4/22/2013 1. A father brings his daughter in for a health supervision visit. She skips (alternating feet) into the room. You give her a piece of paper and a crayon and ask her to draw a person. She proudly draws a person with 6 body parts. You ask her to take off her shoes and sweater in order to obtain an accurate weight and she quickly complies with your request. Of the following, the age that BEST describes this child’s developmental abilities is A) 2 years old B) 3 years old C) 4 years old D) 5 years old E) 6 years old Correct answer(s): D 2. A mother of a patient in your practice reports that she is currently 8 weeks pregnant and just discontinued use of danazol, which she was taking for treatment of severe endometriosis. She has been told that use of this medication in the first trimester of pregnancy can be associated with birth defects and wishes to know what possible birth defects can be seen with use of this medication in pregnancy.Of the following, you are MOST likely to tell her that use of danazol in pregnancy is associated with an increased risk for A) anterior abdominal wall defects B) congenital heart defects C) neural tube defects D) renal malformations E) virilization of a female fetus 1 4/22/2013 Correct answer(s): E 3. You are evaluating a 2‐month‐old male infant who has a history of a moderate‐sized ventricular septal defect. His mother reports that he has been feeding poorly for the last few days. She reports that during feedings the infant coughs and appears short of breath. On physical examination, the infants respiratory rate is 65 breaths/min and heart rate is 155 beats/min; blood pressure and oxygen saturation are normal. He has mild subcostal retractions and fine bilateral crackles. The precordium is active and there is a grade 3/6 holosystolic murmur maximal at the lower left sternal border. The liver is palpable 3 cm below the right costal margin. Pulse rates and perfusion are adequate. Of the following, the medication MOST likely to provide significant clinical improvement is oral A) captopril B) carvedilol C) digoxin D) furosemide E) spironolactone Correct answer(s): D 2 4/22/2013 4. The mother of a 6‐month‐old girl in your practice is a vegetarian. She tells you she is planning to wean her daughter from exclusive breastfeeding over the next few weeks and would like her daughter to also become a vegetarian. The mother does not eat fish or meat but occasionally consumes eggs and milk. She asks your advice on how best to pursue a vegetarian diet for her daughter. Of the following, the statement you are MOST likely to make is A) high‐bulk, high‐fiber foods should be offered at every meal B) infants who consume vegetarian diets are delayed in growth when compared to other infants C) she should continue to exclusively breastfeed her daughter until the girl is 12 months of age D) she should include fortified cereals and legumes to ensure adequate protein, vitamins, and minerals E) vegetarian diets in infants and children are too calorie‐restrictive and should be avoided until school 4. Correct answer(s): D 5. A 15‐month‐old boy comes to the pediatricians office for a new patient visit. His mother reports that she has been feeding him raw goats milk instead of cows milk for the past 3 months. He is at the 50th percentile for weight and height. He is afebrile and his vital signs are normal for his age. He is pale but the remainder of his physical examination is normal. Of the following laboratory values, this patient would MOST likely have A) B) C) D) E) White blood cell count: 2,000/µL (2 x 109) Hemoglobin: 9 g/dl (90 g/L) Mean Corpuscular Volume: 105 1Jm3 (105 fl) White blood cell count: 8,000/µL (8 x 109) Hemoglobin: 9 g/dl (90 g/L) Mean Corpuscular Volume: 105 µm3 (105 fl) White blood cell count: 8,000/µL (8 x 109/L) Hemoglobin: 9 g/dl (90 g/L) Mean Corpuscular Volume: 85 µm3 (85 fl) White blood cell count: 18,000/µL (18 x 109/L) Hemoglobin: 12 g/dl (120 g/L) Mean Corpuscular Volume: 85 µm3 (85 fl) White blood cell count: 2,000/µL (2 x 109/L) Hemoglobin: 12 g/dl (120 g/dl) Mean Corpuscular Volume: 85 µm3 (85 fl) 3 4/22/2013 5. Correct answer(s): B 6. You are caring for a 10‐year‐old girl who has cystic fibrosis. In addition to her regular pulmonary care regimen, she is consuming a high‐protein diet that provides 125% of her calculated daily requirements for energy and protein. Her diet includes 3 meals plus 2 snacks per day, along with pancreatic enzyme supplements that provide 20,000 lipase units per meal and 12,000 lipase units per snack. She also takes daily supplements of fat‐ soluble vitamins. Despite this regimen, she has lost 2 kg over the past 6 months, and her stools have become increasingly bulky and frequent. At the time of her office visit today, her height is at the 50th percentile, and her weight is at the 10th percentile for her age. The remainder of the physical examination demonstrates mild expiratory wheezing at the lung bases but is otherwise unchanged from previous examinations. Of the following, you are MOST likely to recommend A. B. C. D. E. a hydrolyzed protein‐based nutritional supplement increasing mealtime doses of pancreatic enzymes nocturnal enteral feedings reducing fat content of the diet supplementing with medium‐chain triglyceride oil 6. Correct answer(s): B 4 4/22/2013 7. A previously healthy, 16‐year‐old boy presents with a 2‐day history of left‐ sided scrotal pain of mild to moderate intensity. He has no dysuria, penile discharge, or history of trauma, and he is sexually active. On examination, his left hemiscrotum is reddened, warm to touch, and slightly tender to palpation. He is at sexual maturity rating 5 genital development, and both his testicles are normally positioned. A cremasteric reflex is present bilaterally and elevation of the left testicle reduces the pain. There is mild swelling and tenderness of the lower end of the left cord and testicle. Urinalysis reveals 15 white blood cells per high‐power field with a negative nitrite test result. You send urine samples for urine culture and nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Of the following, the MOST appropriate next step would be to A) apply cold compresses to the scrotum B) await results of urine tests before deciding on treatment C) order color Doppler ultrasonography D) provide antibiotics for chlamydia and gonorrhea E) surgically explore the scrotum 7. Correct answer(s): D 8. The parents of a 4‐year‐old boy who was diagnosed with asthma at 15 months want to know if their son will outgrow his asthma. The father had asthma as a child but has not had any exacerbations in many years and feels he has outgrown his asthma; he is optimistic that his son will too. The mother does not have asthma or allergies. The triggers for their sons exacerbations are mainly viral infections during the fall and winter. In addition to asthma, their son has recently started having itchy, watery eyes and sneezing fits in the spring. You treated him as an infant for atopic dermatitis with moisturizers and topical corticosteroids. Of the following, you are MOST likely to advise the family that their son will likely A) not outgrow his asthma since he has risk factors that suggest persistence B) not outgrow his asthma since his triggers are viral infections C) outgrow his asthma after the age of 5 years D) outgrow his asthma since his father outgrew his asthma E) outgrow his asthma since there is no maternal history of asthma 5 4/22/2013 8. Correct answer(s): A 9. A 4‐year‐old boy presents with right‐sided flank pain. His mother says she noticed a tinge of red in his urine earlier this morning. He plays often with his 2 older brothers, but there is no history of obvious trauma. There is no history of fever, frequency, or urgency, although his mother mentions that at times her son appears uncomfortable when voiding. On physical examination, his temperature is 37.3°C, his heart rate is 80 beats/min, his respiratory rate is 18 breaths/min, and his blood pressure is 106/62 mm Hg. You note no costovertebral angle tenderness, suprapubic tenderness, or edema. Urinalysis reveals the following results: Specific gravity, 1.020 pH 6, 2+ blood Trace protein Leukocyte esterase, negative Nitrite, negative Significant for greater than 100 red blood cells/HPF Fewer than 5 white blood cells/HPF Occasional crystals/HPF Of the following, the MOST likely diagnosis in this patient is A) acute pyelonephritis B) papillary necrosis C) renal hematoma D) urolithiasis E) viral cystitis 9. Correct answer(s): D 6 4/22/2013 10. A female newborn is noted to have a sacral subcutaneous lump with a fatty consistency and a slight lateral deviation of the superior aspect of the intergluteal fold. Her physical examination findings were otherwise normal, and there was no patellar hyperreflexia. Magnetic resonance imaging of the thoracic and lumbar spine was obtained and showed a lipomeningomyelocele. It is unclear if the cord is tethered. The infant was referred to a multidisciplinary spina bifida clinic, where renal ultrasonography was normal and urodynamic assessment showed no evidence of detrusor hyperreflexia or bladder‐sphincter dyssynergia. Of the following, the symptom or sign that you are MOST likely to look for during health supervision visits is A) chronic progressive diarrhea B) development of an ataxic gait C) development of a sacral hemangioma D) loss of patellar reflexes E) urinary retention and leakage 10. Correct answer(s): E 11. A worried father calls you because his son returned from camping today with a tick embedded in his neck. He asks you how to remove it. Of the following, the advice that you are MOST likely to offer is that the father should A) cover the tick with petroleum jelly prior to removal B) heat the tick with a match prior to removal C) pull the tick up with steady, even pressure D) remove the tick using a twisting motion E) squeeze the tick while pulling on it 7 4/22/2013 11. Correct answer(s): C 12. A 14‐year‐old boy presents with sneezing, nasal itching, and eye redness in the spring and fall. He has been taking multiple allergy medications for the past 5 years, but recently his symptoms have worsened. He also has attention‐deficit/hyperactivity disorder (ADHD). He and his mother would like to consider the possibility of allergy shots. You set an appointment for him to be seen by an allergist for skin testing and evaluation. Out of concern that some of his medications may alter the results of skin testing, you decide to advise the boys mother of how he should prepare for skin testing. Of the following, you are MOST likely to advise that before skin testing, the boy should discontinue A) antihistamines for 1 week B) ketorolac eye drops for 1 week C) methylphenidate for 2 weeks D) montelukast for 2 weeks E) nasal steroids for 1 week Correct answer(s): A 8 4/22/2013 13. A girl skips (alternating feet) into your examination room for her health supervision visit. She happily exclaims she is able to tie her shoes and ride her bicycle without training wheels. You give her a blank piece of paper and ask her to write her name. She proudly writes her first and last name. Of the following, the age that BEST describes this child is A) 3 years old B) 4 years old C) 5 years old D) 6 years old E) 7 years old 13. Correct answer(s): D 14. A 17‐year‐old boy who had a laparotomy for complicated perforated appendicitis 2 weeks ago has developed diarrhea and a fever of 39.5°C. He has been receiving intravenous antibiotics since his surgery. On physical examination, he is diaphoretic, with a heart rate of 135 beats/min, a respiratory rate of 25 breaths/min, and blood pressure of 90/60 mm Hg. His weight is 70 kg. His conjunctivae and oropharynx are clear, but mucous membranes are dry. Auscultation of the chest reveals decreased breath sounds in the bases bilaterally. Cardiovascular examination reveals tachycardia with a normal rhythm and no murmur. Pulse rates are equal throughout, but capillary refill time is approximately 3 seconds. Examination of his abdomen reveals distention, active bowel sounds, and diffuse tenderness. Results of the remainder of his physical examination are unremarkable. Of the following, the test MOST likely to establish the diagnosis is A) an abdominal ultrasonography B) a chest radiograph C) a stool culture D) a stool red blood cell assay E) a stool toxin assay 9 4/22/2013 14. Correct answer(s): E 15. You are called to the emergency department to evaluate a 3‐year‐ old girl who was rescued by paramedics from a house fire. She was found unconscious at the scene. On arrival at the emergency department, she is difficult to arouse but is in no respiratory distress, and her breath sounds are clear bilaterally. She has no obvious external burns although there is soot around her nares. She has a temperature of 37.0°C, a heart rate of 130 beats/min, a respiratory rate of 24 breaths/min, and her blood pressure is 90/60 mm Hg. Her oxygen saturation by pulse oximetry is 97% on 100% oxygen administered by non‐rebreather mask. Of the following, the MOST likely cause of her depressed neurologic condition is A) acute respiratory distress syndrome B) airway edema C) carbon monoxide exposure D) methemoglobinemia E) shock 15. Correct answer(s): C 10 4/22/2013 16.You are working in the emergency department when a mother brings in her 9‐month‐old daughter for difficulty breathing that began several hours ago. She describes nasal congestion and mild subjective fever over the last 2 days but says that she noticed "noisy breathing" this morning. The girls oral intake has been adequate. Findings on physical examination reveal a respiratory rate of 40 breaths/min, a heart rate of 120 beats/min, and a temperature of 38.3°C. She is alert and interactive. Nasal congestion and audible inspiratory stridor are noted, and the stridor worsens with crying. Her lung sounds are clear except for transmitted upper airway noise. Her mucous membranes are moist but she is not drooling. The remainder of the physical examination findings are normal. Of the following, the therapy that is MOST likely to provide benefit at this time is A) inhaled ipratropium B) inhaled helium‐oxygen C) inhaled racemic epinephrine D) intravenous ceftriaxone E) intravenous fluids 16. Correct answer(s): C 17. The mother of a 15‐month‐old boy asks about whether her son should receive the measles, mumps, and rubella (MMR) vaccine. She did not allow him to be vaccinated when he was 12 months old because she had read on the internet that egg‐allergic children should not receive MMR vaccine. The boys past medical history reveals that he was given a few spoonfuls of scrambled egg 4 months ago and developed generalized hives, coughing, and wheezing within 15 minutes of ingestion. At that time, he was taken to the emergency department and given diphenhydramine and injectable epinephrine. Of the following, you are MOST likely to recommend that her son A. be referred to an allergist for skin testing and graded challenge to the MMR vaccine B. be tested to determine his current level of lgE specific to egg before receiving his MMR vaccine C. never receive MMR vaccine D. receive the MMR vaccine but remain in the clinic for 2 hours after the vaccination in case he has a reaction E. receive the MMR vaccine today and be discharged to home immediately after the vaccine is administered 11 4/22/2013 17. Correct answer(s): E 18. A 16‐year‐old girl in your practice is angry with her parents and wants to move out of the house. She has read on the internet that she can get adult rights if she goes to court and gets "emancipation papers." She asks you for advice on obtaining emancipation. Of the following, she is MOST likely to qualify for emancipation if she A) displays good reasoning and understands the implications of her actions B) is economically self‐sufficient C) is sexually active and in need of contraception D) moves in with her boyfriend E) needs treatment for a sexually transmitted disease 18. Correct answer(s): B 12 4/22/2013 19. An 18‐year‐old reports to your office for a health supervision visit. He was diagnosed as having type 1 diabetes mellitus 2 months ago. His hemoglobin A1c concentration was 10% (0.10) when he was diagnosed. A pediatric endocrinologist sent you a report after seeing the boy 2 weeks ago. You review the report and note that the boys hemoglobin A1c concentration was 6.8% (0.07) and that his insulin regimen was reduced because of recurrent hypoglycemia. The boy states that the endocrinologist mentioned to him that he was entering a "honeymoon" period, but he remains confused by the term and asks you to clarify. Of the following, you are MOST likely to tell the boy that his decreased insulin requirements are due to improved A) binding of insulin to albumin B) binding of insulin to the insulin receptor C) secretion of endogenous glucagon D) secretion of endogenous insulin E) subcutaneous insulin absorption 19. Correct answer(s): D 20. An 8‐year‐old boy comes to your office because of academic issues at school. He is refusing to do his homework and cries when his parents attempt to assist him. He complains that schoolwork is too hard and that he has trouble paying attention. Teachers report that he is very active and has difficulty remaining in his seat. The boy is undergoing psychoeducational testing. His parents are working with a behavioral therapist but still find his behavior to be challenging. They come to your office for guidance as they await the results of the evaluation. On physical examination, you note him to be fidgety with no evidence of motor tics. He is upbeat when discussing his recent sleepover with his friends, but he becomes distressed when the focus of the discussion shifts to his school performance. Of the following, the BEST next step would be an evaluation for A) attention‐deficit/hyperactivity disorder B) central auditory processing disorder C) conduct disorder D) depression E) Tourette disorder 13 4/22/2013 20. Correct answer(s): A 21. A 13‐year‐old boy has complained of dull medial thigh pain for a month, but his parents have only noticed a mild limp for the last 3 days. He has had no trauma, fever, rash, weight loss, or fatigue. His body mass index is at the 95th percentile for his age and he is at sexual maturity rating 3. There is mild tenderness over the thigh. The knee is not red or swollen, and there is no ligamentous laxity. Physical examination of his hip shows mildly limited abduction with decreased internal rotation. Of the following, the MOST appropriate next diagnostic test for this boy is A. B. C. D. E. anterior‐posterior and frog‐leg radiographs of the hip bone scan of the hip magnetic resonance imaging of the knee and thigh serum creatine kinase, complete blood cell count, and C‐ reactive protein levels hip joint aspiration for culture 21. Correct answer(s): A 14 4/22/2013 22. An 8‐year‐old boy in your practice was recently treated in the emergency department for chronic sinusitis. His mother tells you that he has at least 2 to 3 episodes of sinusitis each year, typically in the spring and fall. He also has 2 to 3 ear infections each year. He has had normal growth and the mother denies a history of snoring. On physical examination, he has swollen nasal turbinates with moderate mucoid drainage and tympanic membranes with effusions bilaterally. There is no visible redness, exudate, or nasal polyps . Of the following, the MOST appropriate next study is A. B. C. D. E. allergy skin testing ciliary biopsy lateral neck radiograph serum immunoglobulin levels sweat chloride testing 22. Correct answer(s): A 23. A 15‐year‐old boy was hammering an iron piece into wood when he felt sudden right‐eye pain followed by decreased visual acuity. On physical examination, he appears uncomfortable, and his right eye reveals tearing and conjunctival injection that is localized medially. A fluorescein examination shows no corneal uptake, but a conjunctival laceration is present. You decide to consult an ophthalmologist; he asks you to rule out the presence of a foreign body in the eye because he will be unable to see the child until after he finishes a procedure. Of the following, the MOST appropriate method to ascertain the presence of an ocular foreign body is A. B. C. D. E. computed tomography magnetic resonance imaging plain radiograph profuse irrigation to dislodge any foreign body ultrasonography 15 4/22/2013 23. Correct answer(s): A 24. A 2‐year‐old boy who has a history of premature birth has been diagnosed with hearing loss. He was born at 28 weeks' gestation and required 2 weeks of mechanical ventilation. After discharge, he required home oxygen therapy for 3 months. His mother asks if any medications could have contributed to his hearing loss. Of the following, the medication exposure MOST likely to contribute to hearing loss is A) amphotericin B B) caffeine C) cefotaxime D) chlorothiazide E) furosemide 24. Correct answer(s): E 16 4/22/2013 25. A 7‐year‐old boy with acute lymphocytic leukemia has a central venous catheter for ongoing maintenance chemotherapy. He is admitted with a fever of 39.0°C and neutropenia (absolute neutrophil count of 100/µL). Other than the fever, his vital signs are stable and there is no focus of infection on physical examination. Of the following, the BEST choice for empiric antimicrobial therapy is A) azithromycin and cefotaxime B) cefazolin and gentamicin C) clindamycin and gentamicin D) piperacillin‐tazobactam E) vancomycin and cefotaxime 25. Correct answer(s): D 26. You are taking care of a 5‐year‐old girl who has asthma and was recently hospitalized for an asthma exacerbation. She is currently taking low‐dose inhaled steroids and levalbuterol as needed. She has been hospitalized twice this year and has had 2 other emergency department visits for asthma exacerbations. The girl’s mother does not want any more albuterol‐like medications than necessary because they may make her daughter "jittery." The mother is also concerned that stepping up to high doses of inhaled steroids may make her daughter "hyper," and she prefers oral chewable tablets or syrups because it is difficult to get her daughter to swallow pills. In addition to referring the family for counseling services, you decide to change her asthma medications. Of the following, you are MOST likely to recommend A. B. C. D. E. continuing her on low‐dose inhaled corticosteroids and adding a daily montelukast chewable tablet continuing her on low‐dose inhaled corticosteroids and adding long‐acting beta‐ agonists discontinuing all inhaled steroids and starting her on a daily montelukast chewable tablet alone stepping her up to a combination of inhaled corticosteroids and long‐acting beta‐ agonists stepping her up to medium‐dose inhaled corticosteroids 17 4/22/2013 26. Correct answer(s): A 27. You are evaluating a 16‐year‐old girl who has a mild intellectual disorder. The girl sits calmly in your office and plays with a stuffed animal. The mother reports that the girl has received various vitamins, herbal remedies, and oral chelating agents from another practitioner in an attempt to improve her intellectual disorder. Observing no change in her daughters developmental status, the mother discontinued the treatments. The mother is frustrated by her daughters lack of progress and fearful about her daughters future as an adult. Of the following, the MOST appropriate course of action is to A. B. C. D. E. discuss that the child’s mild intellectual disorder will prevent her from holding a job recommend that the family plan for residential placement for the child once she becomes an adult recommend that the girl begin treatment for attention‐ deficit/hyperactivity disorder recommend that the mother discuss the child’s lack of progress with the practitioner who prescribed the medications refer the mother to a social worker to learn more about resources for her child 27. Correct answer(s): E 18 4/22/2013 28. You order a fasting lipid profile for an 11‐year‐old boy in your practice because of a history of dyslipidemia in his mother and cardiovascular disease and myocardial infarction at 48 years of age in his father. This child has no other risk factors, such as obesity, hypertension, or diabetes mellitus. He is physically active and has a fairly balanced dietary intake according to his parents. His low‐density lipoprotein concentration is high at 175 mg/dL, his total cholesterol is slightly high at 215 mg/dL, and his high‐density lipoprotein level is at the 1Oth percentile for his age at 40 mg/dL. Of the following, the recommendation you are MOST likely to make to improve his lipid profile is A) increase his intake of soluble fiber B) increase his physical activity C) initiate treatment with a statin D) restrict dietary cholesterol E) restrict dietary saturated fats 28. Correct answer(s): C 29. You are examining an infant in the newborn nursery. The infants mother had rheumatic fever as a child and underwent artificial valve replacement for severe mitral regurgitation 5 years before delivery. The pregnancy was unplanned and the mother was not aware that she was pregnant until the 1Oth week of gestation. She had been taking warfarin for anticoagulation until she discovered she was pregnant, at which time she was switched to a low‐ molecular‐weight heparin. She declined ultrasound screening for fetal anomalies. Of the following, the MOST likely craniofacial feature this newborn may have that is related to in utero warfarin exposure is A) bilateral microtia B) infraorbital creases C) nasal hypoplasia D) short palpebral fissures 19 4/22/2013 29. Correct answer(s): D 30. A 10‐month‐old infant is brought to your office for a health supervision visit. The parents are concerned that the infant is excessively clingy, difficult to console, and very active. They are worried that a physical problem may be responsible. You examine the child and determine that he is in good health. You explain that their son likely has a difficult temperament. Of the following, the advice that you are MOST likely to offer the parents is to A) allow the boy to self‐calm when upset B) encourage the parents to be firmer with the boy C) increase the amount of stimulation in the boys environment D) recommend that the parents seek counseling with a behavioral therapist E) stress consistency and establishment of a routine 30. Correct answer(s): E 20 4/22/2013 31. A 6‐year‐old girl who has corrected congenital heart disease and a history of furunculosis presents to the emergency department with fever and increased work of breathing. Physical examination reveals a temperature of 39.5°C, heart rate of 130 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 85/55 mm Hg. Her oxygen saturation is 90% in room air. A new blowing murmur is noted on cardiac examination, and auscultation of the chest reveals diffuse crackles bilaterally. She has hepatosplenomegaly and a capillary refill of 3 to 4 seconds. Her skin examination yields normal results. Her white blood cell count is 30.0 x 103/L (30.0 x 109/L}, with 71% polymorphonuclear leukocytes, 23% lymphocytes, and 6% monocytes. Chest radiograph shows diffuse pulmonary interstitial edema. Of the following, the MOST appropriate initial antibiotic therapy for this patient is A) ampicillin‐sulbactam B) ceftazidime C) doxycycline D) trimethoprim‐sulfamethoxazole E) vancomycin 31. Correct answer(s): E 32. A 16‐year‐old girl comes to your office because of a knee injury that occurred several hours ago. She reports that while playing basketball her left knee "gave out" when she landed after jumping up to shoot a basket. She heard a pop and felt immediate pain. She has been unable to walk since the injury because of pain and knee instability. She has applied ice and taken ibuprofen, but the pain is persistent. On physical examination, her left knee is moderately swollen. She has no knee joint laxity with varus or valgus stress. Anterior traction on her left lower leg (Lachman test) causes significant anterior tibial translation. Of the following, the MOST appropriate next step is to A) immobilize the knee B) obtain magnetic resonance imaging of the knee C) obtain radiographs of the knee D) perform therapeutic arthrocentesis E) refer her for emergent orthopedic evaluation 21 4/22/2013 32. Correct answer(s): A 33. An 18‐year‐old young man presents to your office for evaluation of a 2‐ week history of fatigue, tactile fever, decreased appetite, right upper quadrant abdominal pain, and increasing scleral icterus over the past several days. He admits to frequent alcohol consumption and intravenous drug use over the past year. He is sexually active and has had several episodes of unprotected sex with different partners over the past 3 months. He came to the United States from Mexico at the age of 15 years, and his immunization history is unknown. Upon physical examination, the young man is ill appearing and jaundiced. Examination of his head, eyes, ears, nose, and throat reveals scleral icterus and clear pharynx. His neck is supple and without lymphadenopathy; his lungs are clear; his heart is normal without murmurs, rubs, or gallops; and his abdomen is distended but soft, with his liver palpable 4.5 cm below the right costal margin with the edge smooth and tender and no splenomegaly . Of the following, the MOST likely cause of this young man’s illness is A) alcohol abuse B) Epstein‐Barr virus infection C) hepatitis A infection D) hepatitis B infection E) hepatitis C infection 33. Correct answer(s): D 22 4/22/2013 34. A 2‐year‐old girl presents after a prolonged focal‐onset seizure. She was playing when she suddenly started crying and her right arm started jerking. Her whole body then jerked for 10 to 15 minutes, during which time she could not respond to her mother. The jerking was subsiding when the paramedics arrived, and the child slept en route to the emergency department. The girl was born at 26 weeks gestation and has developmental delay. She sits but does not yet walk. Of the following, the STRONGEST predictor of seizure recurrence in this child is A) exposure to brothers video games B) family history of febrile seizures C) minor trauma the day before the visit D) preexisting neurologic impairment 34. Correct Answer: D 35. You are called to evaluate a newborn infant who has cyanosis shortly after birth. The infant was born at 41 weeks gestation by spontaneous vaginal delivery and he weighs 3,800 grams. Results from the prenatal testing were unremarkable, including negative group B streptococcal status screening. Artificial rupture of the membranes occurred 3 hours before delivery and revealed scant clear fluid. The infant emerged vigorous. After bonding with his mother, he was brought to the warmer where he was noted to be dusky. His pulse oximetry reading was 78% on his right hand on room air. On arrival to the nursery, you find a cyanotic infant breathing comfortably in a 100% oxygen hood. His vital signs include a heart rate of 140 beats/min, respiratory rate of 50 breaths/min, blood pressure of 68/34 mm Hg, and temperature of 37C. Auscultation reveals clear lung fields bilaterally and a 2/6 soft systolic ejection murmur over the left sternal border. You place pulse oximetry probes on his right hand and left foot, obtaining saturation readings of 89% and 77%, respectively. Of the following, the MOST likely diagnosis is A) group B streptococcal pneumonia B) persistent pulmonary hypertension C) total anomalous pulmonary venous return D) transposition of the great vessels E) tricuspid atresia 23 4/22/2013 35. Correct Answer B 36. The parents of a 7‐year‐old girl who has asthma are concerned because her asthma symptoms have worsened recently. In the past, she has experienced asthma exacerbations with viral infections in the winter. The parents have recently noticed that her asthma also worsens during the summer soccer season, although she was fine playing indoor soccer in the winter. Of the following, you are MOST likely to advise them that their daughter needs to A) get exercise challenge testing B) get methacholine challenge testing C) get allergy skin testing D) stop all sports E) stop all summer sports 36. Correct answer(s): C 24 4/22/2013 37. An 8‐year‐old boy comes to your office for a health supervision visit. He is a friendly boy with no medical issues. His mother is concerned that he is struggling in third grade and is concerned that he may fail several subjects this year. Of the following, the MOST appropriate response is to recommend A) behavioral therapy B) grade retention C) psychoeducational evaluation D) special education classes E) tutoring 37. Correct answer(s): C 38. A 3‐day‐old term newborn infant is brought into the emergency department for evaluation of bleeding from the umbilicus. She was delivered vaginally to a 36‐year‐old primigravida after an unremarkable prenatal course. The parents refused intramuscular vitamin K and antibiotic eye ointment at the time of birth, citing sources on the internet. The infant has been exclusively breastfeeding and her weight has decreased 9% since birth. On physical examination, her heart rate is 150 beats/min, respiratory rate is 40 breaths/min, and blood pressure is 60/40 mm Hg. She is alert and well perfused, but there is evidence of bleeding around her umbilicus and from the nares. The remainder of the physical examination findings are normal. Of the following, the laboratory value MOST likely to be abnormal in this infant is the A) 0‐dimer B) fibrinogen C) partial thromboplastin time D) platelet count E) prothrombin time 25 4/22/2013 38. Correct answer(s): E 39. A 7‐year‐old boy is brought to your office because of acute eye pain. His mother reports that he was playing outside with his friends and breaking rocks with a hammer when he suddenly began crying and rubbing his left eye. He reports that the vision in his left eye is blurry. On physical examination, the boy appears uncomfortable and is holding his left eye closed. There is marked epiphora and conjunctival injection. His extraocular movements are normal and his pupils are equally round and reactive to light. His visual acuity is 20/20 in the right eye and 20/30 in the left. With lid eversion, you find and remove a small speck of gravel. Of the following, the MOST appropriate next step is to A) discharge him home with tetracaine eye drops for pain relief B) perform a dilated funduscopic examination C) perform a flourescein examination D) place an eye shield to discourage eye rubbing E) refer for emergent ophthalmologic evaluation 39. Correct answer(s): C 26 4/22/2013 40. A 6‐year‐old boy presents to the emergency department with a prolonged seizure in the absence of a fever. Results from laboratory studies show that he has severe hypocalcemia. Consequently, he is started on calcitriol. In speaking to his parents, you discover that he has been receiving speech therapy since 2 years of age for expressive language delays and a hypernasal voice quality. A chest radiograph performed when he was 3 years old during a hospitalization for a bacterial pneumonia showed that he had an incidental right‐sided aortic arch. Of the following, the test which would be MOST helpful in determining the cause of these findings is A) a cytogenetic analysis B) a nasendoscopy C) parathyroid hormone measurement D) 22q fluorescence in situ hybridization E) urine electrolytes 40. Correct answer(s): D 27