Pediatrics

Match each classic clinical presentation with its most likely pediatric musculoskeletal diagnosis.

A previously healthy $9$-year-old boy is evaluated in the emergency department for a $24$-hour history of severe abdominal pain, intractable vomiting, and progressive somnolence. His parents report that he has been drinking an unusual amount of water and waking up multiple times at night to urinate over the past month. He has lost $3 \text{ kg}$ during this time. On presentation, he is lethargic but arousable. Respirations are deep and rapid at $32\text{/min}$, heart rate is $135\text{/min}$, and blood pressure is $95/60 \text{ mmHg}$. His mucous membranes are markedly dry. Capillary refill is $3 \text{ seconds}$.

He receives a $10 \text{ mL/kg}$ intravenous bolus of $0.9\%$ normal saline. A continuous intravenous insulin infusion and $0.45\%$ normal saline at maintenance rates are initiated.

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

An 18-month-old boy is brought to the pediatric neurology clinic by his parents due to a two-week history of progressive unsteadiness. The parents are highly anxious and state, "He only just started running at 17 months, and now he can barely walk! His development has always been terribly slow." They also express concern regarding his past medical history, noting that during his first week of life, he had a blotchy red rash with tiny yellow pustules on his chest that resolved on its own. They fear this was an untreated viral infection that is now damaging his brain. Furthermore, three weeks ago, he had a mild respiratory illness characterized by a low-grade fever, rhinorrhea, and diffuse wheezing, which resolved over a week with supportive care. Vital signs are within normal limits for his age. Physical examination reveals an irritable child with a broad-based, unsteady gait. While sitting quietly, he exhibits rapid, chaotic, multidirectional conjugate eye movements without a predictable pattern. Brief, shock-like contractions of his proximal arm and leg muscles are also noted. Deep tendon reflexes are 2+ bilaterally, and muscle tone is normal. Which of the following is the most appropriate initial diagnostic or management step for this patient?

An 8-year-old boy is brought to the emergency department by emergency medical services due to severe respiratory distress. The patient has a history of moderate persistent asthma but has been noncompliant with his inhaled fluticasone controller medication. Over the past 48 hours, he has experienced an escalating cough and wheezing that have not responded to his short-acting albuterol inhaler. His temperature is 37.1°C (98.8°F), pulse is 162/min, respiratory rate is 46/min, and blood pressure is 112/70 mm Hg. Pulse oximetry demonstrates an oxygen saturation of 89% on room air. Physical examination reveals an agitated child who is speaking in single words and sitting in a tripod position. He has marked supraclavicular retractions. Auscultation reveals a prolonged expiratory phase with loud, diffuse bilateral wheezing. Which of the following interventions are appropriate for the immediate management of this patient's condition? (Select 3 answers)

A 13-year-old boy is brought to the emergency department after experiencing a sudden, severe "pop" and excruciating pain in his left groin while playing basketball. He was unable to continue playing and had to be carried off the court. Over the preceding 8 weeks, he had been complaining of intermittent, mild aching in his left anterior thigh, which he attributed to a muscle strain. He is currently unable to bear any weight on the left leg. On physical examination, his body mass index is 31 kg/m². The left lower extremity is shortened and held in an externally rotated position. Passive range of motion of the left hip is exquisitely painful and globally restricted. Anteroposterior and frog-leg lateral radiographs of the pelvis demonstrate posterior and inferior displacement of the left proximal femoral epiphysis relative to the metaphysis. Compared to his clinical status yesterday, the acute event that occurred today has most significantly increased his risk for developing which of the following complications?

A 4-day-old male infant is brought to the emergency department due to poor feeding, excessive sleepiness, and jittery movements. He was born at 39 weeks of gestation via uncomplicated vaginal delivery to a 28-year-old primigravid mother. Vital signs show a temperature of 36.1°C (97.0°F), heart rate of 165/min, respiratory rate of 45/min, and blood pressure of 58/36 mmHg. Physical examination reveals a lethargic neonate with mild scleral icterus. Genitourinary examination shows bilateral nonpalpable testes and a stretched penile length of 1.4 cm (normal for term > 2.5 cm). Laboratory studies reveal a capillary blood glucose of 34 mg/dL. He is given an intravenous dextrose bolus with improvement in his symptoms. Additional laboratory results are as follows:

Which of the following is the most likely diagnosis?

Carefully evaluate the following pediatric musculoskeletal case summaries. Pair each specific clinical profile with the most accurate underlying pathologic diagnosis.

Match each pediatric patient's clinical presentation with the most likely underlying diagnosis.

Parents arrive at an urgent care clinic holding their 8-month-old infant, who appears profoundly blue and is crying inconsolably. The family recently immigrated and the child's medical records are unavailable, but the parents mention a doctor once heard a 'hole in the heart'. Vital signs show severe hypoxia with an oxygen saturation of 65% on room air. Physical examination reveals deep central cyanosis and a remarkably quiet precordium with only a faint systolic murmur at the left upper sternal border. The physician identifies a hypercyanotic spell secondary to a right ventricular outflow tract obstruction. Arrange the appropriate acute management steps for this condition in the correct sequential order, from initial first-line intervention to therapy for refractory symptoms.

Match each pediatric patient's clinical presentation with the most accurate description of the underlying pathophysiology or anatomic abnormality.

An infant with an uncorrected congenital heart defect presents to the emergency department with profound cyanosis and severe agitation that began abruptly after a crying fit. He is 10 months of age. Examination reveals tachypnea and a harsh systolic ejection murmur at the left upper sternal border that is noticeably diminished in intensity compared to his baseline. Arrange the following acute management steps in the most appropriate sequential order from first (most immediate) to last (refractory management).

A 2-year-old girl is brought to the urgent care clinic by her father due to a sudden refusal to use her right arm. Thirty minutes ago, the father grabbed the child's right hand to prevent her from stepping into the street while they were walking. The child immediately cried and has since kept her arm close to her side. On physical examination, the child is calm while sitting on her father's lap but cries if her right arm is touched. Her right arm is held closely against her trunk with the elbow slightly flexed and the forearm pronated. There is no visible swelling, bruising, erythema, or obvious deformity of the clavicle, shoulder, elbow, or wrist. Which of the following is the most appropriate next step in management?

A 6-year-old girl is brought to the pediatric endocrinology clinic by her parents due to breast development and rapid growth over the past 6 months. Physical examination reveals Tanner stage 3 breast development and Tanner stage 2 pubic hair. Her height has recently crossed from the 50th to the 95th percentile for age. Assuming her evaluation ultimately leads to a diagnosis of idiopathic central precocious puberty requiring pharmacotherapy, arrange the following clinical steps in the correct chronological order from initial diagnostic evaluation to final management.

A 6-year-old girl is brought to the clinic by her parents due to bilateral breast development and a recent rapid increase in height. Her past medical history is unremarkable. Physical examination reveals Tanner stage 3 breast development and Tanner stage 2 pubic hair. Assume each subsequent test in her workup yields findings that require progression to the next definitive step in the standard diagnostic and therapeutic algorithm for central precocious puberty.

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

A term neonate is delivered via uncomplicated vaginal delivery and immediately takes a vigorous first breath. This initiates the critical transition from parallel fetal circulation to in-series neonatal circulation. Arrange the following physiological and hemodynamic events in the correct chronological sequence that directly culminates in the functional closure of the foramen ovale.

A four-month-old female infant is evaluated in the pediatric neurology clinic for progressive generalized weakness and an inability to hold her head up. She was born at term following an uncomplicated pregnancy and delivery. Over the past eight weeks, her parents have noticed a significant reduction in her spontaneous limb movements. Additionally, her feeding has become prolonged, and her cry sounds abnormally weak. On presentation, her respiratory rate is $52/\text{min}$, and oxygen saturation is $96\%$ on room air. Physical examination reveals an alert infant who maintains normal eye contact and social smiling. She is positioned supine with her hips abducted and externally rotated. Neurological assessment demonstrates profound global hypotonia and complete absence of deep tendon reflexes in all extremities. Gentle tactile stimulation elicits normal sensory responses. Careful observation of the oral cavity while the infant cries reveals small, rapid, undulating movements of the tongue mucosa. Which of the following is the most appropriate next step in the diagnostic workup?

An 8-month-old infant with an unrepaired congenital heart defect presents to the emergency department with an acute episode of extreme irritability, tachypnea, and profound cyanosis. The parents report the episode began shortly after a prolonged crying spell. On physical examination, the infant's oxygen saturation is 56% on room air, and a previously noted harsh, systolic ejection murmur at the left upper sternal border is now remarkably diminished. The medical team determines the patient is experiencing a severe, progressive hypercyanotic ('tet') spell.

Arrange the following therapeutic interventions in the correct sequential order for managing this acute presentation, progressing from immediate initial measures to pharmacological therapies for a refractory episode.

A 6-week-old boy is evaluated in the pediatric clinic due to difficulty with feeding. His mother reports that he requires frequent pauses while nursing and becomes remarkably sweaty and breathless during his feeds. His weight has dropped from the 50th percentile at birth to the 5th percentile currently. Vital signs demonstrate a heart rate of 158/min and a respiratory rate of 68/min. Physical examination reveals a loud, harsh holosystolic murmur heard best at the left lower sternal border, accompanied by a palpable thrill. Lung auscultation reveals bilateral basilar crackles and diffuse wheezing. Which of the following is the most appropriate next step in the management of this patient?

During a busy winter evening clinic, parents arrive with their 2-year-old daughter who developed noisy breathing and a harsh, seal-like cough over the past 12 hours. She initially had nasal congestion and a mild fever that started two days ago. Currently, she appears distressed and is leaning forward slightly in her mother's lap, crying with a hoarse voice. Her temperature is 38.2°C (100.8°F), pulse is 135/min, respiratory rate is 44/min, and oxygen saturation is 95% on ambient air. Physical examination reveals audible inspiratory stridor even when the child is calm, along with prominent suprasternal and intercostal retractions. Auscultation of the lungs demonstrates good air entry bilaterally with transmitted upper airway sounds, but no wheezing or focal crackles are present. Which of the following is the most appropriate next step in the management of this patient?

A 14-year-old adolescent boy presents to a primary care clinic reporting right anterior knee discomfort that has persisted for the past two months. The patient is an active participant in a competitive youth basketball league. He describes the discomfort as a dull ache that peaks during jumping drills and running, but notably subsides after a few hours of rest. He denies any systemic symptoms such as fever, chills, or weight loss, and reports no history of acute trauma. On physical evaluation, vital signs are within normal limits. Examination demonstrates localized swelling and marked point tenderness directly over the tibial tuberosity. The knee joint itself exhibits no effusion, and both varus and valgus stress testing reveal no laxity. Range of motion is fully preserved. Which of the following is the most appropriate management for this patient's condition?