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A $31$-year-old gravida $2$, para $1$ at $25$ weeks gestation presents to the clinic for a scheduled prenatal evaluation. She reports mild shortness of breath when walking up stairs and increased urinary frequency over the past few weeks, but otherwise feels well. Her first pregnancy was uncomplicated, resulting in a term vaginal delivery. Vital signs show a blood pressure of $110/68$ mm Hg, heart rate of $86$/min, and respiratory rate of $18$/min. Physical examination reveals a gravid uterus consistent with gestational age and trace bilateral pedal edema. Laboratory studies reveal the following:

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

Match each classic clinical or imaging finding with its corresponding pediatric gastrointestinal diagnosis.

A 16-month-old boy is brought to the pediatric clinic for a routine well-child evaluation. His mother mentions that he is a picky eater and refuses most solid foods. His diet consists predominantly of $32$ to $40$ ounces (approximately $950$ to $1200 \text{ mL}$) of whole cow's milk daily, supplemented only by small amounts of crackers. He is active but occasionally appears more fatigued than his siblings did at this age. Vital signs are within normal limits. Physical examination reveals conjunctival pallor but no hepatosplenomegaly or lymphadenopathy. Laboratory studies show:

Hemoglobin: $8.4 \text{ g/dL}$
Mean corpuscular volume (MCV): $66 \text{ fL}$
Red cell distribution width (RDW): $19\%$ (normal: $11.5\% - 14.5\%$)
Reticulocyte count: $1.0\%$

Which of the following is the most likely diagnosis?

A 19-month-old boy is evaluated in the emergency department in mid-January for a 4-day history of nasal congestion, low-grade fever, and a worsening cough. Over the past 24 hours, his parents noted rapid breathing and poor oral intake. His medical history includes severe atopic dermatitis. Both parents have persistent asthma. He has had one previous episode of wheezing at 14 months of age during a viral illness. He is up to date on all recommended childhood immunizations.

His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), pulse is $158/\text{min}$, respiratory rate is $62/\text{min}$, and oxygen saturation is $88\%$ on room air.

Physical examination reveals a tired-appearing toddler with marked subcostal and intercostal retractions, nasal flaring, and a prolonged expiratory phase. Copious yellowish-green mucus is noted in the nares. Lung auscultation demonstrates diffuse polyphonic wheezing and coarse crackles bilaterally.

A chest radiograph shows generalized hyperinflation, peribronchial cuffing, and a wedge-shaped opacity in the right upper lobe without air bronchograms.

A trial of nebulized albuterol is administered. Forty-five minutes later, his respiratory rate is $64/\text{min}$, oxygen saturation is $88\%$ on room air, and the wheezing is unchanged.

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

An 8-week-old girl is evaluated in the pediatric clinic for poor weight gain and respiratory difficulty. Her parents report that over the past three weeks, she has become increasingly irritable during feedings, sweats profusely, and frequently pauses to catch her breath. She has gained only 90 grams since her 1-month well-child visit. Her temperature is 37.0°C (98.6°F), heart rate is 166/min, respiratory rate is 65/min, and blood pressure is 85/50 mm Hg. Pulse oximetry shows 97% on room air. Physical examination reveals intercostal retractions and nasal flaring. Auscultation of the lungs demonstrates scattered bilateral wheezes and mild bibasilar crackles. Cardiac examination reveals a hyperdynamic precordium, a palpable thrill, and a harsh, 4/6 holosystolic murmur heard best at the left lower sternal border. The liver edge is palpated 3.5 cm below the right costal margin. Which of the following is the most appropriate next step in management?

A 13-month-old boy is brought to the emergency department by his parents after a witnessed generalized shaking episode that lasted for approximately 2 minutes. The parents report that he lost consciousness, his arms and legs stiffened, and then jerked rhythmically. Afterwards, he was very drowsy but returned to his normal baseline within 30 minutes. He has had nasal congestion, a mild cough, and a subjective fever for the past 24 hours. The patient was born at term, and his developmental history is notable for sitting independently, pulling to a stand, cruising along furniture, and using a neat pincer grasp. He can say "mama" and "dada" purposefully. He has received all age-appropriate vaccinations. In the emergency department, his temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is 145/min, and respirations are 36/min. Physical examination shows a well-appearing, interactive infant who is playing with a stethoscope. The anterior fontanelle is flat and soft, and the neck is supple without resistance to passive flexion. Tympanic membranes are clear. Lung auscultation reveals mild, diffuse wheezing and upper airway noise with no retractions. Neurologic examination shows normal muscle tone, symmetric reflexes, and no focal deficits. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric hematologic or oncologic diagnosis with its most characteristic peripheral blood smear finding.

A 23-year-old primigravida at 18 weeks gestation presents to the clinic for a routine prenatal visit. She reports feeling well and has no complaints. Vital signs are within normal limits. A comprehensive metabolic panel is obtained as part of her evaluation. The results show a blood urea nitrogen (BUN) level of 7 mg/dL and a serum creatinine level of 0.4 mg/dL. Urinalysis reveals no protein or blood. Which of the following physiological adaptations of pregnancy is the most likely cause of these laboratory findings?

A 26-year-old G1P0 presents for a prenatal visit. According to her last menstrual period (LMP), she is at 19 weeks gestation. The patient reports having irregular menstrual cycles occurring every 35 to 45 days prior to conception. She did not establish prenatal care until this week, and a first-trimester ultrasound was not performed. On physical examination, her fundal height is palpable roughly midway between the pubic symphysis and the umbilicus.

Maternal serum quad screening is obtained. The laboratory calculates the multiples of the median (MoM) for her analyte levels based on the estimated gestational age of 19 weeks from her LMP. The results are as follows:

Maternal serum alpha-fetoprotein (MSAFP): $0.5$ MoM (Normal: $0.7 - 2.5$)
Unconjugated estriol: $0.6$ MoM (Normal: $> 0.8$)
Human chorionic gonadotropin (hCG): $2.4$ MoM (Normal: $< 2.0$)
Inhibin A: $2.2$ MoM (Normal: $< 2.0$)

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

Match each clinical presentation and combination of diagnostic findings to the most likely congenital heart defect.

A 22-month-old boy is evaluated in the emergency department in the late evening for a loud, barking cough and noisy breathing. The symptoms began abruptly a few hours ago. He has had clear rhinorrhea, nasal congestion, and a low-grade fever for the past 48 hours. The patient is fully vaccinated according to the standard schedule. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate is $138/\text{min}$, respiratory rate is $42/\text{min}$, and oxygen saturation is $95\%$ on room air. Physical examination reveals an anxious child with a hoarse voice. Inspiratory stridor is clearly audible both when the child is crying and when he is sitting calmly in his father's arms. Mild suprasternal and intercostal retractions are noted. Lung fields are clear to auscultation bilaterally without wheezing. Which of the following is the most appropriate next step in the management of this patient?

A 2-year-old boy is brought to the emergency department after a witnessed choking episode while eating mixed nuts 1 hour ago. He had a severe fit of coughing initially, which has since subsided. On physical examination, he is alert and in mild respiratory distress. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 122/min, respiratory rate of 28/min, and oxygen saturation of 96% on room air. Lung auscultation reveals diminished breath sounds and localized expiratory wheezing over the right middle lobe. Arrange the following interventions in the most appropriate chronological sequence for the evaluation and management of this patient.

A 20-month-old boy is brought to the pediatric emergency department due to a 7-day history of a brassy cough and a rapid decline in his respiratory status over the past 24 hours. The parents report he has been increasingly restless and absolutely refuses to lie flat, insisting on being held in an upright, leaning-forward position. On presentation, his temperature is $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), heart rate is $158/\text{min}$, respiratory rate is $56/\text{min}$, and blood pressure is $92/54\text{ mmHg}$. Oxygen saturation is $90\%$ on a non-rebreather mask. Physical examination reveals prominent cervical lymphadenopathy, facial plethora with distended neck veins, severe suprasternal retractions, and a biphasic stridor. A portable bedside chest radiograph demonstrates a markedly widened superior mediastinum with severe extrinsic compression of the distal trachea, narrowing the airway lumen to approximately $2\text{ mm}$. The child is highly agitated and exhibits worsening work of breathing. Which of the following is the most appropriate next step in management?

Parents arrive at the triage desk with their 14-day-old male infant, reporting that he suddenly began vomiting dark green fluid 4 hours ago. Previously, the infant had been breastfeeding well and passing normal transitional stools. On triage assessment, the infant appears lethargic and pale. Vital signs reveal a heart rate of 195/min, respiratory rate of 65/min, and blood pressure of 55/30 mm Hg. Physical examination demonstrates a rigid, distended abdomen with diffuse guarding and absent bowel sounds. Capillary refill time is 5 seconds. An emergency portable abdominal radiograph shows a paucity of gas in the distal bowel. What is the most appropriate next step in the management of this patient?

Match each pediatric patient's clinical presentation with the congenital cardiovascular anomaly most likely to be found on echocardiography.

A 4-year-old boy is brought to the emergency department by his parents due to a sudden onset of high fever, severe sore throat, and difficulty breathing that started 4 hours ago. His parents state that they recently moved to the country and his childhood immunizations are incomplete. On examination, the patient appears toxic, highly anxious, and is sitting upright on his mother's lap, leaning forward with his neck hyperextended and jaw thrust forward. He is actively drooling and speaks in a muffled voice. Pronounced inspiratory stridor is audible without a stethoscope. Vital signs are temperature 39.8°C (103.6°F), heart rate 155/min, respiratory rate 42/min, and oxygen saturation 93% on room air.

Arrange the following management steps in the most appropriate sequential order for this patient.

A 6-month-old boy is brought to the emergency department after a generalized tonic-clonic seizure. His mother reports that he has been increasingly irritable and "clammy" over the last several weeks, particularly in the early mornings before his first feeding. The infant was born at full term. Developmentally, he sits with pelvic support and rolls front-to-back, which his parents worry is delayed compared to his older sister.

Vital signs show a temperature of 36.8°C (98.2°F), heart rate of 155/min, blood pressure of 85/50 mm Hg, and respiratory rate of 52/min. Physical examination reveals a lethargic infant with a round, "doll-like" face and thin extremities. His abdomen is markedly distended with a firm, smooth liver edge palpable 6 cm below the right costal margin. The spleen is not palpable. Several small, yellowish papules are noted on the extensor surfaces of his arms and legs.

Initial laboratory studies show:

Additional testing reveals markedly elevated serum triglycerides and uric acid.

Which of the following is the most appropriate intervention for this patient?

During a health maintenance visit, a $13$-year-old adolescent male reports a $4$-week history of a constant, dull ache in his left anterior thigh and knee. He has no history of recent trauma, fever, or prior medical conditions. His body mass index is $32 \text{ kg/m}^2$. Vital signs are within normal limits, with a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $78/\text{min}$, and blood pressure of $112/72 \text{ mm Hg}$. On physical examination, the left knee has no effusion, erythema, or joint line tenderness, and range of motion is full and painless. However, his gait is noticeably antalgic, and his left foot rests in an externally rotated position while standing. Passive internal rotation of the left hip is restricted and elicits pain. Laboratory evaluation reveals an erythrocyte sedimentation rate of $9 \text{ mm/h}$, a C-reactive protein level of $0.4 \text{ mg/dL}$, and a leukocyte count of $7,100/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 29-year-old primigravida presents to the obstetrics clinic to establish prenatal care. According to a recent dating ultrasound, she is at 9 weeks gestation. She has no significant past medical history and currently takes a daily prenatal vitamin. Her blood pressure is 112/68 mm Hg, heart rate is 82/min, and body mass index is 23 kg/m $^2$. Physical examination is unremarkable. The patient is eager to understand the upcoming milestones in her pregnancy and asks the physician to explain the precise timeline of routine testing she will undergo over the next several months.

Arrange the following routine prenatal screening tests and evaluations in the chronological order they should be offered or performed during this patient's uncomplicated pregnancy.

An expectant mother at $31$ weeks gestation visits her obstetric provider for a scheduled follow-up. Her pregnancy has progressed without complications, and she reports robust fetal movements. She recently had a comprehensive metabolic panel drawn for an independent life insurance policy application, which revealed an alkaline phosphatase level of $250$ U/L (reference range: $40$-$150$ U/L). Her aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels are completely normal. She specifically denies any generalized pruritus, right upper quadrant abdominal pain, or nausea. Which of the following is the most appropriate next step in management?