Pediatrics

A $5$-day-old male infant is brought to the emergency department for worsening lethargy, vomiting, and tachypnea. He was born full-term following an uncomplicated pregnancy and was discharged home on day $2$ of life. Physical examination reveals a profoundly somnolent infant with marked hypotonia. Initial laboratory studies show a serum ammonia level of $1,250$ $\mu$ mol/L (normal: $15$-$50$ $\mu$ mol/L), a normal serum anion gap, and respiratory alkalosis. The patient is intubated for airway protection. Arrange the following management steps in the most appropriate chronological order for this patient, from immediate acute intervention to definitive long-term care.

A $5$-year-old girl is brought to the emergency department by her parents due to a rapidly worsening headache, fever, and recurrent vomiting over the past $24$ hours. Upon arrival, the patient is lethargic and only opens her eyes to painful stimuli. Her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure is $130/85\text{ mmHg}$, heart rate is $58\text{/min}$, and respiratory rate is $14\text{/min}$. Neurologic examination reveals marked nuchal rigidity and bilateral papilledema on fundoscopy.

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

A 4-year-old boy is brought to the pediatric clinic by his parents due to a 6-day history of green nasal discharge, nasal congestion, and a daytime cough. His parents are concerned because his older sister recently required antibiotics for pneumonia. He has a history of an isolated wheezing episode at age 14 months, for which he received no daily medications. He is currently due for his routine 4-year-old immunizations. His temperature is 37.6°C (99.7°F), heart rate is 105/min, and respiratory rate is 22/min. Physical examination shows a playful child in no acute distress. The nasal turbinates are erythematous and swollen with visible purulent secretions. The posterior pharynx has mild erythema but no exudates or tonsillar enlargement. Ausculation of the lungs reveals clear breath sounds bilaterally. A few scattered, blanching, erythematous macules are noted on the child's anterior chest. Which of the following is the most appropriate next step in management?

A 16-month-old boy is brought to the emergency department by his parents after a witnessed choking episode while eating peanuts. The acute choking spell lasted for about one minute and was followed by a persistent cough. On current physical examination, the child is awake, alert, and breathing comfortably on room air without retractions. Lung auscultation reveals decreased breath sounds and focal wheezing over the right lower hemithorax. His vital signs are stable and within normal limits for his age. Arrange the following interventions in the most appropriate chronological order for the evaluation and definitive management of this patient.

A male infant is delivered at $39$ weeks gestation to a 28-year-old primigravida via emergency cesarean delivery due to a prolonged fetal heart rate deceleration. At birth, the infant is apneic, cyanotic, and limp. Positive pressure ventilation is initiated, and the infant is subsequently intubated. Apgar scores are 1, 3, and 5 at 1, 5, and 10 minutes of life, respectively. An umbilical cord arterial blood gas reveals a pH of $6.95$ and a base deficit of $17 \text{ mEq/L}$. At 45 minutes of life, the infant is breathing spontaneously via continuous positive airway pressure (CPAP). Physical examination reveals a lethargic infant with profound hypotonia, an absent Moro reflex, and a weak suck. Vital signs show a heart rate of $145\text{/min}$, respiratory rate of $40\text{/min}$, and blood pressure of $60/40\text{ mmHg}$. Which of the following is the most appropriate next step in the management of this patient?

A 3-year-old girl is rushed to the emergency department triage desk by her panicked father. He states that she developed a high fever and a severe sore throat earlier in the morning and has rapidly worsened over the past few hours. The family recently immigrated, and her childhood vaccination status is unknown. On physical examination, the child appears highly toxic and anxious. She is sitting upright, leaning forward with her neck hyperextended and her chin thrust forward. She is drooling uncontrollably and speaks with a muffled voice. Vital signs reveal a temperature of 39.8°C (103.6°F), heart rate of 145/min, respiratory rate of 38/min, and oxygen saturation of 91% on room air. Auscultation reveals prominent inspiratory stridor. Which of the following is the most appropriate next step in management?

A 48-hour-old female newborn is evaluated in the nursery for a new skin eruption. She was delivered vaginally at 40 weeks of gestation following an uncomplicated pregnancy. Maternal prenatal laboratory results, including a rectovaginal swab for group B Streptococcus, were negative. The patient's temperature is 37.0°C (98.6°F), heart rate is 140/min, and respiratory rate is 42/min. Physical examination reveals an alert, vigorous infant who is feeding adequately at the breast. Skin examination shows numerous 2-mm pale yellow pustules, each surrounded by a prominent, blotchy erythematous macular base. The lesions are scattered widely over the infant's trunk, face, and proximal arms, but the palms, soles, and mucous membranes are completely spared. Which of the following is the most appropriate next step in management for this patient?

During a severe winter outbreak, parents bring their 6-month-old male infant to the pediatric acute care center. The mother expresses concern that her son has been unusually lethargic and has refused his formula for the past 14 hours, resulting in a single mildly wet diaper. The illness began four days ago with clear nasal discharge and a mild cough. The mother notes she has a strong personal history of childhood asthma. Vital signs on presentation demonstrate a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a heart rate of $168\text{/min}$, a respiratory rate of $76\text{/min}$, and an oxygen saturation of $86\%$ while breathing room air. Examination shows a lethargic infant with prominent nasal flaring, grunting, and deep suprasternal retractions. Thoracic auscultation reveals diffuse, high-pitched expiratory wheezes and scattered inspiratory crackles. A chest radiograph demonstrates bilateral hyperinflation, peribronchial cuffing, and a small area of patchy atelectasis in the right upper lobe. Based on the most likely diagnosis, which of the following interventions are indicated for the initial management of this patient? (Select all that apply)

Match each clinical presentation of a birth-related head injury or finding in a neonate to the most likely diagnosis.

During a routine well-child visit, the parents of a $5$-month-old boy report that he has become increasingly irritable over the past two weeks. The mother notes this is most pronounced in the early mornings, which coincides with him finally "sleeping through the night." She also reports he has been taking rapid, deep breaths during these fussy episodes. Additionally, he had a mild upper respiratory infection last week with rhinorrhea and diffuse wheezing; she requests a rescue inhaler, noting her older child has asthma. On examination, the infant has a "doll-like" facial appearance with prominent, rounded cheeks. His weight is at the $35$ th percentile and length is at the $20$ th percentile. He appropriately tracks objects, smiles socially, and rolls from front to back, but cannot sit unsupported. Abdominal examination reveals a massively enlarged, smooth liver palpable $6$ cm below the right costal margin.

Laboratory tests obtained after a $4$-hour fast reveal:

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

A $6$-year-old boy is brought to the clinic by his father due to a $24$-hour history of left eye redness and swelling. The father reports that the child sustained a mosquito bite near his left eyebrow $3$ days ago. Yesterday, the area became red, and this morning his eye was swollen shut. The boy has been eating and drinking normally and has had no rhinorrhea or sinus pain. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), heart rate is $98/\text{min}$, respiratory rate is $20/\text{min}$, and blood pressure is $100/65\text{ mmHg}$. On physical examination, the left upper and lower eyelids are severely edematous, warm, and erythematous, preventing the patient from opening the eye spontaneously. With gentle manual retraction of the eyelids, the sclera and conjunctiva appear clear without chemosis. The pupils are equal, round, and reactive to light. Visual acuity is $20/20$ in both eyes. Extraocular movements are fully intact in all directions, and the patient denies pain with eye movement. There is no proptosis. Which of the following is the most appropriate next step in the management of this patient?

A family practitioner evaluates a 7-month-old male infant during an urgent clinic visit. The parents mention he has had a runny nose and a mild temperature elevation for the past 48 hours. Today, they noticed he is breathing faster than usual and his chest appears to sink in slightly when he inhales. Vital signs reveal a respiratory rate of 52/min, heart rate of 130/min, and an oxygen saturation of 95% on room air. Lung auscultation demonstrates diffuse polyphonic expiratory wheezes and coarse crackles bilaterally. He is still producing normal wet diapers and taking his bottle adequately. Based on current pediatric guidelines for this presentation, which of the following management strategies are appropriate? (Select 2 that apply)

A physician evaluates a $24$-day-old neonate in the emergency department who presents with progressive respiratory distress and a truncal eruption. The parents note that the symptoms began two days ago with nasal congestion and reduced breast milk intake, following close contact with a sick preschool-aged sibling. The neonate was delivered at term without complications. Current vital signs include a temperature of $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse of $158/\text{min}$, respirations of $66/\text{min}$, and oxygen saturation of $93\%$ on room air. Cardiopulmonary auscultation reveals prolonged expiration, diffuse polyphonic wheezing, and bilateral fine crackles, accompanied by visible subcostal retractions. Dermatologic evaluation shows scattered erythematous macules on the anterior chest and back; several macules have small, central, yellow-white pustules. A rapid microscopic evaluation of the pustular fluid reveals a dense infiltration of eosinophils. Which of the following is the most appropriate clinical intervention?

A 7-month-old female infant is brought to the pediatric acute care clinic by her parents due to a three-day history of poor feeding, increased work of breathing, and a prominent runny nose. She was born at term and has an unrepaired moderate ventricular septal defect that is followed by cardiology. Her current temperature is 38.2°C (100.8°F), heart rate is 168/min, respiratory rate is 66/min, and oxygen saturation is 88% on room air. Physical examination reveals an infant in moderate-to-severe respiratory distress with marked subcostal and intercostal retractions, nasal flaring, and copious clear nasal secretions. Cardiopulmonary auscultation demonstrates a harsh holosystolic murmur at the left lower sternal border, diffuse bilateral polyphonic expiratory wheezes, and scattered fine crackles. Which of the following is the most appropriate initial step in the management of this patient's acute respiratory condition?

A female neonate is delivered at 32 weeks and 4 days of gestation to a 24-year-old primigravida due to preterm labor and rupture of membranes 12 hours prior to delivery. Her birth weight is 1750 g. Apgar scores are 6 and 7 at 1 and 5 minutes, respectively. In the delivery room, the infant exhibits mild grunting and tachypnea, and is subsequently transferred to the neonatal intensive care unit on nasal continuous positive airway pressure (CPAP) at $5 \text{ cm H}_2\text{O}$ with a fractional inspired oxygen ($\text{FiO}_2$) of $0.30$.

At 6 hours of life, the infant's work of breathing markedly increases. Vital signs show a temperature of 36.8°C, heart rate of 175/min, respiratory rate of 88/min, and oxygen saturation of 86% despite escalating the $\text{FiO}_2$ to $0.70$. Physical examination reveals severe subcostal retractions, expiratory grunting, and a scattered rash consisting of 1- to 2-mm pustules on an erythematous base on the chest and back. A chest radiograph demonstrates low lung volumes with diffuse, bilateral reticulogranular opacities and air bronchograms.

An arterial blood gas analysis on current respiratory settings reveals:

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

A 39-week gestation neonate is delivered via emergency cesarean section due to a severe placental abruption. At birth, the infant is profoundly limp, cyanotic, and exhibits no spontaneous respiratory effort. Arrange the following steps of neonatal resuscitation in the correct chronological sequence, assuming the infant exhibits no clinical improvement and the heart rate persistently remains below 60/min despite an adequate duration of each successive intervention.

A 3-year-old boy is brought to the emergency department by his parents with a 24-hour history of high fever and a new-onset limp. Today, he completely refuses to bear weight on his right leg. His temperature is 39.2°C (102.6°F), blood pressure is 95/60 mmHg, heart rate is 135/min, and respiratory rate is 26/min. On physical examination, the right hip is held in a position of flexion, abduction, and external rotation. Any attempted passive movement of the right hip elicits severe pain and inconsolable crying. Laboratory results reveal a leukocyte count of 19,500/mm³ and an erythrocyte sedimentation rate of 65 mm/h. Arrange the following acute management steps in the most appropriate sequential order.

An 8-month-old girl is evaluated in the pediatric clinic in January due to increased work of breathing. She has had a runny nose, mild cough, and low-grade fever for the past three days. The patient was born full-term and is up to date on immunizations. Vital signs show a temperature of 37.6°C (99.7°F), a heart rate of 138/min, a respiratory rate of 56/min, and an oxygen saturation of 95% on room air. Physical examination demonstrates clear rhinorrhea, mild intercostal retractions, and bilateral expiratory wheezing with scattered crackles. The child is consolable and is feeding adequately. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the emergency department at night with a harsh, barking cough and noisy breathing. On examination, he is agitated, has loud inspiratory stridor at rest, and displays significant suprasternal and subcostal retractions. His temperature is 38.0°C (100.4°F) and oxygen saturation is 95% on room air. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 16-year-old adolescent boy with a history of cystic fibrosis complicated by severe bronchiectasis is brought to the emergency department after coughing up copious amounts of bright red blood at home. In the triage room, he expectorates approximately 250 mL of blood into an emesis basin over 15 minutes. He appears pale, anxious, and is in moderate respiratory distress. Vital signs are temperature 37.1°C (98.8°F), heart rate 138/min, blood pressure 92/58 mmHg, respiratory rate 30/min, and oxygen saturation 86% on room air. Lung auscultation reveals coarse crackles and gurgling sounds predominantly over the right hemithorax, with relatively clear breath sounds on the left. Arrange the following acute management steps in the most appropriate sequential order.