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General pediatric in training Examination 2008 Dr. AbdulRahman Alnemri, MD Associate professor of pediatric Consultant Neonatologist AFHSR.

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Presentation on theme: "General pediatric in training Examination 2008 Dr. AbdulRahman Alnemri, MD Associate professor of pediatric Consultant Neonatologist AFHSR."— Presentation transcript:

1 General pediatric in training Examination 2008 Dr. AbdulRahman Alnemri, MD Associate professor of pediatric Consultant Neonatologist AFHSR

2 DIRECTION Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the one that is BEST in each case and mark your answer sheet by filling in the circle containing the corresponding letter.

3 1. A 30-month old, previously healthy girl is brought to the emergency department after her mother grabbed her by the wrist to prevent her from running into the street. The child is alert but the right arm hangs limply at her side with the elbow slightly flexed. She does not seem to be able to straighten the arm nor will she move it actively on request. There are no bruises and no other evidence of trauma. The remainder of the findings on physical examination is normal. Your next step in the management of this child would be to : A.Order an x-ray of the right wrist B.Order an x-ray study of the entire right arm. C.Order an x-ray studies of the skeleton and skull D.Splint the forearm E.Supinate the forearm with the elbow in flexion

4 1. A 30-month old, previously healthy girl is brought to the emergency department after her mother grabbed her by the wrist to prevent her from running into the street. The child is alert but the right arm hangs limply at her side with the elbow slightly flexed. She does not seem to be able to straighten the arm nor will she move it actively on request. There are no bruises and no other evidence of trauma. The remainder of the findings on physical examination is normal. Your next step in the management of this child would be to : A.Order an x-ray of the right wrist B.Order an x-ray study of the entire right arm. C.Order an x-ray studies of the skeleton and skull D.Splint the forearm E.Supinate the forearm with the elbow in flexion

5 2. For a child who has had re-current otitis media and serous otitis, the therapy among the following that is most likely to prevent recurrences of acute otitis media is: A.Administration of polyvalent pneumococcal vaccine B.Myringotomy and tympanostomy tube C.Adenoidectomy D.Daily administration of an antihistamine E.Daily use of a long-acting nasal decongestant spray.

6 2. For a child who has had re-current otitis media and serous otitis, the therapy among the following that is most likely to prevent recurrences of acute otitis media is: A.Administration of polyvalent pneumococcal vaccine B.Myringotomy and tympanostomy tube C.Adenoidectomy D.Daily administration of an antihistamine E.Daily use of a long-acting nasal decongestant spray.

7 3. Tachypnea and progressive weakness gradually develop in a 4-month old boy who appeared normal at birth. He has fed poorly for the past month. Physical examination shows diffuse muscular weakness, a large tongue and hepatomegaly. An x-ray study of the chest demonstrates marked cardiomegaly. An electrogram showed massive voltage and s short PR interval. This clinical picture is most likely associated with A.Congenital hypothyroidism B.Beckwith-Weidman Syndrome C.Prader-Willi Syndrome D.Glycogen storage disease E.Downs Syndrome

8 3. Tachypnea and progressive weakness gradually develop in a 4-month old boy who appeared normal at birth. He has fed poorly for the past month. Physical examination shows diffuse muscular weakness, a large tongue and hepatomegaly. An x-ray study of the chest demonstrates marked cardiomegaly. An electrogram showed massive voltage and s short PR interval. This clinical picture is most likely associated with A.Congenital hypothyroidism B.Beckwith-Weidman Syndrome C.Prader-Willi Syndrome D.Glycogen storage disease E.Downs Syndrome

9 4. A 2 ½ -year old boy is referred to you for evaluation of short stature. His height is 82.5 cm (<3rd percentile). His weight is 10.8 kg (<3rd percentile). Which of the following would be most helpful in the evaluation of this patients condition? A.Developmental history B.Urinalysis C.Previous growth record D.Determination of bone age E.Determination of the serum somatomedin-C concentration

10 4. A 2 ½ -year old boy is referred to you for evaluation of short stature. His height is 82.5 cm (<3rd percentile). His weight is 10.8 kg (<3rd percentile). Which of the following would be most helpful in the evaluation of this patients condition? A.Developmental history B.Urinalysis C.Previous growth record D.Determination of bone age E.Determination of the serum somatomedin-C concentration

11 5. A 4 years old child is found to have the classical murmur of a patent ductus. He is under weight for age but otherwise well. Which of the following would you recommend for this patient ? A. Recommend early operative closure? B.Review the child constantly, expecting spontaneous closure within the next five years? C.recommend prophylactic penicillin until operation is performed?. D.Delay operation until the child has reached its expected weight for age?. E.Explain to the patients that this is of little significance and can be ignored.

12 5. A 4 years old child is found to have the classical murmur of a patent ductus. He is under weight for age but otherwise well. Which of the following would you recommend for this patient ? A. Recommend early operative closure? B.Review the child constantly, expecting spontaneous closure within the next five years? C.recommend prophylactic penicillin until operation is performed?. D.Delay operation until the child has reached its expected weight for age?. E.Explain to the patients that this is of little significance and can be ignored.

13 6. An 11-year old child has had leukemia for some time. It is now clear that the child will die soon. The parents request that their child have the opportunity to die at home, where there are two other children, ages 8 and 15 years. The patient has begun to ask whether he will die or will get better. The issue of impending death in this 11-year old child with leukemia should A.Not be discussed with the 8-year old sibling B.Be discussed with anyone who raises the question C.Be discussed with each family member, including the dying child D.Be discussed with parents only E.Be discussed with the dying child by a psychiatrist

14 6. An 11-year old child has had leukemia for some time. It is now clear that the child will die soon. The parents request that their child have the opportunity to die at home, where there are two other children, ages 8 and 15 years. The patient has begun to ask whether he will die or will get better. The issue of impending death in this 11-year old child with leukemia should A.Not be discussed with the 8-year old sibling B.Be discussed with anyone who raises the question C.Be discussed with each family member, including the dying child D.Be discussed with parents only E.Be discussed with the dying child by a psychiatrist

15 7. Three to four times each while sleeping, a 3 year old girl suddenly sits up and screams. The eyes are open, she appears frightened and she is difficult to console initially. The next morning. She has no memory of the events. Of the following, the most likely diagnosis is: A.Complex partial seizures B.Sleep apnea C.Somniloquism D.Nightmares E.Night terrors

16 7. Three to four times each while sleeping, a 3 year old girl suddenly sits up and screams. The eyes are open, she appears frightened and she is difficult to console initially. The next morning. She has no memory of the events. Of the following, the most likely diagnosis is: A.Complex partial seizures B.Sleep apnea C.Somniloquism D.Nightmares E.Night terrors

17 8. In children with acute lymphocytic leukemia who are receiving intensive maintenance chemotherapy, the greatest reduction in incidence of pneumonia due to Pneumocystis carinii has been achieved by which of the following ? A.Deletion of Prednisolone from the maintenance regimen B.One-week courses of vincristine every ten weeks C.Regular prophylactic injections of pentamidine isethionate D.Regular prophylactic oral administration of trimethroprim with sulfamethoxazole E.Regular prophylactic administration of chloramphenicol

18 8. In children with acute lymphocytic leukemia who are receiving intensive maintenance chemotherapy, the greatest reduction in incidence of pneumonia due to Pneumocystis carinii has been achieved by which of the following ? A.Deletion of Prednisolone from the maintenance regimen B.One-week courses of vincristine every ten weeks C.Regular prophylactic injections of pentamidine isethionate D.Regular prophylactic oral administration of trimethroprim with sulfamethoxazole E.Regular prophylactic administration of chloramphenicol

19 9.The mother of an 18-month old girl consults you regarding her daughters language development. The infants tympanic membranes appear normal and are mobile on pneumatic otoscopy. The patient has a 12-word vocabulary and uses a considerable amount of jargon, but she does not use any two-word phrases. A.Refer the infant for tympanometry B.Refer the infant for brain stem-evoked audiometry C.Refer the infant to a speech pathologist D.Assure the mother that language development is normal E.Refer the infant for a complete developmental evaluation

20 9.The mother of an 18-month old girl consults you regarding her daughters language development. The infants tympanic membranes appear normal and are mobile on pneumatic otoscopy. The patient has a 12-word vocabulary and uses a considerable amount of jargon, but she does not use any two-word phrases. A.Refer the infant for tympanometry B.Refer the infant for brain stem-evoked audiometry C.Refer the infant to a speech pathologist D.Assure the mother that language development is normal E.Refer the infant for a complete developmental evaluation

21 10.Which of the following decreases the serum half-life of theophylline? A.Phenobarbital B.Carbohydrates C.Liver Disease D.Erythromycin E.Fever

22 10. Which of the following decreases the serum half-life of theophylline? A.Phenobarbital B.Carbohydrates C.Liver Disease D.Erythromycin E.Fever

23 11. A 15-year old boy with a history of juvenile-onset obesity expresses his concern with his small genitals. He is somewhat withdrawn, anxious, obese adolescent boy whose height is at the 25th percentile and whose weight is greater than 97th percentile. Sex maturity rating (Tanner) of pubic hair is stage 5 and of genitalia is stage 4. Testes are normally firm, measuring 3.0 by 4.0 cm. Which of the following statements most accurately describes this boys pubertal development? A.His developmental delay is likely the result of his obesity B.He has not attained the peak of his linear growth spurt C.His bone age is expected to be at least two years delayed in comparison with chronologic age D.He has evidence of hypogonadism and should be further evaluated E.Sexual development is normal and appropriate for age.

24 11. A 15-year old boy with a history of juvenile-onset obesity expresses his concern with his small genitals. He is somewhat withdrawn, anxious, obese adolescent boy whose height is at the 25th percentile and whose weight is greater than 97th percentile. Sex maturity rating (Tanner) of pubic hair is stage 5 and of genitalia is stage 4. Testes are normally firm, measuring 3.0 by 4.0 cm. Which of the following statements most accurately describes this boys pubertal development? A.His developmental delay is likely the result of his obesity B.He has not attained the peak of his linear growth spurt C.His bone age is expected to be at least two years delayed in comparison with chronologic age D.He has evidence of hypogonadism and should be further evaluated E.Sexual development is normal and appropriate for age.

25 12. A 5-month old girl brought to your office because of failure to gain weight and intermittent vomiting during the past four weeks. Five weeks ago, she was weaned from breast feeding and a regimen of cow milk, fruits and vegetables were initiated. The most likely diagnosis is A.Hypothyroidism B.Galactosemia C.Hereditary fructose intolerance D.Sensitivity to B-Lactoglobulin E.Glycogen storage disease type I

26 12. A 5-month old girl brought to your office because of failure to gain weight and intermittent vomiting during the past four weeks. Five weeks ago, she was weaned from breast feeding and a regimen of cow milk, fruits and vegetables were initiated. The most likely diagnosis is A.Hypothyroidism B.Galactosemia C.Hereditary fructose intolerance D.Sensitivity to B-Lactoglobulin E.Glycogen storage disease type I

27 13. A 10-year old girl was treated successfully two months ago for a urinary tract infection. Findings on renal ultrasonography now are normal. A voiding cystourethrogram demonstrates reflux into the lower half of the left ureter during voiding. Of the following, the most appropriate course of action would be to A.Schedule intravenous pyelography B.Schedule voiding cystourethrography in two months C.Refer the patient to a urologist for re-implantation of the left urether D.Schedule a renal nucleotide scan E.Obtain a urine culture

28 13. A 10-year old girl was treated successfully two months ago for a urinary tract infection. Findings on renal ultrasonography now are normal. A voiding cystourethrogram demonstrates reflux into the lower half of the left ureter during voiding. Of the following, the most appropriate course of action would be to A.Schedule intravenous pyelography B.Schedule voiding cystourethrography in two months C.Refer the patient to a urologist for re-implantation of the left urether D.Schedule a renal nucleotide scan E.Obtain a urine culture

29 14. The average infant is able to pick up a grain of cereal such as puffed rice between thumb and forefinger at about the same time he or she A.Begins to pull to a standing position B.Can walk without assistance C.First rolls over D.First exhibits a social smile E.First transfers large objects from hand to hand

30 14. The average infant is able to pick up a grain of cereal such as puffed rice between thumb and forefinger at about the same time he or she A.Begins to pull to a standing position B.Can walk without assistance C.First rolls over D.First exhibits a social smile E.First transfers large objects from hand to hand

31 15. An 6-year old, previously well girl has had low grade fever, headache, myalgia, malaise and a generalized maculopapular rash for the past three days. He frequently plays with a 3-month old kitten. You note localized lymphadenopathy with hepatosplenomegaly on physical examination. The most likely diagnosis is A.Cat scratch fever B.Rocky Mountain spotted fever C.Infectious mononucleosis D.Cytomegalovirus infection E.Toxoplasmosis1

32 15. An 6-year old, previously well girl has had low grade fever, headache, myalgia, malaise and a generalized maculopapular rash for the past three days. He frequently plays with a 3-month old kitten. You note localized lymphadenopathy with hepatosplenomegaly on physical examination. The most likely diagnosis is A.Cat scratch fever B.Rocky Mountain spotted fever C.Infectious mononucleosis D.Cytomegalovirus infection E.Toxoplasmosis

33 16. A neonate does not pass meconium for 48 hrs after birth. A fortnight later his mother states that he is not passing stool regularly. He has been bottle fed since discharge. Investigations reveal massive dilatation of the colon proximal to the rectum Where is the developmental abnormality responsible for this childs presentation? A.Ectoderm. B.Endoderm. C.Neural crest. D.Neural ectoderm. E.Splanchnic mesoderm

34 16. A neonate does not pass meconium for 48 hrs after birth. A fortnight later his mother states that he is not passing stool regularly. He has been bottle fed since discharge. Investigations reveal massive dilatation of the colon proximal to the rectum Where is the developmental abnormality responsible for this childs presentation? A.Ectoderm. B.Endoderm. C.Neural crest D.Neural ectoderm. E.Splanchnic mesoderm

35 17. A 12-year old boy has been drinking at least 6 L of fluid each day for the past year. Serum urea nitrogen concentration is 4 mg/dL and serum creatinine concentration is 0.6 mg/dL. Results of urinalysis and determination of serum electrolyte concentrations are normal. After a 12-hour water deprivation test, urine osmolality increased from 80 to 475 mOsm/kg H2O; serum osmolality increased from 285 to 289 mOsm/kg H2O. Body weight decreased from 42 to 40 kg. DDAVP, 5 ug is administered intranasally. One hour later, urine osmolality is 500 mOsm/kg H20. You conclude that the A.Patient has nephrogenic diabetes insipidus B.Patient has hypothalamic diabetes insipidus C.Patient has pseudohyperaldosteronism (Liddle Syndrome) D.Patient has psychogenic polydipsia E.Water deprivation test should be repeated

36 17. A 12-year old boy has been drinking at least 6 L of fluid each day for the past year. Serum urea nitrogen concentration is 4 mg/dL and serum creatinine concentration is 0.6 mg/dL. Results of urinalysis and determination of serum electrolyte concentrations are normal. After a 12-hour water deprivation test, urine osmolality increased from 80 to 475 mOsm/kg H2O; serum osmolality increased from 285 to 289 mOsm/kg H2O. Body weight decreased from 42 to 40 kg. DDAVP, 5 ug is administered intranasally. One hour later, urine osmolality is 500 mOsm/kg H20. You conclude that the A.Patient has nephrogenic diabetes insipidus B.Patient has hypothalamic diabetes insipidus C.Patient has pseudohyperaldosteronism (Liddle Syndrome) D.Patient has psychogenic polydipsia E.Water deprivation test should be repeated

37 18. A 7-year old boy is referred to you because of obesity. By 18 months of age,he was at the 97th percentile for weight and is now 20.5 kg (45 lb) overweight. Developmental landmarks were all delayed. He is presently repeating the first grade after also spending a year in a transitional class between kindergarten and first grade. Present height is at the 10th percentile. The hands and feet are small. There is no family history of obesity. The most likely diagnosis is A.Prader- Willi Syndrome B.Laurence –Moon-Biedl Syndrome C.Lesch-Nyhan Syndrome D.Hurler Syndrome E.Williams Syndrome

38 18. A 7-year old boy is referred to you because of obesity. By 18 months of age,he was at the 97th percentile for weight and is now 20.5 kg (45 lb) overweight. Developmental landmarks were all delayed. He is presently repeating the first grade after also spending a year in a transitional class between kindergarten and first grade. Present height is at the 10th percentile. The hands and feet are small. There is no family history of obesity. The most likely diagnosis is A.Prader- Willi Syndrome B.Laurence –Moon-Biedl Syndrome C.Lesch-Nyhan Syndrome D.Hurler Syndrome E.Williams Syndrome

39 19.For patients receiving intravenous maintenance therapy, which of the following doses of sodium for very 100 kcal metabolized is most appropriate? A.0.5 mEq B.2 to 3 mEq C.4 to 5 mEq D.6 to 7 mEq E.8 to 10 mEq

40 19.For patients receiving intravenous maintenance therapy, which of the following doses of sodium for very 100 kcal metabolized is most appropriate? A.0.5 mEq B.2 to 3 mEq C.4 to 5 mEq D.6 to 7 mEq E.8 to 10 mEq

41 20. The Stanford-Binet test and the Wechsler Scale for children are commonly used with children to measure A.Cognitive functioning B.Social development C.Neurologic development D.Emotional stability E.Academic achievement

42 20. The Stanford-Binet test and the Wechsler Scale for children are commonly used with children to measure A.Cognitive functioning B.Social development C.Neurologic development D.Emotional stability E.Academic achievement

43 21. A 12-year old male is tall and pubertal developmental is normal for age. He has hypermobility of joints, a high-arched palate, and arm span exceeding his height. Which of the following studies should be included in the examination? A.Ultrasonography of the kidneys B.Echocardiography C.Computed tomography (CT scan) of the head D.Liver-spleen scan E.X-ray study of the long bones

44 21. A 12-year old male is tall and pubertal developmental is normal for age. He has hypermobility of joints, a high-arched palate, and arm span exceeding his height. Which of the following studies should be included in the examination? A.Ultrasonography of the kidneys B.Echocardiography C.Computed tomography (CT scan) of the head D.Liver-spleen scan E.X-ray study of the long bones

45 22. You are called to examine a 3-year old boy who has been brought to the emergency department because of increasing lethargy and irritability. His mother states that he has had diarrhea and abdominal cramps for the past two days and was treated with diphenoxylate with atropine to relieve his symptoms. Physical examination reveals a somnolent boy with shallow respirations; his rectal temperature is 36.C 0. The remaining of the physical examination is normal. Which of the following would you do at this time? A.Examine the cerebrospinal fluid B.Administer physostigmine C.Perform a guaiac test of the stool for occult blood D.Order a determination of the blood ammonia concentration E.Administer Naloxone

46 22. You are called to examine a 3-year old boy who has been brought to the emergency department because of increasing lethargy and irritability. His mother states that he has had diarrhea and abdominal cramps for the past two days and was treated with diphenoxylate with atropine to relieve his symptoms. Physical examination reveals a somnolent boy with shallow respirations; his rectal temperature is 36.C 0. The remaining of the physical examination is normal. Which of the following would you do at this time? A.Examine the cerebrospinal fluid B.Administer physostigmine C.Perform a guaiac test of the stool for occult blood D.Order a determination of the blood ammonia concentration E.Administer Naloxone

47 23. A 5-year old girl toes on the left side. Of the following, the most likely diagnosis is A.Femoral anteversion B.Ligamentous lxity C.Blount disease D.Tibial torsion E.Metatarsus adductus

48 23. A 5-year old girl toes on the left side. Of the following, the most likely diagnosis is A.Femoral anteversion B.Ligamentous lxity C.Blount disease D.Tibial torsion E.Metatarsus adductus

49 24. The mother of a 2-year old child enrolled in a day care center is concerned that he has had eight upper respiratory tract infections between October and April. The child should A.Be removed form the day care center B.Be given Gamma Globulin injections monthly until age 4 years C.Have a throat culture every two weeks during the winter months D.Receive prophylactic antibiotic therapy E.Be regarded to have upper respiratory tract infections at a frequency within normal limits

50 24. The mother of a 2-year old child enrolled in a day care center is concerned that he has had eight upper respiratory tract infections between October and April. The child should A.Be removed form the day care center B.Be given Gamma Globulin injections monthly until age 4 years C.Have a throat culture every two weeks during the winter months D.Receive prophylactic antibiotic therapy E.Be regarded to have upper respiratory tract infections at a frequency within normal limits

51 25. A 10 years old boy presents with a history of passing smoky coloured urine for 3 months intermittently. On the day of admission he is admitted with sever right loin pain radiating to the groin coming in spasms every few minutes. On examination he is intermittently writhing around the bed and crying. He is apyrexial but sweating. Respiratory rate is 15/min and heart rate 95/min. He has slight tenderness in the right loin. What is the most likely diagnosis?. A.Benign familial Haematuria B.Renal calculi. C.Urinary tract infection D.IgA nephropathy E.Glomerulonephritis.

52 25. A 10 years old boy presents with a history of passing smoky coloured urine for 3 months intermittently. On the day of admission he is admitted with sever right loin pain radiating to the groin coming in spasms every few minutes. On examination he is intermittently writhing around the bed and crying. He is apyrexial but sweating. Respiratory rate is 15/min and heart rate 95/min. He has slight tenderness in the right loin. What is the most likely diagnosis?. A.Benign familial Haematuria B.Renal calculi. C.Urinary tract infection D.IgA nephropathy E.Glomerulonephritis.

53 26. A mother complains that her 4-year old son wets the bed almost every night. She reports that his sister achieved bladder control at night before 3 years of age. There are no other symptoms. Findings on urinalysis are normal. Which of the following courses of action would you pursue? A.Schedule voiding cystourethrography B.Reassure the mother that this situation is normal C.Prescribe imipramine and restrict fluids after 5 PM D.Prescribe DDAVP E.Set up a program to reward the boy when he is dry and punish him when he wets

54 26. A mother complains that her 4-year old son wets the bed almost every night. She reports that his sister achieved bladder control at night before 3 years of age. There are no other symptoms. Findings on urinalysis are normal. Which of the following courses of action would you pursue? A.Schedule voiding cystourethrography B.Reassure the mother that this situation is normal C.Prescribe imipramine and restrict fluids after 5 PM D.Prescribe DDAVP E.Set up a program to reward the boy when he is dry and punish him when he wets

55 27 A patient with acute asthma is most likely to have decreased A.Forced expiratory volume in 1 second B.Residual volume C.Functional residual capacity D.Total lung capacity E.Tidal volume

56 27 A patient with acute asthma is most likely to have decreased A.Forced expiratory volume in 1 second B.Residual volume C.Functional residual capacity D.Total lung capacity E.Tidal volume

57 28. A 1-day old, 3.0 kg, full term infant has a grade 3/6 ejection murmur. On the third day after birth, hepatomegaly develops. Heart rate is 160/min and respiratory rate is 60/min. Blood pressure is 100/60 mmHg in the upper extremities and 60/40 mmHg in the lower extremities. Which of the following forms of therapy would be most effective ? A.Ballon atrial septostomy B.Intravenous administration of Prostaglandin C.Restriction of fluid intake D.Systemic to pulmonary artery shunt E.Intravenous administration of Indomethacin

58 28. A 1-day old, 3.0 kg, full term infant has a grade 3/6 ejection murmur. On the third day after birth, hepatomegaly develops. Heart rate is 160/min and respiratory rate is 60/min. Blood pressure is 100/60 mmHg in the upper extremities and 60/40 mmHg in the lower extremities. Which of the following forms of therapy would be most effective ? A.Ballon atrial septostomy B.Intravenous administration of Prostaglandin C.Restriction of fluid intake D.Systemic to pulmonary artery shunt E.Intravenous administration of Indomethacin

59 29. A 2.9 kg newborn infant has pink skin, a thick vernix, thin ear cartilage with good recoil, raised breast areolae with 1 to 2 mm breast nodules, a prominent clitoris with size of labia minora equal to size of labia majora, frog leg position and flexion in all limbs. She has no edema, no facial lanugo and no prominent arm recoil. Her gestational age most closely approximates A.28 weeks B.32 weeks C.36 weeks D.38 weeks E.40 weeks

60 29. A 2.9 kg newborn infant has pink skin, a thick vernix, thin ear cartilage with good recoil, raised breast areolae with 1 to 2 mm breast nodules, a prominent clitoris with size of labia minora equal to size of labia majora, frog leg position and flexion in all limbs. She has no edema, no facial lanugo and no prominent arm recoil. Her gestational age most closely approximates A.28 weeks B.32 weeks C.36 weeks D.38 weeks E.40 weeks

61 30. A 10-year old boy has osteomyelitis due to pseudomonas aeruginosa. You elect to treat the patient with Amikacin. When administering this drug, which of the following rules should be observed? A.The drug should not be administered with meals B.Measurement of peak concentrations and trough concentration should be obtained C.The patient should be tested fro conductive hearing loss before therapy is started D.The drug should not be administered if there is evidence of abnormal liver function E.The drug should not be administered for more than ten days

62 30. A 10-year old boy has osteomyelitis due to pseudomonas aeruginosa. You elect to treat the patient with Amikacin. When administering this drug, which of the following rules should be observed? A.The drug should not be administered with meals B.Measurement of peak concentrations and trough concentration should be obtained C.The patient should be tested fro conductive hearing loss before therapy is started D.The drug should not be administered if there is evidence of abnormal liver function E.The drug should not be administered for more than ten days

63 31. A 7-month old boy has been treated for short bowel syndrome with total parenteral nutrition (TPN) for six months. Perioral and perianal erythema and scaling develop. Among the following, the TPN solution is most likely deficient in : A.Copper B.Folic Acid C.Zinc D.Iron E.Vitamin B12

64 31. A 7-month old boy has been treated for short bowel syndrome with total parenteral nutrition (TPN) for six months. Perioral and perianal erythema and scaling develop. Among the following, the TPN solution is most likely deficient in : A.Copper B.Folic Acid C.Zinc D.Iron E.Vitamin B12

65 32. An 11-year old boy has hematuria detected on a routine examination in your office. Three years ago findings on urinalysis were normal. He has had no recent illnesses, trauma, bleeding disorders or ingestion of medications. He looks and feels well. Physical examination discloses no abnormalities. His blood pressure is 90/60 mmHg. Laboratory studies show the erythrocyte sedimentation rate (ESR) is 3 mm/hr. The serum complement concentration, prothrombin time and partial thromboplastin time are normal. Normal urea nitrogen, creatinine, and electrolytes concentrations. An antistreptolysin O titer is normal. Findings on an ultrasonographic examination are normal. Which of the following is the management of choice? A.Order a renal biopsy B.Arrange for a cystoscopic examination C.Begin prophylactic therapy with penicillin D.Arrange for an intravenous pyelogram E.Arrange for periodic re-examinations and urinalyses

66 32. An 11-year old boy has hematuria detected on a routine examination in your office. Three years ago findings on urinalysis were normal. He has had no recent illnesses, trauma, bleeding disorders or ingestion of medications. He looks and feels well. Physical examination discloses no abnormalities. His blood pressure is 90/60 mmHg. Laboratory studies show the erythrocyte sedimentation rate (ESR) is 3 mm/hr. The serum complement concentration, prothrombin time and partial thromboplastin time are normal. Normal urea nitrogen, creatinine, and electrolytes concentrations. An antistreptolysin O titer is normal. Findings on an ultrasonographic examination are normal. Which of the following is the management of choice? A.Order a renal biopsy B.Arrange for a cystoscopic examination C.Begin prophylactic therapy with penicillin D.Arrange for an intravenous pyelogram E.Arrange for periodic re-examinations and urinalyses

67 33. During fetal life, the development of male external genitalia is directly determined by the action of which of the following? A.Testosterone B.Dihydrotestosterone C.Dehydroepiandrosterone D.Androstenedione E.H-Y antigen

68 33. During fetal life, the development of male external genitalia is directly determined by the action of which of the following? A.Testosterone B.Dihydrotestosterone C.Dehydroepiandrosterone D.Androstenedione E.H-Y antigen

69 34. A 3 year old boy in nursery school makes frequent silly excretory activities. The most likely explanation for this is A.Age appropriate behavior B.An excessively stimulating nursery school environment C.Sexually stimulating parental attitudes D.Regressive behavior E.Fear of the toilet

70 34. A 3 year old boy in nursery school makes frequent silly excretory activities. The most likely explanation for this is A.Age appropriate behavior B.An excessively stimulating nursery school environment C.Sexually stimulating parental attitudes D.Regressive behavior E.Fear of the toilet

71 35- A 17-yeard old girl has primary amenorrhea. Her height is normal for her age. The sex maturity rating (Tanner) of breast development is stage 5. She has a paucity of axillary and pubic hair. Vaginal examination reveals a 2 cm in depth with no visible cervix. A 3-4 cm ovoid mass is palpable in each inguinal canal. The most likely result of chromosome analysis in this patient is A.46,XY B.45,X C.47 XXY D.46, XX E.47,XXX

72 35-A 17-yeard old girl has primary amenorrhea. Her height is normal for her age. The sex maturity rating (Tanner) of breast development is stage 5. She has a paucity of axillary and pubic hair. Vaginal examination reveals a 2 cm in depth with no visible cervix. A 3-4 cm ovoid mass is palpable in each inguinal canal. The most likely result of chromosome analysis in this patient is A.46,XY B.45,X C.47 XXY D.46, XX E.47,XXX

73 36-A 10-year old boy with asthma has failed to respond to a home treatment program. He is admitted to the hospital and treated with intravenous administration of fluids, Aminophylline, and corticosteroids. One hour after admission, he appears exhausted. Determination of arterial blood gas and Ph values while the patient is in a 40% humidified oxygen atmosphere reveal a Ph of 7.15, PO2 of 60 mmHg and PCO2 of 60 mmHg. The next step in the management of this patient would be A.intravenous administration of sodium bicarbonate B.Intubation and mechanical ventilation C.intravenous administration of Dexamethasone D.Subcutaneous administration of epinephrine

74 36-A 10-year old boy with asthma has failed to respond to a home treatment program. He is admitted to the hospital and treated with intravenous administration of fluids, Aminophylline, and corticosteroids. One hour after admission, he appears exhausted. Determination of arterial blood gas and Ph values while the patient is in a 40% humidified oxygen atmosphere reveal a Ph of 7.15, PO2 of 60 mmHg and PCO2 of 60 mmHg. The next step in the management of this patient would be A.intravenous administration of sodium bicarbonate B.Intubation and mechanical ventilation C.Subcutaneous administration of epinephrine D.intravenous administration of Dexamethasone

75 37-A 6-year old boy is sent home from school because of an itchy scalp. On examination, you note small ovoid attachments to several otherwise normal hair shafts. The most likely diagnosis is A.Normal hair B.Seborrhea C.Pediculosis capitis D.Tinea Capitis E.Trichorrhxi nodosa (kinky hair disease)

76 37-A 6-year old boy is sent home from school because of an itchy scalp. On examination, you note small ovoid attachments to several otherwise normal hair shafts. The most likely diagnosis is A.Normal hair B.Seborrhea C.Pediculosis capitis D.Tinea Capitis E.Trichorrhxi nodosa (kinky hair disease)

77 38. Daily caloric and protein requirements per kg of body weight are greatest in the A.Adult B.Infants with malabsorption C.Toddler D.Adolescent E.Infant born prematurely

78 38. Daily caloric and protein requirements per kg of body weight are greatest in the A.Adult B.Infants with malabsorption C.Toddler D.Adolescent E.Infant born prematurely

79 39. In an infant who appeared healthy at birth, vomiting and diarrhea developed at 1 week of age. She gained weight poorly despite a change from breast milk to infant formula feeding at 2 weeks of age. At 3 weeks of age, she is brought to the emergency department where she is found to be lethargic and to have hepatomegaly. Of the following, the most likely diagnosis is (A) Inspissated bile syndrome (B) Crigler-Najjar Syndrome C) Galactosem (D) Gilbert Syndrome (E) Dubin-Johnson Syndrome

80 39. In an infant who appeared healthy at birth, vomiting and diarrhea developed at 1 week of age. She gained weight poorly despite a change from breast milk to infant formula feeding at 2 weeks of age. At 3 weeks of age, she is brought to the emergency department where she is found to be lethargic and to have hepatomegaly. Of the following, the most likely diagnosis is (A) Inspissated bile syndrome (B) Crigler-Najjar Syndrome C) Galactosem (D) Gilbert Syndrome (E) Dubin-Johnson Syndrome

81 40. A 12-year old boy is struck in the eye by a tennis ball. He is examined by an Ophthalmologist who finds the optic globe to be intact. He comes to you one week later and reports that he has double vision. Of the following, the most likely diagnosis is A.Glaucoma B.Intraocular hemorrhage C.Fracture of the floor of the orbit D.Oculomotor nerve paralysis E.Sinusitis

82 40. A 12-year old boy is struck in the eye by a tennis ball. He is examined by an Ophthalmologist who finds the optic globe to be intact. He comes to you one week later and reports that he has double vision. Of the following, the most likely diagnosis is A.Glaucoma B.Intraocular hemorrhage C.Fracture of the floor of the orbit D.Oculomotor nerve paralysis E.Sinusitis

83 41. A 14-month old infant has had a clear nasal discharge and a mild cough for about two weeks. Despite therapy with Amoxicillin, his condition has not improved. The cough has worsened and the infant has been vomiting at each feeding. The leukocyte count is 20,000/mm3 with 80% lymphocytes, 15% neutrophils and 5% band forms. X-ray study of the chest shows bilateral perihilar infiltrates with shaggy heart border. The most likely diagnosis is A.Acute bronchial asthma B.Acute lympocytic leukemia with pulmonary infiltration C.Influenza virus infection D.Pertusis E.Hemophilus influenzae pneumonia

84 41. A 14-month old infant has had a clear nasal discharge and a mild cough for about two weeks. Despite therapy with Amoxicillin, his condition has not improved. The cough has worsened and the infant has been vomiting at each feeding. The leukocyte count is 20,000/mm3 with 80% lymphocytes, 15% neutrophils and 5% band forms. X-ray study of the chest shows bilateral perihilar infiltrates with shaggy heart border. The most likely diagnosis is A.Acute bronchial asthma B.Acute lympocytic leukemia with pulmonary infiltration C.Influenza virus infection D.Pertusis E.Hemophilus influenzae pneumonia

85 42. A 10 years old male presents with acute sever asthma. On examination his peripheral pulse volume decreased during inspiration. Which one of the following is the most likely explanation for this clinical sign? A.The cardiac effect of high dose beta agonist bronchodilator drugs. B.A falling heart rate on inspiration. C.Peripheral vasodilatation D.Myocardial depression due to hypoxia E.Reduced left atrial filling pressure on inspiration

86 42. A 10 years old male presents with acute sever asthma. On examination his peripheral pulse volume decreased during inspiration. Which one of the following is the most likely explanation for this clinical sign? A.The cardiac effect of high dose beta agonist bronchodilator drugs. B.A falling heart rate on inspiration. C.Peripheral vasodilatation D.Myocardial depression due to hypoxia E.Reduced left atrial filling pressure on inspiration

87 43. A 4-year old child has a grade 2/6 high-pitched continuous murmur at the right base with maximum intensity in the right supraclavicular fossa. The murmur is not audible when he is in the supine position, and the intensity changes with rotation of the head. There is no thrill. The first and second heart sound are normal. Blood pressure is 94/64 mmHg in the upper extremities and 10 mmHg higher in the lower extremities. The most likely source of the murmur is A.Patent Ductus Arteriosus B.Arteriovenous fistula C.Venous hum D.Right pulmonary artery stenosis E.Aortic valvular insufficiency

88 43. A 4-year old child has a grade 2/6 high-pitched continuous murmur at the right base with maximum intensity in the right supraclavicular fossa. The murmur is not audible when he is in the supine position, and the intensity changes with rotation of the head. There is no thrill. The first and second heart sound are normal. Blood pressure is 94/64 mmHg in the upper extremities and 10 mmHg higher in the lower extremities. The most likely source of the murmur is A.Patent Ductus Arteriosus B.Arteriovenous fistula C.Venous hum D.Right pulmonary artery stenosis E.Aortic valvular insufficiency

89 44.Regarding steroid inhaler therapy for a 4- year old child with asthma, you should tell the mother A.It is most effective with acute exacerbation B.It should be administered every two hours when the child is having an acute episode of asthma C.The primary value is in the prevention of episodes of asthma D.It will not be of value in the management of the childs exercise-induced episodes of asthma E.The most common side effect is the development of oral candidiasis.

90 44.Regarding steroid inhaler therapy for a 4- year old child with asthma, you should tell the mother A.It is most effective with acute exacerbation B.It should be administered every two hours when the child is having an acute episode of asthma C.The primary value is in the prevention of episodes of asthma D.It will not be of value in the management of the childs exercise-induced episodes of asthma E.The most common side effect is the development of oral candidiasis.

91 45. A healthy 15-month old girl has been growing along the 25th percentile for length and weight. Her mother is concerned now because the infant is losing her appetite. Of the following, the most appropriate statement to make to the mother at this time would be A.The infants weigh should be checked more often B.This may be the first sign of a chronic illness C.She will have to make an effort to find special foods the infant will eat D.The decrease in appetite is normal, in response to a decelerating growth rate. E.This is an early manifestation of the normal negativism of infants at this age.

92 45. A healthy 15-month old girl has been growing along the 25th percentile for length and weight. Her mother is concerned now because the infant is losing her appetite. Of the following, the most appropriate statement to make to the mother at this time would be A.The infants weigh should be checked more often B.This may be the first sign of a chronic illness C.She will have to make an effort to find special foods the infant will eat D.The decrease in appetite is normal, in response to a decelerating growth rate. E.This is an early manifestation of the normal negativism of infants at this age.

93 46. A 10-month old infant has had a respiratory tract infection, fever and vomiting for two days. There is evidence of mild dehydration. Which of the following sets of laboratory data would be most consistent with these findings. Sodium potassium Chloride Bicarbonate A.135 4.0102 15 B.125 6.8100 15 C.120 3.092 15 D.155 5.0135 20 E.130 3.580 35

94 46. A 10-month old infant has had a respiratory tract infection, fever and vomiting for two days. There is evidence of mild dehydration. Which of the following sets of laboratory data would be most consistent with these findings. A.135 4.0102 15 B.125 6.8100 15 C.120 3.092 15 D.155 5.0135 20 E.130 3.580 35

95 47. An infant seated in a high chair turns his body around to see you as you approach. You place two cube before him, he takes one in his right hand and the other in his left. When a third cube is presented, he bangs and pushes it with the first. You demonstrate a tower of two cubes and encourage him to take a tower, he hold one cube on top for a second but does not release it. You show him how to release a cube into a cup. He follows suit at once. You ask him for a cube in his hand, extending yours. He drops the cube in your hand. On the floor he walks with one hand held. When he leaves he waves bye-bye. The developmental age of this infant seems closes to A.6 months B.9 months C.12 months D.15 months E.18 months

96 47. An infant seated in a high chair turns his body around to see you as you approach. You place two cube before him, he takes one in his right hand and the other in his left. When a third cube is presented, he bangs and pushes it with the first. You demonstrate a tower of two cubes and encourage him to take a tower, he hold one cube on top for a second but does not release it. You show him how to release a cube into a cup. He follows suit at once. You ask him for a cube in his hand, extending yours. He drops the cube in your hand. On the floor he walks with one hand held. When he leaves he waves bye-bye. The developmental age of this infant seems closes to A.6 months B.9 months C.12 months D.15 months E.18 months

97 48. A 2-1/2 year old child has had cough for two weeks after having been hospitalized one month ago for pneumonia in the right lower lobe. X-ray study of the chest reveals persistence of pneumonia in the right lower lobe. Of the following, the most likely diagnosis is A. Staphylococcal pneumonia B.Foreign body aspiration C.Cystic Fibrosis D.Pneumonia due to Mycoplasma pneumoniae E.Pneumonia due to respiratory synctial virus

98 48. A 2-1/2 year old child has had cough for two weeks after having been hospitalized one month ago for pneumonia in the right lower lobe. X-ray study of the chest reveals persistence of pneumonia in the right lower lobe. Of the following, the most likely diagnosis is A. Staphylococcal pneumonia B.Foreign body aspiration C.Cystic Fibrosis D.Pneumonia due to Mycoplasma pneumoniae E.Pneumonia due to respiratory synctial virus

99 49. On routine examination of a 2-year old boy, you noticed a moderate degree of peritibial bruising. The finding of the physical examination are normal. Of the following, the most appropriate management at this time would be to A.Order x-ray studies of the long bones B.Order determination of the bleeding and clotting times C.Re-assure the mother D.Suggest limited activity for several days E.Request a psychosocial consultation

100 49. On routine examination of a 2-year old boy, you noticed a moderate degree of peritibial bruising. The finding of the physical examination are normal. Of the following, the most appropriate management at this time would be to A.Order x-ray studies of the long bones B.Order determination of the bleeding and clotting times C.Re-assure the mother D.Suggest limited activity for several days E.Request a psychosocial consultation

101 50. A full term, 3-week old infant is pale, irritable, restless, and feeding poorly. Pulse rate is 250/min, respiratory rate is 60/min. The liver edge is palpable 3 cm below the right costal margin. Findings on physical examination are otherwise normal. The most likely diagnosis is A.Sepsis B.Impending shock C.Congestive heart failure due to a structural congenital heart lesion D.Paroxysmal atrial tachycardia E.Sinus tachycardia

102 50. A full term, 3-week old infant is pale, irritable, restless, and feeding poorly. Pulse rate is 250/min, respiratory rate is 60/min. The liver edge is palpable 3 cm below the right costal margin. Findings on physical examination are otherwise normal. The most likely diagnosis is A.Sepsis B.Impending shock C.Congestive heart failure due to a structural congenital heart lesion D.Paroxysmal atrial tachycardia E.Sinus tachycardia

103

104 51. A 3-year old child is brought to you because her speech consist only of single words. She sat at 6 months, walked at 11 months and was toilet trained at 2 years of age. She dresses and undresses herself, except that sometimes she puts the shoes on the wrong feet. She responds to simple requests. Findings on examination except for speech are normal. Which of the following statements concerning this clinical situation is true? A.this child is probably mentally retarded and should be referred for an IQ test B.The childs hearing should be tested C.The child should be referred to a psychiatrist D.The parents can be assured that nothing is wrong and that the child will learn to talk in time E.The parents should be instructed not to give the child anything unless she asks for it using more than one word

105 51. A 3-year old child is brought to you because her speech consist only of single words. She sat at 6 months, walked at 11 months and was toilet trained at 2 years of age. She dresses and undresses herself, except that sometimes she puts the shoes on the wrong feet. She responds to simple requests. Findings on examination except for speech are normal. Which of the following statements concerning this clinical situation is true? A.this child is probably mentally retarded and should be referred for an IQ test B.The childs hearing should be tested C.The child should be referred to a psychiatrist D.The parents can be assured that nothing is wrong and that the child will learn to talk in time E.The parents should be instructed not to give the child anything unless she asks for it using more than one word

106 52. School phobias (school refusals) in grade-school children most commonly result from A.Fear of a strict teacher B.Concern about failing school C.Fear of separation from parent D.Desire to avoid unfriendly classmates E.Inability to do school work

107 52. School phobias (school refusals) in grade-school children most commonly result from A.Fear of a strict teacher B.Concern about failing school C.Fear of separation from parent D.Desire to avoid unfriendly classmates E.Inability to do school work

108 53. A 6-year old boy suffers major abdominal trauma in a motor vehicle accident. One hour later in the emergency department, blood pressure is 65/40 mmHg. Hemoglobin concentration is 6.0 g/dL. Arterial blood gas and pH analysis while the patient is breathing room air shows pH 7.47, PO 2 45 mmHg and PCO 2 30 mmHg, FiO 2 is 0.21. An x-ray study of the chest reveals diffuse bilateral pulmonary infiltrates. Which of the following will provide the greatest improvement in oxygen transport? A.Vasopressors B.Intubation and ventilation with positive end- expiratory pressure (PEEP) C.Administration of 100% oxygen D.Blood transfusion E.Diuretics

109 53. A 6-year old boy suffers major abdominal trauma in a motor vehicle accident. One hour later in the emergency department, blood pressure is 65/40 mmHg. Hemoglobin concentration is 6.0 g/dL. Arterial blood gas and pH analysis while the patient is breathing room air shows pH 7.47, PO 2 45 mmHg and PCO 2 30 mmHg, FiO 2 is 0.21. An x-ray study of the chest reveals diffuse bilateral pulmonary infiltrates. Which of the following will provide the greatest improvement in oxygen transport? A.Vasopressors B.Intubation and ventilation with positive end- expiratory pressure (PEEP) C.Administration of 100% oxygen D.Blood transfusion E.Diuretics

110 54. 7 years old female attends pediatric clinic and is noted to have scattered small, raised lesions on her trunk and axillary freckles. No family history of the same lesions. What is the likely mode of inheritance of this condition? A.Autosomal recessive. B.X- linked recessive C.Trinucleotide repeating D.Autosomal dominant E.multifactorial

111 54. 7 years old female attends pediatric clinic and is noted to have scattered small, raised lesions on her trunk and axillary freckles. No family history of the same lesions. What is the likely mode of inheritance of this condition? A.Autosomal recessive. B.X- linked recessive C.Trinucleotide repeating D.Autosomal dominant E.multifactorial

112 55. You are discusing with a resident who has just evaluated a 4- year-old who has classic varicella lesions and a history that is consistent with this diagnosis.he put small pox as D/D. Of the following, the MOST accurate statement about the tow pathologies is that A.lesions of both varicella and smallpox follow a 7- to 10-day course from eruption to resolution B.lesions of both varicella and smallpox frequently produce deep, pitted scars C.varicella lesions are transient vesicles; smallpox lesions are persistent pustules until resolution of the illness D.varicella lesions are concentrated on the face; smallpox lesions are concentrated over bony Prominences E.varicella lesions appear in stages or crops; smallpox lesions are uniformly in the same stage of development

113 55. You are discusing with a resident who has just evaluated a 4- year-old who has classic varicella lesions and a history that is consistent with this diagnosis.he put small pox as D/D. Of the following, the MOST accurate statement about the tow pathologies is that A.lesions of both varicella and smallpox follow a 7- to 10-day course from eruption to resolution B.lesions of both varicella and smallpox frequently produce deep, pitted scars C.varicella lesions are transient vesicles; smallpox lesions are persistent pustules until resolution of the illness D.varicella lesions are concentrated on the face; smallpox lesions are concentrated over bony Prominences E.varicella lesions appear in stages or crops; smallpox lesions are uniformly in the same stage of development

114 56. A 14-yeard old girl with hyperthyroidism did not respond to antithyroid medication. A subtotal thyroidectomy was performed. After the operation, she had a unilateral convulsion. The best initial means to stop such a seizure is administration of A.Paraldehyde, rectally B.Diazepam, intravenously C.Phenobarbital, intramuscularly D.Calcium, intravenously E.Phenytoin, intravenously

115 56. A 14-yeard old girl with hyperthyroidism did not respond to antithyroid medication. A subtotal thyroidectomy was performed. After the operation, she had a unilateral convulsion. The best initial means to stop such a seizure is administration of A.Paraldehyde, rectally B.Diazepam, intravenously C.Phenobarbital, intramuscularly D.Calcium, intravenously E.Phenytoin, intravenously

116 57. A 10-yeard old girl has a one-month history of progressive symmetrical weakness leading to an inability to walk. She appears ill and has generalized tenderness of the muscles. The face is swollen and the eyelids are discolored. The laboratory test result most likely to be normal in this patient is A.Serum aldolase activity B.Anti-DNAse B titer C.Muscle biopsy D.Serum Creatinine kinase activity E.Electromyography

117 57. A 10-yeard old girl has a one-month history of progressive symmetrical weakness leading to an inability to walk. She appears ill and has generalized tenderness of the muscles. The face is swollen and the eyelids are discolored. The laboratory test result most likely to be normal in this patient is A.Serum aldolase activity B.Anti-DNAse B titer C.Muscle biopsy D.Serum Creatinine kinase activity E.Electromyography

118 58. A 2-year old asymptomatic child is brought to the hospital 30 minutes after ingesting an unknown quantity of kerosene that had been stored in a soda bottle. From the amount of kerosene left in the bottle and the odor of the childs clothing, it is subsequently estimated that a maximum of 10 ml of kerosene may have been ingested. Among the following, the treatment of choice one hour after ingestion would be A.Induction of emesis with ipecac syrup, 30 ml orally B.Gastric lavage C.Gastric lavage after placement of cuffed endotracheal tube D.Administration of olive oil, 60 ml orally E.Observation only

119 58. A 2-year old asymptomatic child is brought to the hospital 30 minutes after ingesting an unknown quantity of kerosene that had been stored in a soda bottle. From the amount of kerosene left in the bottle and the odor of the childs clothing, it is subsequently estimated that a maximum of 10 ml of kerosene may have been ingested. Among the following, the treatment of choice one hour after ingestion would be A.Induction of emesis with ipecac syrup, 30 ml orally B.Gastric lavage C.Gastric lavage after placement of cuffed endotracheal tube D.Administration of olive oil, 60 ml orally E.Observation only

120 59. A 12-year old boy is referred to you by a family physician because of a pectus excavation deformity he has had since birth. Physical examination confirms the diagnosis of pectus excavatum. As a consultant to this boy, you should know that the most common indication for operative correction of pectus excavatum is A.Development of congestive heart failure B.Psychological discomfort with cosmetic appearance C.Progressive pulmonary deterioration D.Failure to thrive stinal problems E.Associated gastrointestinal problems

121 59. A 12-year old boy is referred to you by a family physician because of a pectus excavation deformity he has had since birth. Physical examination confirms the diagnosis of pectus excavatum. As a consultant to this boy, you should know that the most common indication for operative correction of pectus excavatum is A.Development of congestive heart failure B.Psychological discomfort with cosmetic appearance C.Progressive pulmonary deterioration D.Failure to thrive stinal problems E.Associated gastrointestinal problems

122 60. A 16 years old female presents with hypertension and increasing weight. Which of the following features would be most suggestive of cushings syndrome rather than simple obesity? A.Moon face. B.Acanthosis Nigricans C.Abdominal striae. D.Proximal myopathy E.Buffalo Hump

123 60. A 16 years old female presents with hypertension and increasing weight. Which of the following features would be most suggestive of cushings syndrome rather than simple obesity? A.Moon face. B.Acanthosis Nigricans C.Abdominal striae. D.Proximal myopathy E.Buffalo Hump

124 61. A 24 month old boy presents with high fever of 6 days duration, tender neck, red eyes and cracked lips. In the second week he developed maculopapular erythematous rash and blanching. What is the most likely diagnosis A.Kawasaki disease B.Stevens-Johnson syndrome C.Acute toxoplasmosis D.Meningococcal sepsis E.Measles.

125 61. A 24 month old boy presents with high fever of 6 days duration, tender neck, red eyes and cracked lips. In the second week he developed maculopapular erythematous rash and blanching. What is the most likely diagnosis A.Kawasaki disease B.Stevens-Johnson syndrome C.Acute toxoplasmosis D.Meningococcal sepsis E.Measles.

126 62. A 15 years old female underwent a renal transplant. She was concerned about the effects of long-term Cyclosporin treatment. Which on of the following is a common adverse effect of this A.Alopecia. B.Paraesthesiae. C.Hepatotoxicity D.Nephrotoxicity. E.Bone marrow depression

127 62. A 15 years old female underwent a renal transplant. She was concerned about the effects of long-term Cyclosporin treatment. Which on of the following is a common adverse effect of this A.Alopecia. B.Paraesthesiae. C.Hepatotoxicity D.Nephrotoxicity. E.Bone marrow depression

128 63. A 7 years old male presented with a strongly positive Mantoux test. Which one of the following statements regarding his immune reaction is correct? A.The reaction typically develops within 24 hours B.It is a cell mediated immune response C.The area of induration will be less than 10 mm in diameter D.The response is mediated by B lymphocytes E.If a skin biopsy were taken, immunohistochemistry would show immune complex deposition.

129 63. A 7 years old male presented with a strongly positive Mantoux test. Which one of the following statements regarding his immune reaction is correct? A.The reaction typically develops within 24 hours B.It is a cell mediated immune response C.The area of induration will be less than 10 mm in diameter D.The response is mediated by B lymphocytes E.If a skin biopsy were taken, immunohistochemistry would show immune complex deposition.

130 64. The mechanism for Alo-immune thrombocytopena in the newborn infant is A.Production of antifetal platelet antibodies by the mother B.Production of antiplatelet antibodies by the fetus C.Transfer of antimaternal platelet antibodies across the placenta D.Impairment of megakaryocytic function caused by autoantibodies E.Platelet aggregation secondary to occult infection

131 64. The mechanism for Alo-immune thrombocytopena in the newborn infant is A.Production of antifetal platelet antibodies by the mother B.Production of antiplatelet antibodies by the fetus C.Transfer of antimaternal platelet antibodies across the placenta D.Impairment of megakaryocytic function caused by autoantibodies E.Platelet aggregation secondary to occult infection

132 65. A 5-year old girl is brought to your office by her mother who reports that the child is one of four children in her nursery school class who have similar rashes. Two days ago the patient had a low grade fever with the temperature reaching 38 C. The cheeks became red. She denied having sore throat. Today she has a generalized, discrete maculopapular rash.The most likely diagnosis is A.Rubella B.Measles C.Scarlet fever D.Erythema infectiosum E.Pityriasis rosea

133 65. A 5-year old girl is brought to your office by her mother who reports that the child is one of four children in her nursery school class who have similar rashes. Two days ago the patient had a low grade fever with the temperature reaching 38 C. The cheeks became red. She denied having sore throat. Today she has a generalized, discrete maculopapular rash.The most likely diagnosis is A.Rubella B.Measles C.Scarlet fever D.Erythema infectiosum E.Pityriasis rosea

134 66. Stridor, tachypnea and wheezing develop suddenly in a 10-year old girl who has received an injection of contrast medium for intravenous pyelography. Large urticarial lesions appear over the face, chest and extremities. Of the following agents, you should first administer A.Diphenhydramine B.Epinephrine C.Theophylline D.Corticosteroids E.Antibiotics

135 66. Stridor, tachypnea and wheezing develop suddenly in a 10-year old girl who has received an injection of contrast medium for intravenous pyelography. Large urticarial lesions appear over the face, chest and extremities. Of the following agents, you should first administer A.Diphenhydramine B.Epinephrine C.Theophylline D.Corticosteroids E.Antibiotics

136 67. Fever and a swollen eye have been present for one day in a 5-year old boy following an upper respiratory tract infection. There is no history of trauma. The boy is irritable and has proptosis and chemosis of the left eye. Among the following, the most likely diagnosis is A.Corneal foreign body B.Retinoblastoma C.Post-septal orbital Cellulitis D.Hyphema E.Battered child syndrome

137 67. Fever and a swollen eye have been present for one day in a 5-year old boy following an upper respiratory tract infection. There is no history of trauma. The boy is irritable and has proptosis and chemosis of the left eye. Among the following, the most likely diagnosis is A.Corneal foreign body B.Retinoblastoma C.Post-septal orbital Cellulitis D.Hyphema E.Battered child syndrome

138 68. A 2-yeard old boy is brought to you because his mother has never noted his testes. On physical examination the testes are not palpable in the scrotum. The penis is normal. Which of the following would be indicated at this point? A.Examination with the patient in a squatting position B.Administration of human chorionic gonadotropin C.X-ray studies to determine bone age D.Determination of the plasma testosterone concentration E.Assurance of the mother that the testes will ultimately descend

139 68. A 2-yeard old boy is brought to you because his mother has never noted his testes. On physical examination the testes are not palpable in the scrotum. The penis is normal. Which of the following would be indicated at this point? A.Examination with the patient in a squatting position B.Administration of human chorionic gonadotropin C.X-ray studies to determine bone age D.Determination of the plasma testosterone concentration E.Assurance of the mother that the testes will ultimately descend

140 69. A 1-year old infant is admitted to the hospital because of bacterial meningitis. He is treated with intravenous administration of antibodies in 5% glucose with 30 mEq/L of sodium chloride at 5 ml/kg/hour. Six hours after therapy is initiated, he has a generalized tonic clonic seizure. Physical examination reveals a lethargic but responsive infant. Temperature is 39.30C, Pulse rate is 108/min, and blood pressure is 92/78 mmHg. Which of the following would be the most appropriate at this time? A.A second examination of the cerebrospinal fluid B.Computed tomography (CT scan) of the head C.Determination of serum electrolyte concentrations D.Bilateral subdural taps E.Intravenous administration of Phenobarbital

141 69. A 1-year old infant is admitted to the hospital because of bacterial meningitis. He is treated with intravenous administration of antibodies in 5% glucose with 30 mEq/L of sodium chloride at 5 ml/kg/hour. Six hours after therapy is initiated, he has a generalized tonic clonic seizure. Physical examination reveals a lethargic but responsive infant. Temperature is 39.30C, Pulse rate is 108/min, and blood pressure is 92/78 mmHg. Which of the following would be the most appropriate at this time? A.A second examination of the cerebrospinal fluid B.Computed tomography (CT scan) of the head C.Determination of serum electrolyte concentrations D.Bilateral subdural taps E.Intravenous administration of Phenobarbital

142 70. A 4-week old girl was found shortly after birth to have a cardiac murmur. Her color is now good and weight gain has been satisfactory. Pulse rate is 160/min and respiratory rate is 70/min. Her mother has noted that the infant sweats despite normal ambient temperature and that she sleeps poorly. The infant most likely has A.Pneumonia B.Sepsis C.Paroxysmal Atrial tachycardia D.A left to right shunt circulation E.A Septal defect that has begun to close

143 70. A 4-week old girl was found shortly after birth to have a cardiac murmur. Her color is now good and weight gain has been satisfactory. Pulse rate is 160/min and respiratory rate is 70/min. Her mother has noted that the infant sweats despite normal ambient temperature and that she sleeps poorly. The infant most likely has A.Pneumonia B.Sepsis C.Paroxysmal Atrial tachycardia D.A left to right shunt circulation E.A Septal defect that has begun to close

144 71. A woman who is positive for hepatitis B surface antigen (HbsAg) but negative for hepatitis Be antigen (HbeAg), delivers at term. After careful bathing, the BEST management for this womans infant would be to: A.Administer gamma globulin intramuscularly immediately and at 1 month of age. B.Administer HBIG and HB vaccine immediately and HB vaccine again at 1 month and 6 months of age. C.Administer hepatitis B immunoglobulin (HBIG) if cord blood is positive for HBSAg. D.Administer hepatitis B (HB) vaccine immediately and at 1 month and 6 months of age E.Advise mother that breast feeding is contraindicated.

145 71. A woman who is positive for hepatitis B surface antigen (HbsAg) but negative for hepatitis Be antigen (HbeAg), delivers at term. After careful bathing, the BEST management for this womans infant would be to: A.Administer gamma globulin intramuscularly immediately and at 1 month of age. B.Administer HBIG and HB vaccine immediately and HB vaccine again at 1 month and 6 months of age. C.Administer hepatitis B immunoglobulin (HBIG) if cord blood is positive for HBSAg. D.Administer hepatitis B (HB) vaccine immediately and at 1 month and 6 months of age E.Advise mother that breast feeding is contraindicated.

146 72. The parents of an 18-month old boy bring the infant to you as a new patient. They state that he has been constipated since early infancy. He has been managed with fair success with glycerin suppositories and laxatives. Physical examination discloses no distention of the abdomen. A copious amount of fecal material is palpated in the large bowel. The rectal ampulla is empty. The management of choice would be to A.Continue the present treatment regimen B.Continue the present treatment regimen but add more bulk to the diet C.Prescribe mineral oil D.Order a barium enema examination E.Discontinue all medications and observe the patient

147 72. The parents of an 18-month old boy bring the infant to you as a new patient. They state that he has been constipated since early infancy. He has been managed with fair success with glycerin suppositories and laxatives. Physical examination discloses no distention of the abdomen. A copious amount of fecal material is palpated in the large bowel. The rectal ampulla is empty. The management of choice would be to A.Continue the present treatment regimen B.Continue the present treatment regimen but add more bulk to the diet C.Prescribe mineral oil D.Order a barium enema examination E.Discontinue all medications and observe the patient

148 73. 10 years old boy presented with fever, headache and neck stiffness for 24 hours. He had an identical illness requiring admission to hospital at 8 year of age Of the following, the most likely immune defect is A.B lymphocytes. B.Complement pathway. C.Immunoglobulin production. D.Neutrophil count. E.Neutrophil function.

149 73. 10 years old boy presented with fever, headache and neck stiffness for 24 hours. He had an identical illness requiring admission to hospital at 8 year of age Of the following, the most likely immune defect is A.B lymphocytes. B.Complement pathway C.Immunoglobulin production D.Neutrophil count E.Neutrophil function

150 74. A 2-month old boy is hospitalized because of cough and rapid respirations. The infant has been well since birth except for a mild mucoid conjunctivitis. Length and weigh are at the 15th percentile. An x-ray study of the chest reveals hyperinflation and bilateral interstitial pneumonia. His temperature is 38.0C and his respiratory rate is 56/min. Leukocyte count is 10,000/mm3 with 60% Neutrophil, 5% band forms, 35% lymphocytes, and 10% eosinophils. The serum IgM concentration is markedly increased. The most likely diagnosis is A.Pertussis B.Pneumonia due to Chlamydia Trachomatis C.Pneumonia due to Myoplasma pneumoniae D.Pneumonia due to Hemophillus Influenzae E.Pneumonia due to Staphylococcus Aureus

151 74. A 2-month old boy is hospitalized because of cough and rapid respirations. The infant has been well since birth except for a mild mucoid conjunctivitis. Length and weigh are at the 15th percentile. An x-ray study of the chest reveals hyperinflation and bilateral interstitial pneumonia. His temperature is 38.0C and his respiratory rate is 56/min. Leukocyte count is 10,000/mm3 with 60% Neutrophil, 5% band forms, 35% lymphocytes, and 10% eosinophils. The serum IgM concentration is markedly increased. The most likely diagnosis is A.Pertussis B.Pneumonia due to Chlamydia Trachomatis C.Pneumonia due to Myoplasma pneumoniae D.Pneumonia due to Hemophillus Influenzae E.Pneumonia due to Staphylococcus Aureus

152 75. In infants with serious dehydration, the clinical signs of tachycardia, poor turgor and cool distal extremities result primarily from A.metabolic acidosis B.Starvation C.Hypovolemia D.Cortisol deficit E.Oliguria

153 75. In infants with serious dehydration, the clinical signs of tachycardia, poor turgor and cool distal extremities result primarily from A.metabolic acidosis B.Starvation C.Hypovolemia D.Cortisol deficit E.Oliguria

154 76. An infant who has not yet passed meconium begins vomiting when he is 36 hours old. His abdomen has doughy distension. The rectum is empty on examination, no meconium was seen on the examiners finger. An x-ray study of the abdomen shows distended intestinal loops, but fluid levels are not present. The abdomen has a granular, ground glass appearance with flecks of calcium scattered throughout. The most likely diagnosis is A.Aganglionic megacolon (Hirschsprungs disease) B.Intestinal Atresia C.Meconium plug syndrome D.Ruptured appendix E.Cystic fibrosis, Meconium ileus and peritonitis

155 76. An infant who has not yet passed meconium begins vomiting when he is 36 hours old. His abdomen has doughy distension. The rectum is empty on examination, no meconium was seen on the examiners finger. An x-ray study of the abdomen shows distended intestinal loops, but fluid levels are not present. The abdomen has a granular, ground glass appearance with flecks of calcium scattered throughout. The most likely diagnosis is A.Aganglionic megacolon (Hirschsprungs disease) B.Intestinal Atresia C.Meconium plug syndrome D.Ruptured appendix E.Cystic fibrosis, Meconium ileus and peritonitis

156 77. Your 4-yeard old patient who is receiving L-asparaginase and vincristine therapy for acute lymphocytic leukemia played for one hour with a child who has had a varicella rash for 2 hours. The patients mother does not recall that her child has had varicella in the past. Of the following, the most appropriate course of management would be to A.Discontinue chemotherapy for about three weeks and observe B.Discontinue Chemotherapy for about three weeks and administer zoster immune globulin C.Discontinue chemotherapy for about three weeks and administer live attenuated varicella vaccine D.Continued chemotherapy and administer acyclovir E.Continue chemotherapy without changing the regimen

157 77. Your 4-yeard old patient who is receiving L-asparaginase and vincristine therapy for acute lymphocytic leukemia played for one hour with a child who has had a varicella rash for 2 hours. The patients mother does not recall that her child has had varicella in the past. Of the following, the most appropriate course of management would be to A.Discontinue chemotherapy for about three weeks and observe B.Discontinue Chemotherapy for about three weeks and administer zoster immune globulin C.Discontinue chemotherapy for about three weeks and administer live attenuated varicella vaccine D.Continued chemotherapy and administer acyclovir E.Continue chemotherapy without changing the regimen

158 78. Which of the following has the most potential for the subsequent development of malignancy? A.Mongolian spot B.Strawberry hemangiomas C.Giant pigmented nevus D.Nevus flammeus E.Café-au-lait spot

159 78. Which of the following has the most potential for the subsequent development of malignancy? A.Mongolian spot B.Strawberry hemangiomas C.Giant pigmented nevus D.Nevus flammeus E.Café-au-lait spot

160 79. Which of the following is a feature of Neurofibromatosis? A. Cushings syndrome. B.Haemangiomas of the retina. C.Infantile spasm. D.Scoliosis. E.Shagreen patch.

161 79. Which of the following is a feature of Neurofibromatosis? A. Cushings syndrome. B.Haemangiomas of the retina. C.Infantile spasm. D.Scoliosis. E.Shagreen patch.

162 80. The mother of a previously healthy 2-year old boy seeks medical advice because her child is not using his left arm. No definite precipitating event can be established but the mother recalls that the boy and his father were playing rather roughly the evening before he stopped using the arm. The most likely diagnosis is A.Fractured clavicle B.Colles fracture C.Subluxation of the radial head D.Epiphyseal fracture of the upper extremity E.None of the above

163 80. The mother of a previously healthy 2-year old boy seeks medical advice because her child is not using his left arm. No definite precipitating event can be established but the mother recalls that the boy and his father were playing rather roughly the evening before he stopped using the arm. The most likely diagnosis is A.Fractured clavicle B.Colles fracture C.Subluxation of the radial head D.Epiphyseal fracture of the upper extremity E.None of the above

164 81. A 12 years old girl presented with acute Guillain-Barre syndrome and has developed worsening proximal muscle weakness. Which one of the following tests should be used to monitor her respiratory function? A.Arterial blood gas. B.Vital capacity. C.FEV1/FVC ratio. D.Peak expiratory flow rate. E.Chest expansion

165 81. A 12 years old girl presented with acute Guillain-Barre syndrome and has developed worsening proximal muscle weakness. Which one of the following tests should be used to monitor her respiratory function? A.Arterial blood gas. B.Vital capacity. C.FEV1/FVC ratio. D.Peak expiratory flow rate. E.Chest expansion

166 82. 8 years old boy presents with hypertension. Which of the following statements concerning hypertension in the young is true? A.Sodium nitroprusside is useful for the long-term treatment of sever cases. B.Abnormalities are frequently seen on DMSA scan. C. It is defined as systolic blood pressure above the 99th centile for age. D.Headache is the usual presenting feature E.Aortic coarctation is the commonest secondary cause.

167 82. 8 years old boy presents with hypertension. Which of the following statements concerning hypertension in the young is true? A.Sodium nitroprusside is useful for the long-term treatment of sever cases. B.Abnormalities are frequently seen on DMSA scan. C. It is defined as systolic blood pressure above the 99th centile for age. D.Headache is the usual presenting feature E.Aortic coarctation is the commonest secondary cause.

168 83. A child with chronic renal failure has persistent acidosis with an increased anion gap. Increased serum concentration of which of the following substances would likely contribute most to this finding? A.Lactic acid B.Protein C.Urea D.Inorganic acids E.Keto acids

169 83. A child with chronic renal failure has persistent acidosis with an increased anion gap. Increased serum concentration of which of the following substances would likely contribute most to this finding? A.Lactic acid B.Protein C.Urea D.Inorganic acids E.Keto acids

170 84. A 6-month old infant with tachypnea, dyspnea prolonged expiration and an overly expanded chest probably has A.Obstruction in the upper respiratory tract (larynx or above) B.Obstruction in the lower respiratory tract (below the larynx) C.Obstruction in both the upper and lower respiratory tracts D.Extensive exudative disease involving the lung parenchyma E.An intracranial lesion stimulating the respiratory center

171 84. A 6-month old infant with tachypnea, dyspnea prolonged expiration and an overly expanded chest probably has A.Obstruction in the upper respiratory tract (larynx or above) B.Obstruction in the lower respiratory tract (below the larynx) C.Obstruction in both the upper and lower respiratory tracts D.Extensive exudative disease involving the lung parenchyma E.An intracranial lesion stimulating the respiratory center

172 85. 17 years old boy presented with a non-blanching rash over his legs, a swollen knee and painless frank Haematuria. Investigations revealed:serum creatinine: 210 uml/L (60-110). Urine dipstick analysis: blood +++., protein +. Urine culture: negative. Ultrasound of the kidneys was normal. Which glomerular abnormality is most likely to be present at renal biobsy A.Foot process fusion. B.Linear deposition of IgG on the basement membrane. C.mesangial proliferative and focal lesions D.Thickening of basement membranes. E.Mesangial deposition of IgA

173 85. 17 years old boy presented with a non- blanching rash over his legs, a swollen knee and painless frank Haematuria. Investigations revealed:serum creatinine: 210 uml/L (60-110). Urine dipstick analysis: blood +++., protein +. Urine culture: negative. Ultrasound of the kidneys: normal. Which glomerular abnormality is most likely to be present at renal biobsy A.Foot process fusion. B.Linear deposition of IgG on the basement membrane. C.mesangial proliferative and focal lesions D.Thickening of basement membranes. E.Mesangial deposition of IgA

174 86. A mother reports that her 11-month old son who was previously sleeping through the night now awakens several times during each night. This most likely represents A.A normal developmental stage B.Putting the infant to bed too early C.Hunger D.Inconsistent bedtime E.Family disturbance

175 86. A mother reports that her 11-month old son who was previously sleeping through the night now awakens several times during each night. This most likely represents A.A normal developmental stage B.Putting the infant to bed too early C.Hunger D.Inconsistent bedtime E.Family disturbance

176 87. Hyperpnea, lethargy and fever have developed in a 2 year old girl with rheumatoid arthritis. She is not dehydrated or disoriented. There is no nuchal rigidity on physical examination. The lungs are clear. Findings on x-ray study of the chest are normal. Blood oozes from a venipuncture site. Urinalysis reveals reducing substance but no ketones. An aunt has diabetes mellitus. The most likely diagnosis is A.Diabetic Ketoacidosis B.Reactive airways disease C.Gastroenteritis with acidosis D.Salicylate intoxication E.Oranophosphate ingestion

177 87. Hyperpnea, lethargy and fever have developed in a 2 year old girl with rheumatoid arthritis. She is not dehydrated or disoriented. There is no nuchal rigidity on physical examination. The lungs are clear. Findings on x-ray study of the chest are normal. Blood oozes from a venipuncture site. Urinalysis reveals reducing substance but no ketones. An aunt has diabetes mellitus. The most likely diagnosis is A.Diabetic Ketoacidosis B.Reactive airways disease C.Gastroenteritis with acidosis D.Salicylate intoxication E.Oranophosphate ingestion

178 88. A young woman with rheumatoid arthritis receives Prednisolone 15 mg every other day throughout pregnancy. Her newborn infant will most likely A.be small for gestational age B.Have a cleft palate C.Have a cushingoid appearance D.Have adrenal insufficiency E.Have no evident ill effects

179 88. A young woman with rheumatoid arthritis receives Prednisolone 15 mg every other day throughout pregnancy. Her newborn infant will most likely A.be small for gestational age B.Have a cleft palate C.Have a cushingoid appearance D.Have adrenal insufficiency E.Have no evident ill effects

180 89. An infant weighing 5 kg has Hyponatremia with shock and convulsions. The serum sodium concentration is 118 mEq/L. He is treated with 42 ml of (5.85%) sodium chloride solution intravenously over a 30-minute period. At the end of that time, the predicated serum sodium concentration would be closest to A.130 mEq/L B.160 mEq/L C.146 mEq/L D.152 mEq/L E.140 mEq/L

181 89. An infant weighing 5 kg has Hyponatremia with shock and convulsions. The serum sodium concentration is 118 mEq/L. He is treated with 42 ml of (5.85%) sodium chloride solution intravenously over a 30-minute period. At the end of that time, the predicated serum sodium concentration would be closest to A.130 mEq/L B.160 mEq/L C.146 mEq/L D.152 mEq/L E.140 mEq/L

182 90.Thalassemia major has been diagnosed in a 2-yeard old girl who weighs 12 kg. Her hemoglobin concentration is 4 g/Dl. To increase her hemoglobin concentration to 10 g/dL by transfusion with packed erythrocytes having a hemoglobin concentration of 22 g/dL the approximate volume of packed erythrocytes needed would be A.100 ml B.250 ml C.125 ml D.150 ml E.500 ml

183 90.Thalassemia major has been diagnosed in a 2-yeard old girl who weighs 12 kg. Her hemoglobin concentration is 4 g/Dl. To increase her hemoglobin concentration to 10 g/dL by transfusion with packed erythrocytes having a hemoglobin concentration of 22 g/dL the approximate volume of packed erythrocytes needed would be A.100 ml B.250 ml C.125 ml D.150 ml E.500 ml

184 91. Routine physical examination of a 4-year old boy reveals enlargement of the upper and lower left limbs. Which of the following conditions is associated with this physical findings? A.lymphoma B.Wilms tumor C. Rhabdomyosarcoma D.Neuroblastoma E.Acute lymphocytic leukemia

185 91. Routine physical examination of a 4-year old boy reveals enlargement of the upper and lower left limbs. Which of the following conditions is associated with this physical findings? A.lymphoma B.Wilms tumor C. Rhabdomyosarcoma D.Neuroblastoma E.Acute lymphocytic leukemia

186 92. An afebrile 2-week old infant has cough and tachypnea. X-ray study of the chest shows a radiolucent area in the left upper lobe causing a slight mediastinal shift to the right. The most likely diagnosis is A.Cystic fibrosis B.Congenital lobar emphysema C.Pulmonary sequestration D.Lung abscess E.Pneumomediastinum

187 92. An afebrile 2-week old infant has cough and tachypnea. X-ray study of the chest shows a radiolucent area in the left upper lobe causing a slight mediastinal shift to the right. The most likely diagnosis is A.Cystic fibrosis B.Congenital lobar emphysema C.Pulmonary sequestration D.Lung abscess E.Pneumomediastinum

188 93. An 18-month old boy who was circumcised as a newborn infant has had pain on urination for one day. Today his mother noticed blood on his diaper. Physical examination shows a crusted meatal ulcer. Bag collected urine contains 6 erythrocytes/hpf and no bacteria smear. Further management would most appropriately include A.Local application of petroleum jelly and advice to the mother regarding prevention of primary irritant contact dermatitis B.Obtaining a clear catch urine specimen for culture and colony count C.Treatment with sulfisoxazole and plans for subsequent intravenous urography D.Referral to a urologist E.Immediate intravenous pyelography

189 93. An 18-month old boy who was circumcised as a newborn infant has had pain on urination for one day. Today his mother noticed blood on his diaper. Physical examination shows a crusted meatal ulcer. Bag collected urine contains 6 erythrocytes/hpf and no bacteria smear. Further management would most appropriately include A.Local application of petroleum jelly and advice to the mother regarding prevention of primary irritant contact dermatitis B.Obtaining a clear catch urine specimen for culture and colony count C.Treatment with sulfisoxazole and plans for subsequent intravenous urography D.Referral to a urologist E.Immediate intravenous pyelography

190 94- A 2-year-old boy presents with a 3-day history of diarrhea and vomiting. He has been able to tolerate small amounts of fluids. He is moderately dehydrated, with dry mucous membranes and a heart rate of 145 beats/min. Of the following, the BEST management for this patient's fluid status is A. hospitalization with intravenous fluids and a restrictive bland diet B. hospitalization with intravenous fluids and gut rest for 24 hours C. oral rehydration therapy at home followed by a diet of fruits, vegetables, and meats D. oral rehydration therapy at home followed by a clear liquid diet for 24 hours E. oral rehydration therapy at home followed by a restrictive bland diet

191 94- A 2-year-old boy presents with a 3-day history of diarrhea and vomiting. He has been able to tolerate small amounts of fluids. He is moderately dehydrated, with dry mucous membranes and a heart rate of 145 beats/min. Of the following, the BEST management for this patient's fluid status is A. hospitalization with intravenous fluids and a restrictive bland diet B. hospitalization with intravenous fluids and gut rest for 24 hours C. oral rehydration therapy at home followed by a diet of fruits, vegetables, and meats D. oral rehydration therapy at home followed by a clear liquid diet for 24 hours E. oral rehydration therapy at home followed by a restrictive bland diet

192 95. Increased blood concentration of free erythrocyte protoporphyrin in chronic lead poisoning is the result of A.Impaired renal excretion of protoporphyrin B.Impaired binding of protoporphyrin with iron to produce heme C.Increased synthesis of protoprophyrin D.Increased hemoglobin breakdown E.Increased binding of heme to the globin molecule in hemoglobin synthesis

193 95. Increased blood concentration of free erythrocyte protoporphyrin in chronic lead poisoning is the result of A.Impaired renal excretion of protoporphyrin B.Impaired binding of protoporphyrin with iron to produce heme C.Increased synthesis of protoprophyrin D.Increased hemoglobin breakdown E.Increased binding of heme to the globin molecule in hemoglobin synthesis

194 96. A mother brings her 10-month-old son to the emergency department because he has been vomiting for the past 10 days. The child has not experienced any diarrhea. On physical examination, he is lethargic and has dry mucous membranes, reduced tears, a full anterior fontanelle, and 2-second capillary refill. After a second intravenous bolus of 20 mL/kg of normal saline, the boy extends his arms and legs forcefully for 10 seconds. Of the following, the MOST appropriate next step in the management of this child is administration of A. additional intravenous normal saline bolus of 20 mL/kg B. intravenous fosphenytoin bolus at 20 mg/kg phenytoin equivalents over 10 minutes C. intravenous prochlorperazine of 5 mg D. rapid intravenous lorazepam of 0.05 mg/kg E. intravenous dexamethasone of 1 mg/kg

195 96. A mother brings her 10-month-old son to the emergency department because he has been vomiting for the past 10 days. The child has not experienced any diarrhea. On physical examination, he is lethargic and has dry mucous membranes, reduced tears, a full anterior fontanelle, and 2-second capillary refill. After a second intravenous bolus of 20 mL/kg of normal saline, the boy extends his arms and legs forcefully for 10 seconds. Of the following, the MOST appropriate next step in the management of this child is administration of A. additional intravenous normal saline bolus of 20 mL/kg B. intravenous fosphenytoin bolus at 20 mg/kg phenytoin equivalents over 10 minutes C. intravenous prochlorperazine of 5 mg D. rapid intravenous lorazepam of 0.05 mg/kg E. intravenous dexamethasone of 1 mg/kg

196 97. The parents of a child who has Down syndrome and a 47,XX+21 karyotype come to you for counseling about future pregnancies. Of the following, their risk for giving birth to another child who has trisomy is CLOSEST to A.no greater than the general population at risk B.1% added to the mother's age-related risk C.5% added to the mother's age-related risk D.10% added to the mother's age-related risk E.25% added to the mother's age-related risk

197 97. The parents of a child who has Down syndrome and a 47,XX+21 karyotype come to you for counseling about future pregnancies. Of the following, their risk for giving birth to another child who has trisomy is CLOSEST to A.no greater than the general population at risk B.1% added to the mother's age-related risk C.5% added to the mother's age-related risk D.10% added to the mother's age-related risk E.25% added to the mother's age-related risk

198 98. An 8-year old boy is brought to your office because he has fever, bilateral knee pain, and a limp. The patient is a black child with generalized lymphadenopathy, an enlarge spleen and a swollen, tender knee. Laboratory studies reveal a hemoglobin concentration of 5 g/dL and a leukocyte count of 2500 mm3 with 80% lymphocytes. Which of the following studies would be most helpful in confirming the diagnosis? A.Erythrocyte sedimentation rate B.Heterophil titer C.Coagulation profile D.Examination of a bone marrow aspirate E.X-ray study of the knee

199 98. An 8-year old boy is brought to your office because he has fever, bilateral knee pain, and a limp. The patient is a black child with generalized lymphadenopathy, an enlarge spleen and a swollen, tender knee. Laboratory studies reveal a hemoglobin concentration of 5 g/dL and a leukocyte count of 2500 mm3 with 80% lymphocytes. Which of the following studies would be most helpful in confirming the diagnosis? A.Erythrocyte sedimentation rate B.Heterophil titer C.Coagulation profile D.Examination of a bone marrow aspirate E.X-ray study of the knee

200 99. In an infant, chronic hypervitaminosis A is most often manifested by A.Follicular hyperkeratosis B.Excessive growth of hair C.Lymphocytic leukocytosis D.Nephrocalcinosis E.Thickening of the periosterum of the long bones

201 99. In an infant, chronic hypervitaminosis A is most often manifested by A.Follicular hyperkeratosis B.Excessive growth of hair C.Lymphocytic leukocytosis D.Nephrocalcinosis E.Thickening of the periosterum of the long bones

202 100. A diagnosis of Kawasaki Syndrome has been made in a 6-year old girl. Four days after hospitalization, abdominal pain and distention develop. These developments are most likely due to; A.Hydrops of the gallbladder B.Enterocolitis C.Intussusception D.Volvulus E.Hepatic Haematoma

203 100. A diagnosis of Kawasaki Syndrome has been made in a 6-year old girl. Four days after hospitalization, abdominal pain and distention develop. These developments are most likely due to; A.Hydrops of the gallbladder B.Enterocolitis C.Intussusception D.Volvulus E.Hepatic Haematoma

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