Pediatrics

A 12-month-old boy is brought to the clinic for a routine well-child evaluation. His mother, who is 18 weeks pregnant, reports that he is doing well but expresses concern that he is not yet walking independently. On evaluation, the infant is able to pull himself to a stand, cruises along the examination table, and uses a neat pincer grasp to pick up small objects. He babbles frequently, says "mama" and "dada" specifically to his parents, and plays peek-a-boo. The infant is up to date on all immunizations administered prior to 12 months of age. His mother asks if his required immunizations for today are safe for her unborn baby. Which of the following is the most appropriate management for this patient?

A pediatric clinic is implementing a new screening tool for early childhood development. The nursing staff is tasked with organizing a chronological checklist of expected developmental milestones to evaluate pediatric patients over their first three years of life. Arrange the following sets of developmental milestones in chronological order from the earliest expected age of acquisition to the latest.

A male neonate, aged 16 days, is evaluated in the emergency department in mid-winter due to a 24-hour history of poor feeding, rhinorrhea, and a documented axillary temperature of 38.4°C (101.1°F). He was born at 39 weeks gestation via uncomplicated vaginal delivery and discharged on day 2 of life. On physical examination, the patient appears well-perfused but exhibits mild tachypnea with a respiratory rate of 64/min. Auscultation of the chest reveals diffuse high-pitched expiratory wheezing and mild intercostal retractions. Dermatologic examination shows a splotchy, erythematous macular rash with central tiny yellow papules scattered across the chest and abdomen. A rapid antigen detection test for respiratory syncytial virus (RSV) returns positive. What is the most appropriate single best action in the management of this patient?

A 9-year-old boy with a history of mild persistent asthma presents to the emergency department with a 24-hour history of worsening cough, shortness of breath, and chest tightness. He recently had symptoms of a mild viral upper respiratory tract infection. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $115/\text{min}$, respiratory rate of $28/\text{min}$, and oxygen saturation of $94\%$ on room air. Physical examination reveals mild intercostal retractions and diffuse expiratory wheezing bilaterally. Which of the following are appropriate initial steps in the management of this patient's condition? (Select all that apply)

A mother brings her 4-week-old infant to the pediatric emergency department during the winter season. Over the past three days, the infant has developed a progressive cough, copious clear rhinorrhea, and fast breathing. Today, the mother noticed the baby is having difficulty feeding and seems unusually lethargic. The infant was born at 39 weeks of gestation following an uncomplicated pregnancy and delivery. Family history is significant for a father with severe persistent asthma.

Vital signs reveal a temperature of 37.3°C (99.1°F), a heart rate of 152/min, a respiratory rate of 70/min, and an oxygen saturation of 91% on room air. Physical examination demonstrates an infant in moderate respiratory distress with nasal flaring and marked intercostal retractions. Auscultation reveals prolonged expiration with diffuse bilateral wheezing and fine crackles. Skin examination shows scattered, blotchy, erythematous macules with central tiny pale papules on the trunk, which the mother states have intermittently appeared and resolved since the first week of life.

Based on the clinical presentation, which of the following is the most appropriate next step in management?

A $9$-year-old boy is brought to the pediatric clinic due to facial asymmetry that began yesterday. The patient's mother reports he has been unusually tired and has had a low-grade fever for the past $4$ days. Exactly $3$ weeks ago, the family returned from a camping trip in Connecticut. On physical examination, temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate is $92\text{/min}$, and blood pressure is $105/65\text{ mm Hg}$. There is pronounced drooping of the right side of his face, involving both the upper and lower facial muscles. He is unable to completely close his right eye. Neurologic examination is otherwise entirely normal; there is no nuchal rigidity, photophobia, or altered mental status. Cardiovascular examination reveals a regular rhythm with no murmurs. Skin examination reveals a $7\text{-cm}$ annular erythematous plaque with central clearing on the posterior left thigh. Which of the following is the most appropriate next step in management?

A medical student is reviewing normal gross motor developmental milestones in preparation for performing routine well-child screening examinations. Arrange the following gross motor milestones in the chronological order they typically appear in a healthy infant.

Match each pediatric patient scenario with the most appropriate specific preventive care or immunization recommendation.

During a routine health maintenance visit, the parents of a 2-year-old male toddler report anxiety regarding his speech progression. While his peers are beginning to combine words, he currently relies on a vocabulary of approximately 10 to 12 isolated words. He does not yet link words together. He frequently communicates his desires by pointing and grunting, though he readily responds when his name is called and follows simple verbal instructions like "give me the block."

His birth history and past medical history are unremarkable. A parental autism screening questionnaire administered today is negative for behavioral red flags.

Physical examination reveals an alert, socially engaging child who makes appropriate eye contact. He runs steadily, kicks a small ball without falling, and can build a tower using six wooden blocks. He assists his parents in taking off his jacket. Tympanic membranes are translucent with a normal light reflex bilaterally. Which of the following is the most appropriate next step in the evaluation of this patient?

A 2-month-old boy is brought to the clinic for a routine well-child visit. He was diagnosed with 22q11.2 deletion syndrome shortly after birth following an evaluation for a cardiac murmur and tetany. Echocardiography at that time revealed a tetralogy of Fallot, which is awaiting surgical repair. Recent immunologic evaluation demonstrated a markedly reduced CD3+ T-lymphocyte count of 200/mm³. Today, the infant is feeding well and gaining weight appropriately. During the examination, he demonstrates a social smile, vocalizes with cooing sounds, and tracks a colorful toy past the midline. He does not yet roll over or reach for objects. The mother expresses concern that his development may be delayed. His immunization records show he received the hepatitis B vaccine at birth and 1 month of age. Which of the following is the most appropriate management for this patient today?

A 12-year-old girl is brought to the clinic by her father for a routine sports physical. The father expresses concern because his daughter has not yet experienced her first menstrual period, noting that her older sister began menstruating at age 11. The patient is active, eats a well-balanced diet, and has no significant past medical history. Her height is at the 75th percentile and weight is at the 60th percentile for her age. Physical examination reveals breast and papilla elevated as a small mound with an increased areolar diameter. There is a sparse growth of long, slightly pigmented, downy hair primarily along the labia majora. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate response to the father's concern?

A $6$-day-old female infant is brought to the emergency department by her parents due to poor feeding, irritability, and lethargy over the past $24$ hours. She was born at $39$ weeks gestation via uncomplicated vaginal delivery to a mother with negative group B *Streptococcus* screening. On examination, the infant is lethargic with a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$). Her anterior fontanelle is full and tense. Skin examination reveals a scattered rash consisting of $2$-mm yellow pustules on a broad erythematous base over the trunk; the parents state this rash appeared on the second day of life and has been waxing and waning since.

A lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals the following:

The physician immediately initiates empiric treatment with intravenous vancomycin and cefotaxime.

Which of the following is the most appropriate modification to this patient's pharmacotherapy?

A 9-month-old boy is brought to the pediatric emergency department during the winter due to a 3-day history of low-grade fever, rhinorrhea, and worsening cough. Today, his mother noted that he is breathing faster than usual and has been fussy, feeding slightly less than normal. His temperature is 37.9°C (100.2°F), pulse is 145/min, respirations are 56/min, and blood pressure is 90/55 mm Hg. Pulse oximetry shows 94% on room air. On examination, the patient has clear nasal discharge. There are mild subcostal retractions. Lung auscultation reveals diffuse bilateral polyphonic wheezes and scattered coarse crackles. Cardiovascular and abdominal examinations are unremarkable. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the pediatric clinic due to a 2-day history of fever, cough, and rapid breathing. He has had no previous significant medical illnesses and his immunizations are up to date. His temperature is 39.2°C (102.6°F), heart rate is 142/min, blood pressure is 90/55 mmHg, and respiratory rate is 46/min. Pulse oximetry is 96% on room air. On examination, the patient appears tired but is consolable and readily drinks oral rehydration solution. Chest auscultation reveals focal fine crackles and decreased breath sounds over the left lower lung base. There are no intercostal retractions, nasal flaring, or wheezing. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 4-month-old girl is brought to the pediatrician for a routine well-child visit. She was born at 32 weeks gestation and had an uncomplicated neonatal intensive care unit stay before being discharged at 36 weeks postmenstrual age. For the past two days, she has had clear rhinorrhea and a mild cough. Her temperature is 37.6°C (99.7°F), pulse is 120/min, and respirations are 32/min. Physical examination reveals clear lung fields and no increased work of breathing. The father expresses concern about administering vaccines today because the infant is "fighting off a cold" and because she was born prematurely. She received her 2-month immunizations without any adverse events. Which of the following is the most appropriate recommendation regarding her immunizations today?

A 10-day-old female neonate is evaluated in the neonatal intensive care unit for sudden clinical deterioration. She was born at 29 weeks of gestation via urgent cesarean delivery due to severe maternal preeclampsia. Birth weight was 1,150 g (2 lb 8 oz). Apgar scores were 5 and 7 at 1 and 5 minutes, respectively. Over the past 8 hours, the neonate has developed temperature instability and frequent episodes of apnea and bradycardia. She is currently supported with continuous positive airway pressure. She had been tolerating advancing volumes of expressed maternal milk via an orogastric tube; however, the most recent feed yielded a large bilious gastric residual. Temperature is 35.8°C (96.4°F), pulse is 175/min, and respirations are 68/min. The abdomen is grossly distended, shiny, and erythematous with absent bowel sounds. Complete blood count shows a leukocyte count of 2,200/mm³ and a platelet count of 82,000/mm³. Arterial blood gas analysis reveals a pH of 7.26, $\text{pCO}_2$ of 38 mm Hg, and $\text{HCO}_3^-$ of 15 mEq/L. An anteroposterior abdominal radiograph demonstrates prominent, dilated bowel loops with linear radiolucencies in the intestinal wall, without free air under the diaphragm. Which of the following is the most appropriate next step in management?

A 12-hour-old male neonate is evaluated in the nursery due to rapid breathing. He was born at 38 weeks gestation via scheduled cesarean delivery for a breech presentation. The pregnancy was uncomplicated, and maternal group B Streptococcus screening was negative. Apgar scores were 8 and 9 at 1 and 5 minutes. His temperature is 36.9°C (98.4°F), heart rate is 148/min, respiratory rate is 74/min, and oxygen saturation is 96% on room air. Physical examination shows a vigorous infant with mild subcostal retractions. Breath sounds are clear and equal bilaterally without murmurs. Skin examination reveals multiple scattered 2-mm pustules on a broad erythematous base across the anterior chest, abdomen, and proximal extremities. A chest radiograph demonstrates hyperinflation, prominent perihilar linear densities, and fluid within the interlobar fissures. Which of the following is the most appropriate next step in management?

Match each classic physical examination finding or auscultatory feature with the most likely associated pediatric congenital heart defect.

A $16$-year-old female high school student presents to an outpatient neurology practice after suffering a generalized convulsion. The event occurred this morning shortly after she woke up. Her mother states that for the past $6$ months, the patient has experienced sudden, brief, symmetric muscle jerks in her upper extremities, predominantly occurring within the first hour of awakening. These jerks have occasionally caused her to drop her hairbrush. Her past medical history is unremarkable. She met all early developmental milestones on time, including sitting without support at $6$ months and walking independently at $12$ months. Neurologic examination today demonstrates normal tone, power, and reflexes. An interictal electroencephalogram shows bursts of bilateral, synchronous $4$- to $6$-Hz polyspike-and-wave discharges on a normal background. Which of the following statements regarding this patient's diagnosis and management are correct? (Select 2)

A 9-month-old boy is brought to the pediatric clinic by his parents due to progressive lethargy, poor feeding, and loss of motor milestones over the past two months. Previously, he was able to sit without support, but he now has pronounced head lag and generalized weakness. Physical examination reveals a pale, apathetic infant with generalized hypotonia and a smooth, erythematous tongue. There is no hepatosplenomegaly, and no dysmorphic facial features are noted.

Laboratory studies are obtained and reveal the following:

Which of the following is the most likely primary underlying defect in this patient?