Pediatrics

A 5-month-old female infant is brought to a primary care clinic by her parents due to rapid breathing and poor feeding. She developed nasal congestion and a mild cough three days ago. Over the past 24 hours, the cough has deepened, and she has consumed only one-third of her usual breast milk volume. She was born at term, and her immunizations are up to date. Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), a heart rate of $165/\text{min}$, and a respiratory rate of $68/\text{min}$. Room air pulse oximetry demonstrates an oxygen saturation of $88\%$. Physical examination reveals an irritable infant with prominent nasal flaring and significant subcostal retractions. Chest auscultation reveals diffuse fine crackles and scattered expiratory wheezes throughout both lung fields. The physician arranges for immediate transfer to the pediatric emergency department. Which of the following interventions are appropriate in the initial management of this patient? (Select all that apply)

An 8-year-old boy is evaluated in the emergency department for severe shortness of breath and wheezing that began four hours ago. He has a history of moderate persistent asthma and ran out of his controller medications a week ago. His respiratory rate is 45/min, and oxygen saturation is 88% on room air. Physical examination reveals severe suprasternal and subcostal retractions. Auscultation demonstrates diminished air entry with faint, high-pitched expiratory wheezes globally. The patient is visibly fatigued and speaking in single words. Arrange the following interventions in the most appropriate step-wise sequence for managing this patient's acute respiratory compromise, from the immediate first-line therapy to advanced refractory management.

An 8-week-old infant is evaluated in the pediatric emergency department for poor feeding and excessive sweating during meals. Over the past two weeks, his mother has noticed that he breathes unusually fast and becomes exhausted after consuming only 1 to 2 ounces of formula. A previous evaluation at a local clinic attributed the rapid breathing to a viral respiratory infection, but his symptoms have progressively worsened. Vital signs include a heart rate of 172/min, respiratory rate of 68/min, and blood pressure of 85/45 mmHg. Pulse oximetry is 97% on room air. On physical examination, the infant appears mildly distressed. Auscultation of the lungs reveals bilateral basilar crackles and scattered expiratory wheezes. Cardiovascular examination shows a palpable parasternal heave and a grade 3/6 pansystolic murmur best heard at the left lower sternal border. Abdominal examination demonstrates a firm liver edge palpable 3.5 cm below the right costal margin. Which of the following is the most likely underlying hemodynamic derangement responsible for this patient's presentation?

A 3-year-old boy is rushed to the emergency department by his parents. The family recently immigrated to the United States, and the child's vaccination history is unknown. Over the past 6 hours, he has developed a high fever, severe difficulty breathing, and a muffled voice. Upon evaluation, the child is sitting upright, leaning forward with his neck extended, and drooling profusely. He appears highly anxious. He has marked inspiratory stridor and moderate intercostal retractions. Oxygen saturation is 92% on room air.

Arrange the following next steps in management in the most appropriate sequential order for this patient.

A $10$-month-old female infant is brought to the emergency department by her parents due to severe, episodic abdominal pain and lethargy. The parents report she has been pulling her legs up to her chest and crying inconsolably for the past $24$ hours. In the last $4$ hours, she has become increasingly difficult to arouse. She recently passed a stool described by the parents as looking like "currant jelly."

Physical examination reveals:
Temperature: $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$)
Heart rate: $185/\text{min}$
Respiratory rate: $55/\text{min}$
Blood pressure: $65/40\text{ mmHg}$

The infant appears toxic, mottled, and lethargic. The abdomen is grossly distended, rigid, and exquisitely tender to light palpation. Bowel sounds are absent.

Laboratory results:
pH: $7.24$
PaCO $_2$: $30\text{ mmHg}$
HCO $_3^-$: $12\text{ mEq/L}$
Lactate: $5.8\text{ mmol/L}$ (Normal: $0.5-1.5$)

After initiating airway management and aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

Parents bring their 5-year-old son to the emergency department because he has developed worsening weakness in his legs over the past two days. According to his mother, he has been stumbling frequently and today refused to get out of bed, complaining that his legs feel "like jelly." Three weeks ago, the boy experienced a self-resolving episode of abdominal cramps and bloody diarrhea. On physical examination, his temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), heart rate is $108/\text{min}$, respiratory rate is $20/\text{min}$, and blood pressure is $102/64\text{ mm Hg}$. He is alert and interactive. Cranial nerve examination shows no abnormalities. Motor examination reveals symmetric $3/5$ strength in the proximal and distal lower extremities, and $5/5$ strength in the upper extremities. Deep tendon reflexes are absent at the patellae and Achilles, and $1+$ at the biceps. Sensory examination to light touch and pinprick is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 9-year-old boy is hospitalized for the management of acute myeloid leukemia. He recently completed his first cycle of induction chemotherapy. Five days ago, he developed a fever of $39.4^\circ C$ ($102.9^\circ F$) and was found to have an absolute neutrophil count (ANC) of $120/\mu L$. Blood and urine cultures were drawn, and empiric intravenous cefepime was initiated.

Today (hospital day 6 of fever), his temperature remains elevated at $39.2^\circ C$ ($102.6^\circ F$). His blood pressure is 105/65 mmHg, and heart rate is 110/min. Physical examination reveals a clean central venous catheter site with no surrounding erythema or tenderness. The lungs are clear to auscultation, and there are no oral lesions or skin rashes.

Laboratory studies today show:

Blood cultures from admission and from two days ago have shown no growth. A chest radiograph reveals no infiltrates. Which of the following is the most appropriate next step in management?

A $3$-year-old boy is brought to the pediatric emergency department due to sudden onset of severe, colicky abdominal pain that began $12$ hours ago. Initially, the pain was intermittent, but it has now become constant. He has vomited bilious material four times in the past $6$ hours. The parents report that over the last month, the child had two episodes of painless, dark red rectal bleeding, which resolved spontaneously. On physical examination, the child appears lethargic and toxic. Temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), pulse is $160/\text{min}$, respirations are $32/\text{min}$, and blood pressure is $75/40\text{ mmHg}$. Abdominal examination reveals a rigid, distended abdomen with diffuse guarding, rebound tenderness, and a palpable sausage-shaped mass in the right mid-abdomen. Laboratory studies show:

Following initial fluid resuscitation, which of the following is the most appropriate next step in management?

A 15-month-old girl is brought to the pediatric clinic for a 2-day history of low-grade fever, mild cough, and clear rhinorrhea. Her temperature is 37.8°C (100.0°F), and her respiratory rate is 24/min. Lung auscultation reveals transmitted upper airway sounds but no true wheezing or crackles. During the visit, her mother expresses deep concern that the child is developmentally delayed because she only speaks three words and cannot yet run.

Physical examination reveals an active, well-appearing toddler. Skin examination shows eight flat, uniformly hyperpigmented macules measuring 1 to 2 cm in diameter scattered across her chest and back, along with distinct clustering of freckles in both axillae. Neurologic examination shows normal muscle tone and strength. She is able to walk independently and uses a neat pincer grasp to pick up small objects.

Which of the following is the most appropriate next step in the comprehensive management of this patient?

Emergency medical services bring a 10-year-old boy to the acute care bay after his parents reported severe difficulty breathing at home. He has a documented history of moderate persistent asthma. According to his parents, he has been using his albuterol metered-dose inhaler every hour for the past six hours, but his symptoms have progressively worsened. On presentation, his temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), respiratory rate is $45/\text{min}$, heart rate is $142/\text{min}$, and oxygen saturation is $88\%$ on room air. The patient is visibly anxious, sitting in a tripod position, and can only speak in isolated words. Physical examination highlights prominent suprasternal and intercostal retractions. Lung auscultation reveals prolonged expiration, diffuse high-pitched wheezing across all lung fields, and globally decreased air entry. Which of the following interventions are indicated in the initial, immediate management bundle for this patient? (Select all that apply)

A $2$-year-old boy is brought to the emergency department by his parents after they noticed a large amount of maroon-colored stool in his diaper this morning. He has had one additional bloody bowel movement since arrival. The parents report that the child has been completely asymptomatic otherwise; he has had no fever, vomiting, diarrhea, or apparent abdominal pain, and his appetite has been normal. He has no significant past medical history and has met all developmental milestones. Vital signs are temperature $37.1^\circ$ C ($98.8^\circ$ F), blood pressure $95/60$ mm Hg, pulse $115$/min, and respiratory rate $22$/min. Physical examination reveals an alert and playful child. The abdomen is soft, non-distended, and non-tender to palpation, with no palpable masses. Laboratory studies show a hemoglobin level of $10.4$ g/dL and a platelet count of $250,000$/mm $^3$. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A $9$-year-old boy with a known history of sickle cell anemia (HbSS) is brought to the emergency department by his parents. $1$ hour ago, he suddenly developed slurred speech and weakness in his right arm and leg. On presentation, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, heart rate is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals an alert child with a right-sided facial droop and dense right-sided hemiparesis. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 14-year-old girl is hospitalized for an acute, severe exacerbation of newly diagnosed ulcerative colitis. Over the past 48 hours, she has been treated with intravenous fluids, methylprednisolone, and prophylactic low-molecular-weight heparin. The nursing staff urgently calls the physician to the bedside due to an abrupt deterioration in her clinical status. The patient reports continuous, excruciating abdominal pain that is no longer crampy. Her temperature is 39.4°C (102.9°F), blood pressure is 84/50 mmHg, heart rate is 142/min, and respiratory rate is 28/min. Physical examination demonstrates a markedly distended, tympanitic abdomen with diffuse rigidity, guarding, and rebound tenderness. Bowel sounds are absent. A portable supine abdominal radiograph reveals a transverse colon diameter of 7.5 cm, loss of normal haustral markings, and mucosal edema, with no free intraperitoneal air.

Which of the following is the most appropriate next step in management?

A 2-day-old male neonate is evaluated in the neonatal intensive care unit after two episodes of bilious emesis. He was born at 38 weeks gestation via uncomplicated spontaneous vaginal delivery to a 29-year-old primigravida. Prenatal ultrasonography at 32 weeks revealed polyhydramnios. His temperature is 37.1°C (98.8°F), heart rate is 145/min, blood pressure is 65/40 mm Hg, and respiratory rate is 42/min. Physical examination reveals a soft, non-distended abdomen without guarding, rigidity, or erythema of the abdominal wall. Bowel sounds are decreased. A nasogastric tube is placed, returning 25 mL of dark green fluid. An anteroposterior abdominal radiograph demonstrates a distended stomach and proximal duodenum (double bubble sign), along with a small amount of scattered gas in the distal small and large bowels. There is no pneumatosis intestinalis or free intraperitoneal air. Which of the following is the most appropriate next step in management?

An 8-month-old female infant is brought to the pediatric emergency department due to sudden episodes of severe, inconsolable crying. During these episodes, she draws her knees to her chest. The episodes began 24 hours ago and have progressively worsened in frequency. Earlier today, she began having non-bilious vomiting, which recently transitioned to bilious emesis. Her last bowel movement contained dark red blood and thick mucus.

On physical examination, her temperature is 38.8°C (101.8°F), heart rate is 175/min, respiratory rate is 45/min, and blood pressure is 68/40 mmHg. She appears lethargic and pale. Abdominal examination reveals a rigid, distended abdomen with severe, diffuse tenderness and involuntary guarding. Bowel sounds are absent. Arterial blood gas analysis demonstrates a $pH$ of 7.24, $pCO_2$ of 28 mmHg, and $HCO_3^-$ of 12 mEq/L.

Which of the following is the most appropriate next step in management?

A 5-year-old boy is brought to the pediatrician by his parents because he has been limping since yesterday morning. The parents report that he had a mild upper respiratory tract infection about one week ago, which resolved without treatment. He refuses to bear full weight on his right leg but is able to walk with a noticeable limp. His temperature is 37.4°C (99.3°F), blood pressure is 95/60 mm Hg, pulse is 98/min, and respirations are 20/min. Physical examination shows no erythema or swelling of the lower extremities. There is full range of motion of the right knee and ankle. However, internal rotation and abduction of the right hip elicit discomfort. Laboratory studies show:

Leukocyte count: $7,500/\text{mm}^3$
Erythrocyte sedimentation rate: $15 \text{ mm/h}$
C-reactive protein: $0.5 \text{ mg/dL}$

Radiographs of the right hip and pelvis are unremarkable. Which of the following is the most appropriate next step in management for this patient?

A $14$-day-old female neonate, born at $26$ weeks gestation, is evaluated in the neonatal intensive care unit for worsening respiratory distress. She was initially treated with surfactant for respiratory distress syndrome and successfully extubated to noninvasive positive pressure ventilation on day $3$ of life. Over the past $24$ hours, she has required an increasing fraction of inspired oxygen ($FiO_2$) and has experienced three episodes of apnea. Her temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), heart rate is $178/\text{min}$, and blood pressure is $50/20\text{ mmHg}$. Physical examination reveals bounding palmar and pedal pulses and a hyperactive precordium. A continuous, machinery-like murmur is heard loudest at the left infraclavicular region. Lung auscultation reveals bilateral crackles. An echocardiogram confirms a left-to-right shunt through a vascular structure connecting the descending aorta and the left pulmonary artery. The medical team decides to initiate targeted pharmacologic therapy to close this structure. Which of the following is a well-recognized potential adverse effect of the most appropriate medication for this indication?

A full-term male newborn, aged 4 hours, is evaluated in the neonatal care unit due to the sudden onset of a bluish discoloration of the lips and face. The pregnancy and vaginal delivery were entirely uncomplicated, and Apgar scores were normal. Current vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), a heart rate of $160/\text{min}$, a respiratory rate of $62/\text{min}$, and an oxygen saturation of $71\%$ on room air. The patient is placed in a headbox with $100\%$ fraction of inspired oxygen; a repeat saturation measurement after 15 minutes is $73\%$. Physical examination reveals a tachypneic infant with profound central cyanosis but no nasal flaring or retractions. Cardiac auscultation identifies a loud, single second heart sound (S2) and a grade 2/6 holosystolic murmur heard best at the left lower sternal border. Palpation of the brachial and femoral pulses reveals symmetric, 2+ intensity with no pulse discrepancies. A portable chest radiograph displays a narrow mediastinal silhouette resembling an egg on a string, alongside normal pulmonary vascular markings. Which of the following is the most appropriate next step in the management of this patient?

A 4-year-old boy is brought to the emergency department by his parents because he has been refusing to walk since he woke up this morning. The parents note that he complains of pain in his right anterior thigh and knee. He had a mild upper respiratory tract infection two weeks ago but has otherwise been healthy. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $90/60\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $22/\text{min}$. On physical examination, the child appears uncomfortable and refuses to stand or bear any weight on his right leg. The right hip is held in slight flexion, abduction, and external rotation. There is no visible erythema or swelling of the hip, thigh, or knee. Range of motion of the right knee is full and painless, but any attempt to internally rotate the right hip elicits severe pain and crying. Laboratory studies show:

Which of the following is the most appropriate next step in the management of this patient?

A newborn male, delivered at 38 weeks of gestation following an uncomplicated pregnancy, develops profound perioral and truncal cyanosis at 4 hours of life. His peripheral oxygen saturation is 58% on room air and increases to only 62% after 15 minutes of 100% fraction of inspired oxygen ($FiO_2$) via headbox. His respiratory rate is 65/min with minimal work of breathing. Cardiac auscultation reveals a single, loud second heart sound ($S_2$) and a faint, non-radiating systolic murmur at the left mid-sternal border. Urgent echocardiography confirms the aorta arising anteriorly from the right ventricle and the pulmonary trunk arising posteriorly from the left ventricle. The ventricular septum is intact, and color Doppler demonstrates a highly restrictive patent foramen ovale ($PFO$) with minimal bidirectional flow. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from immediate life-saving stabilization to definitive treatment.