Pediatrics

During a prompt visit to the pediatric emergency department, the parents of a 16-day-old boy report that he developed a fever earlier in the day. A rectal thermometer reading at home was 38.6°C (101.5°F). Upon arrival, the infant's vital signs include a temperature of 38.4°C (101.1°F), heart rate of 158/min, and respiratory rate of 48/min. The parents also mention a rash that appeared on his trunk yesterday, described as blotchy and red with small, pale papules in the center. He has a mild, occasional cough but is breastfeeding vigorously and producing adequate wet diapers. The infant was born at 39 weeks of gestation via an uncomplicated spontaneous vaginal delivery. Maternal group B Streptococcus screening was negative. Physical examination reveals the described rash over the chest and abdomen; a microscopic smear of a papule demonstrates numerous eosinophils. His lungs are clear to auscultation, and the remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 5-month-old boy is brought to the clinic in late January with a 3-day history of worsening nasal congestion, clear rhinorrhea, and a mild cough. Over the past 12 hours, his parents have noticed that he is breathing more rapidly than usual and appears fussy. He was born at 39 weeks gestation and has no underlying medical conditions. He has received all recommended age-appropriate vaccinations. His temperature is 37.8°C (100.0°F), pulse is 148/min, and respiratory rate is 64/min. Pulse oximetry shows 94% on room air. Physical examination reveals flaring of the nasal alae, mild subcostal retractions, and prolonged expiration. Lung auscultation demonstrates diffuse bilateral wheezing and scattered fine crackles. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 5-year-old girl is brought to the emergency department by her parents due to a severe headache, high fever, and worsening lethargy over the past 12 hours. She has not received any childhood vaccinations. On examination, her temperature is 39.8°C (103.6°F), heart rate is 150/min, respiratory rate is 28/min, and blood pressure is 85/50 mm Hg. She is somnolent, responding only to painful stimuli. Physical examination reveals nuchal rigidity and a rapidly expanding, non-blanching purpuric rash on her lower extremities. Fundoscopic examination demonstrates bilateral papilledema. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

During a scheduled 15-month health maintenance visit, the parents of a toddler report that she has been acutely ill for the past 3 days. Her symptoms include a "wet-sounding" cough, rapid breathing, and sustained high fevers. The patient has no significant past medical history and previously received all immunizations recommended for her first year of life. Current vital signs show a temperature of 39.1°C (102.4°F), a pulse of 145/min, and a respiratory rate of 48/min. Pulse oximetry displays 96% saturation on room air. On physical examination, the toddler is fussy but easily consolable, and she readily drinks from a sippy cup. Auscultation of the chest reveals decreased breath sounds and focal crackles over the right lower lung field, without any wheezing or intercostal retractions. Cardiovascular and abdominal examinations are unremarkable. Which of the following is the most appropriate next step in management?

A 7-year-old girl is evaluated in the pediatric ward on hospital day 3. She was admitted with high fever, severe right thigh pain, and refusal to bear weight. Magnetic resonance imaging (MRI) of the right lower extremity at admission demonstrated bone marrow edema and a subperiosteal fluid collection in the distal femur consistent with acute hematogenous osteomyelitis. In the emergency department, she was started on empiric intravenous vancomycin and ceftriaxone. Over the past 48 hours, her temperature has trended down, and she reports decreased pain. Blood cultures drawn on admission are now growing Staphylococcus aureus. Susceptibility testing reveals the isolate is sensitive to oxacillin, cefazolin, and clindamycin, but resistant to penicillin and ampicillin. Vital signs today show a temperature of 37.1°C (98.8°F), blood pressure of 105/65 mm Hg, pulse of 92/min, and respiratory rate of 18/min. Which of the following is the most appropriate modification to her pharmacotherapy?

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

A 4-year-old boy is brought to the emergency department by his parents due to the sudden onset of severe throat pain, a muffled voice, and difficulty breathing. His parents note that he has not been able to swallow his saliva for the past two hours and has been leaning forward continuously. He has missed several childhood vaccinations. On observation, the patient is toxic-appearing, drooling, and exhibits inspiratory stridor. His temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate is $155/\text{min}$, and respiratory rate is $36/\text{min}$. He becomes highly agitated when a nurse approaches him with a blood pressure cuff. Arrange the following management steps in the most appropriate chronological order for this patient.

A mother brings her 10-month-old daughter to a pediatric clinic for evaluation of a fever and a new rash. The infant developed a high fever, a persistent cough, and a runny nose four days ago. Since yesterday, her eyes have been markedly red and watering. This morning, the mother noticed a rash starting on the child's face. The infant has not received any vaccinations due to the family's personal beliefs. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $155/\text{min}$, and respirations are $38/\text{min}$. Physical examination reveals an ill-appearing infant. There is a blanching, erythematous maculopapular rash prominent on the face and neck, with early spread to the upper trunk. Oral examination shows clustered, $1$- to $2\text{ mm}$ white lesions on an erythematous base on the bilateral buccal mucosa. Lung auscultation reveals transmitted upper airway sounds. Which of the following is the most appropriate next step in management?

A 4-year-old boy is brought to the emergency department by his parents for a 1-day history of high fever, severe right hip pain, and an inability to bear weight. His temperature is 39.2°C (102.6°F), heart rate is 130/min, respiratory rate is 24/min, and blood pressure is 95/60 mm Hg. Examination reveals the right hip is held in flexion, abduction, and external rotation. Passive movement of the joint elicits severe pain and guarding. There is no history of trauma. Assuming the patient remains hemodynamically stable, arrange the following steps in the most appropriate sequential order for the diagnostic and therapeutic management of this patient.

During routine morning rounds in the newborn nursery, a physician evaluates a male neonate at $48$ hours of life due to a newly developed cutaneous eruption. The infant was born at $39$ weeks gestation via an uncomplicated spontaneous vaginal delivery to a $26$-year-old primigravida. The mother's prenatal laboratory screening was unremarkable. The infant has been breastfeeding robustly and passing normal transitional stools. Vital signs demonstrate a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), a heart rate of $138/\text{min}$, and a respiratory rate of $38/\text{min}$. Physical examination highlights a well-appearing, alert neonate. A widely disseminated rash consisting of prominent erythematous macules and papules is visible across the anterior thorax, back, and proximal thighs. Several of the erythematous bases contain small, $1\text{- to }2\text{-mm}$ central yellowish pustules. The palms and plantar surfaces are completely clear of lesions. A Wright-stained smear of the pustular contents is examined under light microscopy and demonstrates a striking predominance of eosinophils. Based on these findings, which of the following is the most appropriate next step in management?

Match the following classic pediatric clinical presentations with their most likely causative viral pathogen.

A $3$-week-old male infant is evaluated in the emergency department for a $12$-hour history of decreased feeding and increased somnolence. The parents report that he has been difficult to rouse for his usual feedings. He was born at term via an uncomplicated vaginal delivery to a mother who received standard prenatal care. Vital signs reveal a rectal temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), heart rate of $168/\text{min}$, respiratory rate of $54/\text{min}$, and blood pressure of $70/45\text{ mmHg}$. Physical examination shows a lethargic infant who awakens only briefly to stimulation. The anterior fontanelle is soft and flat. Cardiopulmonary examination is unremarkable, with no wheezing or retractions. Skin examination reveals scattered $1$ to $2\text{ mm}$ yellow-white pustules on a splotchy erythematous base distributed over the anterior chest and back. Which of the following is the most appropriate next step in management?