Pediatrics

During a busy winter clinic session, a pediatrician evaluates an infant aged $5$ months who has been exhibiting noisy breathing and nasal congestion for the past $3$ days. The caregiver notes that the child's formula intake remains at baseline, but his breathing appears more rapid than usual. He was born at $39$ weeks of gestation without perinatal complications. Current vital signs include a temperature of $37.6^{\circ}\text{C}$ ($99.7^{\circ}\text{F}$), pulse of $138$/min, respiratory rate of $56$/min, and an oxygen saturation of $94\%$ on ambient air. On examination, the infant is alert with mild subcostal retractions. Auscultation of the lungs reveals widespread expiratory wheezes and fine crackles bilaterally. Which of the following are appropriate components of the initial management for this patient? (Select all that apply)

A 24-month-old toddler is brought to the pediatric clinic by her parents, who noticed an unusual lump in her abdomen while dressing her. Over the past month, the child has been increasingly fussy, has experienced intermittent bone pain, and has lost a noticeable amount of weight. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 115/min, and a blood pressure of 138/88 mmHg. Physical examination reveals a firm, irregular, nodular abdominal mass that extends across the anatomic midline. Additional findings include bilateral periorbital ecchymoses and a right-sided mild ptosis with miosis. Which of the following laboratory studies is most appropriate to help confirm this patient's most likely diagnosis?

A mother brings her 7-month-old female infant to the pediatrician's office in early November for a routine well-child evaluation. The infant was born prematurely at 28 weeks of gestation. Her neonatal course was complicated by respiratory distress syndrome, requiring mechanical ventilation and exogenous surfactant administration. She was successfully extubated and eventually discharged home at 36 weeks corrected gestational age without the need for supplemental oxygen. The mother reports that the infant is feeding well, gaining weight, and has not been hospitalized since birth. Vital signs are temperature 37.1°C (98.8°F), heart rate 120/min, and respiratory rate 30/min. Physical examination reveals a healthy-appearing infant with clear breath sounds bilaterally and no cardiac murmurs. The mother expresses concern about the upcoming winter season and asks what can be done to protect her child's lungs from severe viral infections. Assuming all routine immunizations for her age are up to date, which of the following is the most appropriate additional pharmacological intervention for this patient?

Parents bring their $3$-year-old son to the clinic after noticing he has been uncharacteristically lethargic and refusing to walk for the past two weeks. The child has also experienced intermittent subjective fevers. Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), heart rate of $115$/min, blood pressure of $92/60$ mmHg, and respiratory rate of $22$/min. On examination, the patient appears pale and tired. There are widespread petechiae on his shins and forearms. Palpation of the abdomen reveals the liver edge $4$ cm below the right costal margin and the spleen tip $5$ cm below the left costal margin. Cervical lymph nodes are enlarged, firm, and non-tender. The physician suspects a primary hematologic malignancy and initiates a comprehensive evaluation. Arrange the following diagnostic and staging steps in the most appropriate chronological sequence.

A 14-day-old male infant is evaluated in the neonatal intensive care unit for new-onset feeding intolerance, abdominal distension, and lethargy. The infant was born prematurely at 28 weeks gestation and has been receiving advanced enteral formula feeds. Current vital signs reveal a temperature of $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), pulse of $175/\text{min}$, respirations of $65/\text{min}$, and blood pressure of $45/25\text{ mm Hg}$. Physical examination demonstrates a markedly distended, tense, and visibly erythematous abdomen with absent bowel sounds. Capillary refill time is 4 seconds. Arterial blood gas analysis on room air shows a pH of 7.15, $p\text{CO}_2$ of $35\text{ mm Hg}$, and $\text{HCO}_3^-$ of $12\text{ mEq/L}$. An anteroposterior abdominal radiograph demonstrates extensive pneumatosis intestinalis and a distinct radiolucency over the liver shadow, indicating free intraperitoneal air. Which of the following is the most appropriate next step in the management of this patient?

A $10$-week-old female infant is brought to the pediatric emergency department by her parents due to severe spells of coughing. The mother reports that the infant had a runny nose, mild cough, and tactile fever for about a week. Over the past $5$ days, the cough has worsened significantly, occurring in sudden, rapid bursts. During these episodes, the infant's face turns red, and she makes a high-pitched "whooping" sound when she finally catches her breath. She has vomited her formula after several of these coughing spells. The infant has not received any routine immunizations because the family recently immigrated. Vital signs between episodes are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse $140$/min, and respirations $40$/min. Physical examination between coughing spells shows a well-appearing infant with clear lungs on auscultation. Laboratory studies reveal a leukocyte count of $24,000/\text{mm}^3$ with $72\%$ lymphocytes. Which of the following is the most appropriate next step in management?

Match each brief clinical presentation of a pediatric gastrointestinal disorder with its most appropriate initial or definitive management step.

A 5-year-old girl with acute lymphoblastic leukemia (ALL) comes to the hematology-oncology clinic with her father for a routine visit. She is currently in the maintenance phase of her treatment regimen, taking daily oral mercaptopurine and weekly methotrexate. Her father reports that she developed a mild cough and runny nose two days ago but has remained afebrile and active. He also expresses concern that she is unable to ride a two-wheeled bicycle without training wheels, although she effortlessly pedals her tricycle.

Vital signs show a temperature of $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), a heart rate of $98/\text{min}$, a blood pressure of $95/60\text{ mmHg}$, and a respiratory rate of $18/\text{min}$. Physical examination reveals clear rhinorrhea and clear lung fields bilaterally.

The father notes that she is due for her kindergarten immunizations, having last received vaccines at $18$ months of age.

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

A medical student is reviewing pathologic specimens during a pediatric hematology and oncology rotation. Match each described histologic or peripheral blood smear finding with the most appropriate diagnosis.

A $24$-month-old boy is brought to the emergency department by his parents after they noticed a large amount of maroon-colored stool in his diaper. The parents state the child has not had any fever, vomiting, diarrhea, or crying episodes suggesting abdominal pain. He has been eating well and his activity level is at baseline. He was born at $39$ weeks gestation and has met all developmental milestones. His vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate $110/\text{min}$, respiratory rate $22/\text{min}$, and blood pressure $90/60\text{ mm Hg}$. Physical examination reveals an alert, playful child with pale conjunctivae. The abdomen is soft, non-distended, and non-tender without palpable masses. Bowel sounds are normal. Examination of the perianal area shows no fissures or skin tags. Hemoglobin level is $9.2\text{ g/dL}$. Which of the following is the most appropriate next step in management?

Concerned parents present to the urgent care clinic with their 15-month-old son due to worsening breathing difficulties. The illness started four days prior with severe nasal congestion, clear rhinorrhea, and low-grade pyrexia. Over the past 24 hours, the parents noticed that his abdomen pulls inward with each breath, prompting the visit. The child was born at full term via an uncomplicated vaginal delivery and has received all age-appropriate immunizations. Vital signs show a temperature of 38.2°C (100.8°F), heart rate of 140/min, respiratory rate of 52/min, and oxygen saturation of 94% on room air. Examination shows an alert toddler in mild respiratory distress with subcostal retractions. Auscultation of the lungs reveals widespread expiratory wheezes and scattered coarse crackles. Which of the following is the most appropriate next step in the management of this patient?

A $12$-year-old boy with a known history of Ewing sarcoma is brought to the emergency department due to worsening, severe back pain for the past $48$ hours. This morning, he developed weakness in both legs and has been unable to urinate. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, pulse is $98\text{/min}$, and respirations are $20\text{/min}$. Physical examination reveals $2/5$ motor strength in the bilateral lower extremities, exaggerated deep tendon reflexes at the knees and ankles, and a loss of sensation to pinprick below the level of the umbilicus. Anal sphincter tone is markedly decreased. Arrange the following steps in the most appropriate chronological order for the management of this patient's current condition.

A $4$-year-old girl is brought to the pediatric clinic by her mother due to a $6$-month history of foul-smelling, bulky stools and poor weight gain. Her mother reports that the child frequently complains of diffuse abdominal discomfort and has become increasingly irritable. The patient's growth chart indicates that her weight has dropped from the $50^{\text{th}}$ percentile to the $10^{\text{th}}$ percentile over the past year, while her height remains tracking at the $40^{\text{th}}$ percentile. Physical examination reveals a visibly distended abdomen and decreased subcutaneous fat in the extremities. Laboratory evaluation demonstrates a hemoglobin of $9.2 \text{ g/dL}$ with a mean corpuscular volume of $72 \text{ fL}$. Which of the following is the most appropriate initial diagnostic step for this patient?

An $8$-year-old girl with a history of homozygous sickle cell anemia (HbSS) is brought to the pediatric emergency department due to a two-day history of progressive shortness of breath, right-sided chest pain, and fever. Her temperature is $38.9^\circ \text{C}$ ($102.0^\circ \text{F}$), blood pressure is $100/60\text{ mmHg}$, heart rate is $128/\text{min}$, and respiratory rate is $34/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals shallow breathing and crackles over the right lower posterior lung fields. Laboratory studies show:

* Hemoglobin: $7.1\text{ g/dL}$
* Leukocyte count: $19,500/\mu \text{L}$
* Reticulocytes: $11\%$

Chest radiography demonstrates a new alveolar infiltrate in the right lower lobe. The patient is immediately started on supplemental oxygen, pain control, and intravenous normal saline. Which of the following is the most appropriate additional pharmacologic therapy for this patient?

A 2-hour-old term male newborn is evaluated in the neonatal nursery for excessive drooling, frothy oral secretions, and episodes of choking and coughing accompanied by perioral cyanosis immediately upon his first feeding. The infant is currently breathing comfortably on room air after the feeding was abruptly stopped. Prenatal ultrasound was notable for severe polyhydramnios. Physical examination is unremarkable except for the continuous reaccumulation of copious oral secretions. Arrange the following steps in the most appropriate chronological order for the acute management and evaluation of this patient.

Parents bring their $4$-week-old male infant to the acute care clinic because he has been forcefully vomiting after feeds for the past five days. The nonbilious vomitus frequently shoots across the crib. Despite the recurrent emesis, the infant appears remarkably hungry and demands to feed again immediately. Over the last $48$ hours, his urine output has decreased to only one wet diaper per day. Vital signs show a heart rate of $165\text{/min}$, blood pressure of $68/38\text{ mm Hg}$, and respiratory rate of $32\text{/min}$. Physical examination reveals a lethargic infant with sunken eyes, a depressed anterior fontanelle, and a capillary refill time of $5$ seconds. Abdominal examination is notable for a palpable, firm, olive-shaped mass in the right upper quadrant.

Laboratory studies demonstrate the following:

What is the most appropriate initial step in the management of this patient?

A pediatric pathology team is correlating characteristic genetic and microscopic findings with their corresponding childhood malignancies. Match each specific diagnostic description with the most likely pediatric hematologic or oncologic diagnosis.

A preschool-aged male is evaluated in the emergency department due to a new-onset fever of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$) and extreme lethargy. The patient is currently in the consolidation phase of cytotoxic chemotherapy for an underlying high-risk neuroblastoma. Two days prior to arrival, an implanted central venous access port was surgically placed without immediate complications. On evaluation, he is tachycardic at $165/\text{min}$, tachypneic at $32/\text{min}$, and hypotensive with a blood pressure of $72/40\text{ mm Hg}$. Capillary refill time is $4\text{ seconds}$. The surgical site appears clean with no surrounding erythema, and the lungs are clear to auscultation. A complete blood count reveals a total leukocyte count of $400/\text{mm}^3$ with $10\%$ segmented neutrophils and $5\%$ band forms. What is the most appropriate next step in the management of this patient?

Parents bring their 8-month-old male infant to the pediatric clinic due to worsening noisy breathing and new-onset feeding difficulties. The infant has had a "raspy" breathing sound since he was approximately 2 months old. The parents note that the noise occurs constantly during both inspiration and expiration, and it becomes significantly louder when the infant cries. Over the past four weeks, since the introduction of pureed solid foods, he has frequently gagged and regurgitated during meals. The parents report that he seems to breathe most comfortably when he sleeps with his head arched backward, and his breathing worsens if his chin is pushed toward his chest. He has no history of fever, cough, or sick contacts. His immunizations are up to date. Temperature is 37.0°C (98.6°F), pulse is 128/min, respirations are 32/min, and oxygen saturation is 98% on room air. Physical examination reveals a well-nourished infant with biphasic stridor. Auscultation of the lungs reveals clear breath sounds bilaterally with no wheezing or crackles. The stridor does not improve when the infant is placed in the prone position.

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

Match each pediatric clinical vignette to the microbiologic description of its most likely causative pathogen.