1.

A 5-year-old girl is brought to the physician because of temperatures to 40 C (104 F), tachypnea,
and a nonproductive cough for 12 hours. Four days ago she was treated with an oral antibiotic for
suspected pneumococcal pneumonia. Examination shows diminished breath sounds over the
lower right lung fields and dullness to percussion at the right costophrenic angle. Which of the
following is the most likely diagnosis?

A ) Bronchopleural fistula
B ) Empyema *
C ) Lung abscess
D ) Pleurodynia
E ) Pneumothorax

2. A 5-month-old boy is brought for a follow-up examination. He was born at 37 weeks' gestation
and has had persistent wheezing since shortly after birth despite treatment with nebulized and
oral bronchodilators and oral corticosteroids. His diet consists of 32 ounces of iron-fortified cow's
milk-based formula daily. He appears well nourished and happy. On examination, there is
moderate relief of wheezing with extension of the neck. Which of the following is the most likely
mechanism of this infant's wheezing?

A ) Allergic reaction to cow's milk

B ) Aspiration of a foreign body
C ) Compression of the airway by a vascular ring *
D ) Concurrent upper respiratory tract infection
E ) Persistent immaturity of lungs

3. An 18-month-old boy is brought to the emergency department because he has not used his left
arm since he fell while walking and holding hands with his 8-year-old sister 2 hours ago. On
examination, he holds his left upper extremity at his side with his forearm pronated. There is no
tenderness of the left lower extremity, but there is restricted movement of the elbow. The
remainder of the examination shows no abnormalities. Which of the following is the most
appropriate initial step in management?

A ) Passive hypersupination of the forearm *

B ) Application of figure-of-8 strap
C ) Administration of analgesics and application of ice
D ) Aspiration of the elbow joint
E ) In-place splint immobilization of the elbow
4. A 6-month-old girl is brought to the physician for a routine health maintenance examination. She
was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age.
The anterior fontanelle is 6 x 8 cm and bulging, and the posterior fontanelle is 3 x 4 cm and
bulging. She has severe motor and sensory deficits involving both lower extremities. A head
growth chart shows the following values:

Age Head circumference (cm)

Birth 34.2
1 month 36.6
2 months 38
4 months 44
6 months 47

Which of the following is the most likely cause of increased intracranial pressure?

A ) Acute cerebral edema

B ) Decreased absorption of cerebrospinal fluid
C ) Dilation of cerebral arteries
D ) Intracranial mass lesion
E ) Obstruction of lateral sinus
F ) Obstruction of superior vena cava
G ) Obstruction of cerebrospinal fluid flow *
H ) Overproduction of cerebrospinal fluid

5. A 6-year-old girl is brought to the physician because of a 4-week history of headache, fatigue,
and decreased appetite. During this period, she has had nausea and vomiting. At the age of 4
years, she was diagnosed with poststreptococcal glomerulonephritis. She is at the 15th percentile
for height and the 10th percentile for weight. Examination shows no abnormalities. Her serum
urea nitrogen (BUN) level is 50 mg/dL. Which of the following is most likely to limit progression of
this patient's renal failure?

A) Increased potassium and sodium bicarbonate intake

B) Decreased sodium and daily calorie intake
C) Low-protein diet *
D) Strict fluid restriction
E) Dialysis
6. A previously healthy 3-month-old girl is brought to the emergency department because of a 3-
day history of grunting and increasing difficulty breathing. She appears ill. Her temperature is
36.7 C (98 F), pulse is 160/min, and respirations are 76/min. Examination shows grunting, nasal
flaring, and marked intercostal retractions. Bronchial breath sounds and occasional bilateral
crackles are heard on auscultation. Serum studies show:

Ca2+ 5.6 mg/dL

Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L

Capillary blood gas analysis on 100% oxygen:

pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg

An x-ray film of the chest shows bilateral, diffuse interstitial infiltrates and absence of the thymic
shadow. Bronchoalveolar lavage is positive for numerous Pneumocystis carinii. Which of the
following is the most likely mechanism of these findings?

A ) Adenosine deaminase deficiency

B ) Consumption of complement
C ) Defective opsonization
D ) Destruction of CD4+ T lymphocytes
E ) Developmental arrest of maturation of B lymphocytes
F ) Dysmorphogenesis of the third and fourth pharyngeal pouches *
G ) Impaired chemotaxis
H ) Impaired phagocytic oxidative metabolism

7. A 4-year-old boy is brought to the emergency department 20 minutes after being involved in a
motor vehicle collision. He was an unrestrained passenger. On arrival, his blood pressure is
110/70 mm Hg, pulse is 100/min, and respirations are 32/min with grunting and retractions.
Examination shows multiple bruises over the chest. Arterial blood gas analysis while breathing
40% oxygen shows:

pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg

An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the right side. Which
of the following is the most likely diagnosis?

A) Acute respiratory distress syndrome

B) Aspiration pneumonia
C) Fat embolism
D) Hemothorax
E) Pulmonary contusion *
8. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants.
Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal
areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no
visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her
hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live
with them and who has never been left alone with the girl. They live with the mother's 27-year-
old brother who only baby-sits the children when they are asleep. Which of the following is the
most appropriate next step in management?

A) Psychiatric assessment of the mother

B) DNA typing of the mother's palmar wart for papillomavirus
C) Treatment of the mother's palmar wart
D) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the
child*
E) Laser therapy of the condylomata acuminata in the child

9. A 16-year-old girl is brought to the physician because of episodes of palpitations over the past 6
months. The episodes occur when she runs or plays basketball. She is otherwise asymptomatic.
Her blood pressure is 124/46 mm Hg, pulse is 78/min, and respirations are 18/min. She weighs
55 kg (121 lb) and is 180 cm (71 in) tall. Her arm span is 188 cm (74 in), and the upper segment
to lower segment ratio is 0.85. Her fingers appear long and are hyperextensible. A grade 4/6,
early diastolic murmur is heard along the upper and middle left sternal border with radiation to
the apex. Peripheral pulses are bounding. Which of the following is the most likely cause of these
findings?

A) Aortic incompetence *
B) Aortic stenosis
C) Mitral incompetence
D) Mitral stenosis
E) Pulmonary incompetence
F) Pulmonary stenosis
G) Tricuspid incompetence
H) Tricuspid stenosis

10. A previously healthy 4-year-old girl is brought to the physician because of fever and refusal to
walk for 1 day. She appears mildly ill. Her temperature is 38.6 C (101.5 F), pulse is 120/min, and
respirations are 22/min. The right knee is erythematous and swollen. She holds her right knee in
flexion and resists any attempted movement of her right leg. She cries when the right knee is
moved. Which of the following is the most appropriate next step in management?

A) Acetaminophen with codeine therapy

B) Arthrocentesis *
C) Bone marrow aspiration
D) Bone scan
E) Immobilization and traction
F) Lyme titer
G) MRI of the spine
H) Physical therapy
I) Reassurance
J) Serum rheumatoid factor assay
K) Systemic antibiotic therapy
11. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of
increasing academic problems. His parents say that he has always been hyperactive and
distractible, but now his academic performance has deteriorated to the point that he is failing
ninth grade. His teachers say that his hyperactivity is disrupting the classroom. He weighs 54 kg
(120 lb) and is 152 cm (60 in) tall. Sexual development is Tanner stage 5; examination shows
macro-orchidism, which was not shown on previous examinations. He has a high forehead and
long, protruding ears. He exhibits poor eye contact during the examination. Psychoeducational
testing shows an IQ of 70. Which of the following is the most likely diagnosis?

A) Attention-deficit/hyperactivity disorder
B) Autistic disorder
C) Down syndrome
D) Fetal alcohol syndrome
E) Fragile X syndrome *
F) Lesch-Nyhan syndrome
G) Pervasive developmental disorder, not otherwise specified
H) Prader-Willi syndrome
I) Rett's disorder
J) Seminiferous tubule dysgenesis (Klinefelter's syndrome)

12. A 5-week-old boy is brought to the physician because of vomiting for 3 days. Switching from a
cow's milk-based formula to a soy-based formula and one bottle of an electrolyte solution has not
decreased his vomiting. His mother says that there is no yellow color to the vomitus, but it is
forceful and occurs immediately after he has had 1 to 2 ounces of liquid. He appears to vomit
more liquid than he drank. He has one mustard-colored seedy stool daily. Examination shows no
abnormalities. Which of the following is the most likely explanation for his vomiting?

A) Duodenal atresia
B) Gastroesophageal reflux
C) Hypertrophic pyloric stenosis
D) Lactose intolerance *
E) Protein malabsorption
F) Rotavirus infection

13. A 10-year-old girl is brought to the emergency department because of diffuse, aching abdominal
pain, nausea, and recurrent vomiting over the past 5 hours. She has an 8-year history of type 1
diabetes mellitus treated with 20 U of NPH and 6 U of regular insulin in the morning and 14 U of
NPH and 5 U of regular insulin in the evening. She appears lethargic but is easily arousable.
There is an obvious odor of ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is
95/min, and respirations are 20/min and deep. Serum studies show:

Na+ 142 mEq/L

K+ 5.3 mEq/L
HCO3– 6 mEq/L
Glucose 710 mg/dL

Which of the following laboratory findings is most likely to be increased?

A ) Arterial pH
B ) Serum C-peptide level
C ) Serum magnesium level
D ) Serum osmolality *
E ) Serum phosphorus level
14. A 5-year-old girl with a ventricular septal defect is scheduled for tonsillectomy in 2 weeks. She
has no known drug allergies. Her temperature is 37 C (98.6 F). Examination shows no
abnormalities. Which of the following is the most appropriate prophylaxis prior to tonsillectomy?

A) Amoxicillin *
B) Ciprofloxacin
C) Rifampin
D) Tetracycline
E) Trimethoprim-sulfamethoxazole
F) No prophylaxis indicated

15. A 3-year-old boy who is HIV positive is brought for a routine examination. His diet is appropriate
for age. His medications include three antiretroviral drugs and trimethoprim-sulfamethoxazole for
Pneumocystis carinii prophylaxis. Laboratory studies show:

Hemoglobin 8.6 g/dL

Mean corpuscular hemoglobin 38 pg/cell
Mean corpuscular hemoglobin concentration 30% Hb/cell
Mean corpuscular volume 101 μm3
Leukocyte count 5600/mm3
Segmented neutrophils 60% (many hypersegmented)
Bands 3%
Lymphocytes 37%
Red cell distribution width 21% (N=10–16)

Which of the following is most likely to have prevented this patient's anemia?

A) Folic acid supplementation *

B) Iron supplementation
C) Thyroid supplementation
D) Vitamin B12 (cyanocobalamin) supplementation
E) Monthly intravenous immune globulin therapy

16. An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency department 10
minutes after being involved in a motor vehicle collision. She was in the back seat of a small
automobile that was rear-ended. Initially, she was alert during transport and reported bilateral
thigh pain, but then she stopped talking, closed her eyes, and became unresponsive to voice; on
arrival, she responds to noxious stimuli with brief grimaces and no withdrawal. Her blood
pressure is 40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air entry is
symmetric. The pupils are equal and react to light. No cardiac murmur is heard. The abdomen is
soft. There is swelling of the upper portions of both thighs. Her hematocrit is 37%. Which of the
following is the most appropriate next step in management?

A) Measurement of arterial blood gases

B) X-ray film of the chest
C) CT scan of the head
D) Administration of 50% dextrose in water
E) Infusion of 0.9% saline *
17. A previously healthy 16-year-old boy is brought to the emergency department 20 minutes after
an episode of left arm shaking that lasted approximately 3 minutes. Over the past 2 days, he has
had fever and emotional lability. On arrival, his temperature is 38.9 C (102 F). He is somnolent
and disoriented to person, place, and time. He responds poorly to pain. Neurologic examination
shows no other abnormalities. Laboratory studies show:

Hematocrit 34%
Leukocyte count 6000/mm3
Segmented neutrophils 50%
Lymphocytes 50%
Platelet count 280,000/mm3

Analysis of cerebrospinal fluid shows:

Leukocyte count 120/mm3
Segmented neutrophils 20%
Lymphocytes 80%
Erythrocyte count 300/mm3
Glucose 60 mg/dL
Protein 400 mg/dL

Which of the following is the most likely cause of this patient's neurologic findings?

A) Bacterial infection
B) Congenital malformation
C) Fungal infection
D) Hemorrhage
E) Immune-mediated demyelination
F) Parasitic infection
G) Viral infection *

18. A 15-year-old boy is brought to the emergency department 30 minutes after a 2-minute episode
of loss of consciousness after completing a 400-meter race. On awakening, he says that he feels
fine except for shortness of breath. He weighs 82 kg (180 lb) and is 191 cm (75 in) tall. His blood
pressure is 110/70 mm Hg, pulse is 70/min and regular, and respirations are 15/min. The lungs
are clear to auscultation. A grade 2/6 systolic murmur is heard at the left sternal border with
minimal radiation to the neck; the murmur becomes louder when he stands.

For each patient with loss of consciousness, select the most likely diagnosis.

A) Aortic stenosis
B) Carotid sinus hypersensitivity
C) Conversion reaction
D) Hypertrophic obstructive cardiomyopathy *
E) Hypoglycemia
F) Mitral valve prolapse
G) Orthostatic hypotension
H) Pulmonary embolus
I) Seizure
J) Vasovagal syncope
K) Vertebrobasilar insufficiency
19. A 3-year-old boy is brought to the physician because of a 7-day history of fever and a painful
swollen lymph node in his groin. This is his sixth episode of lymph node swelling; the previous
episodes resolved after drainage and prolonged antibiotic therapy. He also had pneumonia at the
age of 12 months that required chest tube placement for drainage. A maternal uncle died during
childhood of recurrent infections. The patient is at the 5th percentile for height and weight. His
temperature is 38.5 C (101.3 F). Examination shows a warm, tender, erythematous lymph node
in the right inguinal area. There are several healed incisions over the inguinal area and neck from
old drainage sites. Laboratory studies show:

Hematocrit 35%
Leukocyte count 17,000/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 25%
Platelet count 350,000/mm3

A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils filled with
bacteria; cultures grow Staphylococcus aureus. Which of the following is the most likely
mechanism for these findings?

A) Adenosine deaminase deficiency

B) Consumption of complement
C) Defective opsonization
D) Destruction of CD4+ T lymphocytes
E) Developmental arrest of maturation of B lymphocytes
F) Dysmorphogenesis of the third and fourth pharyngeal pouches
G) Impaired chemotaxis
H) Impaired phagocytic oxidative metabolism *

20. A newborn is in severe respiratory distress immediately following delivery. She was born at 35
weeks' gestation to a 35-year-old woman, gravida 2, para 1, aborta 1, who did not receive
prenatal care. The newborn's pulse is 60/min, and respirations are irregular and labored.
Examination shows pallor with perioral cyanosis, anasarca, hepatosplenomegaly, and scattered
petechiae. Cord blood hemoglobin is 4 g/dL, and reticulocyte count is 18%. A direct antiglobulin
(Coombs') test is positive. Which of the following sets of blood groups is most likely in the mother
and her newborn?

Mother Newborn

A) A, Rh-positive O, Rh-positive
B) A, Rh-positive O, Rh-negative
C) A, Rh-negative O, Rh-negative
D) O, Rh-positive O, Rh-negative
E) O, Rh-negative O, Rh-positive *
21. A 3-year-old boy is brought for a follow-up examination. He just completed a 10-day course of
amoxicillin that has not resolved his right ear pain. He appears irritable. His temperature is 38.9
C (102 F). Examination shows downward and lateral displacement of the right auricle with
tenderness to palpation of the posterior auricular area; his neck is supple. Which of the following
is the most appropriate next step in diagnosis?

A) Bone scan
B) CT scan of the head *
C) Tympanometry
D) Lumbar puncture
E) Tympanocentesis

22. A 14-month-old girl is brought to the physician because of a 14-hour history of irritability and
episodes of drawing her knees toward her chest. During this period, she has vomited nonbilious
fluid twice and had a bowel movement containing a small amount of blood. She had an upper
respiratory tract infection 2 weeks ago. She is listless except for intermittent episodes of
discomfort. Her temperature is 38 C (100.4 F). Abdominal examination shows right-sided
tenderness without guarding or rebound; bowel sounds are present. Rectal examination shows
bright red blood and mucus. An x-ray film of the abdomen shows no abnormalities. Which of the
following is the most appropriate next step in management?

A) X-ray film of the upper gastrointestinal tract with contrast

B) Water-soluble contrast enema *
C) Corticosteroid enemas
D) Admission to the hospital for total parenteral nutrition
E) Immediate laparotomy

23. On a routine examination, a 2-year-old boy has a hemoglobin level of 10.5 g/dL, hematocrit of
30%, and mean corpuscular volume of 72 μm3. He drinks four to five 8-oz bottles of milk daily.
He maintains a regular diet but does not eat vegetables. Which of the following is the most likely
diagnosis?

A) Folic acid deficiency

B) Iron deficiency *
C) Sickle cell disease
D) Thalassemia
E) Vitamin B6 deficiency

24. A 28-month-old boy has a history of cyanosis since birth with episodes of syncope. Examination
shows cyanosis and clubbing. The lungs are clear to auscultation. There is a right ventricular
heave, a systolic click, a single S2, and a grade 3/6 systolic murmur. Which of the following is the
most likely diagnosis?

A) Bicuspid aortic valve

B) Coarctation of the aorta
C) Mitral stenosis
D) Patent ductus arteriosus
E) Tetralogy of Fallot *
25. A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She has
had several similar episodes since the age of 4 months. Three months ago, she and her family
visited her grandmother in Finland for 2 weeks. She is at the 25th percentile for length and 5th
percentile for weight. She appears thin and pale. Her temperature is 38 C (100.4 F), pulse is
150/min, and respirations are 40/min. Examination shows mild clubbing. Wheezing and bilateral
crackles are heard at the lung bases. An x-ray film of the chest shows streaky densities bilaterally
with mild hyperinflation.

A) α1-Antitrypsin deficiency
B) Cystic fibrosis *
C) Pneumothorax
D) Pulmonary alveolar proteinosis
E) Pulmonary aspergillosis
F) Pulmonary hemorrhage
G) Pulmonary tuberculosis

26. A previously healthy 16-year-old boy is brought to the physician because of fever and cough with
right-sided chest pain for 2 weeks. Six months ago, he visited his grandparents in Albania for 2
weeks. He weighs 54 kg (120 lb) and is 173 cm (68 in) tall. He appears thin and pale. His
temperature is 38.2 C (100.8 F), pulse is 76/min, and respirations are 36/min. Examination
shows shallow respirations with decreased breath sounds at the right lung base. An x-ray film of
the chest shows a right pleural effusion and hilar adenopathy.

A) α1-Antitrypsin deficiency
B) Cystic fibrosis
C) Pneumothorax
D) Pulmonary alveolar proteinosis
E) Pulmonary aspergillosis
F) Pulmonary hemorrhage
G) Pulmonary tuberculosis *
27. 7-day-old newborn is brought for a well-child examination. He was born at home. His mother has
taken acetaminophen for perineal discomfort. The newborn is breast-feeding well. He is at the
75th percentile for length and weight. Examination shows no abnormalities. After vaccination with
hepatitis B, he has prolonged bleeding at the injection site. There is no family history of excessive
bleeding. Laboratory studies show:

Hemoglobin 16 g/dL
Leukocyte count 6800/mm3
Segmented neutrophils 48%
Bands 2%
Lymphocytes 50%
Platelet count 280,000/mm3
Prothrombin time 20 sec (INR=1.6)
Partial thromboplastin time 60 sec

Which of the following is the most likely mechanism for these findings?

A) Autoimmunization
B) Bacterial toxic effect
C) Factor VIII deficiency
D) Factor IX deficiency
E) Immunoglobulin deficiency
F) Iron deficiency
G) Pharmacologic effect
H) Viral toxic effect
I) Vitamin deficiency *

28. A healthy 7-year-old boy is brought to the physician 1 week after he was exposed for several
hours to a child with chickenpox. The patient and his healthy sister have not had chickenpox.
They have not received varicella vaccine. Which of the following is the most appropriate
management for the patient and his sister at this time?

A) Administer acyclovir as prophylaxis

B) Administer immune globulin, intravenously
C) Administer aspirin therapy if vesicles appear
D) Advise the parents to keep the siblings home from school to prevent exposing their classmates
E) Inform the parents that a vesicular rash may appear at any time over the next 2 weeks *

29. A 6-year-old boy is brought to the physician by his mother because of progressive visual loss over the
past year. Over the past 2 years, he has had deterioration of his hearing, speech, writing, and
intellectual performance. His maternal uncle had similar symptoms. Visual acuity is 20/200 bilaterally.
Funduscopic examination shows optic atrophy. His hearing is markedly impaired. There is weakness
and spasticity of all extremities. Deep tendon reflexes are extremely hyperactive. Babinski's sign is
present bilaterally. On mental status examination, he is not oriented to place, year, month, or the
names of his siblings. An MRI of the brain shows marked symmetric white matter disease involving all
lobes. Diagnostic studies are most likely to show which of the following?

A) Abnormally decreased serum cholesterol level

B) Acanthocytes on blood smear
C) An excess of very long chain fatty acids*
D) Normal nerve conduction studies
E) Vitamin E deficiency
30. A 5-year-old boy is brought to the emergency department 30 minutes after he fainted at home
after standing up from a sitting position. His symptoms began 3 days ago with diarrhea and
vomiting. He has had no urine output for 18 hours. He is alert but quiet. His temperature is 37.5
C (99.5 F), blood pressure is 75/45 mm Hg, pulse is 120/min, and respirations are 28/min.
Examination shows dry lips and tenting of the skin. There is no abdominal tenderness. Bowel
sounds are hyperactive. The remainder of the examination shows no abnormalities. His capillary
refill time is 5 seconds. Intravenous bolus doses of 0.9% saline are administered. Bladder
catheterization yields 5 mL of urine. Urinalysis is most likely to show which of the following?

A) Blood
B) Erythrocyte casts
C) Hyaline casts *
D) Leukocyte casts
E) Oxalate crystals

31. A 2-year-old boy is brought to the physician because of fever and cough for 2 days. He had
Streptococcus pneumoniae meningitis at the age of 1 year, S. pneumoniae bacteremia at the age
of 18 months, and pneumonia at the age of 22 months. Two maternal uncles died before the age
of 2 years from "infection." His temperature is 39.8 C (103.6 F), pulse is 150/min, and
respirations are 60/min. Examination shows subcostal retractions on inspiration. Laboratory
studies show:

Hemoglobin 10 g/dL
Leukocyte count 36,000/mm3
Segmented neutrophils 70%
Bands 20%
Lymphocytes 8%
Monocytes 2%
Platelet count 240,000/mm3
Serum
IgA <5 mg/dL
IgG 30 mg/dL
IgM <5 mg/dL

An x-ray film of the chest shows an infiltrate in the left upper lobe. Which of the following is the
most appropriate next step in management?

A) Reexamination in 12 weeks
B) Prednisone therapy only
C) Prednisone, vincristine, doxorubicin, asparaginase, and methotrexate therapy
D) Zidovudine (AZT), lamivudine (3TC), and ritonavir therapy
E) Intravenous immunoglobulin infusion *
F) Bone marrow transplantation
G) Thymus transplantation
32. A previously healthy 13-year-old girl is brought to the physician because of a 2-month history of
intermittent abdominal pain and loose stools. She has had a 2.3-kg (5-lb) weight loss during this
period due to a decreased appetite, but she drinks up to 1 liter of fruit juice daily. At her last visit
9 months ago, she was at the 50th percentile for height and the 50th percentile for weight. She is
now at the 50th percentile for height and the 10th percentile for weight. Her temperature is 37.8
C (100 F), pulse is 80/min, and respirations are 18/min. Examination shows no other
abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:

Hemoglobin 8.5 g/dL

Leukocyte count 9100/mm3
Segmented neutrophils 55%
Lymphocytes 35%
Monocytes 10%
Platelet count 650,000/mm3
Erythrocyte sedimentation rate 75 mm/h

Serum

Na+ 139 mEq/L

Cl– 101 mEq/L
K+ 3.2 mEq/L
HCO3– 23 mEq/L
Urea nitrogen (BUN) 8 mg/dL
Glucose 73 mg/dL
Creatinine 0.2 mg/dL

A barium enema shows patches of ulcerations along the proximal colon with reflux of dye into the
terminal ileum. Which of the following is the most appropriate next step in management?

A) Eliminate fruit juice from the patient's diet

B) Switch to a gluten-free diet
C) H2- receptor blocking agent therapy
D) Prednisone and aminosalicylate therapy *
E) Bowel resection

33. An otherwise healthy 4-month-old girl is brought to the physician because of a birthmark on her
arm that has increased in size over the past several weeks. Examination shows a 3 x 2-cm, bright
red, raised, soft, nontender, compressible patch over the left forearm. Which of the following is
the most appropriate next step in management?

A) Topical corticosteroid therapy

B) Biopsy
C) Laser therapy
D) Excision
E) No intervention is necessary *
34. A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1
day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination
shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no
significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of
the following is the most appropriate next step in management?

A) Monospot test *
B) Throat culture
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy

35. A 6-month-old girl is brought to the physician because of poor feeding and labored breathing for
2 months. She has had recurrent respiratory tract infections since birth. Examination shows a to-
and-fro murmur in the second left intercostal space, a loud S2, bounding peripheral pulses, and a
widened pulse pressure. Which of the following is the most likely diagnosis?

A) Atrial septal defect (ostium primum type)

B) Atrial septal defect (ostium secundum type)
C) Atrioventricular canal
D) Coarctation of the aorta
E) Hypoplastic left heart syndrome
F) Patent ductus arteriosus *
G) Tetralogy of Fallot
H) Transposition of the great arteries
I) Tricuspid atresia
J) Ventricular septal defect

36. A 6-month-old boy is brought to the physician because of respiratory distress for 1 day. He had a
persistent dry cough 3 days ago. He has not had a fever or nasal discharge, but he has had
chronic watery stools. He is at the 50th percentile for height and 10th percentile for weight. He
appears ill and is in respiratory distress. His temperature is 37 C (98.6 F), pulse is 140/min, and
respirations are 78/min. Pulse oximetry shows an oxygen saturation of 70% while breathing room
air. Examination shows white plaques on the mucous membranes of his mouth and diffuse
adenopathy. There are intercostal retractions, and diffuse crackles are heard throughout all lung
fields. In addition to oxygen and antibiotic therapy, which of the following is the most appropriate
next step in management?

A) Stool culture for bacterial pathogens

B) Urinalysis
C) HIV testing *
D) Quantitative measurement of immunoglobulins
E) Nitroblue tetrazolium testing
F) Platelet morphology evaluation
G) Tympanocentesis