Pediatrics

A 14-day-old male infant is evaluated in the neonatal intensive care unit for acute clinical deterioration. He was born at 26 weeks gestation via emergency cesarean delivery for maternal severe preeclampsia. Birth weight was 850 g (1 lb 14 oz). Apgar scores were 4 and 6 at 1 and 5 minutes, respectively. Two days ago, the infant developed feeding intolerance, abdominal distension, and grossly bloody stools. An abdominal radiograph demonstrated pneumatosis intestinalis. He was made nil per os (NPO) and started on gastric decompression, intravenous fluids, and broad-spectrum antibiotics (ampicillin, gentamicin, and metronidazole).

Over the past 2 hours, the infant has become increasingly lethargic. His temperature is 35.4°C (95.7°F), heart rate is 190/min, respiratory rate is 70/min, and blood pressure is 38/20 mmHg. He requires endotracheal intubation for escalating apneic episodes and hypoxia. Physical examination reveals a tense, rigid abdomen with marked erythema of the abdominal wall. A stat anteroposterior supine abdominal radiograph demonstrates prominent linear radiolucencies within the bowel wall and a new, large, continuous radiolucent shadow centrally that outlines the falciform ligament.

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

During routine morning rounds, a pediatrician evaluates a 48-hour-old female infant. The parents are highly anxious because they noticed multiple "red blotches with white centers" appearing on their daughter's trunk and thighs earlier this morning. The infant was born at 39 weeks of gestation via uncomplicated spontaneous vaginal delivery. Vital signs are within normal limits, and the infant is actively breastfeeding. Physical examination reveals widely scattered erythematous macules, several of which contain 1- to 2-mm central pale-yellow pustules. The infant's palms and soles are completely unaffected. Which of the following is the most appropriate next step in management?

An 18-month-old boy is brought to the pediatrician for a well-child visit and vaccination update. He was diagnosed with minimal change disease one month ago and has been taking oral prednisone at a dose of 2 mg/kg/day since the diagnosis. His parents report that he is doing well overall and his edema has resolved. They are concerned about his development, noting that while he can walk backward, scribble with crayons, and use about 15 individual words, he cannot yet jump with both feet or use two-word phrases. The patient missed his 12-month and 15-month appointments and has not received any immunizations since 6 months of age. Vital signs are within normal limits. Physical examination reveals a playful child with a cushingoid appearance but no peripheral edema. Which of the following is the most appropriate management regarding his immunizations and development?

Match each classic pediatric infectious disease clinical presentation with its correct causative pathogen.

Match each pediatric patient's clinical presentation with the most likely causative viral pathogen.

A 15-month-old boy is brought to the clinic for a routine well-child examination. Three months ago, he was hospitalized for 5 days with a persistent high fever, bilateral bulbar conjunctival injection, cracked erythematous lips, and a diffuse maculopapular rash. During that admission, he was successfully treated with a single dose of intravenous immunoglobulin (IVIG, $2 \text{ g/kg}$) and high-dose aspirin. An echocardiogram performed at the time was normal. He was discharged on low-dose aspirin, which was discontinued last week following a normal follow-up echocardiogram. His last immunizations were administered at his 6-month well-child visit. His temperature is 37.1°C (98.8°F), heart rate is 105/min, and blood pressure is 85/50 mm Hg. Physical examination today shows a well-appearing, active toddler with no abnormalities. The parents are requesting that he receive all vaccines he is currently eligible for to catch up on his schedule. Which of the following is the most appropriate recommendation regarding this patient's immunizations today?

A 3-week-old full-term boy is brought to the pediatric outpatient clinic by his parents due to a new facial rash. The parents first noticed the lesions 4 days ago, and they have gradually increased in number. The infant is exclusively breastfed, feeds vigorously, and has appropriate wet and dirty diapers. Vital signs are within normal limits. Physical examination reveals multiple scattered inflammatory papules and pustules located on the cheeks, chin, and forehead. There are no open or closed comedones. The remainder of the skin examination is unremarkable. Which of the following is the most appropriate next step in management?

Evaluate the following pediatric patients presenting with signs and symptoms concerning for acute bacterial meningitis. Which initial empiric intravenous antimicrobial regimen is most appropriate for each patient's clinical presentation? Match each patient to the correct regimen.

A medical student is reviewing developmental screening tools used during routine well-child preventive care visits. To correctly administer screening questionnaires and identify potential delays, the student must know the normal progression of infant and toddler development. Arrange the following fine motor milestones in the chronological order in which they are typically achieved by a healthy neurotypical child, from earliest to latest.

Match the following clinical presentations of neonatal respiratory distress with their primary underlying pathophysiologic mechanism.

A 5-year-old girl presents to the clinic with her adoptive parents for an initial health assessment. The family recently immigrated, and the parents state that the child has no previous medical or vaccination records. The patient's past medical history is notable for severe persistent asthma. Three weeks prior to her arrival, she suffered a severe asthma exacerbation that required a pediatric intensive care unit admission. She was discharged on a regimen of oral prednisone 2 mg/kg daily, which she has continued taking for the past 21 days. Her other medications include high-dose inhaled fluticasone and as-needed albuterol. Vital signs are within normal limits. Physical examination reveals cushingoid features but is otherwise unremarkable, with clear breath sounds bilaterally. The physician is planning her catch-up immunization schedule. Which of the following is the most appropriate immunization management for this patient at today's visit?

A male infant is born at 39 weeks gestation via spontaneous vaginal delivery to a 28-year-old primigravida. The pregnancy was complicated by maternal preeclampsia and intrauterine growth restriction. Birth weight is 2100 g. APGAR scores are 8 and 9 at 1 and 5 minutes.

At 14 hours of life, the infant is evaluated for lethargy, jitteriness, and poor feeding. Vital signs show a temperature of 36.8°C (98.2°F), heart rate of 150/min, and respiratory rate of 64/min. Physical examination reveals a plethoric appearance, sluggish capillary refill, and scattered erythematous macules with central yellow-white papules on the infant's trunk.

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

A pediatric oncology clinic is evaluating a 5-year-old girl who is currently on a maintenance chemotherapy regimen for acute lymphoblastic leukemia. Her parents arranged this urgent visit after learning that a child in her kindergarten class was diagnosed with chickenpox (varicella) two days ago. The two children sit next to each other in class. The patient has no history of clinical varicella infection and has never received the varicella vaccine. She currently feels well, is playing comfortably in the examination room, and is completely asymptomatic. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $105/\text{min}$, and respiratory rate of $24/\text{min}$. Physical examination reveals a clear oropharynx, clear lungs, and normal skin without any rashes or lesions. Based on this exposure, which of the following is the most appropriate next step in management?

A 48-hour-old term male neonate is evaluated in the newborn nursery for a newly developed skin rash. He was born via uncomplicated vaginal delivery to a 26-year-old primigravida. The mother has a history of recurrent genital herpes simplex virus (HSV) infections but had no active lesions or prodromal symptoms at the time of delivery. She took suppressive oral acyclovir from 36 weeks of gestation. The infant's temperature is 37.1°C (98.8°F), heart rate is 145/min, and respiratory rate is 40/min. He is feeding well and has normal tone. Physical examination reveals widespread 2- to 3-mm firm, pale yellow pustules surrounded by a prominent erythematous macular base (a "flea-bitten" appearance), distributed over his trunk, face, and proximal extremities. The palms and soles are spared. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

An unvaccinated 6-month-old infant is evaluated for a prolonged, severe cough. The pediatrician suspects an infection with Bordetella pertussis. This illness typically progresses through a very predictable sequence of distinct clinical phases. Arrange the following classic stages of a pertussis infection in the correct chronological order, from earliest (first) to latest (last).

A 40-week gestation female infant is delivered vaginally to a 29-year-old gravida 2, para 1 mother following an uncomplicated pregnancy and labor. At the time of birth, the infant is breathing spontaneously, crying vigorously, and exhibits active flexion of all extremities. Arrange the following standard neonatal care interventions in the correct chronological sequence in which they should be executed for this healthy newborn, from earliest (immediately after birth) to latest (prior to hospital discharge).

A 12-year-old girl is brought to the emergency department with a 1-day history of high fever, severe headache, and recurrent vomiting. On examination, her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure is $110/70$ mm Hg, pulse is $115$/min, and respiratory rate is $20$/min. She is lethargic and oriented only to person. Neck flexion produces involuntary flexion of the hips and knees. Fundoscopic examination reveals bilateral blurring of the optic disc margins. Arrange the following steps in the most appropriate chronological sequence for the initial management of this patient.

A series of neonates evaluated in the intensive care unit present with severe hypoxemia. To isolate the etiology, the clinical team performs hyperoxia testing (measuring $PaO_2$ before and after administration of $100\%$ $FiO_2$) and dual pulse oximetry (measuring $SpO_2$ simultaneously in the right hand and right foot). Match each neonatal clinical and oximetry profile with its corresponding primary underlying hemodynamic or pathophysiological mechanism.

A 5-year-old boy is brought to the clinic by his father due to a runny nose and cough that began four days ago. The boy initially had a subjective fever on the first day of illness, but he has been afebrile since. The cough is non-productive and occurs intermittently throughout the day. He is eating and drinking normally and remains active at home. His temperature is 37.1°C (98.8°F), blood pressure is 94/60 mm Hg, pulse is 98/min, and respirations are 20/min. Physical examination reveals clear rhinorrhea and slightly boggy nasal turbinates. The tympanic membranes are translucent and mobile bilaterally. The oropharynx is clear without erythema or exudates. Auscultation of the lungs reveals clear breath sounds bilaterally without wheezes, crackles, or rhonchi. Which of the following is the most appropriate next step in management?

Evaluate the following pediatric patients presenting with localized or generalized lymphadenopathy. Match each clinical vignette with the most appropriate specific management or pharmacotherapy.