A 4-year-old boy is brought to the clinic for a well-child e

A 4-year-old boy is brought to the clinic for a well-child examination and immunizations.
He is usually very healthy, but he happens to have a "cold and fever" for the past 3 days.
The mother reports that he is doing well at home and in school. You notice in his chart
that he has missed a few scheduled appointments in the past but he has had no serious
problems. His temperature is 38.0 C (100.0 F). Physical examination shows clear nasal
discharge, but is otherwise unremarkable. He is due for the measles mumps rubella, polio,
and diphtheria tetanus and pertussis vaccines at this time. The most appropriate next step
in management is to
A. administer all of the vaccines at this time
B. administer the inactivated polio and the diphtheria tetanus and pertussis vaccines only
at this time
C. advise him to return for the vaccines when he is feeling better
D. give him the vaccines at the next scheduled well-child examination
E. prescribe azithromycin and schedule an appointment in 10 days for immunizations
A: The answer is A. A minor illness with or without fever is not a contraindication for
immunizations. There are often misconceptions about this idea. According to the
American Academy of Pediatrics and the Report of the Committee on Infectious
Diseases, there is no evidence that indicates that immunizations should not be given
during a minor febrile illness. This is important because deferring immunizations to a
later date may lead to inadequately immunized children. This is especially important in
this case because he has missed regularly scheduled appointments in the past.
All vaccines can be administered at this visit, including the MMR (which is a live
vaccine), even though he has a minor febrile illness. A minor respiratory illness with
fever is not a contraindication for live vaccines because these children have similar
serologic responses to vaccines as afebrile, well children. Therefore, it is incorrect to
administer the inactivated polio and the diphtheria tetanus and pertussis vaccines only at
this time (choice B).
Since he has missed scheduled appointments in the past and has a minor febrile illness,
this is not a contraindication for immunizations. It is incorrect to advise him to return for
the vaccines when he is feeling better (choice C). If you advise him to return when he is
feeling better, he may not return and this will lead to an inadequately immunized child.
It is incorrect to give him the vaccines at the next scheduled well-child examination
(choice D). He has missed appointments in the past and there is no reason that he should
not be given the vaccines that he is due for at this time.
Azithromycin (choice E) is not given for 3 days of "cold and fever" and clear nasal
discharge. It is given for infections due to Moraxella catarrhalis and Legionella
pneumophila, not for viral infections, which he most likely has. Also, he should be given
the immunizations now, and not in 10 days.
1.

A 4-year-old girl is brought to the pediatrician with a 4-mo

A 4-year-old girl is brought to the pediatrician with a 4-month history of limping, swelling of the
left knee, and pain in the right wrist. Her parents note that she has difficulty extending her
knee fully. There is no history of trauma to the knee. She frequently refuses to walk in the
morning because of stiffness and pain, but seems fine later in the day. Physical examination is
normal, except for an erythematous left knee with joint swelling and limitation of flexion to 120
degrees. There is atrophy of the extensor muscles in the thigh. Joint aspiration from the knee
shows 22,000/L white cells, normal glucose, and absence of crystals. She is HLA-DR5 positive,
and antinuclear antibody serology is 1:120. Which of the following is the most appropriate
screening test to prevent morbidity from disease?
A. Bone scan
B. Complete blood count with differential and platelet count
C. Erythrocyte sedimentation rate
D. MRI of the knee
E. Slit lamp examination
F. Urinalysis
1.

2.

The answer is E.
This child presents with pauciarticular juvenile rheumatoid arthritis (JRA).
Characteristics of pauciarticular JRA include chronic asymmetric arthritis of four or
less large weight-bearing joints. Systemic features are uncommon, but the most
feared complication is the development of asymptomatic iridocyclitis, which can
cause blindness if untreated. Iridocyclitis/uveitis may be present in all subtypes of
JRA, but it is particular to the pauciarticular disease of early childhood, in which
approximately 30% of patients develop the complication. All children with JRA
should have regular ophthalmologic examinations, including slit lamp
examinations,to ensure prompt management with corticosteroids.
Bone scanning (choice A) is used as a means of identifying a focus of
osteomyelitis or other abnormality. However, the child in this case presents with
the classic findings of pauciarticular JRA and should undergo slit lamp
examination to identify possible ophthalmic complications.
Complete blood count with differential and platelet count (choice B) is appropriate
for screening anemia in patients with JRA. However, it is not the most important
screening test to perform because of the significant morbidity that may occur
with undiagnosed uveitis/iridocyclitis.
Erythrocyte sedimentation rate (ESR; choice C)is often within reference range in
patients with pauciarticular JRA. For this reason, ESR is not an appropriate
screening test in pauciarticular JRA. It may be used to follow the success of
medical treatment in patients with acute febrile JRA or polyarticular JRA.
A 4 year old child is brought to the clinic by his mother.A

A 4 year old child is brought to the clinic by his mother.A week ago the child receiver an MMr
vaccine after with he developed an unusual rash.What is the most likely cause of this?
A- Vaccine contaminated with live virus
B- Rash is a normal side effect
C- A latent infection in the child has been reactivated
D- The child has been exposed to grandparents with shingles
E- The child has been exposed to a child with chicken pox virus

2.

1. B....usually due to measles component

A 5-year-old boy is brought to the clinic because of a fever for 5 days and a sore throat
and malaise. The mother tells you that he is usually a very healthy child and he is up
to date on all of his immunizations. Besides the mother, he lives at home with an older
brother and sister, neither of whom are sick. His temperature is 39.5 C (103.1 F). On
examination, he has a peeling rash on his extremities, one 2 cm lymph node on the
right anterior cervical chain, a confluent truncal rash, and mild conjunctivitis.
Appropriate management is taken. The most important long-term management of this
child is
A. antibiotic prophylaxis to prevent rheumatic fever

3.
4.

B. echocardiograms to look for coronary artery aneurysms

C. excisional biopsy and surveillance of lymph nodes for malignancy
D. nothing, as this is a case of scarlet fever and he will completely recover
E. serial lumbar punctures
B. echocardiograms to look for coronary artery aneurysms
A 1-year-old child is brought to the clinic for a routine ch

A 1-year-old child is brought to the clinic for a routine child health examination. His parents
have been very compliant and have not missed any of his other health maintenance visits. He
is a healthy child with no significant past medical history. Thus far, he has received the
following vaccines (at the appropriate times): inactivated polio (IPV) 3 times,
diphtheria/tetanus/acellular pertussis (DTaP) 3 times, hepatitis B (hep B) 3 times, haemophilus
influenza type B (Hib) 3 times, and Pneumococcal conjugate (PCV) 3 times. At this time you
should administer
A. DTaP, Hib, MMR, varicella
B. DTaP, IPV, varicella, PCV
C. DTaP, MMR, varicella, PCV
D. Hib, MMR, varicella, PCV
1.

2.

as DTaP has already been given 3 times that is 2, 4, 6 months and the next dose
shud be at 15 months...not at 1 year.
A 6-year-old boy is brought to the pediatrician because of a

A 6-year-old boy is brought to the pediatrician because of a 3-day history of skin lesions. On
physical examination, he has multiple yellow, crusted erosions below the nares and on the
cheeks, chin, and upper extremities. The rest of the examination is normal. Which of the
following is the most appropriate treatment for this condition?
A. Oral acyclovir
B. Oral amoxicillin
C. Oral cephalexin
D. Topical ketoconazole
E. Topical 2% hydrocortisone
1.

The answer is C:
-Bullous impetigo (staphylococcal impetigo) is caused by an epidermolytic toxin
produced at the site of infection, most commonly by staphylococci of phage
group II. The toxin causes intraepidermal cleavage below or within the stratum
granulosum. Bullous impetigo is most common in infants and children. It typically
occurs on the face, but it may infect any body surface. There may be a few
lesions localized in one area, or the lesions may be numerous and widely
scattered. One or more vesicles enlarge rapidly to form bullae in which the
contents turn from clear to cloudy. The center of the thin-roofed bulla collapses,
and a thin, flat, honey-colored crust may appear in the center with a bright red,
inflamed, moist base that oozes serum. In most cases, a tinea-like scaling border
replaces the fluid-filled rim as the round lesions enlarge and become contiguous
with the others .The border dries and forms a crust. The lesions have little or no
surrounding erythema. Regional lymphadenitis is uncommon with pure
staphylococcal impetigo. There is some evidence that the responsible
staphylococci colonize the nose and then spread to normal skin prior to infection.
Serious secondary infections (e.g., osteomyelitis, septic arthritis, and pneumonia)
may follow seemingly innocuous superficial infections in infants. The drug of
choice for impetigo is oral cephalexin. Cloxacillin, dicloxacillin, and azithromycin
are good alteratives.
Because some cases of impetigo are due to a mixed staphylococcal/streptococcal

infection penicillin and amoxicillin (choice B) are inadequate for treatment.

Oral acyclovir (choice A) is used to treat herpes simplex virus infection.
Topical ketoconazole (choice D) is used to treat fungal infection of the skin.
2.

Topical 2% hydrocortisone (choice E) is ineffective against impetigo.

A 4-year-old boy is brought to the clinic for a well-child e

A 4-year-old boy is brought to the clinic for a well-child examination and immunizations. He is
usually very healthy, but he happens to have a "cold and fever" for the past 3 days. The
mother reports that he is doing well at home and in school. You notice in his chart that he has
missed a few scheduled appointments in the past but he has had no serious problems. His
temperature is 38.0 C (100.0 F). Physical examination shows clear nasal discharge, but is
otherwise unremarkable. He is due for the measles mumps rubella, polio, and diphtheria
tetanus and pertussis vaccines at this time. The most appropriate next step in management is
to
A. administer all of the vaccines at this time
B. administer the inactivated polio and the diphtheria tetanus and pertussis vaccines only at
this time
C. advise him to return for the vaccines when he is feeling better
D. give him the vaccines at the next scheduled well-child examination
E. prescribe azithromycin and schedule an appointment in 10 days for immunizations
1.

The answer is A. A minor illness with or without fever is not a contraindication for
immunizations. There are often misconceptions about this idea. According to the
American Academy of Pediatrics and the Report of the Committee on Infectious
Diseases, there is no evidence that indicates that immunizations should not be
given during a minor febrile illness. This is important because deferring
immunizations to a later date may lead to inadequately immunized children. This
is especially important in this case because he has missed regularly scheduled
appointments in the past.
All vaccines can be administered at this visit, including the MMR (which is a live
vaccine), even though he has a minor febrile illness. A minor respiratory illness
with fever is not a contraindication for live vaccines because these children have
similar serologic responses to vaccines as afebrile, well children. Therefore, it is
incorrect to administer the inactivated polio and the diphtheria tetanus and
pertussis vaccines only at this time (choice B).
Since he has missed scheduled appointments in the past and has a minor febrile
illness, this is not a contraindication for immunizations. It is incorrect to advise
him to return for the vaccines when he is feeling better (choice C). If you advise
him to return when he is feeling better, he may not return and this will lead to an
inadequately immunized child.
It is incorrect to give him the vaccines at the next scheduled well-child
examination (choice D). He has missed appointments in the past and there is no
reason that he should not be given the vaccines that he is due for at this time.

2.

Azithromycin (choice E) is not given for 3 days of "cold and fever" and clear nasal
discharge. It is given for infections due to Moraxella catarrhalis and Legionella
pneumophila, not for viral infections, which he most likely has. Also, he should be
given the immunizations now, and not in 10 days.
A normally developing 10 month old child should be able to d

A normally developing 10 month old child should be able to do all of the following except :
1. Stand alone.
2. Play peek a boo.

3. Pick up a pellet with thumb and index finger.

4. Build a tower of 3-4 cubes.
1.

A 3-year-old child with cystic fibrosis presents with weight

A 3-year-old child with cystic fibrosis presents with weight loss, irritability, and a chronic
productive cough. On physical exam, he is afebrile and lung exam reveals intercostal
retractions, wheezing, rhonchi, and rales. Chest x-ray demonstrates patchy infiltrates and
atelectasis and Gram's stain of the sputum reveals slightly curved, motile gram-negative rods
that grow aerobically. The microorganism responsible for this child's pneumonia is also the
most common cause of which of the following diseases?
A. Croup
B. Epiglottitis
C. Meningitis
D. Otitis externa
E. Otitis media

2.

1. D. Otitis externa
The first child was born with cystic fibrosis (CF)

A married couple requests genetic counseling. Their first child was born with cystic fibrosis
(CF). They are wondering what their chances are of having a second child with CF. Both parents
are healthy. The probability that the couples next child will have cystic fibrosis is which of the
following?
A. 1/2
B. 1/4
C. 3/4
D. 2/3
E. 1/8
1.

2.

Choice (B) is the answer.

Cystic fibrosis is an autosomal recessive disease. Since both parents are healthy,
they are both carriers of the cystic fibrosis gene. There is a 1 in 4 chance that
their next child be affected. The other choices are incorrect.
The mother of a 6-month-old boy says that her child has been

The mother of a 6-month-old boy says that her child has been having choking spells for 10
days. Each spell begins with repetitive coughing, and then he turns red or blue, gasps for
breath, and makes a strange sound when he inhales. He has also been vomiting. His pulse is
160/min, and respirations are 72/min. Blood studies show a white blood cell count of
15,500/mm3 with 70% lymphocytes. A nasal swab specimen is cultured on Bordet-Gengou
agar, and a small, encapsulated, gram-negative coccobacillus is isolated. The causative
organism's ability to induce many of the clinical manifestations of this patient's disease is
attributable to which of the following?
A) Capsule that activates complement
B) Cytotoxin that causes the lysis of red blood cells
C) Enterotoxins that increase the level of intracellular cyclic guanosine monophosphate (cGMP)
D) Exotoxins that increase the synthesis of cyclic adenosine monophosphate (cAMP)
E) Exotoxins that inhibit the synthesis of proteins
1.

A) Capsule that activates complement

Explanation: Although fresh isolates of B. pertussis are encapsulated, the capsule
is not considered to be a virulence factor for B. pertussis.
B) Cytotoxin that causes the lysis of red blood cells
Explanation: B. pertussis produces tracheal cytotoxin. This cytotoxin does not lyse
red blood cells; it kills ciliated epithelial cells.

2.

C) Enterotoxins that increase the level of intracellular cyclic guanosine

monophosphate (cGMP)
Explanation: B. pertussis does not produce enterotoxins and does not cause
gastrointestinal manifestations.
D) Exotoxins that increase the synthesis of cyclic adenosine monophosphate
(cAMP)
Explanation: The patient's clinical and laboratory findings are consistent with the
diagnosis of whooping cough (pertussis), a disease caused by Bordetella
pertussis. The bacterium produces two important exotoxins, the pertussis toxin
and the adenylate cyclase toxin. Both toxins increase cAMP levels, but they do so
by different mechanisms. The actions of these exotoxins lead to an increase in
respiratory secretions and mucus production and to the inhibition of phagocytic
activity.
E) Exotoxins that inhibit the synthesis of proteins
Explanation: B. pertussis does not produce an exotoxin that directly inhibits
protein synthesis.
A 9-year-old child in a developing country is brought to a c

A 9-year-old child in a developing country is brought to a clinic by his parents because he has
trouble keeping up with his classmates on the playground. Physical examination is remarkable
for pulmonary rales. Chest x-ray shows biventricular dilation of the heart. Deficiency of which
of the following vitamins is the most likely cause of this child's condition ?
A. Ascorbic acid
B. Retinol
C. Riboflavin
D. Thiamine
E. Vitamin K
1.

Explanation:
The answer is D. Thiamine deficiency is most frequently encountered in alcoholics
and in developing countries. Deficiency of this vitamin can take several forms:
dilated cardiomyopathy (wet beriberi ), polyneuropathy (dry beriberi), and
mamillary body degeneration (Wernicke-Korsakoff syndrome).
Ascorbic acid (choice A, Vitamin C) deficiency causes scurvy, associated with
capillary fragility, bony abnormalities, and poor wound healing.
Retinol (choice B, Vitamin A) deficiency causes blindness and impaired immune
responses.
Riboflavin ( choice C) deficiency causes cheilosis, glossitis, and dermatitis.
Vitamin K (choice E) deficiency causes impaired blood clotting because of
decreased production of factors II, VII, IX, and X.