Pediatrics

A 30-month-old male toddler presents to the emergency department with a persistent cough and noisy breathing. The symptoms began abruptly 3 hours ago during a family picnic while the child was eating trail mix. The parents witnessed a brief, severe choking episode that resolved spontaneously, but the child has had a mild cough and increased work of breathing since. His temperature is 37.0°C (98.6°F), blood pressure is 92/58 mm Hg, pulse is 124/min, and respirations are 34/min. Pulse oximetry is 95% on room air. On physical examination, the child is alert but appears mildly anxious. Lung auscultation reveals decreased breath sounds and a monophonic expiratory wheeze exclusively over the right hemithorax. A right lateral decubitus chest radiograph demonstrates hyperlucency of the right lung, with a failure of the dependent lung to deflate, and a leftward mediastinal shift. Which of the following is the most appropriate next step in management?

A female adolescent seeks evaluation at the outpatient endocrinology clinic due to distressing changes in her physical appearance. Over the preceding year, she has developed coarse, dark hair on her chin and upper lip, along with persistent nodulocystic acne that has not responded to topical therapies. She achieved menarche at $12$ years of age, but her menstrual cycles have become increasingly erratic, currently occurring at intervals of $3$ to $5$ months. Blood pressure is $112/72 \text{ mmHg}$ and body mass index is $23 \text{ kg/m}^2$. Physical examination reveals a Ferriman-Gallwey score of $11$, with normal breast and female external genital development. There is no clitoromegaly.

Early morning serum analyses yield the following results:
Total testosterone: $92 \text{ ng/dL}$ (Normal: $15-70 \text{ ng/dL}$)
Dehydroepiandrosterone sulfate (DHEA-S): $580 \text{ } \mu\text{g/dL}$ (Normal: $65-380 \text{ } \mu\text{g/dL}$)
$17$-hydroxyprogesterone: $3,800 \text{ ng/dL}$ (Normal: $< 200 \text{ ng/dL}$)
Thyroid-stimulating hormone (TSH): $1.6 \text{ mU/L}$ (Normal: $0.5-5.0 \text{ mU/L}$)
Free thyroxine (T4): $1.1 \text{ ng/dL}$ (Normal: $0.8-2.0 \text{ ng/dL}$)

Transabdominal ultrasonography reveals normal-appearing ovaries with no evidence of cysts.

Which of the following best describes the fundamental pathophysiologic mechanism responsible for this patient's condition?

A 28-day-old male infant is urgently evaluated in the emergency department after his parents noted a sudden onset of inconsolable crying and repeated episodes of vomiting over the past 5 hours. The vomitus was initially composed of digested breast milk but has recently become dark green. He was born at 38 weeks gestation without complications and had been feeding well until this morning. On physical examination, the infant appears mottled and lethargic. Vital signs reveal a temperature of 38.1°C (100.6°F), heart rate of 192/min, respiratory rate of 65/min with intercostal retractions, and blood pressure of 54/32 mm Hg. Capillary refill time is prolonged at 6 seconds. The abdomen is distended, markedly rigid, and exquisitely tender to palpation, with a faint erythematous discoloration of the periumbilical skin. Bowel sounds are absent. A portable plain radiograph of the abdomen demonstrates a paucity of distal bowel gas with no evidence of pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

A 3-year-old unimmunized boy is brought to the emergency department with a rapid onset of high fever, severe sore throat, and drooling. He is sitting upright, leaning forward with his neck extended, and appears highly anxious. He has significant inspiratory stridor and suprasternal retractions. Arrange the following management steps in the most appropriate sequential order for this patient.

A 6-month-old male infant, born prematurely at $32$ weeks gestation, is evaluated in the emergency department in mid-January. For the past four days, he has had profuse rhinorrhea and a low-grade fever. Today, he developed significant breathing difficulty and has been unable to breastfeed. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate of $165/\text{min}$, respiratory rate of $68/\text{min}$, and oxygen saturation of $88\%$ on room air. Physical examination reveals marked intercostal and subcostal retractions, nasal flaring, and head bobbing. Lung auscultation demonstrates diffuse coarse crackles and prolonged expiratory wheezing bilaterally. Which of the following are appropriate interventions for this patient's acute management? (Select all that apply)

Match each pediatric patient's clinical vignette (left) with the underlying pathophysiological or embryological mechanism responsible for the condition (right).

A 15-month-old girl is brought to the pediatrician for a routine well-child visit. She was born at 28 weeks gestation via emergency cesarean delivery due to a placental abruption, and her neonatal course was complicated by respiratory distress syndrome requiring mechanical ventilation. Her parents are concerned about her development, noting that she cannot walk independently and her vocabulary consists only of the words "mama" and "dada." However, the parents proudly mention that she is "advanced in her motor skills on the right side," as she has consistently used her right hand to feed herself and reach for toys since she was 8 months old. On physical examination, the patient's growth parameters are at the 50th percentile for her corrected age. She can pull to a stand and cruise along furniture. She makes good eye contact, points to a desired toy across the room, and plays peek-a-boo. When a small block is placed on the examination table, she picks it up using a precise right-sided thumb and index finger grasp. Her left hand remains mostly fisted during the encounter, and there is noticeable resistance to passive extension of the left elbow. Which of the following is the most appropriate next step in management?

A 14-month-old boy is brought to the pediatrician for a well-child visit. His parents report that he has been developing normally and has met all his developmental milestones on time. Arrange the following gross motor milestones in the chronological order in which this patient most likely achieved them, from earliest to latest.

A medical student is reviewing the typical progression of motor development in early childhood. Arrange the following gross motor milestones in the chronological order in which they typically emerge in a healthy, full-term infant.

A clinician is designing a standardized developmental screening tool for a pediatric outpatient clinic. The module focusing on visual-motor and adaptive skill progression needs to be organized developmentally. Arrange the following pediatric fine motor milestones in chronological order, from the earliest typical age of expected acquisition to the latest.

A 3-year-old boy is brought to the clinic by his parents for a routine well-child visit. The parents express concern about his development, noting that he is unable to draw a cross or a square. They mention that their older daughter was able to draw these shapes at his age. They report that the patient is otherwise active and playful. He can pedal a tricycle and alternate his feet when walking up the stairs. He feeds himself with a spoon and can build a tower of 9 blocks. He speaks in 3-word sentences and strangers can understand approximately 75% of what he says. His physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A pediatric clinic evaluates several children for routine well-child visits. Match each patient's age with the most appropriate cluster of expected developmental milestones.

A healthy pediatric patient is evaluated during a routine health maintenance visit. While waiting, the physician observes the child successfully pedaling a tricycle. In the examination room, the child confidently copies a circle onto a piece of paper using a crayon but is unable to draw a cross. The child converses in sentences containing three to four words, and the physician can understand approximately three-quarters of the speech. When prompted, the child correctly identifies their own gender. Based on this documented developmental profile, which of the following is the most likely age of this patient?

During a pediatric clerkship, a medical student is evaluating several children in the outpatient clinic. Match each set of observed developmental milestones to the most appropriate expected chronological age.

Match each clinical presentation of a child's current developmental abilities with their most accurate estimated developmental age.

An 11-year-old girl is brought to the pediatric clinic by her father for a routine well-child visit. The father mentions that he has noticed recent changes in his daughter's physical appearance and is wondering what to expect regarding her development over the next few years. The patient is otherwise healthy, eats a well-balanced diet, and plays competitive soccer. Her height is at the 60th percentile and her weight is at the 55th percentile. On physical examination, the breast and papilla are elevated as a small mound, and the areolar diameter is enlarged. Examination of the genitalia reveals sparse, straight, lightly pigmented hair primarily along the medial border of the labia. The remainder of the examination is unremarkable. Based on these findings, which of the following is the most accurate anticipatory guidance to provide to this family?

A pediatric clinic is reviewing developmental milestones for medical students. Match each clinical presentation of a child's highest level of developmental achievements across four domains (gross motor, fine motor, language, and social) with the corresponding typical chronological age.

A pediatric resident is evaluating a child's developmental progression during a series of well-child visits. Arrange the following sets of developmental milestones in the exact chronological order of their typical emergence in a healthy, neurotypical child, starting from the earliest achievements to the latest.

A male child is evaluated by his pediatrician on his fourth birthday for a routine health maintenance visit. His parents state that he is an active and happy child but express significant anxiety regarding his development and school readiness. According to his mother, the patient is unable to draw a triangle, cannot skip across the room, and requires assistance to tie his shoelaces. The parents note he has an older cousin of the exact same age who can perform all these tasks. On examination, the child is cooperative and interactive. He is able to hop on one foot, catch a bounced ball, copy a cross, and draw a person with four distinct body parts. His speech is completely intelligible to the physician, and he tells a detailed story about a recent trip to the park. He easily engages in cooperative, turn-taking play with a toy set in the examination room. Which of the following is the most appropriate next step in the management of this patient?

A couple consults a family physician during a community health fair regarding their son, who recently turned 36 months of age. The father reports that the child confidently pedals a tricycle around their driveway and walks up the playground steps using alternating feet. However, he is concerned because the child cannot yet hop on one foot and struggles to draw a cross with a crayon. The mother adds that while the family understands everything the child says, strangers seem to comprehend his speech about 75% of the time. The parents are worried about potential developmental delays because an older sibling was already performing these missing tasks at this age. Which of the following is the most appropriate action?