Pediatrics

A 10-month-old boy is brought to the clinic by his parents due to fever, irritability, and crying when laid down to sleep. The symptoms began 2 days ago following a mild viral upper respiratory tract infection. His temperature is 39.1°C (102.4°F), heart rate is 130/min, and respiratory rate is 28/min. Otoscopic examination reveals bulging, intensely erythematous tympanic membranes bilaterally with absent mobility on pneumatic otoscopy. He has no known medical conditions, takes no daily medications, and has no known drug allergies. He has not received any antibiotics since birth. Which of the following is the most appropriate next step in management?

A $3$-year-old girl is evaluated in the hospital on day $4$ of admission for acute mastoiditis. She initially presented to the emergency department with a $3$-day history of high fever, severe left ear pain, and outward displacement of the left auricle. On admission, she underwent tympanostomy tube placement and was empirically started on intravenous vancomycin and ceftriaxone. Cultures of the purulent middle ear fluid obtained during the procedure grew Streptococcus pneumoniae. Susceptibility testing reveals the organism has a penicillin minimum inhibitory concentration (MIC) of $0.06$ $\mu$ g/mL (highly susceptible). It is also susceptible to clindamycin, ceftriaxone, and levofloxacin. Currently, the patient has been afebrile for $48$ hours, the postauricular erythema has resolved, and she is tolerating a regular diet. The medical team plans to discharge her today to complete a $14$-day total course of antimicrobial therapy as an outpatient. Which of the following is the most appropriate oral pharmacotherapy to prescribe for discharge?

A full-term newborn develops visible scleral icterus and facial jaundice at 36 hours of life. Arrange the following steps in the correct chronological order for the standard evaluation and escalating management of neonatal hyperbilirubinemia.

Match each pediatric clinical vignette with the most appropriate next step in management.

Match each pediatric respiratory or upper airway infectious clinical presentation with its most likely causative pathogen.

A 7-month-old boy is brought to the clinic in January by his parents due to a 3-day history of nasal congestion, clear rhinorrhea, and a low-grade fever. Over the last 24 hours, he has developed a harsh cough and rapid breathing. The patient was born at term and has received all age-appropriate vaccinations. His temperature is 37.9°C (100.2°F), heart rate is 135/min, respiratory rate is 58/min, and oxygen saturation is 95% on room air. Physical examination demonstrates nasal flaring, mild intercostal retractions, and diffuse bilateral wheezing with fine crackles. Which of the following is the most appropriate next step in management?

A 4-year-old girl is brought to the pediatric clinic for a routine well-child visit. She has a history of perinatally acquired HIV infection. Her mother admits they have struggled with adherence to her antiretroviral therapy regimen over the past year. Her most recent laboratory studies from two weeks ago show an HIV viral load of 150,000 copies/mL and a CD4 T-lymphocyte count of 250 cells/mm³ (CD4 percentage of 11%). She recently recovered from a mild upper respiratory tract infection but has no symptoms today. Vital signs are within normal limits for her age. Review of her immunization record indicates she received all age-appropriate vaccines during infancy and toddlerhood, but she is currently due for her 4-year preschool boosters. During the physical examination, the girl is observed hopping on one foot and successfully copying a cross drawn by the physician. Her mother notes that she frequently engages in cooperative play with other children at daycare. Which of the following is the most appropriate plan for this patient today?

A 24-day-old male neonate, born at 27 weeks gestation, is currently in the neonatal intensive care unit (NICU). Birth weight was $950 \text{ g}$. His hospital course has been complicated by respiratory distress syndrome requiring mechanical ventilation for the first two weeks of life, and he is currently on continuous positive airway pressure (CPAP). A peripherally inserted central catheter (PICC) has been in place since birth for parenteral nutrition.

Over the past 12 hours, the infant has developed temperature instability with a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), recurrent episodes of apnea, and poor feeding tolerance. Vital signs show a heart rate of $185\text{/min}$, respiratory rate of $65\text{/min}$, and blood pressure of $42/24 \text{ mmHg}$. Physical examination is notable for hypotonia, a full anterior fontanelle, and sluggish pupillary reflexes.

A full sepsis evaluation is performed. Lumbar puncture yields cloudy cerebrospinal fluid (CSF). CSF analysis reveals:

Serum glucose is $65 \text{ mg/dL}$. Blood and urine cultures have been obtained.

Which of the following is the most appropriate empiric intravenous antimicrobial regimen for this patient?

A 48-hour-old full-term male newborn is evaluated in the nursery prior to discharge due to the appearance of a new rash. He was born via an uncomplicated spontaneous vaginal delivery to a 26-year-old primigravid woman. The mother received regular prenatal care, and her screening tests for group B *Streptococcus*, hepatitis B, HIV, and syphilis were negative. She has no history of genital herpes. The infant has been breastfeeding well and has normal urine output and bowel movements. Vital signs show a temperature of 37.0°C (98.6°F), heart rate of 142/min, and respiratory rate of 42/min. Physical examination reveals an alert, vigorous infant. There are numerous blanching, erythematous macules and papules, many of which contain central 1- to 2-mm yellow-white pustules, widely distributed across the chest, back, and proximal extremities. The palms and soles are completely spared. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 2-day-old male newborn is evaluated in the nursery for a newly developed skin rash. He was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravid mother. Maternal prenatal laboratory testing, including group B Streptococcus screening, was negative. The infant has been breastfeeding well and stooling normally. Vital signs are temperature 36.8°C (98.2°F), heart rate 140/min, and respiratory rate 40/min. Physical examination reveals multiple erythematous macules and papules with small central pustules scattered across the trunk and proximal extremities. The palms and soles are spared. The infant is vigorous and in no apparent distress. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the emergency department by his parents due to a sudden onset of a harsh, barking cough and noisy breathing. On examination, he has inspiratory stridor at rest and moderate suprasternal retractions. He is currently crying and agitated, which appears to be worsening his respiratory distress. His oxygen saturation is 96% on room air. Arrange the following steps in the most appropriate clinical sequence for the acute management of this patient's condition.

A $3$-hour-old male neonate is evaluated in the nursery for jitteriness, lethargy, and poor feeding. He was born at $39$ weeks gestation to a mother with poorly controlled type 2 diabetes mellitus. His birth weight was $4.5\text{ kg}$ ($9.9\text{ lb}$). Vital signs include a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $150/\text{min}$, and respiratory rate of $45/\text{min}$. Physical examination reveals a markedly plethoric (ruddy) skin appearance. Small, firm, white nodules are noted on the alveolar ridges. A peripheral venous hematocrit is $72\%$. Capillary blood glucose is $52\text{ mg/dL}$. Which of the following is the most appropriate next step in management?

A $14$-year-old male is brought to the clinic due to a $4$-week history of right knee pain and an altering gait. He has no history of trauma, fever, or recent illnesses. His weight is at the $98^{\text{th}}$ percentile for his age. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $78\text{/min}$, and blood pressure of $118/76\text{ mm Hg}$. Physical examination of the right knee reveals no effusion, joint line tenderness, or ligamentous laxity. During the examination of the lower extremities in the supine position, passive flexion of the right hip results in obligatory external rotation of the thigh. Laboratory studies show a leukocyte count of $6,800/\text{mm}^3$, an erythrocyte sedimentation rate of $8\text{ mm/h}$, and a C-reactive protein level of $0.3\text{ mg/dL}$. Which of the following is the most appropriate next step in management?

A $14$-day-old male infant is brought to the pediatric emergency department by his parents due to a fever noted at home. The parents report that he has been feeding slightly less than usual over the past $24$ hours but is producing a normal number of wet diapers. He was born at $38$ weeks gestation via uncomplicated spontaneous vaginal delivery. Maternal group B *Streptococcus* screening was negative. The mother reports no history of genital ulcers, although she does have a history of occasional oral cold sores. On physical examination, the infant is awake and alert. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), heart rate of $160/\text{min}$, and respiratory rate of $42/\text{min}$. Skin examination reveals a cluster of $4$ small, erythematous vesicles on the right shoulder. The anterior fontanelle is flat, and the neurological examination is nonfocal. Laboratory studies show a peripheral leukocyte count of $12,500/\mu\text{L}$. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

A 48-hour-old full-term male newborn develops bright green vomiting in the nursery. He was born via an uncomplicated vaginal delivery and passed meconium at 18 hours of life. His vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate 145/min, respiratory rate 42/min, and blood pressure 65/40 mm Hg. Physical examination shows a mildly distended but soft abdomen without erythema. The patient is hemodynamically stable. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to evaluate and definitively manage the most critical time-sensitive etiology of this presentation.

An unimmunized 4-year-old male child arrives at the pediatric triage with sudden-onset high fever, a muffled voice, and severe drooling. He is sitting upright, leaning forward with his neck extended, and exhibits notable inspiratory stridor. The clinical presentation is highly suspicious for acute epiglottitis. Arrange the following management steps in the most appropriate sequential order, from first to last.

A newborn is delivered at $38$ weeks gestation and immediately exhibits severe respiratory distress and cyanosis. Physical examination reveals a scaphoid abdomen and absent breath sounds over the left hemithorax. The neonate's heart rate is $110/\text{min}$, and oxygen saturation is $78\%$ on room air. Based on the suspected diagnosis, arrange the following management steps in the most appropriate chronological sequence.

An 8-week-old boy is brought to the pediatric clinic by his mother due to a 3-week history of severe nasal congestion and a skin rash. The mother reports that the infant has a thick, blood-tinged nasal discharge that frequently interferes with his ability to feed. A few days ago, a red, peeling rash appeared on the infant's extremities, distinctly involving the palms and soles. The infant was born at home in a rural setting, and the mother did not receive any formal prenatal care. On physical examination, the infant's temperature is 37.5°C (99.5°F), pulse is 145/min, and respirations are 38/min. The infant appears mildly fussy but easily consolable. Generalized lymphadenopathy and firm hepatosplenomegaly are palpable. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric infectious disease exposure scenario with the most appropriate post-exposure management or prophylaxis strategy.

Match each pediatric patient's clinical presentation or medical history with the most appropriate vaccine management decision.