely diagnosis?
Q87
A 16-month-old male patient, with no significant past medical history, is brought into the emergency department for the second time in 5 days with tachypnea, expiratory wheezes and hypoxia. The patient presented to the emergency department initially due to rhinorrhea, fever and cough. He was treated with nasal suctioning and discharged home. The mother states that, over the past 5 days, the patient has started breathing faster with chest retractions. His vital signs are significant for a temperature of 100.7 F, respiratory rate of 45 and oxygen saturation of 90%. What is the most appropriate treatment for this patient?
Q88
A 10-month-old girl is brought to the clinic by her mother with skin lesions on her chest. The mother says that she noticed the lesions 24 hours ago and that they have not improved. The patient has no significant past medical history. She was born at term by spontaneous transvaginal delivery with no complications, is in the 90th percentile on her growth curve, and has met all developmental milestones. Upon physical examination, several skin-colored umbilicated papules are visible. Which of the following is the most appropriate treatment of this patient's likely diagnosis?
Q89
An 8-year-old boy is brought to the physician because of a 7-day history of a progressively worsening cough. The cough occurs in spells and consists of around 5–10 coughs in succession. After each spell he takes a deep, noisy breath. He has vomited occasionally following a bout of coughing. He had a runny nose for a week before the cough started. His immunization records are unavailable. He lives in an apartment with his father, mother, and his 2-week-old sister. The mother was given a Tdap vaccination 11 years ago. The father's vaccination records are unavailable. His temperature is 37.8°C (100.0°F). Examination shows no abnormalities. His leukocyte count is 42,000/mm3. Throat swab culture and PCR results are pending. Which of the following are the most appropriate recommendations for this family?
Q90
A 7-year-old boy is brought to the emergency department by his parents for worsening symptoms. The patient recently saw his pediatrician for an acute episode of sinusitis. At the time, the pediatrician prescribed decongestants and sent the patient home. Since then, the patient has developed a nasal discharge with worsening pain. The patient has a past medical history of asthma which is well controlled with albuterol. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young boy. Cardiopulmonary exam is within normal limits. Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood. The rest of the patient's exam is within normal limits. Which of the following is the most likely diagnosis?
Infectious Disease US Medical PG Practice Questions and MCQs
Question 81: A 5-year-old boy is brought to the emergency department by his grandmother because of difficulty breathing. Over the past two hours, the grandmother has noticed his voice getting progressively hoarser and occasionally muffled, with persistent drooling. He has not had a cough. The child recently immigrated from Africa, and the grandmother is unsure if his immunizations are up-to-date. He appears uncomfortable and is sitting up and leaning forward with his chin hyperextended. His temperature is 39.5°C (103.1°F), pulse is 110/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pulmonary examination shows inspiratory stridor and scattered rhonchi throughout both lung fields, along with poor air movement. Which of the following is the most appropriate next step in management?
A. Nebulized albuterol
B. Direct laryngoscopy and pharyngoscopy
C. Immediate nasotracheal intubation in the emergency department
D. Prepare for emergency airway management in the operating room with anesthesia and ENT backup (Correct Answer)
E. Intravenous administration of antibiotics
Explanation: ***Prepare for emergency airway management in the operating room with anesthesia and ENT backup***
- The constellation of **hoarseness**, **muffled voice**, **drooling**, **inspiratory stridor**, **fever**, and the classic **tripod position** (sitting up, leaning forward, hyperextended chin) in an unimmunized child strongly indicates **epiglottitis**.
- Given the risk of **complete airway obstruction**, securing the airway in a controlled environment like the **operating room** with specialized personnel (**anesthesia**, **ENT**) is the safest and most appropriate immediate step.
*Nebulized albuterol*
- This medication is a **bronchodilator** primarily used for conditions like **asthma** or **bronchiolitis** that involve bronchospasm.
- It would not alleviate airway obstruction caused by supraglottic swelling in epiglottitis and could potentially worsen the child's distress.
*Direct laryngoscopy and pharyngoscopy*
- Performing a direct laryngoscopy or pharyngoscopy in the emergency department, especially without immediate intubation capabilities, could precipitate **laryngospasm** and **complete airway obstruction** in a child with suspected epiglottitis.
- Visualization of the airway should only be attempted in a controlled setting where immediate intubation or tracheostomy can be performed.
*Immediate nasotracheal intubation in the emergency department*
- While intubation is necessary, attempting it immediately in the emergency department without the controlled environment of an operating room and without the full support of anesthesia and ENT specialists carries significant risks.
- The swelling can make intubation extremely difficult and increase the likelihood of failed attempts or trauma, further compromising the airway.
*Intravenous administration of antibiotics*
- Although antibiotics are a crucial part of epiglottitis treatment (typically **ceftriaxone** or **cefotaxime** to cover *Haemophilus influenzae* type b), they are not the immediate priority.
- The most urgent threat is airway compromise; therefore, securing the airway takes precedence over initiating antibiotic therapy.
Question 82: A 10-year-old boy with bronchial asthma is brought to the physician by his mother because of a generalized rash for 2 days. He has also had a fever and sore throat for 4 days. The rash involves his whole body and is not pruritic. His only medication is a fluticasone-salmeterol combination inhaler. He has not received any routine childhood vaccinations. His temperature is 38.5°C (101.3°F) and pulse is 102/min. Examination shows dry mucous membranes and a flushed face except around his mouth. A diffuse, maculopapular, erythematous rash that blanches with pressure is seen over the trunk along with a confluence of petechiae in the axilla. Oropharyngeal examination shows pharyngeal erythema with a red beefy tongue. His hemoglobin is 13.5 mg/dL, leukocyte count is 11,200/mm3 (75% segmented neutrophils, 22% lymphocytes), and platelet count is 220,000/mm3. The clinical presentation is consistent with scarlet fever. Which of the following is the most likely sequela of this condition?
A. Encephalitis
B. Hemolytic anemia
C. Coronary artery aneurysms
D. Rheumatic fever
E. Postinfectious glomerulonephritis (Correct Answer)
Explanation: ***Postinfectious glomerulonephritis***
- This patient presents with classic signs of **scarlet fever**, including fever, sore throat, generalized non-pruritic maculopapular rash that blanches, flushed face with circumoral pallor, petechiae in skin folds (Pastia's lines), and a "strawberry tongue."
- Scarlet fever is caused by **Group A Streptococcus (GAS)** producing erythrogenic toxin.
- **Post-streptococcal glomerulonephritis (PSGN)** is the **most common serious sequela** of GAS infections, occurring 1-3 weeks after pharyngitis or 3-6 weeks after skin infections.
- PSGN can follow both pharyngitis and impetigo, making it overall more common than other GAS sequelae.
- Presents with hematuria, proteinuria, edema, hypertension, and elevated anti-streptolysin O (ASO) or anti-DNase B titers.
*Encephalitis*
- **Encephalitis** is inflammation of the brain parenchyma and is not a recognized sequela of scarlet fever or streptococcal infections.
- More commonly associated with **viral infections** (e.g., herpes simplex virus, arboviruses, enteroviruses) or autoimmune/post-infectious encephalitis from other pathogens.
*Hemolytic anemia*
- **Hemolytic anemia** is not a typical complication of Group A Streptococcus pharyngitis or scarlet fever.
- While some bacteria can cause hemolysis (e.g., Clostridium perfringens, Mycoplasma), this is not a characteristic feature of GAS.
*Coronary artery aneurysms*
- **Coronary artery aneurysms** are the hallmark complication of **Kawasaki disease**, not scarlet fever.
- Kawasaki disease presents differently with persistent fever (≥5 days), bilateral non-exudative conjunctivitis, polymorphous rash, oral changes (strawberry tongue, cracked lips), cervical lymphadenopathy, and extremity changes (edema, erythema, desquamation).
- While both conditions can present with strawberry tongue and rash, the clinical picture here is classic for scarlet fever with pharyngitis.
*Rheumatic fever*
- **Acute rheumatic fever (ARF)** is also an important sequela of untreated GAS pharyngitis, occurring 2-4 weeks after infection.
- ARF affects the heart (carditis, valvulitis), joints (migratory polyarthritis), brain (Sydenham chorea), and skin (erythema marginatum, subcutaneous nodules).
- However, ARF follows only pharyngitis (not skin infections), and its incidence has decreased significantly in developed countries with antibiotic use.
- **PSGN remains more common overall** as it can follow both pharyngitis and impetigo, and occurs even with appropriate antibiotic treatment (unlike ARF, which is prevented by early antibiotics).
Question 83: A 12-year-old girl is brought to the emergency department by her parents due to severe shortness of breath that started 20 minutes ago. She has a history of asthma and her current treatment regime includes a beta-agonist inhaler as well as a medium-dose corticosteroid inhaler. Her mother tells the physician that her daughter was playing outside with her friends when she suddenly started experiencing difficulty breathing and used her inhaler without improvement. On examination, she is struggling to breathe and with subcostal and intercostal retractions. She is leaning forward, and gasping for air and refuses to lie down on the examination table. Her blood pressure is 130/92 mm Hg, the respirations are 27/min, the pulse is 110/min and O2 saturation is 87%. There is prominent expiratory wheezes in all lung fields. The patient is put on a nonrebreather mask with 100% oxygen. An arterial blood gas is collected and sent for analysis. Which of the following is the most appropriate next step in the management of this patient?
A. Intramuscular epinephrine
B. Intravenous corticosteroid
C. Inhaled ipratropium bromide
D. Inhaled albuterol (Correct Answer)
E. Intravenous theophylline
Explanation: ***Inhaled albuterol***
- Given the patient's acute and severe asthma exacerbation, **inhaled albuterol**, a short-acting beta-agonist (SABA), is the most crucial initial bronchodilator to relieve bronchospasm.
- Her symptoms (severe dyspnea, retractions, tachypnea, tachycardia, low oxygen saturation, and prominent wheezing despite prior SABA use) indicate a need for immediate and aggressive bronchodilation.
*Intramuscular epinephrine*
- **Epinephrine** is primarily used for **anaphylaxis** or severe allergic reactions, which is not suggested by this patient's history or presentation (no mention of allergen exposure, urticaria, angioedema, or circulatory collapse typical of anaphylaxis).
- While it has bronchodilatory effects, it is not the first-line treatment for acute asthma exacerbations.
*Intravenous corticosteroid*
- **Systemic corticosteroids** (e.g., prednisone, methylprednisolone) are essential for reducing airway inflammation in moderate to severe asthma exacerbations and preventing relapse.
- However, their onset of action is typically several hours, so they are not the immediate solution for acute bronchospasm but should be administered shortly after initial bronchodilators.
*Inhaled ipratropium bromide*
- **Ipratropium bromide**, an anticholinergic bronchodilator, is often used in conjunction with albuterol for severe asthma exacerbations.
- It provides additional bronchodilation by blocking muscarinic receptors, but albuterol (a SABA) remains the primary and most rapid-acting bronchodilator for acute relief.
*Intravenous theophylline*
- **Theophylline** is a methylxanthine bronchodilator administered intravenously or orally, not by inhalation.
- It is rarely used in acute asthma management due to its narrow therapeutic index, significant side effect profile, requirement for drug level monitoring, and availability of safer, more effective alternatives.
- It may be considered only in refractory cases that do not respond to standard therapy.
Question 84: A 15-month-old girl is brought to the physician because of the sudden appearance of a rash on her trunk that started 6 hours ago and subsequently spread to her extremities. Four days ago, she was taken to the emergency department because of a high fever and vomiting. She was treated with acetaminophen and discharged the next day. The fever persisted for several days and abated just prior to appearance of the rash. Physical examination shows a rose-colored, blanching, maculopapular rash, and postauricular lymphadenopathy. Which of the following is the most likely diagnosis?
A. Roseola infantum (Correct Answer)
B. Rubella
C. Erythema infectiosum
D. Drug allergy
E. Nonbullous impetigo
Explanation: ***Roseola infantum***
- The classic presentation includes several days of **high fever** that **abruptly resolves**, followed by the appearance of a **rose-colored, blanching maculopapular rash**, primarily on the trunk.
- This condition is most common in infants and young children, often accompanied by **postauricular lymphadenopathy**.
*Rubella*
- While rubella presents with a **maculopapular rash** and **postauricular lymphadenopathy**, the rash typically appears *with* or *shortly after* the fever, not after the fever has completely abated.
- The fever in rubella is usually milder than the high fever seen in roseola.
*Erythema infectiosum*
- This condition, also known as fifth disease, typically presents with a **"slapped cheek" rash** on the face, followed by a lacy rash on the extremities, often without the distinct pattern of high fever followed by rash offset.
- The fever is often low-grade or absent, unlike the high fever experienced by the patient.
*Drug allergy*
- A drug allergy could cause a rash, but it's less likely to selectively manifest several days after acetaminophen administration once the fever has disappeared, especially without other allergic symptoms like **pruritus** or **urticaria**.
- The precise sequence of high fever followed by rash resolution is not typical for most drug-induced rashes.
*Nonbullous impetigo*
- This is a **bacterial skin infection** characterized by **honey-crusted lesions**, most commonly around the nose and mouth, not a generalized maculopapular rash.
- It is typically not preceded by a systemic illness with high fever and vomiting in this manner.
Question 85: A 9-year-old boy presents to the emergency department with a 12-hour history of severe vomiting and increased sleepiness. He experienced high fever and muscle pain about 5 days prior to presentation, and his parents gave him aspirin to control the fever at that time. On presentation, he is found to be afebrile though he is still somnolent and difficult to arouse. Physical exam reveals hepatomegaly and laboratory testing shows the following results:
Alanine aminotransferase: 85 U/L
Aspartate aminotransferase: 78 U/L
Which of the following is the most likely cause of this patient's neurologic changes?
A. Subarachnoid hemorrhage
B. Viral meningitis
C. Reye syndrome
D. Cerebral edema (Correct Answer)
E. Bacterial sepsis
Explanation: ***Cerebral edema***
- The combination of a recent **viral illness** treated with **aspirin** in a child, leading to severe vomiting, increased sleepiness, hepatomegaly, and elevated transaminases, is highly suggestive of **Reye syndrome**.
- **Cerebral edema** is a critical and life-threatening complication of **Reye syndrome**, causing the neurologic symptoms like somnolence, difficulty arousing, and ultimately coma.
*Subarachnoid hemorrhage*
- While subarachnoid hemorrhage can cause acute neurological changes, it typically presents with a **sudden, severe headache** ("thunderclap headache") and signs of meningeal irritation, which are not described here.
- There is no clinical indication such as trauma or ruptured aneurysm to suggest a subarachnoid hemorrhage in this patient.
*Viral meningitis*
- Viral meningitis would typically present with **fever**, headache, and **nuchal rigidity**, often accompanied by photophobia, which are not the prominent features in this case.
- The elevated liver enzymes and hepatomegaly are not characteristic of viral meningitis.
*Reye syndrome*
- **Reye syndrome** is the underlying diagnosis, characterized by acute **encephalopathy** and hepatic dysfunction following a viral infection treated with salicylates.
- However, the question asks for the **most likely cause of the neurological changes**, which is specifically the brain swelling, or cerebral edema, that occurs as a direct result of Reye syndrome pathophysiology.
*Bacterial sepsis*
- Bacterial sepsis would present with signs of systemic infection, often including **high fever**, tachycardia, and hypotension, which are not present as the patient is afebrile.
- While sepsis can cause encephalopathy, the presence of **hepatomegaly** and the history of **aspirin use** point much more strongly toward Reye syndrome with its associated cerebral edema.
Question 86: A previously healthy 10-year-old boy is brought to the emergency department 15 minutes after he had a seizure. His mother reports that he complained of sudden nausea and seeing “shiny lights,” after which the corner of his mouth and then his face began twitching. Next, he let out a loud scream, dropped to the floor unconscious, and began to jerk his arms and legs as well for about two minutes. On the way to the hospital, the boy regained consciousness, but was confused and could not speak clearly for about five minutes. He had a fever and sore throat one week ago which improved after treatment with acetaminophen. He appears lethargic and cannot recall what happened during the episode. His vital signs are within normal limits. He is oriented to time, place, and person. Deep tendon reflexes are 2+ bilaterally. There is muscular pain at attempts to elicit deep tendon reflexes. Physical and neurologic examinations show no other abnormalities. Which of the following is the most likely diagnosis?
A. Sydenham chorea
B. Convulsive syncope
C. Generalized tonic-clonic seizure
D. Focal to bilateral tonic-clonic seizure (Correct Answer)
E. Generalized myoclonic seizure
Explanation: ***Focal to bilateral tonic-clonic seizure***
- The initial symptoms of **nausea, seeing shiny lights**, and facial twitching are characteristic of an **aura**, which indicates a **focal onset** of the seizure.
- The subsequent **loss of consciousness** and generalized jerking of all limbs indicate a **secondary generalization** to a tonic-clonic seizure.
*Sydenham chorea*
- This is a **post-streptococcal autoimmune disorder** characterized by involuntary, jerky movements, particularly of the face and limbs.
- While there was a recent sore throat, the primary manifestation here is a seizure with a clear progression, not choreiform movements.
*Convulsive syncope*
- Convulsive syncope is a common form of **reflex anoxic syncope**, which is caused by a self-limiting episode of **cerebral anoxia**.
- While it can involve brief, self-limiting tonic or myoclonic movements, it is typically triggered by specific factors like pain, fear, or prolonged standing, and does not usually involve a focal aura or a prolonged post-ictal phase.
*Generalized tonic-clonic seizure*
- A **generalized tonic-clonic seizure** arises from a sudden, widespread electrical discharge in both hemispheres of the brain **without a focal onset or aura**.
- The patient's initial focal symptoms (sensory aura and focal twitching) rule out a primary generalized onset.
*Generalized myoclonic seizure*
- **Generalized myoclonic seizures** involve sudden, brief, shock-like jerks or twitches of one or more muscle groups.
- This typically presents as non-rhythmic jerks and does not involve the initial focal symptoms or the prolonged tonic-clonic phase described.
Question 87: A 16-month-old male patient, with no significant past medical history, is brought into the emergency department for the second time in 5 days with tachypnea, expiratory wheezes and hypoxia. The patient presented to the emergency department initially due to rhinorrhea, fever and cough. He was treated with nasal suctioning and discharged home. The mother states that, over the past 5 days, the patient has started breathing faster with chest retractions. His vital signs are significant for a temperature of 100.7 F, respiratory rate of 45 and oxygen saturation of 90%. What is the most appropriate treatment for this patient?
A. Albuterol, ipratropium and IV methylprednisolone
B. IV cefotaxime and IV vancomycin
C. Intubation and IV cefuroxime
D. Humidified oxygen, racemic epinephrine and intravenous (IV) dexamethasone
E. Nasal suctioning, oxygen therapy and IV fluids (Correct Answer)
Explanation: ***Nasal suctioning, oxygen therapy and IV fluids***
- This patient's presentation with rhinorrhea, fever, cough, tachypnea, expiratory wheezes, and hypoxia, particularly a 16-month-old, strongly suggests **bronchiolitis**, likely caused by **RSV**.
- Management of bronchiolitis is primarily **supportive care**, including maintaining airway patency via nasal suctioning, providing oxygen for hypoxia, and ensuring adequate hydration with IV fluids.
*Albuterol, ipratropium and IV methylprednisolone*
- **Bronchodilators** like albuterol and ipratropium are generally **not recommended** for routine management of bronchiolitis due to lack of consistent efficacy in infants.
- **Corticosteroids** (e.g., methylprednisolone) are also **not routinely indicated** for bronchiolitis and have not been shown to improve outcomes.
*IV cefotaxime and IV vancomycin*
- These are **broad-spectrum antibiotics** used to treat **bacterial infections**, such as severe pneumonia or sepsis.
- The clinical presentation is more consistent with a **viral respiratory infection** (bronchiolitis), and there is no evidence of a bacterial co-infection or sepsis.
*Intubation and IV cefuroxime*
- **Intubation** is an invasive procedure reserved for patients with impending respiratory failure and is not indicated at this stage given the current oxygen saturation of 90% with supportive measures.
- **Cefuroxime** is an antibiotic, and like other antibiotics, is not indicated for a viral illness like bronchiolitis.
*Humidified oxygen, racemic epinephrine and intravenous (IV) dexamethasone*
- **Racemic epinephrine** may be considered for severe bronchiolitis with significant bronchospasm, but its use is not routine and its efficacy is debated.
- **IV dexamethasone** is a corticosteroid, which is not recommended for routine bronchiolitis management. Humidified oxygen is helpful, but the overall regimen is not standard for bronchiolitis.
Question 88: A 10-month-old girl is brought to the clinic by her mother with skin lesions on her chest. The mother says that she noticed the lesions 24 hours ago and that they have not improved. The patient has no significant past medical history. She was born at term by spontaneous transvaginal delivery with no complications, is in the 90th percentile on her growth curve, and has met all developmental milestones. Upon physical examination, several skin-colored umbilicated papules are visible. Which of the following is the most appropriate treatment of this patient's likely diagnosis?
A. Cryotherapy or podophyllotoxin (0.15% topically)
B. Observation/watchful waiting (Correct Answer)
C. Acyclovir
D. Wide-spectrum antibiotics
E. Topical antifungal therapy
Explanation: ***Observation/watchful waiting***
- The patient's presentation with **skin-colored umbilicated papules** is classic for **molluscum contagiosum**, a benign self-limited viral infection caused by a **poxvirus**.
- In **immunocompetent children**, **observation is the first-line management** as most cases resolve spontaneously within **6-18 months** without intervention.
- The lesions have only been present for **24 hours**, and the patient is a healthy **10-month-old infant** with no complications, making watchful waiting the most appropriate approach.
- Active treatment is typically reserved for **immunocompromised patients**, **extensive or persistent lesions**, or cases with **significant psychosocial impact** or cosmetic concerns.
*Cryotherapy or podophyllotoxin (0.15% topically)*
- While these can be used for molluscum contagiosum, they are **not first-line** in healthy young children.
- **Podophyllotoxin** is generally **contraindicated in children under 2 years** due to safety concerns and potential toxicity.
- **Cryotherapy** is painful and can cause scarring, making it inappropriate as initial management in a **10-month-old infant** with recent-onset lesions.
- These treatments may be considered for **persistent cases** after a period of observation or in specific circumstances.
*Acyclovir*
- **Acyclovir** is an antiviral medication effective against **herpes simplex virus (HSV)** and **varicella-zoster virus (VZV)**.
- It has **no activity against poxviruses** and is not indicated for **molluscum contagiosum**.
*Wide-spectrum antibiotics*
- **Antibiotics** are effective against **bacterial infections** only and have no role in treating **viral skin infections** like molluscum contagiosum.
- Inappropriate antibiotic use contributes to **antimicrobial resistance**.
*Topical antifungal therapy*
- **Antifungal medications** treat **fungal infections** such as tinea (ringworm) or candidiasis.
- They are not effective against **molluscum contagiosum**, which is a **viral infection**.
Question 89: An 8-year-old boy is brought to the physician because of a 7-day history of a progressively worsening cough. The cough occurs in spells and consists of around 5–10 coughs in succession. After each spell he takes a deep, noisy breath. He has vomited occasionally following a bout of coughing. He had a runny nose for a week before the cough started. His immunization records are unavailable. He lives in an apartment with his father, mother, and his 2-week-old sister. The mother was given a Tdap vaccination 11 years ago. The father's vaccination records are unavailable. His temperature is 37.8°C (100.0°F). Examination shows no abnormalities. His leukocyte count is 42,000/mm3. Throat swab culture and PCR results are pending. Which of the following are the most appropriate recommendations for this family?
A. Administer oral azithromycin to the baby and father and Tdap vaccination to the father
B. Administer oral azithromycin to all family members and Tdap vaccination to the father and mother (Correct Answer)
C. Administer oral azithromycin to all family members and Tdap vaccination to the father
D. Administer oral erythromycin to all family members and Tdap vaccination to the father
E. Administer oral trimethoprim-sulfamethoxazole to the father and baby and Tdap vaccination to the father
Explanation: ***Administer oral azithromycin to all family members and Tdap vaccination to the father and mother***
- The 8-year-old boy presents with classic symptoms of **pertussis** (whooping cough), including **paroxysmal cough**, post-tussive emesis, and a preceding catarrhal phase (runny nose). The high **leukocyte count** further supports this diagnosis. Given his exposure, the 2-week-old sister is at high risk of severe sequelae.
- **Prophylactic antibiotics** (e.g., azithromycin) are indicated for all close contacts, especially infants and pregnant women, to prevent the spread of *Bordetella pertussis*. Tdap vaccination is recommended for the father (whose vaccination status is unknown) and the mother, as her last Tdap was 11 years ago, and there is a high-risk infant in the household.
*Administer oral azithromycin to the baby and father and Tdap vaccination to the father*
- This option misses administering **prophylactic antibiotics** to the mother and **Tdap vaccination** to the mother, both of whom are close contacts and have a high-risk infant in the household.
- The mother's Tdap vaccination from 11 years ago may no longer provide sufficient protection, especially with a neonate in the home.
*Administer oral azithromycin to all family members and Tdap vaccination to the father*
- While this option correctly suggests prophylactic antibiotics for all family members, it incorrectly omits **Tdap vaccination for the mother**, whose last vaccination was 11 years ago.
- Updating the mother's Tdap vaccination status is crucial, especially in a household with a 2-week-old infant.
*Administer oral erythromycin to all family members and Tdap vaccination to the father*
- **Erythromycin** is an alternative macrolide for pertussis treatment/prophylaxis, but **azithromycin** is preferred due to a shorter course and better tolerability, especially in infants.
- This option also incorrectly omits **Tdap vaccination for the mother**.
*Administer oral trimethoprim-sulfamethoxazole to the father and baby and Tdap vaccination to the father*
- **Trimethoprim-sulfamethoxazole** is a less preferred antibiotic for pertussis prophylaxis/treatment and is generally reserved for patients who cannot tolerate macrolides.
- This option incorrectly limits antibiotic prophylaxis to only the father and baby, excluding the mother and the 8-year-old boy, and also omits **Tdap vaccination for the mother**.
Question 90: A 7-year-old boy is brought to the emergency department by his parents for worsening symptoms. The patient recently saw his pediatrician for an acute episode of sinusitis. At the time, the pediatrician prescribed decongestants and sent the patient home. Since then, the patient has developed a nasal discharge with worsening pain. The patient has a past medical history of asthma which is well controlled with albuterol. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young boy. Cardiopulmonary exam is within normal limits. Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood. The rest of the patient's exam is within normal limits. Which of the following is the most likely diagnosis?
A. Sinusitis with bacterial superinfection
B. Bleeding and infected vessel of Kiesselbach plexus
C. Foreign body obstruction (Correct Answer)
D. Nasopharyngeal carcinoma
E. Septal perforation
Explanation: ***Foreign body obstruction***
- The presence of **unilateral purulent discharge mixed with blood** in a young child strongly suggests a **foreign body** in the nasal cavity.
- While initial symptoms might mimic sinusitis, the worsening unilateral discharge, especially with blood, is a classic sign of an impacted foreign body causing local irritation and infection.
*Sinusitis with bacterial superinfection*
- While bacterial superinfection of sinusitis can cause purulent discharge, it typically presents with **bilateral symptoms** unless there's an anatomical obstruction.
- The **unilaterality** of the discharge, particularly with blood, makes a foreign body a more likely explanation.
*Bleeding and infected vessel of Kiesselbach plexus*
- **Kiesselbach's plexus** is a common site for epistaxis (nosebleeds), but it primarily presents with **active bleeding**, not typically chronic purulent discharge.
- While infection could occur, it wouldn't usually lead to the profuse, unilateral, bloody-purulent discharge described without an underlying cause like a foreign body.
*Nasopharyngeal carcinoma*
- **Nasopharyngeal carcinoma** is extremely **rare in children** and typically presents with symptoms such as **epistaxis**, **nasal obstruction**, **cranial nerve palsies**, or **cervical lymphadenopathy**.
- The presented unilateral discharge in a 7-year-old is not characteristic of this malignancy.
*Septal perforation*
- A **septal perforation** is a hole in the nasal septum, often caused by trauma, drug use (e.g., cocaine), or chronic inflammation, and would primarily present with **crusting**, **whistling sounds**, and **epistaxis**.
- It would not typically cause a persistent, unilateral, purulent, and bloody discharge as the primary symptom.
