Pediatrics

A 5-month-old girl, born at 34 weeks of gestation, is brought to the emergency department in mid-winter by her parents due to a worsening cough and rapid breathing for the past 48 hours. Her symptoms began four days ago with a runny nose and a low-grade fever. The parents report she has been too tired to feed and has had only one wet diaper since yesterday evening.

On physical examination, her temperature is 37.9°C (100.2°F), heart rate is 170/min, respiratory rate is 72/min, and oxygen saturation is 86% on room air. The infant appears lethargic and is grunting. There is significant nasal flaring, as well as marked subcostal and intercostal retractions. Auscultation of the lungs reveals diffuse coarse crackles and prominent expiratory wheezing bilaterally.

Which of the following interventions are appropriate in the immediate management of this patient? (Select all that apply)

A 6-year-old girl is brought to the pediatric emergency department via ambulance due to a prolonged seizure. The parents report that she started having generalized tonic-clonic movements 15 minutes ago, which have been continuous since onset. She has no prior history of seizures. On arrival, she is unresponsive and actively convulsing. Her vital signs are temperature 37.8°C (100°F), blood pressure 110/70 mm Hg, pulse 145/min, and respirations 24/min. Paramedics were unable to establish intravenous access during transport.

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

Match each pediatric clinical presentation to the congenital cardiovascular anomaly most classically associated with the underlying condition.

During a parent-teacher conference, a first-grade educator expresses concern regarding a 7-year-old student's classroom behavior. The teacher notes that the child frequently halts his activities, stares into space with intermittent eyelid fluttering, and remains entirely unresponsive to verbal prompts for approximately 10 to 15 seconds. Following these brief interruptions, he immediately resumes his tasks with no apparent awareness of the pause. The student's father brings him to an outpatient clinic for evaluation. The father reports that his son has always met developmental expectations and performs well academically overall. The patient's vital signs are within normal limits. A comprehensive neurologic examination reveals no focal deficits.

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

During a routine health maintenance visit, a 9-year-old male is evaluated by a new family physician. His parents mention that he frequently stops to rest while playing outdoors with friends, complaining that his legs ache and feel weak. He has no history of significant illnesses and takes no daily medications. His vital signs show a temperature of 36.8°C (98.2°F), a heart rate of 82/min, and a respiratory rate of 18/min. Measurement of his blood pressure yields 146/92 mm Hg in the right upper extremity and 144/90 mm Hg in the left upper extremity. Upon further examination, simultaneous palpation reveals that his femoral pulses are significantly diminished in amplitude and temporally delayed compared to his brachial pulses. Auscultation of the heart demonstrates a regular rhythm without extra heart sounds, but a grade 2/6 systolic ejection murmur is audible over the left interscapular region. Which of the following findings is most likely to be present on further evaluation of this patient?

A $7$-year-old girl is evaluated in the pediatric emergency department for severe abdominal pain and vomiting. She underwent a laparoscopic appendectomy for perforated appendicitis $6$ days ago and was discharged home on postoperative day $3$. Over the past $12$ hours, she has developed intense, colicky abdominal pain and repeated episodes of bilious emesis. Her parents note she has not passed stool or flatus since yesterday. On presentation, the child appears toxic, pale, and lethargic. Vital signs reveal a temperature of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), heart rate of $145\text{/min}$, respiratory rate of $30\text{/min}$, and blood pressure of $85/50\text{ mm Hg}$. Physical examination demonstrates a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with a left shift and a serum lactate of $4.6\text{ mmol/L}$. An upright plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Following the initiation of aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A $28$-month-old boy is brought to the emergency department late in the evening due to noisy breathing that began abruptly. His parents report that he had a mild subjective fever and nasal congestion for the past $3$ days. Earlier tonight, he awoke from sleep with a harsh, barking cough and severe respiratory distress. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $140/\text{min}$, respirations are $42/\text{min}$, and pulse oximetry is $95\%$ on room air. The patient is sitting upright on his mother's lap and appears highly anxious. Physical examination reveals high-pitched inspiratory sounds audible without a stethoscope, along with pronounced suprasternal and intercostal retractions. Auscultation of the lungs demonstrates referred upper airway noise but no focal wheezes or crackles. The oropharynx is clear without excessive drooling. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the emergency department at 11:00 PM by his parents due to a harsh, 'seal-like' barking cough and noisy breathing. The parents report he has had a low-grade fever and rhinorrhea for the past two days. On examination, the child is visibly anxious, has prominent inspiratory stridor while sitting quietly on his mother's lap, and exhibits marked suprasternal and subcostal retractions. Oxygen saturation is 94% on room air. Arrange the following management steps in the most appropriate sequential order for this patient.

A $5$-week-old male infant is brought to the pediatric evaluation center by his mother due to a $5$-day history of progressively forceful vomiting. The mother reports that the infant vomits large amounts of milk immediately after feeding but remains eager to eat again shortly afterward. The vomitus does not contain bile or blood. The infant has had fewer wet diapers over the last $2$ days. Vital signs are temperature $37.0^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$), heart rate $178/\text{min}$, respiratory rate $42/\text{min}$, and blood pressure $70/40\text{ mm Hg}$. On physical examination, the infant appears lethargic with a sunken anterior fontanelle, dry mucous membranes, and delayed capillary refill. Palpation of the abdomen reveals a $2$-cm, firm, mobile mass in the right upper quadrant. Laboratory studies demonstrate:

Sodium: $131\text{ mEq/L}$
Potassium: $2.7\text{ mEq/L}$
Chloride: $85\text{ mEq/L}$
Bicarbonate: $36\text{ mEq/L}$
Blood urea nitrogen: $32\text{ mg/dL}$
Creatinine: $0.9\text{ mg/dL}$

Based on the patient's presentation and laboratory findings, which of the following is the most appropriate initial step in management?

An otherwise healthy neonate, delivered at term 4 days ago, presents to the emergency room after developing green-colored emesis. The parents report three episodes of vomiting since this morning. On triage, the patient appears lethargic but maintains normal perfusion, blood pressure, and heart rate for his age. Abdominal examination demonstrates a non-distended, soft abdomen with no signs of peritonitis. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 2-day-old full-term male newborn is evaluated in the nursery for failure to pass meconium since birth. He has developed abdominal distension and is refusing to feed. Physical examination reveals a markedly distended, tympanitic abdomen and a tight anal sphincter. A digital rectal examination results in an explosive expulsion of gas and stool.

Arrange the following steps in the most appropriate chronological order for the diagnosis and definitive management of this patient's condition.

Match each classic clinical presentation and associated radiographic or sonographic finding with the most appropriate pediatric gastrointestinal diagnosis.

An $8$-month-old male infant is currently hospitalized for severe viral bronchiolitis. For the past $24$ hours, he has been supported with a heated humidified high-flow nasal cannula to manage his respiratory distress. The on-call physician is urgently summoned to the bedside after the patient's respiratory status abruptly declines. On evaluation, the infant is lethargic and profoundly cyanotic. Current vital signs indicate a heart rate of $190/\text{min}$, a respiratory rate of $72/\text{min}$, and an oxygen saturation of $78\%$ despite maximal supplemental oxygen delivery. Clinical assessment reveals severe generalized retractions. Percussion of the chest yields a hyperresonant note over the right chest cavity, alongside a complete lack of breath sounds in the same area. The cardiac point of maximal impulse is palpated in the left axilla. Which of the following is the most appropriate immediate action for this patient?

An emergency medical team evaluates a $22$-day-old male neonate who was rushed to the hospital after developing forceful, green-tinged emesis. His parents note that he became suddenly lethargic and irritable this morning. Previously, the infant had been breastfeeding adequately and gaining weight appropriately. Vital signs reveal significant tachycardia at $190$/min, tachypnea at $58$/min, and profound hypotension ($58/34$ mm Hg). The patient appears pale, mottled, and diaphoretic. Palpation of the abdomen elicits diffuse rigidity and involuntary guarding, with visually apparent distension. Digital rectal examination yields normal-appearing stool with no gross blood. Venous blood analysis demonstrates a pH of $7.21$, bicarbonate of $12$ mEq/L, and a lactate level of $7.1$ mmol/L. A plain radiograph of the abdomen demonstrates a gasless abdomen with a single prominent gastric bubble. Which of the following is the most appropriate next step in the management of this patient?

During a routine health maintenance visit, the parents of a $4$-year-old girl inquire about her eligibility for required preschool immunizations. The patient was diagnosed with standard-risk acute lymphoblastic leukemia (ALL) two years ago. She successfully completed induction and consolidation therapy and is currently in the maintenance phase of her treatment, taking daily oral mercaptopurine and weekly oral methotrexate. She has been feeling well, with no recent fevers, weight loss, or respiratory symptoms. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $95/60\text{ mmHg}$, and heart rate is $90/\text{min}$. Physical examination reveals a well-appearing, active child with no lymphadenopathy or hepatosplenomegaly.

Laboratory evaluation shows:
Hemoglobin: $11.5\text{ g/dL}$
Leukocyte count: $4,500/\mu\text{L}$
Absolute neutrophil count: $1,800/\mu\text{L}$
Platelet count: $250,000/\mu\text{L}$

A review of her immunization record indicates that she received all scheduled vaccines during her first year of life but has not yet received her $4$- to $6$-year booster series, which includes the diphtheria, tetanus, and acellular pertussis (DTaP), inactivated poliovirus (IPV), measles, mumps, and rubella (MMR), and varicella vaccines.

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

Match each pediatric patient's clinical and laboratory presentation to the most likely hematologic or oncologic diagnosis.

A $3$-year-old boy is brought to the pediatrician's office by his father, who noticed a firm, painless swelling on the right side of the child's abdomen while dressing him. The child has been eating well, is as active as usual, and has had no fever, vomiting, or bone pain. Vital signs are within normal limits for age, except for a blood pressure of $120/78$ mmHg (which is $>95$ th percentile for his age). On physical examination, a smooth, firm, non-tender mass is palpated in the right upper and lower quadrants; it does not cross the midline. The remainder of the examination is unremarkable. Urinalysis reveals $10$-$15$ red blood cells per high-power field. Which of the following is the most appropriate next step in the evaluation of this patient?

A 9-month-old boy is brought to the emergency department by his parents due to sudden-onset, intermittent episodes of severe crying. During these episodes, he draws his knees up to his chest and appears inconsolable. Between episodes, the parents note that he appears uncharacteristically lethargic. He has vomited twice since the morning, and a recent diaper change revealed dark red, mucus-like stool. On physical examination, temperature is 37.2°C (99.0°F), heart rate is 170/min, and blood pressure is 85/50 mm Hg. Capillary refill time is 4 seconds. Abdominal examination reveals a palpable, sausage-shaped mass in the right upper quadrant, with no rebound tenderness, guarding, or rigidity.

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

A 2-month-old female infant is brought to the pediatrician by her parents due to noisy breathing. The parents state they first noticed the sound when she was three weeks old. The noise is characterized as a high-pitched sound that is most prominent when the infant is crying, feeding, or lying in a supine position. The noisy breathing seems to partially resolve when she is asleep or placed in a prone position. She has had no fever, cough, or rhinorrhea. The infant breastfeeds vigorously, and her growth chart shows she has increased from the 50th percentile for weight at birth to the 60th percentile currently. On physical examination, vital signs are normal for her age. A high-pitched inspiratory sound is auscultated over the neck, but there is no evidence of cyanosis, intercostal retractions, or respiratory distress. Lung auscultation is otherwise clear bilaterally. Which of the following is the most appropriate next step in management?

A $16$-day-old male infant, born at $27$ weeks gestation, is being evaluated in the neonatal intensive care unit for sudden clinical deterioration. For the past $24$ hours, he has been managed for necrotizing enterocolitis with bowel rest, nasogastric decompression, intravenous fluids, and broad-spectrum antibiotics. Over the last $2$ hours, the infant has developed recurrent apnea and profound bradycardia. His temperature is $35.1^\circ\text{C}$ ($95.2^\circ\text{F}$), heart rate is $190$/min, respiratory rate is $70$/min, and blood pressure is $40/20 \text{ mm Hg}$. Physical examination reveals a grossly distended, shiny, and erythematous abdomen with absent bowel sounds. Capillary refill time is $5$ seconds. A stat bedside cross-table lateral abdominal radiograph reveals massive pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?