Pediatrics: NBME 1 and 2 thread

[Apoplexy__]

The official thread to discuss, ask, and answer the NBME's for Peds. Be sure and paraphrase/reword any questions you ask to avoid copyright infringement.

NBME 1 questions:
A 3 yr old comes to the ED after an episode of syncope followed by a tonic-clonic seizure. She becomes fully alert, then stops talking, closes her eyes, and has 3-4 rhythmic jerks of her arm. During this second episode, an ECG was recorded that showed P waves at 80/min with no QRS complexes. NSR resumes shortly thereafter. She becomes alert one minute after. Most likely diagnosis?
A) Absence seizure
B) Adams-Stokes attack
C) Adverse effect of medication (incorrect)
D) Breath-holding episode
E) Carotid artery trauma
F) Narcolepsy-cataplexy
G) Vasovagal episode
H) Ventricular tachyarrhythmia

A 6-month-old boy gets a UTI and is successfully treated with antibiotics. Renal ultrasonography shows no abnormalities. What is the next appropriate step in management?
A) Observe for recurrent symptoms (incorrect...I thought voiding cystourethrography was only if UTIs were recurrent or renal u/s was positive)
B) Repeat urine culture in 3 months
C) IV pyelography
D) Voiding cystourethrography
E) Cystoscopy

A 2-year-old boy has a 5-day fever of up to 104 F. He appears ill. Temp = 102.2 F, pulse = 130, BP = 90/60. A 3/6 systolic murmur is heard at the left sternal border, though the child has no history of murmur. Splenomegaly present. In addition to echocardiography, which of the following is most likely to confirm the diagnosis?

A) ANA

B) ESR
C) Cardiac enzymes (incorrect...thought this was myocarditis, I dunno. Can't explain the splenomegaly)
D) Blood cultures
E) ECG

A 4-day-old female newborn has lower extremity jaundice and icterus. She has been breastfeeding with normal stool and urine output. Born at term, needed vacuum delivery. She had a large cephalhematoma at birth and currently as well. The newborn is O+, and the mother is A+. Direct Coombs is negative. Total bill is 20.8. What is the next best step in management?
A) Cessation of breast feeding
B) Supplementation of breast-feeding with formula
C) Repeat bili in 6 hours
D) Phototherapy
E) IV fluid bolus
F) Partial exchange transfusion (incorrect)
G) No intervention necessary

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[Apoplexy__]

NBME 2 questions
A 28-month-old boy is brought to the ED 20 minutes after swallowing an unknown amount of drain cleaner. He is crying, drooling, and in respiratory distress with stridor and suprasternal retractions. Temp = 100.4 F, Pulse = 124/min, respirations = 40/min, BP = 122/87. He has blisters on the lips and erythematous areas on the tongue. After stabilizing the airway, what’s the best next step?
A) Lateral x-ray of the neck and soft tissues (incorrect)
B) ECG
C) CT of head and neck
D) Esophagography
E) Fiberoptic endoscopy

 

[Apoplexy__]

Answered questions: NBME 1 (from the official Peds shelf thread)

13yo girls brought in for 6 weeks of constant abdominal pressure, breast tenderness, and weight gain. Never had menstrual period. Vitals are normal. Breast and pubic hair Tanner 3. Abdominal exam shows a nontender mass below umbilicus. Next step in diagnosis?
a. urinalysis
b. measure serum alpha-fetorotein
c. measure serum beta-hCG (best 1st step working up amenorrhea, even if primary)
d. x-ray of abdomen
e. CT scan of pelvice


17yo girl brought to ED after found lying on the street. Outside temp is 40F. En route to hospital, paramedics administered O2 and ECG showed J-wave. She is lethargic and poorly responsive to verbal commands. Temp is 32 (89.6F). Puls = 60, RR = 12, BP = 90/60. There is an odor of ethanol on her breath. Which of the following is most likely explanation for the patient's cardiac findings?
a. cocaine toxicity
b. ethanol toxicity
c. hyperkalemia
d. hypocalcemia
e. hypothermia (J wave = hypothermia)
f. increased intracranial pressure
g. MI

1week old newborn has 1 day history of difficulty breathing and discoloration of extremities. Appears ill, temp = 97.5, pulse = 160, resp = 52, BP = 60/36 in upper extremities and unobtainable in lower extremities. Skin, mucous membranes, and nail beds are dusky, and there is mottled discoloration of the extremeties. Moderate intercostal retractiosn and grunting. Lungs clear. Holosystolic murmuc along left sternal border. Liver edge palpable 4cm below costal margin.
pH = 7.15, CO2 = 28, O2 = 98
Intubation, mechanical ventilation, and iv fluid initiated, but no improvement one hour later. x-ray shows cardiomegaly and pulmonary congestion. Explanation of this condition?
a. closure of ductus arteriosus
b. deacreased pulm vascular resistance
c. increased pulm vascular resistance
d. intracardiac right to left shunt
e. opening of ductus arteriosus

3yo comes in for rapid breathing and cant catch his breath. pulse = 100, RR = 30, BP=120/80. lungs clear. slight hyperresonance on right chest. decreased breatah sounds on right. x-ray shows slight overexpansion of right lung compared with left. no infiltrates or effusions. Best management?
a. hyperbaric Oxygen
b. CT of chest
c. bronchoscopy (best 1st step in evaluating aspiration)
d. Thoracotomy
e. Tube thoracostomy

16yo boy comes for routine health exam. Both maternal and paternal family history includes premature coronary artery disease, HTN, and hyperlipidemia. BMI is 35. Cardiac exam no abnormalities. Fasting serum lipids studies show:
Choldesterol (total): 214; HDL: 32, LDL: 144
Triglycerides: 187
Best step in management?
a. reduced calorie diet
b. weight training program
c. Beta-blocking agent therapy
d. cholesterol binding resin therapy
e. stating (wrong)

15 month old girl has a 1 day history of rash and fever for the last 3 days. She got the MMR 10 days ago. No acute distress, temp is 101.2 F. She has an erythematous maculopapular rash over the face, trunk, and extremities. Which of the following is the most likely explanation for these findings?

A) arthus reaction from preexisting antibody to rubella virus
B) delayed type hypersensitivity reaction to rubella antigen
C) immune complex disease from vaccine preservatives
D) replication of a live vaccine virus strain
E) viral dissemination in an immunocompromised host

A previously healthy 3 year old girl brought to physician because of a 2-month history of a right-sided limp. The limp is most obvious when she awakens and gradually becomes less noticeable as she plays. She has no recent history of fever, rash, or other illness and has not been exposed to pets or ticks. Today she appears well but walks with a limp. Temp is 98.2 F. No rash, normal pupils, normal red reflex, normal pharynx, normal cardiac exam. Right knee is swollen and warm but not erythematous or tender. The patient holds the right lower extremity in a slightly flexed position and will not fully extend it when she stands or walks. Laboratory studies show:
ESR 64 mm/h

Serum ANA+
Rheumatoid Factor -
ASO titer -
Lyme Ab -

In addition to the administration of naproxen, what's the best next step?
A) slit lamp exam (routine slit lamp exams indicated in juvenile rheumatoid arthritis)
B) Bartonella henselae titer
C) Upper GI series
D) Arthroscopy
E) Surgical Aspiration of the right knee

An 18 hour old female newborn is being evaluated bc of jaundice. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery to a 31 year old woman, G2P1. She weighed 3799 g/8 lb 6 oz at birth. Mother's blood group is O+. Newborn has urinated twice but has had no bowel movements. Urine is dark yellow. She has had difficulty latching onto the breast correctly. She is alert. Exam shows jaundice of the face and chest. Abdomen is soft. Liver edge palpated 1 cm below the right costal margin, and the spleen tip is palpated 1 cm below the left costal margin. Serum total bilirubin is 11.1 with direct component of 0.1. What's the most likely diagnosis?

A) Breast milk jaundice
B) Galacatosemia
C) Hemolytic disease of the newborn (ABO incompatibility; can't be physiological until >24 hrs of life)
D) Physiologic jaundice of the newborn
E) Sickle cell disease

An 8 year old girl brought to physician because of pallor and easy fatigability for the past 2 months. Symptoms began after URI. She was adopted, and her family history is unknown. She appears pale, spleen tip palpated 2 cm below left costal margin. Her HCT is 28%, retic count is 4% with 3+ spherocytes. Splenectomy is most likely to prevent which of the following complications?

A) cholelithiasis
B) esophageal varices
C) overwhelming sepsis
D) painful crises
E) pancreatitis

A 10 year old girl is brought to the the emergency department following a generalized tonic clonic seizure. She has a 1 month history of behavior disturbances and a 2 week history of fever, weakness, and painful swelling of the left knee. Her hemoglobin concentration is 9, leukocyte count is 3800, platelet count is 65K. Coomb's test is positive. UA shows protein and microscopic blood. What's the most likely diagnosis?

A) Hodgkin disease
B) Henoch Schonlein Purpura
C) Mononucleosis
D) Systemic lupus erythematosus
E) Viral encephalitis

A 5lb 5 oz newborn is delivered at 37 weeks gestation to a 32 year old women, gravida 1 para 1, following an uncomplicated delivery. The mom has history of IV drug use and received no prenatal care. She did not take any med during pregnancy. Rapid HIV testing of the mother after delivery is positive. Exam of newborn shows no abnormalities. Which of the following is the best next step to manage the newborn?
A) A 6-week course of oral AZT beginning at the 2 week exam
B) A 6-week course of oral AZT only if CD4 count decreases to less than 200/mm
C) A 6-week course of oral AZT within 12 hours after delivery
D) A 6-week course of triple antiretroviral therapy beginning at the 2 week exam
E) A 6-week course of triple antiretroviral therapy if the CD4 T count decrease to less than 200/mm
F) A 6-week course of triple antiretroviral therapy within 24 hours after delivery

 

[Apoplexy__]

Answered questions: NBME 2 (from official Peds shelf thread)
38 week AGA neonate with features of Down syndrome, Apgars 6 and 9, AFVSS. Exam reveals hypotonia, pulse ox is 92% on room air. What is the next step?

A) Measure CK and MRI of the brain
B) CXR and blood cultures
C) ECG and karyotype
D) PGE1 and O2 supplementation
E) Surfactant + IV amp/gent

Previously healthy 2yo boy presents with acute fever and inspiratory stridor. Has had rhinorrhea for the last day. Symptoms improve "when mom took him outside to come to the emergency department" [no idea what that is supposed to mean]. Immunizations UTD, exam significant for retractions and stridor, nothing else.

A) Alveolar atelectasis
B) Edema of the epiglottis
C) Narrowing of moderate-sized airways
D) Pulmonary parenchymal inflammation
E) Subglottic edema (this is croup)

A 10 mo girl brought by parents for well child check up. Parents concerned b/c of recent lazy eye development. Born at 38 wks, following an uncomplicated pregnacy and required Oxygen by Nasal cannula for the first day of life. No hx of serious illnes. Vital signs within normal limitis. Examination of the Left eye shows hyphema and esotropia. Conjuctiva is not injectied and there is no discharge. The left pupil appears white on relex testing. The remainder of the exam shows no abnromailties. What is the most likely cause of these findings?
a) congential cataract
b) glaucoma
C) retinoblastoma
D) Retinopathy of prematurity
E) Retintis pigementosa

2yo has 2week history of irritability, poor appetite, occasional cough, and reluctance to walk. Has had 2kg weight loss since her last exam 6mo ago. No history of reuccrent respiratory illness, constipation, vomiting, or diarrhea. Appears uncomfortable and quiet. 7th%ile for height and 25%ile for weight. Temp = 100.2, Pulse: 140, RR: 24, and BP: 145/100. Bluish discoloration under both eyelids. Cardiac and abdominal exam normal. Labs:
Hgb: 10.5
Leukocyte: 8300 (Neu: 40%, Lymph: 55%)
Plate: 240,000
Lateral x-ray of chest shows mass in posterior mediastnum. Diagnosis?
A. anthroax
B. Congenital heart disease
C. CF
D. Dermatomyositis
E. Neuroblastoma (masses of the POSTERIOR mediastinum are typically neurogenic; rule out thymoma because the mass is not in the ANTERIOR mediastinum)
F. Pulmonary Sequestration
G. Thymoma
H. TB

Healthy 16yo from Africa has painless lesion on vulva for 4 days. Sexually active with one male and no contraception used. 10-mm, sharply demarcated, elevated, round lesion on right labium majus. Base of the lesion is smooth and nonpurulent. Organism??
A. Chlamydia
B. Gardnerella Vaginitis
C Haemophilus ducrey
D. HSV
E. HPV
F. Neisseria Gonorrhea
G. Teponema pallidum
H. Trichomonas vaginalis

4. 4wk old girl brought in because 2weeks of irritability and passing stools streaked with mucus and blood. No vomiting. 2 weeks ago, switched from cow's milk-based formula to soy milk-based formula. She is at 35%ile for length, weight, and head circum. Weight remains unchanged from 2wks ago. Most appropriate next step is to begin what?
A. Electrolyte rehydration solution for 24hrs (WRONG)
B. Formula with evaporated milk, water, and corn syrup
C. Formula with hydrolyzed casein
D. Oral Amoxicillin
E. Oral Ranitidine

A previously healthy 7 y.o brought to peds b/c 1 week history of low grade fever and fatigue and a 3 day history of rash and moderate pain and swelling of ankles. Rash first appeared on ankles but has spread over his legs during the past 24 hrs. Tep 38.2. Exam shows palpable petechiae and confluent purpuric areas over lower extremities. Ankles are swollen and mildly tender.
A. ankylosing spondylitis
B. Behcet syndrome
C. dermatomyositis
D. henoch schonlein purpura
E. Juvenile rheumatoid arthiritis
F. Kawasaki
G. Psoriatic arthiritis
H. Reactive arthritis
I. Sarcoidosis
J. Sjogren
K. SLE
L. scleroderma

A previously healthy 3 year old boy brought to doc b/c fever, sore throat, malaise, poor appetite for 2 days. He says that his throat feels scratchy. There has been no vomiting, diarrhea, rhinorrhea. Active and alert. Temp of 38.7. Exam shows no abnormalities of tympanic membrane or pharynx. Leukocyte count is 9500.
A. acetaminophen
B. IV antibiotics
C. IVIG
D. IM ceftriaxone
E. Oral antibiotics
F. Oral corticosteroid
G. Xray chest

Previously healthy 1 month old boy brought to ER 2 hrs after onset of bilious vomiting. Less active than usual and feeding poorly. Last bowel 1 day ago. Born at 38 weeks. Appears ill. Tep of 38, pulse 180, resp 60, BP 70/40. Abdomen firm and distended. bowel sounds decreased. normal rectal tone. small amt of stool in rectal vault. occult blood positive.
A. hirschsprung
B. gastroenteritis
C. hypertrophic pyloric stenosis
D. intussusception
E. midgut vovulus (bilious vomiting + distended abdomen + blood in stool = malrotation/volvulus)

7 month old brought ot ER 35 min after seizure onset. Jerking mvts began in left arm the to right arm and both legs. Cyanotic. Temp 39.7, pulse 160, resp 30, BP 90/60. upward deviation of eyes. generalized rigidity and hyperextension of neck, back, all extremities. Clonic jerking mvts. oxigen administered. next step?
A. acetaminophen
B. diazepam
C. Glucose
D. Naloxone
E. Thiamine

A 7 year old fainted while on field trip. Progressively lethargic over past winter, and complexion darkened. Her height and weight at 50th percentile. BP 80/40. Lab test?
A. plasma cortisol
B. serum glucose
C. serum gonadotropin
D. serum PTH
E. serum TSH

 

[Cytarabine]

For the one with the VCUG - I think the recommendation away from doing VCUG for 1st episode of pyelo is a new one. Test might just be outdated

 

[J ROD]

The official thread to discuss, ask, and answer the NBME's for Peds.

NBME 1 questions:
A 3 yr old comes to the ED after an episode of syncope followed by a tonic-clonic seizure. She becomes fully alert, then stops talking, closes her eyes, and has 3-4 rhythmic jerks of her arm. During this second episode, an ECG was recorded that showed P waves at 80/min with no QRS complexes. NSR resumes shortly thereafter. She becomes alert one minute after. Most likely diagnosis?
A) Absence seizure
B) Adams-Stokes attack
C) Adverse effect of medication (incorrect)
D) Breath-holding episode
E) Carotid artery trauma
F) Narcolepsy-cataplexy
G) Vasovagal episode
H) Ventricular tachyarrhythmia

A 6-month-old boy gets a UTI and is successfully treated with antibiotics. Renal ultrasonography shows no abnormalities. What is the next appropriate step in management?
A) Observe for recurrent symptoms (incorrect...I thought voiding cystourethrography was only if UTIs were recurrent or renal u/s was positive)
B) Repeat urine culture in 3 months
C) IV pyelography
D) Voiding cystourethrography
E) Cystoscopy

A 2-year-old boy has a 5-day fever of up to 104 F. He appears ill. Temp = 102.2 F, pulse = 130, BP = 90/60. A 3/6 systolic murmur is heard at the left sternal border, though the child has no history of murmur. Splenomegaly present. In addition to echocardiography, which of the following is most likely to confirm the diagnosis?

A) ANA

B) ESR
C) Cardiac enzymes (incorrect...thought this was myocarditis, I dunno. Can't explain the splenomegaly)
D) Blood cultures
E) ECG

A 4-day-old female newborn has lower extremity jaundice and icterus. She has been breastfeeding with normal stool and urine output. Born at term, needed vacuum delivery. She had a large cephalhematoma at birth and currently as well. The newborn is O+, and the mother is A+. Direct Coombs is negative. Total bill is 20.8. What is the next best step in management?
A) Cessation of breast feeding
B) Supplementation of breast-feeding with formula
C) Repeat bili in 6 hours
D) Phototherapy
E) IV fluid bolus
F) Partial exchange transfusion (incorrect)
G) No intervention necessary

I got all of them right except the second one that has already been discussed. I also thought the aspirin overdose was just resp alkalosis since it had only been 20 min.

 

[Apoplexy__]

I got all of them right except the second one that has already been discussed. I also thought the aspirin overdose was just resp alkalosis since it had only been 20 min.

Thanks! Yeah, I'm assuming they were looking for mixed respiratory alkalosis and metabolic acidosis, but in Step 1 that would have been wrong...

A couple follow-up questions if you can elaborate:
-What alerted you to the possibility of sepsis in that child, and what's with the heart + spleen manifestations?
-Why phototherapy? I thought exchange transfusion is indicated in total bili > 20.

EDIT: Just found out that phototherapy is indicated in bili > 20, and exchange transfusion is reserved for >25 or symptomatic patients. That explains it.

 

[J ROD]

Thanks! Yeah, I'm assuming they were looking for mixed respiratory alkalosis and metabolic acidosis, but in Step 1 that would have been wrong...

A couple follow-up questions if you can elaborate:
-What alerted you to the possibility of sepsis in that child, and what's with the heart + spleen manifestations?
-Why phototherapy? I thought exchange transfusion is indicated in total bili > 20.

I did a process of elimination and thought blood cultures would be the next best step based on what the patient looked like. The others did not seem right or less likely to help to me.

On rotation, we were taught phototherapy and then exchange in severe patients. The patient does not appear severe to me.

I hate these exams.

 

[TOUCHDOWNNNNN]

Answered questions: NBME 2 (from official Peds shelf thread)
38 week AGA neonate with features of Down syndrome, Apgars 6 and 9, AFVSS. Exam reveals hypotonia, pulse ox is 92% on room air. What is the next step?

A) Measure CK and MRI of the brain
B) CXR and blood cultures
C) ECG and karyotype
D) PGE1 and O2 supplementation
E) Surfactant + IV amp/gent

Previously healthy 2yo boy presents with acute fever and inspiratory stridor. Has had rhinorrhea for the last day. Symptoms improve "when mom took him outside to come to the emergency department" [no idea what that is supposed to mean]. Immunizations UTD, exam significant for retractions and stridor, nothing else.

A) Alveolar atelectasis
B) Edema of the epiglottis
C) Narrowing of moderate-sized airways
D) Pulmonary parenchymal inflammation
E) Subglottic edema (this is croup)

A 10 mo girl brought by parents for well child check up. Parents concerned b/c of recent lazy eye development. Born at 38 explaining:
ing an uncomplicated pregnacy and required Oxygen by Nasal cannula for the first day of life. No hx of serious illnes. Vital signs within normal limitis. Examination of the Left eye shows hyphema and esotropia. Conjuctiva is not injectied and there is no discharge. The left pupil appears white on relex testing. The remainder of the exam shows no abnromailties. What is the most likely cause of these findings?
a) congential cataract
b) glaucoma
C) retinoblastoma
D) Retinopathy of prematurity
E) Retintis pigementosa

2yo has 2week history of irritability, poor appetite, occasional cough, and reluctance to walk. Has had 2kg weight loss since her last exam 6mo ago. No history of reuccrent respiratory illness, constipation, vomiting, or diarrhea. Appears uncomfortable and quiet. 7th%ile for height and 25%ile for weight. Temp = 100.2, Pulse: 140, RR: 24, and BP: 145/100. Bluish discoloration under both eyelids. Cardiac and abdominal exam normal. Labs:
Hgb: 10.5
Leukocyte: 8300 (Neu: 40%, Lymph: 55%)
Plate: 240,000
Lateral x-ray of chest shows mass in posterior mediastnum. Diagnosis?
A. anthroax
B. Congenital heart disease
C. CF
D. Dermatomyositis
E. Neuroblastoma (masses of the POSTERIOR mediastinum are typically neurogenic; rule out thymoma because the mass is not in the ANTERIOR mediastinum)
F. Pulmonary Sequestration
G. Thymoma
H. TB

Healthy 16yo from Africa has painless lesion on vulva for 4 days. Sexually active with one male and no contraception used. 10-mm, sharply demarcated, elevated, round lesion on right labium majus. Base of the lesion is smooth and nonpurulent. Organism??
A. Chlamydia
B. Gardnerella Vaginitis
C Haemophilus ducrey
D. HSV
E. HPV
F. Neisseria Gonorrhea
G. Teponema pallidum
H. Trichomonas vaginalis

4. 4wk old girl brought in because 2weeks of irritability and passing stools streaked with mucus and blood. No vomiting. 2 weeks ago, switched from cow's milk-based formula to soy milk-based formula. She is at 35%ile for length, weight, and head circum. Weight remains unchanged from 2wks ago. Most appropriate next step is to begin what?
A. Electrolyte rehydration solution for 24hrs (WRONG)
B. Formula with evaporated milk, water, and corn syrup
C. Formula with hydrolyzed casein
D. Oral Amoxicillin
E. Oral Ranitidine

A previously healthy 7 y.o brought to peds b/c 1 week history of low grade fever and fatigue and a 3 day history of rash and moderate pain and swelling of ankles. Rash first appeared on ankles but has spread over his legs during the past 24 hrs. Tep 38.2. Exam shows palpable petechiae and confluent purpuric areas over lower extremities. Ankles are swollen and mildly tender.
A. ankylosing spondylitis
B. Behcet syndrome
C. dermatomyositis
D. henoch schonlein purpura
E. Juvenile rheumatoid arthiritis
F. Kawasaki
G. Psoriatic arthiritis
H. Reactive arthritis
I. Sarcoidosis
J. Sjogren
K. SLE
L. scleroderma

A previously healthy 3 year old boy brought to doc b/c fever, sore throat, malaise, poor appetite for 2 days. He says that his throat feels scratchy. There has been no vomiting, diarrhea, rhinorrhea. Active and alert. Temp of 38.7. Exam shows no abnormalities of tympanic membrane or pharynx. Leukocyte count is 9500.
A. acetaminophen
B. IV antibiotics
C. IVIG
D. IM ceftriaxone
E. Oral antibiotics
F. Oral corticosteroid
G. Xray chest

Previously healthy 1 month old boy brought to ER 2 hrs after onset of bilious vomiting. Less active than usual and feeding poorly. Last bowel 1 day ago. Born at 38 weeks. Appears ill. Tep of 38, pulse 180, resp 60, BP 70/40. Abdomen firm and distended. bowel sounds decreased. normal rectal tone. small amt of stool in rectal vault. occult blood positive.
A. hirschsprung
B. gastroenteritis
C. hypertrophic pyloric stenosis
D. intussusception
E. midgut vovulus (bilious vomiting + distended abdomen + blood in stool = malrotation/volvulus)

7 month old brought ot ER 35 min after seizure onset. Jerking mvts began in left arm the to right arm and both legs. Cyanotic. Temp 39.7, pulse 160, resp 30, BP 90/60. upward deviation of eyes. generalized rigidity and hyperextension of neck, back, all extremities. Clonic jerking mvts. oxigen administered. next step?
A. acetaminophen
B. diazepam
C. Glucose
D. Naloxone
E. Thiamine

A 7 year old fainted while on field trip. Progressively lethargic over past winter, and complexion darkened. Her height and weight at 50th percentile. BP 80/40. Lab test?
A. plasma cortisol
B. serum glucose
C. serum gonadotropin
D. serum PTH
E. serum TSH

Thanks for you answers and explanations! They were really helpful!

Would you mind further explaining: the 1 mo with midgut volvulus? How do you rule out intussusception?

Also, can you give an explanation for how a splenectomy will prevent cholelithiasis?

I take my peds shelf tomorrow!! Help!

Thanks in advance!

 

[TOUCHDOWNNNNN]

NBME 2 Questions:

Previously healthy 9 mo male with Tmax of 40 degrees Celsius, fussiness, and decreased PO intake for past 5 days. No sick contacts. Current temp 39.6. Exam shows cracked, fissured lips, redness of oral mucosa and conjunctiva, and single enlarged cervical LN. Maculopapular rash on trunk and extremities, and dorsal edema of hands. What next?

Acetaminophen (wrong)
IV Abx
IVIG
IM ceftriaxone
PO Abx
PO corticosteroids
CXR

14 yo female with amenorrhea. Pubic and axillary hair at 11 yo; breast dev at 12 yo. Bone age of 8 yo. BP is 140/100. Breast Tanner stage 2; Pubic hair Tanner stage 4. Modest. Axilllary hair. Next step?

Measure serum prolactin concentration (wrong)
Karyotype analysis
Measure serum insulin concentration
CXR
EEG

14 yo male with 3 mos of "dragging" sensation of Left scrotum. 30 weeks GA. Born with Left scrotal hydrocele which resolved. Both testes are descended. Left scrotum hangs lower, left soft tissue mass that feels like bag of worms. Mass disappears in supine position. If untreated, what is a complication?

Testicular torsion (wrong)
Distant mets
Incarceration
Infertility
Testicular carcinoma
Torsion of appendix of testis

Previously healthy 3 week old newborn with progressive jaundice for past 6 mos. Stools light in color for past 3 days. Full term with no complications. Formula since birth. Total bilirubin is 14, direct is 6. What is mechanism for condition?

Hepatic enzyme deficiency (wrong)
Decreased conjugation of bilirubin
Decreased excretion of bilirubin
Increased enterohepatic circulation of bilirubin
Increased production of bilirubin

7 yo with 7 days of bloody diarrhea. Generalized fatigue for past 2 days. Afebrile. BP 105/65. Exam shows pallor and scleral icterus. No hepatomegaly. Retic count 12 %. MCV I0. WBC 18. Hb 6. Plts 50. What is the diagnosis?

ALL (wrong)
Bone marrow suppression
G6PD deficiency
Sickle cell disease
HUS
Iron deficiency
Thalassemia

Answers with explanations would be really helpful!

I take my peds shelf exam tomorrow morning! Please help!!

Thanks in advance!

 

[Apoplexy__]

Thanks for you answers and explanations! They were really helpful!

No problem, thanks for everyone in that thread who answered them. 🙂

Would you mind further explaining: the 1 mo with midgut volvulus? How do you rule out intussusception?

The triad of distended abdomen + bilious vomiting + blood in stool is indicative of midgut volvulus. Intussusception is less likely because you'll see "intermittent attacks" of pain described in the question stem, where the kid is fine in between episodes. Sometimes they'll even give the buzz-phrase "brings knees up to chest during pain". I've also never seen bilious vomiting in an intussusception question stem, though I'm sure it happens clinically.

Also, can you give an explanation for how a splenectomy will prevent cholelithiasis?

The kid has spherocytosis, causing constant extravascular hemolysis, indirect bilirubinemia, and therefore pigment gallstones. The only way to stop the gallstones is to take out the spleen, preventing the extravascular hemolysis.

I take my peds shelf tomorrow!! Help!

Thanks in advance!

NBME 2 Questions:

Previously healthy 9 mo male with Tmax of 40 degrees Celsius, fussiness, and decreased PO intake for past 5 days. No sick contacts. Current temp 39.6. Exam shows cracked, fissured lips, redness of oral mucosa and conjunctiva, and single enlarged cervical LN. Maculopapular rash on trunk and extremities, and dorsal edema of hands. What next?

Acetaminophen (wrong)
IV Abx
IVIG
IM ceftriaxone
PO Abx
PO corticosteroids
CXR

This is Kawasaki disease. 5 days of fever + all the classical findings (oral, conjunctival, lymph nodal, skin). The edema on hands (also seen in feet) really clinches it. You treat these kids with IVIG + Aspirin, then monitor them with Echo for coronary aneurysms until the disease runs its course.

14 yo female with amenorrhea. Pubic and axillary hair at 11 yo; breast dev at 12 yo. Bone age of 8 yo. BP is 140/100. Breast Tanner stage 2; Pubic hair Tanner stage 4. Modest. Axilllary hair. Next step?

Measure serum prolactin concentration (wrong)
Karyotype analysis
Measure serum insulin concentration
CXR
EEG

This is Turner syndrome. There are two tip-offs in this question: 1) She's as tall as an 8-year-old (it actually doesn't say bone age, it only mentions her height). 2) What you didn't put in your excerpt is that she has decreased femoral pulses, indicative of a coarctation of the aorta. Coarctation is associated with Turner's. In summary: Coarctation + short stature + primary amenorrhea = Turner syndrome.

14 yo male with 3 mos of "dragging" sensation of Left scrotum. 30 weeks GA. Born with Left scrotal hydrocele which resolved. Both testes are descended. Left scrotum hangs lower, left soft tissue mass that feels like bag of worms. Mass disappears in supine position. If untreated, what is a complication?

Testicular torsion (wrong)
Distant mets
Incarceration
Infertility
Testicular carcinoma
Torsion of appendix of testis

This is a varicocele; the "bag of worms" description is the buzzword. Varicocele is one of the most common causes of male infertility, due to increased testicular temperature and pressure.

Previously healthy 3 week old newborn with progressive jaundice for past 6 mos. Stools light in color for past 3 days. Full term with no complications. Formula since birth. Total bilirubin is 14, direct is 6. What is mechanism for condition?

Hepatic enzyme deficiency (wrong)
Decreased conjugation of bilirubin
Decreased excretion of bilirubin
Increased enterohepatic circulation of bilirubin
Increased production of bilirubin

The infant has cholestatic jaundice. I don't think they give you enough info to tell what the exact etiology is (e.g. biliary atresia vs. a metabolic disorder, etc.) but you know because of the pattern of acholic ("light-colored") stool + direct bilirubinemia.

7 yo with 7 days of bloody diarrhea. Generalized fatigue for past 2 days. Afebrile. BP 105/65. Exam shows pallor and scleral icterus. No hepatomegaly. Retic count 12 %. MCV I0. WBC 18. Hb 6. Plts 50. What is the diagnosis?

ALL (wrong)
Bone marrow suppression
G6PD deficiency
Sickle cell disease
HUS
Iron deficiency
Thalassemia

Bloody diarrhea + hemolysis + low platelets = HUS. This patient probably had enterohemorrhagic E. Coli (O157:H7 blablabla) colitis. The picture of icterus, anemia, and increased reticulocytes showed you hemolysis was occurring. ALL is suggested against by a leukocytosis better explained by hemorrhagic diarrhea and a bone marrow that is responding well with reticulocytosis.

Answers with explanations would be really helpful!

I take my peds shelf exam tomorrow morning! Please help!!

Thanks in advance!

Answers in both quotes. Good luck tomorrow!

 

[TOUCHDOWNNNNN]

Answers in both quotes. Good luck tomorrow!

Thanks a bunch!!

 

[Bancrofti]

Newborn with irritability and difficult breathing has a 2 min. TC seizure. Mother had diabetes, no insulin therapy. Apgar scores fine. Exam shows decreased tone/lethargy. Pulse ox = 99%. Prolonged QT interval. Measured glucose, what other serum level do you want?

Bicarb
Bilirubin
Calcium
Mg
TSH??

13 yo girl, 6 weeks of fatigue/irritability. School is overwhelming. Problems in school, no interest in friends, 4 pound weight loss in a month. exam and labs are normal. most likely diagnosis?

several different options for adjustment disorders
ADHD
dysthymic disorder
Major depressive disorder
Substance abuse
Age-appropriate behavior

 

[ShenMeYiSi]

NBME 2 questions
A 28-month-old boy is brought to the ED 20 minutes after swallowing an unknown amount of drain cleaner. He is crying, drooling, and in respiratory distress with stridor and suprasternal retractions. Temp = 100.4 F, Pulse = 124/min, respirations = 40/min, BP = 122/87. He has blisters on the lips and erythematous areas on the tongue. After stabilizing the airway, what’s the best next step?
A) Lateral x-ray of the neck and soft tissues (incorrect)
B) ECG
C) CT of head and neck
D) Esophagography
E) Fiberoptic endoscopy

Does anyone have the correct answer to this? I'm leaning towards choice E- fiberoptic scope to eval the damage through the tract that was done by the chemicals. UpToDate says you scope any kid with a definite h/o caustic ingestion, so I'm guessing that's it. I am trying to definitely rule out choice D, but by esophagography, do they mean like a barium swallow? I understand how that would be wrong, because I imagine that after a kid just swallowed drain cleaner, you'd probably not want them to swallow barium. Thoughts?

 

[Cytarabine]

Does anyone have the correct answer to this? I'm leaning towards choice E- fiberoptic scope to eval the damage through the tract that was done by the chemicals. UpToDate says you scope any kid with a definite h/o caustic ingestion, so I'm guessing that's it. I am trying to definitely rule out choice D, but by esophagography, do they mean like a barium swallow? I understand how that would be wrong, because I imagine that after a kid just swallowed drain cleaner, you'd probably not want them to swallow barium. Thoughts?

My understanding of the management of caustic ingestion - secure/ensure airway, NPO, scope within 24 hr to assess damage. Further management depends on the scope results

 

[Melo17]

A 5lb 5 oz newborn is delivered at 37 weeks gestation to a 32 year old women, gravida 1 para 1, following an uncomplicated delivery. The mom has history of IV drug use and received no prenatal care. She did not take any med during pregnancy. Rapid HIV testing of the mother after delivery is positive. Exam of newborn shows no abnormalities. Which of the following is the best next step to manage the newborn?
A) A 6-week course of oral AZT beginning at the 2 week exam
B) A 6-week course of oral AZT only if CD4 count decreases to less than 200/mm
C) A 6-week course of oral AZT within 12 hours after delivery
D) A 6-week course of triple antiretroviral therapy beginning at the 2 week exam
E) A 6-week course of triple antiretroviral therapy if the CD4 T count decrease to less than 200/mm
F) A 6-week course of triple antiretroviral therapy within 24 hours after delivery[/QUOTE]

Zidovudine (Retrovir) prophylaxis is recommended for most infants exposed to HIV in utero to decrease the risk of vertical transmission. Beginning eight hours after birth, these neonates should receive zidovudine in a dosage of 2 mg per kg every six hours for at least six weeks.

The landmark study proving the benefits of zidovudine prophylaxis was the Pediatric AIDS Clinical Trials Group Protocol 076 (ACTG 076).13 Maternal zidovudine treatment during pregnancy and labor, and neonatal zidovudine therapy for the first six weeks of life, reduced the relative risk of vertical transmission of HIV by 66 percent.13 Mothers and infants who did not receive zidovudine had a 25.5 percent chance of vertical transmission, whereas those who received the antiretroviral drug had an 8.3 percent chance (number needed to treat is 5.8). Ideally, HIV-infected mothers receive zidovudine during pregnancy and labor. Even if the mothers have not received antiretroviral drug therapy, their infants should be given zidovudine, with treatment started before eight hours after birth and continuing for six weeks.

 

[vitalsdoc]

a

 

[vitalsdoc]

bump

 

[ilovemed1]

hope this helps for a few of them...

1) 2 yr little boy brought to ED after major respiratory distress…rapid breathing/retractions…previously had fever cough which didn’t respond to tylenol…all we know is his mama used drugs prior to 5 mo of age. since then the little boy failed to thrive, had diarrhea constantly, and also had thrush all the time..5th percentile weight and height…fever…high pulse…high respirations…low bp….ox saturation 82%…on exam has tachypnea, grunting, flaring of the nose, diffuse crackles, symmetrical air entry, hepatosplenomegaly, diffuse interstitial infiltrates..what do do next for this pt?

1. sputum culture
2. blood culture
3. serologic VDRL test
4. silver stain of bronchoalveolar fluid
5. ct scan of chest

3) 12 y/o girl headache and change in mental behavior. Diagnosed with Diabetes type 1 and treated for ketoacidosis. .9% saline given and her glucose decreased from 874 mg/dl to 400 mmg/dl. only reacts to pain. regular temp, regular respirations, 146/88 BP, absent venous pulsations. cause of altered mental behavior in this poor chap?

1. cerebral edema
2. hypoglycemia
3. hypovolemia
4. metabolic acidosis
5. persistent hyperglycemia

5) a teen had appendectomy..peritonitis was discovered..she was given 3.5 L lactated ringer solution..whats the cause of hyponatremia?

a)acute tubular necrosis

b)anemia

c)chronic glumerular disease

d)excessive administration of free water during the operation

e)hyperglycemia

f) sepsis


10) 14 y/o lady enlarging neck, decreased energy and can’t tolerate cold. large contender thyroid gland. T4 3ug/dl and tsp 15uU/mL. thyroid scan shows patchy irregular uptake of radioisotope. what seen on biopsy of thyroid gland?

1. epstein barr virus dna
2. granulomas
3. lymphocytic infiltration
4. medullary carcinoma
5. microabscesses

11) 9 month boy sits with support, hits two blocks together, can’t scribble, says mama dada but just not his parents. 50th percentile for length and weight.

Grossmotor development: delayed or normal?

Finemotor development: delayed or normal?

language development: delayed or normal?


12) A 6-month-old boy gets a UTI and is successfully treated with antibiotics. Renal ultrasonography shows no abnormalities. What is the next appropriate step in management? Why voiding cystourethrography??

A) Observe for recurrent symptoms

B) Repeat urine culture in 3 months

C) IV pyelography

D) Voiding cystourethrography

E) Cystoscopy



13) 2 mo boy vomiting for 3 days. drinks cow milk formula but throws up after drinking it. non bloody, non bilious and undigested formula. 25th percentile for length and 10 percentile for weight. diagnosis?

1. formula intolerance
2. GERD
3. intussesception
4. pyloric stenosis
5. volvulus

15) 13 y/o girl for last month been feeling tired, irritable, school becoming tough, trouble concentrating, loss of interest in frients, 3 lb weight loss, normal exam. Diagnosis?

is this age appropriate behavior?

1. adjustment disorder with anxiety
2. adjustment disorder with depressed mood
3. adjustment disorder with disturbance of conduct
4. adhd
5. dysthymic
6. major depression disorder
7. substance abuse
8. age appropriate behavior

 

[ilovemed1]

Hey guys any help on this one would be greatly appreciated. All are from Pediatrics NBME Form 1

1 - "A 5-year-old boy is brought to the physician by his parents because of a painful limp for 3 weeks. He has no history of serious illness or trauma and has not had any other symptoms. Developmental milestones are appropriate for age. On examination, he is unable to bear his full weight on the right and winces when he is asked to stand on his right foot. Flexion and internal rotation of the right hip are decreased. Muscle strength is 4/5 on abduction of the right hip. AP x-rays of the pelvis show a dense, contracted right femoral capital epiphysis. The left femoral capital epiphysis appears normal. Which of the following is the most likely diagnosis?"

Congenital hip dysplasia
Osgood-Schlatter disease
Diastematomyelia
Femoral anteversion
Proximal focal femoral deficiency
Fibular hemimelia
Septic arthritis of the hip
Jumper's knee
Slipped capital femoral epiphysis (wrong)
Legg-Calvé-Perthes disease
Spondylolisthesis of L4 on L5
Metatarsus adductus
Tibial hemimelia

2 - "A previously healthy 11-year-old boy is brought to the physician because of a 14-day history of fever, headache, and yellow-green nasal discharge. He has had a nocturnal cough during this period. His 8-year-old sister has a cold. He appears mildly ill. His temperature is 39°C (102.2°F), pulse is 100/min, and respirations are 18/min. Pulse oximetry on room air shows an oxygen saturation of 96%. The posterior pharyngeal wall is erythematous and covered with thin gray mucus. The lungs are clear to auscultation. An x-ray of the chest shows no abnormalities." Was this one sinusitis?

Atelectasis
Laryngotracheobronchitis
Bacterial pneumonia (wrong)
Mycoplasma pneumoniae infection
Bacterial tracheitis
Pancreatitis
Bronchial asthma
Pertussis
Bronchiectasis
Pneumocystis jiroveci (formerly P. carinii) pneumonia
Bronchiolitis
Pneumothorax
Cystic fibrosis
Pulmonary tuberculosis
Foreign body aspiration
Sinusitis

3- "An 18-month-old boy is brought to the physician because of diarrhea for 3 days. He attends day care, and several other children at the center have similar symptoms. The water source for the day-care center is a private well. The center has a pet turtle and two canaries. The patient's temperature is 37.7°C (99.9°F). He is well hydrated. The remainder of the examination shows no abnormalities. Examination of the stool for ova and parasites is negative. A stool culture grows no enteric pathogens. Rotavirus testing is positive."

Laboratory studies show

Hemoglobin 12 g/dL
Leukocyte count 8400/mm3
Segmented neutrophils 39%
Bands 1%
Lymphocytes 60%
Platelet count 240,000/mm3

Cholera immunization
Cooking meats completely
Day-care center closure
Removing the pets from the day-care center
Strict hand-washing techniques at the day-care center
Swimming prohibition in the lake
Typhoid immunization
Use of only disposable diapers at the day-care center
Well water filtration (wrong)

4- "A 17-year-old girl comes for a precollege physical examination. She is not sexually active. Her menses occur at regular 28-day intervals. She has smoked one-half pack of cigarettes daily for 3 years and drinks 1 oz of alcohol weekly. Her 50-year-old mother was diagnosed with breast cancer 1 year ago. Her father and grandfather died of heart disease during their 30s. Her blood pressure is 130/70 mm Hg while sitting. Which of the following is the most appropriate screening test?"

Serum lipid studies
UA (wrong)
Mammo
CXR
Stress Test

5- "A 12-hour-old female newborn becomes irritable, has difficulty breathing, and then has a 2-minute generalized tonic-clonic seizure. She was born at 36 weeks' gestation by cesarean delivery for a breech presentation and weighed 3997 g (8 lb 13 oz). Her mother had gestational diabetes poorly controlled with diet; she refused insulin therapy. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Examination shows decreased tone and lethargy. Pulse oximetry shows an oxygen saturation of99%. An ECG shows a prolonged QT interval. In addition to measurement of serum glucose concentration, the most appropriate next step is measurement of which of the following serum concentrations?"

Bicarb
Bili
Mg
TSH (wrong)
Calcium

6- "12 month-old African American girl with sickle cell disease is brought to the emergency department because of the sudden onset of high fever, irritability, and tachypnea 6 hours ago. Her diet consists of iron-fortified formula and pureed fruits and vegetables. Her mother states that she only misses an occasional dose of her penicillin prophylaxis. She appears ill. Her temperature is 39°C (102.2°F), pulse is 180/min, and respirations are 48/min. Examination shows conjunctival pallor. A grade 2/6 systolic murmur is heard best at the left sternal border. Laboratory studies show a hematocrit of 23%, leukocyte count of 23,000/mm3, and platelet count of 250,000/mm3. The most appropriate initial step in management is administration of which of the following?"

Oral penicillin
Intravenous cefotaxime
Intravenous corticosteroids
Intravenous immune globulin
Intravenous nafcillin
Intravenous penicillin (wrong)

 

[God's Son]

1. ans is Legg Calve Perthes cos of the age grp. LCPD ( AGES 4-10) , SCFE(in male adolecents 9-14)
2. Sinusitis, yeah cos it is acute and he appears mildly ill..plus thin mucus
3. Strict hand washing techniques
4. Serum Lipid Studies
5.IDM are at risk of HYPOCalcemia, so its CALCIUM
6. Not sure about this one , but i will go for I.V Cefotaxime ( Broad Spectrum)
Hope this helps

Cheers

Hey guys any help on this one would be greatly appreciated. All are from Pediatrics NBME Form 1

1 - "A 5-year-old boy is brought to the physician by his parents because of a painful limp for 3 weeks. He has no history of serious illness or trauma and has not had any other symptoms. Developmental milestones are appropriate for age. On examination, he is unable to bear his full weight on the right and winces when he is asked to stand on his right foot. Flexion and internal rotation of the right hip are decreased. Muscle strength is 4/5 on abduction of the right hip. AP x-rays of the pelvis show a dense, contracted right femoral capital epiphysis. The left femoral capital epiphysis appears normal. Which of the following is the most likely diagnosis?"

Congenital hip dysplasia
Osgood-Schlatter disease
Diastematomyelia
Femoral anteversion
Proximal focal femoral deficiency
Fibular hemimelia
Septic arthritis of the hip
Jumper's knee
Slipped capital femoral epiphysis (wrong)
Legg-Calvé-Perthes disease
Spondylolisthesis of L4 on L5
Metatarsus adductus
Tibial hemimelia

2 - "A previously healthy 11-year-old boy is brought to the physician because of a 14-day history of fever, headache, and yellow-green nasal discharge. He has had a nocturnal cough during this period. His 8-year-old sister has a cold. He appears mildly ill. His temperature is 39°C (102.2°F), pulse is 100/min, and respirations are 18/min. Pulse oximetry on room air shows an oxygen saturation of 96%. The posterior pharyngeal wall is erythematous and covered with thin gray mucus. The lungs are clear to auscultation. An x-ray of the chest shows no abnormalities." Was this one sinusitis?

Atelectasis
Laryngotracheobronchitis
Bacterial pneumonia (wrong)
Mycoplasma pneumoniae infection
Bacterial tracheitis
Pancreatitis
Bronchial asthma
Pertussis
Bronchiectasis
Pneumocystis jiroveci (formerly P. carinii) pneumonia
Bronchiolitis
Pneumothorax
Cystic fibrosis
Pulmonary tuberculosis
Foreign body aspiration
Sinusitis

3- "An 18-month-old boy is brought to the physician because of diarrhea for 3 days. He attends day care, and several other children at the center have similar symptoms. The water source for the day-care center is a private well. The center has a pet turtle and two canaries. The patient's temperature is 37.7°C (99.9°F). He is well hydrated. The remainder of the examination shows no abnormalities. Examination of the stool for ova and parasites is negative. A stool culture grows no enteric pathogens. Rotavirus testing is positive."

Laboratory studies show

Hemoglobin 12 g/dL
Leukocyte count 8400/mm3
Segmented neutrophils 39%
Bands 1%
Lymphocytes 60%
Platelet count 240,000/mm3

Cholera immunization
Cooking meats completely
Day-care center closure
Removing the pets from the day-care center
Strict hand-washing techniques at the day-care center
Swimming prohibition in the lake
Typhoid immunization
Use of only disposable diapers at the day-care center
Well water filtration (wrong)

4- "A 17-year-old girl comes for a precollege physical examination. She is not sexually active. Her menses occur at regular 28-day intervals. She has smoked one-half pack of cigarettes daily for 3 years and drinks 1 oz of alcohol weekly. Her 50-year-old mother was diagnosed with breast cancer 1 year ago. Her father and grandfather died of heart disease during their 30s. Her blood pressure is 130/70 mm Hg while sitting. Which of the following is the most appropriate screening test?"

Serum lipid studies
UA (wrong)
Mammo
CXR
Stress Test

5- "A 12-hour-old female newborn becomes irritable, has difficulty breathing, and then has a 2-minute generalized tonic-clonic seizure. She was born at 36 weeks' gestation by cesarean delivery for a breech presentation and weighed 3997 g (8 lb 13 oz). Her mother had gestational diabetes poorly controlled with diet; she refused insulin therapy. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Examination shows decreased tone and lethargy. Pulse oximetry shows an oxygen saturation of99%. An ECG shows a prolonged QT interval. In addition to measurement of serum glucose concentration, the most appropriate next step is measurement of which of the following serum concentrations?"

Bicarb
Bili
Mg
TSH (wrong)
Calcium

6- "12 month-old African American girl with sickle cell disease is brought to the emergency department because of the sudden onset of high fever, irritability, and tachypnea 6 hours ago. Her diet consists of iron-fortified formula and pureed fruits and vegetables. Her mother states that she only misses an occasional dose of her penicillin prophylaxis. She appears ill. Her temperature is 39°C (102.2°F), pulse is 180/min, and respirations are 48/min. Examination shows conjunctival pallor. A grade 2/6 systolic murmur is heard best at the left sternal border. Laboratory studies show a hematocrit of 23%, leukocyte count of 23,000/mm3, and platelet count of 250,000/mm3. The most appropriate initial step in management is administration of which of the following?"

Oral penicillin
Intravenous cefotaxime
Intravenous corticosteroids
Intravenous immune globulin
Intravenous nafcillin
Intravenous penicillin (wrong)

 

[ilovemed1]

1. ans is Legg Calve Perthes cos of the age grp. LCPD ( AGES 4-10) , SCFE(in male adolecents 9-14)
2. Sinusitis, yeah cos it is acute and he appears mildly ill..plus thin mucus
3. Strict hand washing techniques
4. Serum Lipid Studies
5.IDM are at risk of HYPOCalcemia, so its CALCIUM
6. Not sure about this one , but i will go for I.V Cefotaxime ( Broad Spectrum)
Hope this helps

Cheers

thank you so much! your explanations were very helpful! for #5 just realized that the patient also had a prolonged QT interval which also explains it..thx

 

[God's Son]

Yeah that's true , the Prolonged QT, i have that in my note. You are welcome.

thank you so much! your explanations were very helpful! for #5 just realized that the patient also had a prolonged QT interval which also explains it..thx

 

[spartan564]

some more from NBME 1:
1) 5 ear old with fatigue for 3 weeks, acute onset of fever and chills for 2 hours. Traveled to asia 1 month ago and received chloroquine. Exam shows pallor and splenomegaly. HCT 22, leuko 18, platelets 80. Diagnosis?
assay for strep
assay for heterophile
measure PT and PTT ( i was thinking gram negative DIC but this is wrong so is heterophile test the answer? seems strange for acute onset of fever and chills though)
Measure AST and ALT
thick and thin blood smears

2) 16 with painless mass in scrotum. can milk to abdomen through inguinal ring. diagnosis?
hydrocele (not correct so I'm assuming inguinal)
inguinal hernia
varicocele

3) 5 year old in ER 30 min after acute onset of left shoulder pain after wrestling with brothers and has exquisite tenderness of humeral area. What is the cause of the pain? Xray shows broken mid shaft humerus and possibly some sclerotic area near fracture site
acromioclavicular separation
clavicle fracture
glenohumeral dislocation
pathologic fracture
unicameral bone cyst (i thought this because they can cause thinning of nearby bone and cause fractures so I guess pathologic is the answer?)

 

[spartan564]

Also this is incorrect, I put it and got it wrong. Im assuming it is delayed gross, normal fine, normal language

11) 9 month boy sits with support, hits two blocks together, can’t scribble, says mama dada but just not his parents. 50th percentile for length and weight.

Grossmotor development: delayed or normal?

Finemotor development: delayed or normal?

language development: delayed or normal?

 

[Meatspin]

8yo w/ murmur
(-) cyanosis, decreased exercise tolerance, rheumatic fever, thrills, cardiomegaly
(+) apical impulse tapping, split s1 w/ inspiration, sinus brady, low-pitched vibratory murmur thought cardiac cycle most prominent in LU sternal border, murmur disappears when supine and when neck is rotated

ASD, coarct, PDA, peripheral pulmonic stenosis, venous hum?

Not coarct, so venous hum?

 

[spartan564]

^ yes

 

[doc0610]

In the morning, a 30 month old girl has abdominal pain, two loose stools and a temperature of 101F. She has fever that is persistent throughout the day. and has 2 more loose stools. She also has a generalized tonic clonic seizure. No nuchal rigidity, and slightly decreased skin turgor. What is the diagnosis?
a) HUS
b) HSP
c) idiopathix sezuire disorder
d) shigellosis
e) toxicmegacolon

Please explain your answer! Also, can anyone explain Atelectasis finding on a chest X-ray? I never get how to identify this on the test other than it is post op most of the times.

Appreciate it. Thank you!

 

[docmcfar]

In the morning, a 30 month old girl has abdominal pain, two loose stools and a temperature of 101F. She has fever that is persistent throughout the day. and has 2 more loose stools. She also has a generalized tonic clonic seizure. No nuchal rigidity, and slightly decreased skin turgor. What is the diagnosis?
a) HUS
b) HSP
c) idiopathix sezuire disorder
d) shigellosis - some sources I've seen say it's bc of the shiga toxin but Medscape says the etio/mech is unclear and that data now shows it's not the shiga toxin. So basically just remember shigella diarrhea and seizures...
e) toxicmegacolon

Please explain your answer! Also, can anyone explain Atelectasis finding on a chest X-ray? I never get how to identify this on the test other than it is post op most of the times.

Appreciate it. Thank you!

 

[vitalsdoc]

🙂

 

[doc0610]

1. 18 month boy, intermittent ab pain, no vomiting or diarrhea, lethargic. Soft, contender abdomen. Mass palpated in RLQ. decreased bowel sounds. Red stool, occult blood positive. X-ray of abdoment shows no air in ascending or transverse colon. Next step management?

1. air contrast enema
2. upper gastrointestinal series
3. meckel scan
4. upper endoscopy
5. laparotomy

2) 14 y/o boy w/ 1 year history of learning disability, hyperactivity, short attention span, can’t concentrate in homework, generalized tonic clonic seizure at 8 yrs. PE shows nine lesions with coffee stain like appearance on chest and abdomen. Small areas of increased pigmentation in the axillae and small skin tags over chest, abdomen, and back. Diagnosis.

1. hereditary hemorrhagic telangiectasia
2. Neurofibromatosis, type 1
3. sturge-weber syndrome
4. tuberous sclerosis
5. von hippel disease

3) 9 y/o acute appendicitis brought by adult neighbor to ED. neighbor offers to sign consent form for the operation on behalf of childs parent who cant be reached. management by doc?

1. perform operation because it’s an emergency and no consent is required
2. perform operation, because a responsible adult has given consent
3. perform the operation only if the child gives consent
4. delay the operation until the parent can be contacted, while closely monitoring the child’s status

4) 4 mo female brought for exam. spent few months in hospital, where she was treated for sepsis and respiratory distress syndrome. currently receiving oxygen and diuretic therapy. 5th percentile for length and wight, fever, pulse 104, respirations 32/min, BP of 115/67 in right arm and 105/67 in left arm. breath sounds decreased bilaterally, wheezing heard occasionally. pronounced s2 and precordial heave. hepatomegaly on abdominal exam. ecg shows right axis deviation and right ventricular hypertrophy. normal sized kidneys on ultrasound. cause of increased BP?

1. bronchopulmonary dysplasia I got this wrong, but from what I have researched, a pt with RDS and intubation (i think this patient was intubated) There is a high risk of broncho pulmonary dysplasia. Again, I don't know this 100%
2. coartation of aorta
3. essential HTN
4. Pheochromocytoma
5. Renal artery thrombosis

5) 2 yr boy fever for 3 days, right elbow pain for a day, had group b step meningitis at 5 months and septic arthritis caused by H influenza type B at 9 months. Brother and three uncles died in infancy of septicemia. Immunizations up to date. Fever of 104. redness and swelling of right elbow, limited range of motion. Leukocytes 34,000. Segmented neutro 60%. Bands 15%. Lymphocytes 25%. Strep Pneumo grew on blood culture. Impairment of what?

1. B-lymphocyte function ( uncle and brother also had this, X linked Brutons )
2. Complement function
3. Segmented neutrophil adhesion
4. Segmented neutrophil chemotaxis
5. T-lymphocyte function

6) 26 y/o lady gives birth to newborn vaginally 42 weeks gestation. Spontaneous and no complication. Fetal growth restriction was noted by third trimester. Mother didn’t travel, smoke, drink, or use drugs during pregnancy, and no pets in household. Initial exam showed hepatosplenomegaly. X-ray shows periventricular intracranial calcifications. Most likely agent?

1. cytomegalovirus (no pets so, can't be Toxo)
2. herpes simplex virus 1
3. parvovirus
4. rubella virus
5. treponema pallidum

7) A 3 month boy with 2 day history of fever and irritability. 50th percentile for length weight and head circumference. Temp of 100.6 F, pulse 130, respiration 26/min, BP 85/50. Fussy throughout exam.

Urinalysis shows-

specific gravity: 1.015

glucose negative

protein 1+

RBC 0-3 hpf

WBC 20-50 hpf

bacteria few gram-negative rods



Urine culture shows greater than 100,00 colonies of E.Coli. Started antibiotics. Next appropriate step in diagnosis?

1. intravenous pyelography
2. renal digital subtraction angiography
3. renal ultrasonography
4. ct scan of abdomen
5. renal dimercaptosuccinic acid scan

8) A 16 y/o boy brought to doc cuz of 2 week history of increasing pain, swelling, and rash over right knee and 1 week of moderate pain and redness in both eyes. Fever of 100F. Eyes have injected conjunctivae with mucopurulent discharge. Diffuse, macular, erythematous rash over lower extremities and marked swelling of the right knee. Range of motion of the right knee is limited by pain. There is erythema and edema of the urethral meatus. Most likely diagnosis?

1. ankylosing spondylitis
2. behcet syndrome
3. dermatomyositis
4. Henoch schonlein purpora
5. juvenile rheumatoid arthritis
6. mucocutaneous lymph node syndrome (kawasaki disease)
7. psoriatic arthritis
8. reactive arthritis ( has urethritis, conjunctivitis, arthritis)
9. sarcoidosis
10. sjogren syndrome
11. SLE
12. Systemic sclerosis (scleroderma)

I have highlighted the answers.

 

[vitalsdoc]

Thanks

 

[doc0610]

thank you 🙂

 

[rcdamania]

NBME Form 1

Got this question wrong...couldn't find an explanation?? lol thanks
3) 5 year old in ER 30 min after acute onset of left shoulder pain after wrestling with brothers and has exquisite tenderness of humeral area. What is the cause of the pain? Xray shows broken mid shaft humerus and possibly some sclerotic area near fracture site

acromioclavicular separation (this is what I put)
clavicle fracture
glenohumeral dislocation
pathologic fracture
unicameral bone cyst

Also I am so confused on why the answer is closure of PDA!?
1week old newborn has 1 day history of difficulty breathing and discoloration of extremities. Appears ill, temp = 97.5, pulse = 160, resp = 52, BP = 60/36 in upper extremities and unobtainable in lower extremities. Skin, mucous membranes, and nail beds are dusky, and there is mottled discoloration of the extremeties. Moderate intercostal retractiosn and grunting. Lungs clear. Holosystolic murmuc along left sternal border. Liver edge palpable 4cm below costal margin.
pH = 7.15, CO2 = 28, O2 = 98
Intubation, mechanical ventilation, and iv fluid initiated, but no improvement one hour later. x-ray shows cardiomegaly and pulmonary congestion. Explanation of this condition?
a. closure of ductus arteriosus
b. deacreased pulm vascular resistance
c. increased pulm vascular resistance
d. intracardiac right to left shunt (I put this... Eisenmengers or TOF?)
e. opening of ductus arteriosus

16 year old with the rash that looks like acne, started on his chin and then gradually is spreading over the face. No other abnormalities.
A. Allergic contact dermitis (this is what I put)
B. Herpes Simplex
C. Impetigo contagiosa
D. Tinea facei

 

[doc0610]

NBME Form 1

Got this question wrong...couldn't find an explanation?? lol thanks
3) 5 year old in ER 30 min after acute onset of left shoulder pain after wrestling with brothers and has exquisite tenderness of humeral area. What is the cause of the pain? Xray shows broken mid shaft humerus and possibly some sclerotic area near fracture site

acromioclavicular separation (this is what I put)
clavicle fracture
glenohumeral dislocation
pathologic fracture
unicameral bone cyst

I put the same answer as you, thought they looked dislocated, but then I looked at the X-ray and then it looked like there were some spots on the humerus, hazy area. SO, i am guessing it has something to do with that. Or maybe it is an illusion.

Also I am so confused on why the answer is closure of PDA!?
1week old newborn has 1 day history of difficulty breathing and discoloration of extremities. Appears ill, temp = 97.5, pulse = 160, resp = 52, BP = 60/36 in upper extremities and unobtainable in lower extremities. Skin, mucous membranes, and nail beds are dusky, and there is mottled discoloration of the extremeties. Moderate intercostal retractiosn and grunting. Lungs clear. Holosystolic murmuc along left sternal border. Liver edge palpable 4cm below costal margin.
pH = 7.15, CO2 = 28, O2 = 98
Intubation, mechanical ventilation, and iv fluid initiated, but no improvement one hour later. x-ray shows cardiomegaly and pulmonary congestion. Explanation of this condition?
a. closure of ductus arteriosus
b. deacreased pulm vascular resistance
c. increased pulm vascular resistance
d. intracardiac right to left shunt (I put this... Eisenmengers or TOF?)
e. opening of ductus arteriosus

this patient has hypo plastic left heart, i think. From what I googled and researched. He has increased flow to the plumonary which would not be in the case of TOF or Eisenmengers.

16 year old with the rash that looks like acne, started on his chin and then gradually is spreading over the face. No other abnormalities.
A. Allergic contact dermitis (this is what I put)
B. Herpes Simplex
C. Impetigo contagiosa
D. Tinea facei

 

[rcdamania]

thank u!! hypoplastic left heart smh nbme

 

[CodeRedDew]

From NBME Peds #1:
16 y/o athletic kid who has 1 week hx of itching/rash between 2nd/3rd toes of both feet comes in with a fever of 101. Has erythema and induration present from interdigital spaces to medial malleolus and groin lymphadenopathy. Asked which bug is causing his fever/pain?

I guess looking back on it I got tricked into haphazardly picking Trichophyton but I'm assuming the answer is Staph aureus (cellulitis?). Can someone confirm? Other choices were: E. coli, MTb, and pseudomonas.

 

[deleted564496]

From NBME Peds #1:
16 y/o athletic kid who has 1 week hx of itching/rash between 2nd/3rd toes of both feet comes in with a fever of 101. Has erythema and induration present from interdigital spaces to medial malleolus and groin lymphadenopathy. Asked which bug is causing his fever/pain?

I guess looking back on it I got tricked into haphazardly picking Trichophyton but I'm assuming the answer is Staph aureus (cellulitis?). Can someone confirm? Other choices were: E. coli, MTb, and pseudomonas.

Yup, S. aureus was correct.. I nearly picked Trichophyton as well.

Maybe I'm really over-thinking this, but I was confused on this one... Sorry if it's been asked, but it's a 3 y/o boy with increasing anorexia, apathy, poor coordination, and sporadic vomiting with a microchromic, hypochromic anemia and they ask what would have prevented this disease.. Delayed introduction of cows milk, supplemental iron, supplemental vitamins, removing lead from the house, or enrollment in an early intervention program.. It screams lead poisoning to me, but I got too hung on the anemia I think.

Does lead poisoning cause a microcytic/hypochromic anemia? I guess I did not think that it did, but the symptoms do not match an iron deficiency imo. Really just kind of confused on this one, I ended up picking supplemental iron thinking that since this kid is now three y/o so I don't think when he would have got cows milk would matter even if it was iron deficiency.

Any help would be great!

Also the kid with recurrent URIs + steatorrhea who is now snoring and they want to know the cause of it... Choices were nasal polyps, tonsillar hypertrophy, deviated septum, branchial cleft cyst, and respiratory muscle weakness.. Is this supposed to be a CF kid who has an associated nasal polyp? Wasn't sure, I automatically like to blame the tonsils... I had this problem 🙂

 

[Apoplexy__]

Yup, S. aureus was correct.. I nearly picked Trichophyton as well.

Maybe I'm really over-thinking this, but I was confused on this one... Sorry if it's been asked, but it's a 3 y/o boy with increasing anorexia, apathy, poor coordination, and sporadic vomiting with a microchromic, hypochromic anemia and they ask what would have prevented this disease.. Delayed introduction of cows milk, supplemental iron, supplemental vitamins, removing lead from the house, or enrollment in an early intervention program.. It screams lead poisoning to me, but I got too hung on the anemia I think.

Does lead poisoning cause a microcytic/hypochromic anemia? I guess I did not think that it did, but the symptoms do not match an iron deficiency imo. Really just kind of confused on this one, I ended up picking supplemental iron thinking that since this kid is now three y/o so I don't think when he would have got cows milk would matter even if it was iron deficiency.

Any help would be great!

Also the kid with recurrent URIs + steatorrhea who is now snoring and they want to know the cause of it... Choices were nasal polyps, tonsillar hypertrophy, deviated septum, branchial cleft cyst, and respiratory muscle weakness.. Is this supposed to be a CF kid who has an associated nasal polyp? Wasn't sure, I automatically like to blame the tonsils... I had this problem 🙂

Lead poisoning. The anemia I think is usually normocytic (hemolytic), but if it causes sideroblastic anemia, that could be hypochromic+microcytic.

Yeah, it's CF. The recurrent URIs and steatorrhea are too serious to be considered unrelated (and therefore to consider something benign like the tonsils).

 

[Boostedhoo]

Lead poisoning. The anemia I think is usually normocytic (hemolytic), but if it causes sideroblastic anemia, that could be hypochromic+microcytic.

Yeah, it's CF. The recurrent URIs and steatorrhea are too serious to be considered unrelated (and therefore to consider something benign like the tonsils).

my understanding is that lead blocks steps in porphyrin pathway leading to decreased hemoglobin production, hence the hypochromia.

 

[starstarie]

Hey all! I needed some help with the following:

3 yo F with failure to thrive. 3mo hx of large, greasy stools. Hx of delayed meconium (at 3 days of age). Clear lungs.

a. Hirschprungs (wrong)
b. biliary atresia
c. dilated lymphatic vessles
d. exocrine pancreatic insufficiency (could this be right... CF? I thought with the clear lung exam it wouldn't be though?)
e. parasitic infection (?? giardia?)
f. villous atrophy of small bowel

 

[Cytarabine]

Hey all! I needed some help with the following:

3 yo F with failure to thrive. 3mo hx of large, greasy stools. Hx of delayed meconium (at 3 days of age). Clear lungs.

a. Hirschprungs (wrong)
b. biliary atresia
c. dilated lymphatic vessles
d. exocrine pancreatic insufficiency (could this be right... CF? I thought with the clear lung exam it wouldn't be though?)
e. parasitic infection (?? giardia?)
f. villous atrophy of small bowel

I don't believe you'd get greasy stools with hirschsprung

 

[IncognitoGuy]

I got all of them right except the second one that has already been discussed. I also thought the aspirin overdose was just resp alkalosis since it had only been 20 min.

About this one, the question states that the kid was brought in 20 minutes after the mother found the child with symptoms. The mom did not witness the child taking the aspirin so I think we were supposed to be cued into the fact that they're into later stages of salicylate toxicity, which is the mixed met-acid/resp alk.

 

[IncognitoGuy]

Hey all! I needed some help with the following:

3 yo F with failure to thrive. 3mo hx of large, greasy stools. Hx of delayed meconium (at 3 days of age). Clear lungs.

a. Hirschprungs (wrong)
b. biliary atresia
c. dilated lymphatic vessles
d. exocrine pancreatic insufficiency (could this be right... CF? I thought with the clear lung exam it wouldn't be though?)
e. parasitic infection (?? giardia?)
f. villous atrophy of small bowel

It's D. Delayed meconium + hx of greasy stools + FTT is basically CF until proven otherwise.

 

[MD4L1f3]

Anybody know the answer to this and explanation?

4) 14 y/o girl had a 4 min generalized tonic clonic seizure occurred at a bar. pt arousable but confused. Fever of 102. Deep tendon reflexes present, babinsiki present bilaterally. most common organism?

1. arbovirus
2. borrelia burgdorferi
3. cytomegalovirus
4. enterovirus
5. herpes simplex virus
6. hiv
7. listeria monocytogenes
8. rickettsia rickettsii
9. toxoplasma gondii
10. varicella zoster virus

 

[MD4L1f3]

Another one:
8 month old girl with persistent diarrhea for a month. 2.2lb weight loss. multiple episodes of thrush and recent hospitalization for parainfluenza. 40th percentile height, 5th for weight. 99F temp, thick white plaques over buccal mucosa. grade 3/6 harsh systolic murmur at left sternal border. What is deficiency?

a. mucosal immunoglobulin (wrong)
b. NADPH oxidase
c. segmented neutrophils
d. serum complement
e. t lymphocytes

 

[Apoplexy__]

Anybody know the answer to this and explanation?

4) 14 y/o girl had a 4 min generalized tonic clonic seizure occurred at a bar. pt arousable but confused. Fever of 102. Deep tendon reflexes present, babinsiki present bilaterally. most common organism?

1. arbovirus
2. borrelia burgdorferi
3. cytomegalovirus
4. enterovirus
5. herpes simplex virus
6. hiv
7. listeria monocytogenes
8. rickettsia rickettsii
9. toxoplasma gondii
10. varicella zoster virus

HSV. The key clue is the seizure presentation, suggesting temporal lobe involvement. They give you confirmation of this with the CT involvement in the temporal lobes. Recall that HSV classically localizes here.

Another one:
8 month old girl with persistent diarrhea for a month. 2.2lb weight loss. multiple episodes of thrush and recent hospitalization for parainfluenza. 40th percentile height, 5th for weight. 99F temp, thick white plaques over buccal mucosa. grade 3/6 harsh systolic murmur at left sternal border. What is deficiency?

a. mucosal immunoglobulin (wrong)
b. NADPH oxidase
c. segmented neutrophils
d. serum complement
e. t lymphocytes

T lymphocytes (DiGeorge syndrome). You could arrive at the answer by seeing the T cell deficiency pattern of opportunistic infections (fungal and viral infections -- remember this because the thrush presents just like AIDS). Or, you could notice the cardiac defect and combine it with immunodeficiency to arrive at the answer.

 

[MD4L1f3]

HSV. The key clue is the seizure presentation, suggesting temporal lobe involvement. They give you confirmation of this with the CT involvement in the temporal lobes. Recall that HSV classically localizes here.



T lymphocytes (DiGeorge syndrome). You could arrive at the answer by seeing the T cell deficiency pattern of opportunistic infections (fungal and viral infections -- remember this because the thrush presents just like AIDS). Or, you could notice the cardiac defect and combine it with immunodeficiency to arrive at the answer.

Thanks, appreciate it. Makes sense now.

 

[1dayatatime]

15 year old boy examination before school basketball participation. 5 year history of well control type 1 diabetes. Uses 25 units of intermediate acting insulin and 12 units of short acting insulin every morning and 15 units of intermediate acting insulin and 7 units of short acting insulin each afternoon. Hemoglobin a1c 6.5% 2 weeks ago. Examination on remarkable. If you request advice about how to decrease his risk of diabetes related complications during his basketball practices what is the most appropriate recommendations?

A decrease the insulin dosage by 10 to 15% only on practice days
b limit exercise to 30 minutes
c measure urine glucose concentration every 30 minutes during exercise
d only participate in non contact sport
E switch to short acting insulin

 

[1dayatatime]

3 month old boy two day history of fever and irritability. Previous well child examinations normal. 50 percentile for length-weight head circumference. 100.6 degrees Fahrenheit temperature, pulse 130 / minute, respirations 26, blood pressure 85 over 50. He is fussy. Urine obtained by catheterization. Urine analysis shows protein 1 + , red blood cells 0 to 3, white blood cells 20 to 50, bacteria few gram negative rods. Urine culture grows greater than 100,000 colonies of e.coli. Treatment with antibiotics is begun. Which of the following is the most appropriate next step in diagnosis?
A. Ivp
C renal ultrasound
d CT scan abdomen
e dimercapto succinic acid scan