{"id" : 113, "question_text" : "You are caring for a 2-month-old infant who has hypoplastic left heart syndrome. He weighed 2,800 g at term birth. The baby has undergone the first stage of the multistage corrective surgical procedure. His medications include digoxin and furosemide to ameliorate congestive heart failure. He visited his cardiologist last week, where his weight was 3,250 g, and no changes in medication dosages were recommended. At the time of his office visit today, his parents report that the baby is taking 60 mL of a 24 kcal/30 mL cow milk protein-based formula every 4 hours, but he seems to tire easily. He spits up formula once or twice after each feeding. His weight today is 3,300 g. Of the following, the MOST appropriate recommendation for feeding this infant is", "options" : "[\"an every-2-hours feeding schedule\", \"an amino acid-based formula\", \"formula thickened with rice cereal\", \"medium-chain triglyceride supplements\", \"nasogastric feedings\"]"}
{"id" : 114, "question_text" : "You are examining a term infant on the second day after birth in the well-baby nursery. Her mother is 29 years old and has a remote history of heroin abuse. She had been in a methadone maintenance program throughout the pregnancy, taking 50 mg daily. On physical examination, the infant has mild tremors when disturbed, a normal Moro reflex, and normal muscle tone. Her heart rate is 130 beats/min, respiratory rate is 60 breaths/min, and temperature is 37.4°C. The nurse describes the infant as being slightly irritable, with poor bottle feeding and several intervals of sneezing overnight but no vomiting or loose stools. Neonatal abstinence scores using the Finnegan scoring system ranged from 5 to 7 over the past 24 hours. Of the following, the MOST appropriate treatment at this time for this infant is", "options" : "[\"diazepam\", \"morphine\", \"paregoric\", \"phenobarbital\", \"swaddling\"]"}
{"id" : 115, "question_text" : "A mother brings her 7-year-old son to your office because he is having pain from a sunburn. As part of his care, you discuss sun protection with the boy and his mother. Of the following, the MOST important information to provide is that", "options" : "[\"sun exposure in childhood sufficient to cause sunburn increases the risk of developing melanoma\", \"sunscreen is less important on cloudy than on sunny days\", \"sunscreen should not be used on babies younger than 6 months of age\", \"sunscreen with a minimum SPF rating of 45 is recommended for children\", \"ultraviolet B (UVB) protection is the only value to consider when choosing sunscreen\"]"}
{"id" : 116, "question_text" : "The intern rotating through the newborn nursery reports on rounds that she ordered a hematocrit measurement for a term newborn who appeared plethoric on physical examination at 6 hours of age. She suspects the infant has polycythemia, and the hematocrit is 65% (0.65). When you examine the infant, he appears to be a bit \"ruddy.\" Other findings on the examination are normal, including his vital signs; feeding and elimination patterns are also normal. You ask the intern what method she used to obtain the specimen, and she reports that a heelstick specimen was obtained. Of the following, the MOST appropriate method for confirming the hematocrit in this infant is to obtain a sample via", "options" : "[\"brachial artery\", \"peripheral venipuncture\", \"repeat heelstick\", \"umbilical artery\", \"umbilical vein\"]"}
{"id" : 117, "question_text" : "You are evaluating a 5-year-old boy who is hospitalized in the pediatric intensive care unit with findings of poor perfusion, renal failure, and respiratory compromise requiring intubation. You note an abnormality on the cardiac monitor (Item Q5). Of the following, the MOST likely cause of this patient's electrocardiographic findings is", "options" : "[\"hyperkalemia\", \"hypernatremia\", \"hypocalcemia\", \"hypokalemia\", \"hyponatremia\"]"}
{"id" : 118, "question_text" : "A term 3,500-g male infant is the admitted to the neonatal intensive care unit after a precipitous delivery in the emergency department to a gravida 34, para 4, 24-year-old woman who did not seek prenatal care. On physical examination, the infant has normal vital signs, a head circumference of 35.5 cm, and normal general examination findings. Twelve hours after birth, the nurse notes brief jerking of one of the infant's arms. Thirty minutes later, the other arm jerks and the nurse places a hand on the arm, noting that the jerking is not suppressible. Of the following, the MOST likely cause of the jerking is", "options" : "[\"benign neonatal myoclonus\", \"jitteriness due to drug withdrawal\", \"seizure due to cytomegalovirus infection\", \"seizure due to hypocalcemia\", \"seizure due to hypoxic-ischemic injury\"]"}
{"id" : 119, "question_text" : "Your local newborn screening laboratory notifies your office that a two-week old infant in your practice has an elevated phenylalanine level. A review of the infant's medical record reveals that the infant was seen in your office last week for a health supervision visit. The mother stated that the infant was breastfeeding well. The infant's physical examination was normal. Your next step in managing this patient would be to", "options" : "[\"begin the infant on a low phenylalanine formula\", \"order an assay for dihydropteridine reductase\", \"order an assay for urine pterins\", \"order plasma amino acids\", \"switch the infant to soy formula\"]"}
{"id" : 120, "question_text" : "The mother of one of your adolescent patients asks you about human papillomavirus (HPV) vaccination. She explains that she has just learned that HPV is the most common sexually-transmitted infectious agent and that there are vaccines available to prevent infection. In discussing this virus, you inform her that there are more than 100 strains of the virus but that the vaccines protect against the most important strains. Of the following, the MOST accurate specific information about HPV strains is that", "options" : "[\"type 43 causes most recurrent respiratory papillomatosis\", \"types 11 and 35 account for most cervical cancer\", \"types 16 and 18 account for most cervical cancer\", \"types 6 and 54 account for most anogenital warts\", \"types 43 and 44 account for most anogenital warts\"]"}
{"id" : 121, "question_text" : "You are evaluating an 8-month-old previously healthy infant who has a 3-day history of nonbilious vomiting, watery diarrhea, and decreased oral intake. He is sitting in his mother's lap and responds appropriately when you examine him. His heart rate is 120 beats/min, respiratory rate is 30 breaths/min, and blood pressure is 85/50 mm Hg, and he has palpable peripheral pulses. A capillary blood gas on room air reveals a pH of 7.22, PaCO2 of 25 mm Hg, and bicarbonate (HCO3) of 10 mEq/L (10 mmol/L). Initial electrolyte values are: Sodium, 141 mEq/L (141 mmol/L); Potassium, 4.0 mEq/L (4.0 mmol/L); Chloride, 120 mEq/L (120 mmol/L); Bicarbonate, 11 mEq/L (11 mmol/L); Glucose, 100 mg/dL (5.6 mmol/L). Of the following, the MOST likely cause of the infant's metabolic acidosis is", "options" : "[\"gastrointestinal loss of bicarbonate\", \"hypoaldosteronism\", \"new-onset diabetes mellitus\", \"renal failure\", \"septic shock\"]"}
{"id" : 122, "question_text" : "A 14-year-old boy suffers a nondisplaced fracture of his left radius and ulna while playing soccer. He had a similar injury to his right radius and ulna 9 months ago. Physical examination reveals Sexual Maturity Rating 2 pubic hair and testicular volume of 6 mL. A thorough review of his dietary habits suggests that his daily intake of calcium and phosphorus are 800 mg each. He takes a 400 IU of vitamin D supplement daily. Serum calcium measures 7.9 mg/dL (1.97 mmol/L), serum phosphorus measures 2.7 mg/dL (0.87 mmol/L), and 25-hydroxyvitamin D (25-OHD) measures 55 pg/mL (normal, 30 to 80 pg/mL). Of the following, the MOST appropriate recommendation for this boy is to increase his", "options" : "[\"calcium and phosphorus intake to 1,300 mg/day\", \"calcium and phosphorus intake to 2,000 mg/day\", \"calcium intake to 1,000 mg/day\", \"phosphorus intake to 1,000 mg/day\", \"vitamin D supplementation to 2,000 IU/day\"]"}
{"id" : 123, "question_text" : "A father brings in his daughter for a routine health supervision visit. The father quietly holds her in his lap while you call to her. She immediately turns toward you and begins to make babbling sounds. You respond by saying \"dada\" while pointing to the father. The girl begins to imitate the \"dada\" sounds. Of the following, these developmental milestones are MOST typical for a child whose age is", "options" : "[\"2 months\", \"4 months\", \"6 months\", \"9 months\", \"12 months\"]"}
{"id" : 124, "question_text" : "You are precepting a group of medical students and leading a discussion on vaccine-preventable diseases. One of the students asks you to describe how to differentiate varicella from smallpox in a child presenting with a vesicular rash. Of the following, the clinical feature MOST suggestive of smallpox is", "options" : "[\"abrupt onset of rash in a previously well child\", \"centripetal spread of the skin lesions\", \"involvement of the palms and soles with rash\", \"lesions in multiple stages on the same part of the body\", \"superficial nature of the skin vesicles\"]"}
{"id" : 125, "question_text" : "You are seeing an infant in the newborn nursery who was born this morning to a woman who has hepatitis C virus (HCV) infection. The infant is healthy. The mother wants to know if she should breastfeed her infant. Of the following, the MOST appropriate information to share with this mother is that", "options" : "[\"breastfeeding is contraindicated if the mother has evidence of liver dysfunction\", \"breastfeeding is contraindicated when a mother has HCV infection\", \"breastfeeding is recommended if the mother does not also have hepatitis B virus infection\", \"breastfeeding is recommended if the mother does not also have human immunodeficiency virus infection\", \"breastfeeding is recommended only if viral cultures of human milk show no evidence of HCV\"]"}
{"id" : 126, "question_text" : "A 1-day-old male infant fails to pass urine in the nursery. He was born at 37 weeks' gestation to a 30-year-old woman who received prenatal care. On physical examination, the infant exhibits mild tachypnea, wrinkling of the skin on the anterior abdominal wall (Item Q14), and undescended testicles. Of the following, the MOST useful test to diagnose the cause of anuria in this infant is", "options" : "[\"mercaptoacetyltriglycine (MAG-3) furosemide renal scan\", \"renal/bladder ultrasonography\", \"serum creatinine measurement\", \"urinalysis obtained by urethral catheterization\", \"voiding cystourethrography\"]"}
{"id" : 127, "question_text" : "A mother brings in her 12-month-old infant for evaluation. One month ago she transitioned him from human milk to a cow milk formula but noted that each time her son drank the formula, he developed a rash around his mouth and scattered hives on his trunk. After speaking with her pediatrician she switched to rice milk, which the infant has tolerated well. She reports that last week when her son accidently drank cow milk, he developed a perioral rash and vomited once. Of the following, you are MOST likely to counsel the mother that", "options" : "[\"bloody stools is a common presenting symptom\", \"he is unlikely to tolerate a soy-based formula\", \"he may tolerate foods containing cow milk if they are extensively heated\", \"he will most likely develop other food allergies\", \"negative allergy skin testing will exclude the diagnosis\"]"}
{"id" : 128, "question_text" : "An 18-month-old boy is brought to the office because he has been difficult to arouse for the past hour. His mother reports that earlier in the day she found him in his grandmother's room playing with her medicine bottles, but none of the bottles were opened. The mother explains that the grandmother takes \"pills for her heart.\" The child is somnolent and responsive only to pain. His temperature is 38.6°C, heart rate is 130 beats/min, respiratory rate is 56 breaths/min, and blood pressure is 90/60 mm Hg, and his pupils are midsized and reactive. The remainder of his physical examination findings are normal. Of the following, the MOST likely explanation for this child's symptoms is", "options" : "[\"aspirin ingestion\", \"intracranial hemorrhage\", \"lisinopril ingestion\", \"metoprolol ingestion\", \"sepsis\"]"}
{"id" : 129, "question_text" : "You are caring for a 7-year-old boy who developed a mid-gut volvulus at age 3, necessitating resection of most of his small bowel. Only 10 cm of ileum and a few centimeters of duodenum remain, and the child is dependent on parenteral nutrition for most of his protein-energy intake. He recently developed a cough and dyspnea on exertion. Physical examination demonstrates a gallop cardiac rhythm and the presence of rales at the lung bases. Chest radiography shows cardiomegaly. Of the following, the nutritional deficiency that is MOST likely responsible for this boy's symptoms and signs is", "options" : "[\"chromium\", \"copper\", \"manganese\", \"selenium\", \"zinc\"]"}
{"id" : 130, "question_text" : "You are seeing a 36-year-old primigravida in your office for a pediatric prenatal visit. She is presently at 32 weeks' gestation, and her pregnancy is complicated by chronic hypertension and smoking. She relates that her obstetrician has told her that she likely will need to be delivered by 36 weeks' gestation because \"my baby is not growing well.\" She has read in the newspaper that late preterm infants may have more medical problems than infants born at term and questions why her infant needs to be delivered so early. Of the following, you are MOST likely to advise this expectant mother that delivery at 36 weeks' gestation may decrease her baby's risk of", "options" : "[\"asphyxia\", \"hyperbilirubinemia\", \"hypoglycemia\", \"hypothermia\", \"polycythemia\"]"}
{"id" : 131, "question_text" : "A 3-year-old child presents with the sudden onset of labored breathing and a barking cough. His father explains that he was fine yesterday and had no respiratory symptoms. He has had two similar episodes in the past 18 months. Physical examination reveals a temperature of 37.2°C, respiratory rate of 28 breaths/min, and heart rate of 132 breaths/min. He has stridor with agitation, occasional suprasternal retractions, and clear lungs. Of the following, the MOST likely additional finding to expect for this boy is", "options" : "[\"a 5-mm hemangioma on his leg\", \"episodes of wheezing associated with past respiratory illnesses\", \"exposure to family members who have strep throat\", \"four past episodes of otitis media\", \"receipt of only two doses of Haemophilus influenzae type b vaccine\"]"}
{"id" : 132, "question_text" : "A game warden accompanies his wife, new baby, and 13-year-old stepson to the infant's 2-week health supervision visit. He explains that he must store the gun he is required to carry for his job at home, but he is concerned about the risks of having a gun in the home.\n\nOf the following, the BEST advice to give this father is to", "options" : "[\"enroll his stepson in a formal firearm safety course\", \"show the stepson how to handle the gun appropriately\", \"store the gun locked and loaded in a high, secret cabinet\", \"store the gun locked and unloaded with ammunition locked and stored separately\", \"store the gun unloaded in a locked gun safe with the ammunition stored adjacently\"]"}
{"id" : 133, "question_text" : "The mother of a 9-year-old boy in your practice requests a refill of his medications. He has a past history of disruptive behavior, irritability, and impulsivity for which a psychiatrist prescribed methylphenidate 10 mg three times a day and risperidone 0.5 mg daily. Both medications were initiated about 18 months ago. His mother says he is now relatively asymptomatic and has been doing \"OK\" in school for the past year The mother states that the psychiatrist did not share with her any specific diagnoses for the boy and he is no longer available for consultation. You note that the boy's weight has increased from 25 kg (25th percentile) to 40 kg (95th percentile) over the past year, with his height remaining at the 25th percentile (now 132 cm). His body mass index is now 23 (>95th percentile). You counsel the family on nutritional management.\n\nOf the following, the approach that is MOST likely to assist in his weight management is to", "options" : "[\"discontinue the risperidone\", \"increase his methylphenidate dosage to a total of 40 mg daily\", \"initiate metformin at 500 mg twice a day\", \"initiate topiramate at 50 mg every night at bedtime\", \"stop the risperidone and start olanzapine 2.5 mg daily\"]"}
{"id" : 134, "question_text" : "A 3-year-old girl presents to the emergency department with irritability and weakness that was followed by the development of nausea and vomiting and finally a seizure. Her mother reports that earlier in the day she found the girl playing in the medicine cabinet but did not see her take any pills. Physical examination reveals a toxic-appearing, febrile child who has hypertension, tachycardia, dilated pupils, hyperreflexia, reduced muscle strength, and abdominal tenderness. You order a toxicology panel.\n\nOf the following, the MOST likely cause of the child's clinical findings is an overdose of", "options" : "[\"acetaminophen\", \"amphetamines\", \"barbiturates\", \"digoxin\", \"narcotics\"]"}
{"id" : 135, "question_text" : "A 9-year-old boy who has acquired short stature presents to the emergency department with a headache and vomiting. He had been one of the tallest boys in his class in the first grade but now is one of the shortest. His clothing size has not changed in 18 months. Review of systems is positive for frequent nocturnal urination and negative for fever, stomach pain, and diarrhea. On physical examination, the boy appears well after vomiting, and general examination findings are within normal parameters. On neurologic examination, he converses appropriately. Visual field testing shows an apparent inability to count fingers in either lateral visual field. Extraocular movements are full, facial movements are symmetric, and tongue and palate movements are normal. Strength and reflexes are normal in all limbs. His gait is normal and not broad-based. Brain magnetic resonance imaging shows a midline mass with both cystic and enhancing solid components.\n\nOf the following, the MOST likely explanation of these findings is", "options" : "[\"brain abscess\", \"craniopharyngioma\", \"meningioma\", \"primitive neuroectodermal tumor\", \"subependymal giant cell astrocytoma\"]"}
{"id" : 136, "question_text" : "During the health supervision visit of a 5-year-old girl, her 37–year-old mother reports that she and her husband have decided to have another child. She states that since the birth of her daughter, she has been diagnosed with type 2 diabetes and requires insulin twice a day to control her blood glucose concentrations. She is monitoring her blood glucose carefully, and her hemoglobin A1C is less than 7.5%. She asks if her diabetes poses any additional risks for her pregnancy.\n\nOf the following, the MOST helpful piece of information that she should have before becoming pregnant is that", "options" : "[\"excellent maternal blood glucose control will prevent neonatal hypoglycemia and macrosomia\", \"her greatest risk of having a child with a birth defect is her age\", \"her risk of having a child with a birth defect is similar to a woman who has gestational diabetes\", \"second-trimester level II ultrasonography is recommended\", \"the most common birth defect occurs in the kidney\"]"}
{"id" : 137, "question_text" : "A sexually active girl presents with a slightly itchy, yellowish discharge and occasional dyspareunia. She says she is in a monogamous relationship, so they do not use condoms. Her boyfriend has no symptoms. Results of her external genital examination are normal. On speculum examination, the vaginal walls appear erythematous and a frothy discharge is present. The pH is 4.7, and you perform wet mount microscopy.\n\nOf the following, the MOST likely cause of this girl's vaginal discharge is", "options" : "[\"bacterial vaginosis\", \"Candida vaginalis\", \"Chlamydia trachomatis\", \"nonspecific vaginitis\", \"trichomoniasis\"]"}
{"id" : 138, "question_text" : "You are called to evaluate the abnormal laboratory findings for a 16-year-old boy who you admitted to the hospital yesterday for a presumed community-acquired pneumonia. The boy had been reported to be improving on the antibiotics you ordered, but his serum electrolyte results were abnormal this morning, so the resident on call obtained additional laboratory studies. On physical examination, the young man is alert and complains of no distress. His temperature is 37.0°C, heart rate is 80 beats/min, respiratory rate is 15 breaths/min, and blood pressure is 120/80 mm Hg. He reports that he has not urinated since yesterday afternoon. His skin turgor is normal, and you do not notice jugular venous distension or signs of edema. Results of his laboratory studies include:\n• Serum sodium, 125 mEg/L (125 mmol/L)\n• Serum potassium, 4 mEq/L (4 mmol/L)\n• Serum chloride, 95 mEq/L (95 mmol/L)\n• Serum bicarbonate, 25 mEq/L (25 mmol/L)\n• Blood urea nitrogen, 10 mg/dL (3.6 mmol/L)\n• Serum creatinine, 1.0 mg/dL (88.4 mcmol/L)\n• Serum glucose, 100 mg/dL (5.6 mmol/L)\n• Serum osmolality, 260 mOsm/kg\n• Urine osmolality, 500 mOsm/kg\n• Urine sodium, 30 mEq/L (30 mmol/L)\n\nOf the following, the MOST likely cause of the patient's hyponatremia is", "options" : "[\"acute renal failure\", \"congestive heart failure\", \"diabetes insipidus\", \"mineralocorticoid deficiency\", \"syndrome of inappropriate antidiuretic hormone\"]"}
{"id" : 139, "question_text" : "A 15-year-old girl presents to your clinic for evaluation of primary amenorrhea. She has a history of mild seasonal allergies and a right radius fracture at age 9. Her mother's height is 5 ft 9 in and father's height is 6 ft 2 in. The mother reports that her menarche occurred at 11 years, and the father recalls shaving at 14 years. On physical examination, the girl has Sexual Maturity Rating (SMR) 3 pubic hair and SMR 1 breast development. Bone age radiography shows a skeletal maturity of 13 years. No other abnormalities are noted. Her growth curve is shown.\n\nOf the following, the MOST appropriate next step in this girl's evaluation and treatment is to", "options" : "[\"initiate oral conjugated estrogen therapy\", \"measure serum estradiol\", \"measure serum thyroid-stimulating hormone\", \"obtain a karyotype\", \"perform a bimanual examination\"]"}
{"id" : 140, "question_text" : "During a health supervision visit, a boy calls to his father by saying \"dada.\" His mother enters the room holding a snack. The child reaches out to her and cries loudly \"mama.\" When the boy notices his mother is holding a banana, he smiles and says \"nana.\" His mother picks him up and offers him the banana. You inquire if he is saying any other words. His mother replies \"not yet.\"\n\nOf the following, these findings are MOST expected for a typically developing child who is", "options" : "[\"9 months old\", \"12 months old\", \"15 months old\", \"18 months old\", \"24 months old\"]"}
{"id" : 141, "question_text" : "An 8-year-old boy has been hospitalized for 2 days with Neisseria meningitidis meningitis that has been confirmed by culture. He is responding well to intravenous antibiotic therapy. He has a healthy 8-year-old twin brother.\n\nOf the following, the BEST choice for prophylaxis for his twin brother is", "options" : "[\"azithromycin\", \"ciprofloxacin\", \"penicillin VK\", \"rifampin\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 142, "question_text" : "A 15-year-old girl presents with a 2-day history of abdominal pain, fever, and worsening emesis. On physical examination, her temperature is 40.0°C, heart rate is 115 beats/min, and respiratory rate is 25 breaths/min. Abdominal examination reveals diffuse rebound tenderness greatest in the lower quadrants and decreased bowel sounds. On gynecologic examination, you note purulent endocervical discharge and acute cervical motion and adnexal tenderness. The white blood cell count is 25.0x103/mcL (25.0x109/L), with 75% polymorphonuclear leukocytes, 20% lymphocytes, and 5% monocytes. The patient has a history of hives and shortness of breath after receiving ceftriaxone for a sexually transmitted infection.\n\nOf the following, the MOST appropriate initial antimicrobial therapy for this girl is", "options" : "[\"ampicillin-sulbactam plus doxycycline\", \"cefotetan plus doxycycline\", \"clindamycin plus gentamicin\", \"levofloxacin plus metronidazole\", \"trimethoprim-sulfamethoxazole plus metronidazole\"]"}
{"id" : 143, "question_text" : "A grandmother discovers her 18-month-old grandson in the garage near an opened container of greenish fluid that she suspects to be antifreeze. She brings the child to the urgent care center for evaluation. On physical examination, the boy appears sleepy and somewhat ataxic. Initial laboratory evaluation reveals:\n• Sodium, 140 mEq/L (140 mmol/L)\n• Potassium, 4.1 mEq/L (4.1 mmol/L)\n• Chloride, 105 mEq/L (105 mmol/L)\n• Bicarbonate, 16 mEq/L (16 mmol/L)\n• Calcium, 9.0 mg/dL (2.25 mmol/L)\n• Magnesium, 2.0 mEq/L (1.0 mmol/L)\n• Phosphorus, 5.5 mg/dL (1.8 mmol/L)\n• Glucose, 90 mg/dL (5.0 mmol/L)\n• Blood urea nitrogen, 14 mg/dL (5.0 mmol/L)\n• Creatinine, 0.4 mg/dL (35.4 mcmol/L)\n• Albumin, 4.0 g/dL (40 g/L)\n• Serum osmolality, 310 mOsm/kg\n\nOf the following, the osmolar gap in this child, who has a possible ingestion, is CLOSEST to", "options" : "[\"8\", \"12\", \"16\", \"20\", \"24\"]"}
{"id" : 144, "question_text" : "A 12-year-old girl presents to your office for a follow-up visit. She has had several episodes of abdominal pain over the past 3 months but has had no associated vomiting, weight loss, fever, gastrointestinal bleeding, or pain that awakens her at night. Laboratory testing for anemia, Helicobacter pylori infection, and celiac disease has yielded no findings of note. Dietary adjustments (fiber supplementation and lactose-free diet trial) have resulted in little relief. On physical examination, she has no abdominal tenderness or mass, and she has no history of constipation. The girl has missed numerous days of school due to the pain.\n\nOf the following, the MOST appropriate next step is to", "options" : "[\"administer a screening tool for anxiety\", \"prescribe a selective serotonin reuptake inhibitor\", \"prescribe a tricyclic antidepressant\", \"refer her for cognitive behavioral therapy\", \"refer her to a gastroenterologist\"]"}
{"id" : 145, "question_text" : "A 13-year-old girl who has moderate persistent asthma complains of daily ocular and nasal allergy symptoms. She states that her symptoms are worse at home and bother her, despite a regimen of an oral antihistamine and a nasal corticosteroid. On further questioning, she states that she has five dogs and two cats, sleeps in a finished room in the basement, and enjoys collecting stuffed animals. She asks how she can reduce her symptoms at home after learning that her serum immunoglobulin (Ig) E tests were positive to cat and dust mite.\n\nOf the following, you are MOST likely to advise her that she should", "options" : "[\"decrease indoor humidity to less than 50%\", \"install a high-efficiency particulate air (HEPA) filter\", \"use an impermeable mattress cover\", \"vacuum carpets twice a week\", \"wash the cats once a month\"]"}
{"id" : 146, "question_text" : "A father brings his 2-year-old son to the emergency department after they had spent several hours in the garage while the father worked on the car. The father reports that approximately 30 minutes ago he heard the child coughing and found him with an open bottle of charcoal lighter fluid in his hands. On physical examination, the awake and alert child's temperature is 37.0°C, heart rate is 120 beats/min, respiratory rate is 24 breaths/min, blood pressure is 90/60 mm Hg, and oxygen saturation is 98%. His shirt is saturated with lighter fluid. You remove the boy's shirt and decontaminate his skin.\n\nOf the following, the MOST appropriate next step is to", "options" : "[\"obtain a STAT chest radiograph\", \"obtain a urine toxicology screen\", \"perform gastric lavage\", \"place the child under observation\", \"reassure the father and discharge the patient\"]"}
{"id" : 147, "question_text" : "A 5-month-old male infant presents to your office because of pallor and irritability. He was born at term following an uncomplicated pregnancy and delivery and had a birthweight of 3,150 g. Because of newborn screening results, a sweat chloride examination was performed at 1 month of age that confirmed a diagnosis of cystic fibrosis. Since birth, the baby has been exclusively breastfed. At the time of diagnosis, pancreatic enzyme supplementation was begun and now includes 8,000 units of lipase per nursing session. Approximately 1 week ago, the mother noted that the baby was \"breathing fast\" and appeared very pale. On physical examination today, the well-developed infant has a weight of 6.0 kg, heart rate of 160 beats/min, and respiratory rate of 40 breaths/min. You also note conjunctival and mucous membrane pallor and a liver edge palpable 2 cm below the right costal margin. Laboratory results include:\n• Hemoglobin, 9.0 g/dL (90 g/L)\n• White blood cell count, 9.0x103/mcL (9.0x109/L)\n• Albumin, 3.8 g/dL (38 g/L)\n• Reticulocyte count, 12.5% (0.125)\n\nA blood smear demonstrates polychromasia and numerous schistocytes.\n\nOf the following, the MOST appropriate treatment for this infant is", "options" : "[\"alpha-tocopherol\", \"ascorbic acid\", \"cyanocobalamin\", \"folic acid\", \"thiamine\"]"}
{"id" : 148, "question_text" : "A 12-year-old girl who has a history of chronic rhinitis, recurrent sinusitis, and multiple pneumonias has had a productive cough for 2 months. She has had no fever or other systemic symptoms except fatigue. Bronchodilators provide limited symptomatic relief. Two previous courses of antibiotics have produced transient but limited improvement. On physical examination, you note a slender child without clubbing. Her respiratory rate is 28 breaths/min, and faint crackles and wheezes are audible throughout her chest. She has purulent rhinitis with maxillary sinus tenderness. A chest radiograph shows areas of linear atelectasis with thickened airways. Results of sweat chloride testing and direct mutation analysis for cystic fibrosis are negative. Of the following, the MOST appropriate next test in her evaluation is", "options" : "[\"allergy skin testing\", \"echocardiography\", \"high-resolution chest computed tomography scan\", \"nasopharyngeal culture for virus\", \"sinus radiographs\"]"}
{"id" : 149, "question_text" : "A 14-year-old girl presents for an office visit because of fatigue and increased sleepiness. Menarche occurred when she was 11 years old, but her menses have always been irregular, and she has noted some \"spotting\" at times between menses. She also reports a normal diet with occasional constipation. Physical examination reveals slightly pale conjunctivae and oral mucosa. Her heart rate is 110 beats/min, she has a grade I/VI systolic ejection murmur heard best at the left sternal border, and her blood pressure measures 110/70 mm Hg supine and 105/60 mm Hg sitting. Abdominal examination is negative for tenderness or mass. There is a small amount of blood on a sanitary pad on external genitourinary examination. Laboratory studies reveal: White blood cell count, 14.0x103/mcL (14.0x109/L); Hemoglobin, 9.9 mg/dL (99 g/L); Hematocrit, 29% (0.29); Mean corpuscular volume, 65 fL; Reticulocyte count, 0.2% (0.002). Of the following, the BEST treatment for this patient is", "options" : "[\"daily multivitamin with iron\", \"dietary counseling for iron-rich foods\", \"intramuscular iron administration\", \"oral supplementation with folic acid\", \"prescription for oral ferrous sulfate three times daily\"]"}
{"id" : 150, "question_text" : "You have been following a healthy 5-year-old boy since birth. You noted a heart murmur at his 6-month health supervision visit, and you have heard it intermittently at subsequent evaluations. You are seeing the boy today because of a viral upper respiratory tract infection associated with 2 days of fever. On physical examination, the murmur sounds particularly prominent. Of the following, the finding that MOST strongly suggests that this murmur is benign is", "options" : "[\"a decrease in murmur intensity when moving from supine to upright position\", \"a higher blood pressure in the arms than legs\", \"its continuous \\\"machinery\\\" quality in the left infraclavicular position\", \"its diastolic nature\", \"the harsh, high-pitched auscultatory features heard best on the lateral neck\"]"}
{"id" : 151, "question_text" : "A 12-year-old 40-kg girl presents for a health supervision visit. Physical examination, including vital signs, yields normal results. The mother notes that the girl had to come home from school three times last semester due to headaches. Her typical headaches are bifrontal, with sensitivity to light and sound and often nausea. They last 1 to 6 hours. During the headache, she feels and looks sick and prefers to lie in a dark room. The mother requests an acute treatment plan for her daughter. You provide education about migraine headaches and discuss lifestyle issues, including good sleep hygiene, exercise, diet, hydration, and stress management. For abortive headache treatment, you explain that it is ideal to treat within 30 minutes, even at school. Of the following, the PREFERRED abortive treatment for this girl is", "options" : "[\"butalbital (50 mg), acetaminophen (325 mg), caffeine (40 mg) orally\", \"ibuprofen (400 mg) orally\", \"promethazine (12.5 mg) rectally\", \"sumatriptan (5 mg) intranasally\", \"topiramate (25 mg) orally\"]"}
{"id" : 152, "question_text" : "A 16-year-old boy complains of pain in his feet after running long distances as well as intermittent numbness and tingling in his fingers and toes for the past 4 months. On physical examination, the only finding of note is somewhat high arches (pes cavus). Consultation with an orthopedist results in referral for electromyography and nerve conduction studies, and the finding of low-normal nerve conduction velocities is suggestive of Charcot-Marie-Tooth Disease type 2 (CMT2). Review of the family history reveals that neither of the boy's parents nor his younger sister have any signs or symptoms of hereditary motor and sensory neuropathy. His maternal grandfather \"may have had\" high foot arches and later in life had an awkward gait believed to be a result of poor balance. This grandfather also had a brother who had foot drop, and their mother had to retire from working on an assembly line in a factory in her forties due to hand weakness, but she never had any recognizable problems with her feet. Of the following, the MOST likely cause for CMT2 in this patient is", "options" : "[\"a new (de novo) autosomal dominant mutation in one of the CMT2 genes\", \"an unbalanced chromosomal translocation that disrupts one of this boy's CMT2 genes\", \"incomplete penetrance of this autosomal dominant gene passed down through his mother\", \"preferential gender expression of this autosomal dominant gene, with males more likely to be symptomatic\", \"variable expression of a mitochondrial gene passed to him from his mother and to his other affected relatives from their mother\"]"}
{"id" : 153, "question_text" : "A 13-year-old boy presents for a routine health supervision visit. He is asymptomatic today, has no findings of significance on past medical history, and currently is not taking any medications. He appears well and has normal vital signs and a body mass index of 20.6. He is at Sexual Maturity Rating 2. You find a slightly tender, rubbery mass under his right areola that is approximately 2 cm in diameter. The remainder of his examination results, including a testicular evaluation, are normal. He tells you that one of his grandmothers has breast cancer. He was embarrassed to tell you about the lump, and he is concerned that he might have cancer. Of the following, the MOST appropriate statement to make to the boy is that", "options" : "[\"his risk of breast cancer is high because of his family history\", \"the breast mass should regress spontaneously\", \"weight loss is necessary to resolve the mass\", \"you will refer him to a plastic surgeon\", \"you will refer him to an endocrinologist\"]"}
{"id" : 154, "question_text" : "The mother of a 14-year-old girl brings her in for an appointment. Her daughter was sexually assaulted by two older boys 2 months ago. The girl immediately told her mother, who brought her for a medical examination and notified the police. Charges were filed against the boys, and the case is moving through the court system. Physically, the girl has no residual problems, but her mother has been concerned that she is not handling this experience well. She is increasingly clingy and tearful, will not go to parties with friends if there might be new people there, will not talk about what happened, is not sleeping well, and is having nightmares. She will not answer the door or the phone because she is afraid it might be an unfamiliar man. The mother understands that these symptoms are likely related to the stressful event, but the girl's most recent report card indicates that she is failing two classes for the first time ever, and her teachers note that she appears to be having problems concentrating. The mother asks what she should do to help her daughter get over this event and get her life back on track, noting that \"she was totally fine before they did this to her.\" In your office, the girl is very quiet, has downcast eyes, and says she has nothing further to add to mom's recounting of her story. Findings on her physical examination are normal. Of the following, the MOST appropriate next step is to", "options" : "[\"initiate sertraline therapy\", \"initiate trazodone therapy\", \"reassure the mother that her daughter will get past this soon\", \"recommend trauma-focused cognitive behavioral therapy\", \"suggest that the girl take time off from school to relax\"]"}
{"id" : 155, "question_text" : "You are evaluating an 8-year-old boy who developed the acute onset of coughing of bright red, frothy blood. He has had no previous illnesses but has experienced fevers, cough, and fatigue over the past week or two. On physical examination, the boy is in mild respiratory distress. He has a temperature of 38.0°C, heart rate of 110 beats/min, respiratory rate of 25 breaths/min, blood pressure of 110/70 mm Hg, and oxygen saturation of 88% in room air. His lung sounds are coarse bilaterally. Physical examination of his naso- and oropharynx reveal no evidence of trauma. Of the following, the BEST initial test to aid in the diagnosis of the patient's cause of hemoptysis is", "options" : "[\"bronchoscopy\", \"chest radiography\", \"echocardiography\", \"open lung biopsy\", \"pulmonary function testing\"]"}
{"id" : 156, "question_text" : "A 13-year-old boy presents with concerns about his pubertal progression. He is otherwise healthy and takes no medications. His mother reports that she had menarche at 14 years of age, and his father reports shaving for the first time in the 12th grade. Physical examination of the boy reveals Sexual Maturity Rating 2 pubic hair and testicular volumes of 2 mL (testicular lengths of 2 cm) bilaterally. His growth curve is shown in the image provided. Of the following, the MOST appropriate next step in the evaluation of this boy is to", "options" : "[\"determine bone age\", \"measure follicle-stimulating and luteinizing hormones\", \"measure testosterone\", \"measure thyroid-stimulating hormone\", \"obtain a karyotype\"]"}
{"id" : 157, "question_text" : "When a mother and her child enter the examination room for a health supervision visit, the child quickly states, \"I want book.\" Her mother takes out her picture book, and you ask the girl to find the baby in the story book. She looks through the book and points to a picture of a baby. She then turns and points to her doll and says \"mine.\" Her mother proudly states that her daughter has just begun to combine words. Of the following, these findings are MOST expected for a typically developing child who is", "options" : "[\"12 months\", \"18 months\", \"24 months\", \"30 months\", \"36 months\"]"}
{"id" : 158, "question_text" : "An 18-month-old girl in your practice has been evaluated for recurrent episodes of hemolytic anemia. Her hematologist has diagnosed hereditary spherocytosis and recommended an elective splenectomy. Of the following, the MOST appropriate treatment before splenectomy for this child is", "options" : "[\"hepatitis A vaccine\", \"measles, mumps, rubella vaccine\", \"meningococcal conjugate vaccine\", \"penicillin prophylaxis for 2 months\", \"pneumococcal vaccine\"]"}
{"id" : 159, "question_text" : "A 14-year-old previously well boy presents to your office with a 10-day history of cough and posttussive emesis. His grandmother also has a coughing illness. His 3-week-old sibling, with whom he lives, is well. On physical examination, the boy appears generally well, with a temperature of 37.0°C, heart rate of 80 beats/min, and respiratory rate of 16 breaths/min. He has mild nasal congestion, and his lungs are clear to auscultation. When you use a tongue depressor to examine his posterior oropharynx, he begins coughing and cannot stop. This cough paroxysm lasts about 30 seconds and is followed by gasping and vomiting. Of the following, the MOST appropriate intervention for the patient's 3-week-old healthy sibling is", "options" : "[\"azithromycin for 5 days\", \"clarithromycin for 7 days\", \"erythromycin for 14 days\", \"penicillin for 10 days\", \"trimethoprim-sulfamethoxazole for 14 days\"]"}
{"id" : 160, "question_text" : "A 4-year-old boy presents with a 3-day history of vomiting followed by diarrhea. The vomiting resolved after 24 hours, and for the past 2 days, he has been keeping down clear liquids. On physical examination, the afebrile boy has a heart rate of 90 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 106/58 mm Hg. He has tacky mucous membranes and a capillary refill time of 3 seconds. Other findings are within normal parameters. Laboratory evaluation reveals: Sodium, 130 mEq/L (130 mmol/L); Potassium, 3.7 mEq/L (3.7 mmol/L); Chloride, 102 mEq/L (102 mmol/L); Bicarbonate, 16 mEq/L (16 mmol/L); Glucose, 100 mg/dL (5.6 mmol/L); Blood urea nitrogen, 34 mg/dL (12.1 mmol/L); Creatinine, 0.6 mg/dL (53 mcmol/L). Urinalysis reveals a specific gravity of 1.030, pH of 5.5, 1+ ketones, and otherwise negative findings. Of the following, the MOST likely urine sodium concentration and urine osmolality for this patient are", "options" : "[\"Urine Sodium: 6 mEq/L, Urine Osmolality: 1,100 mOsm/kg\", \"Urine Sodium: 28 mEq/L, Urine Osmolality: 300 mOsm/kg\", \"Urine Sodium: 60 mEq/L, Urine Osmolality: 450 mOsm/kg\", \"Urine Sodium: 90 mEq/L, Urine Osmolality: 900 mOsm/kg\", \"Urine Sodium: 130 mEq/L, Urine Osmolality: 1,100 mOsm/kg\"]"}
{"id" : 161, "question_text" : "You are evaluating a 6-month-old girl who has mild eczema that improves with regular use of a topical moisturizer with a group of pediatric residents. After evaluating the infant, you decide to discuss atopy and its components with them. Of the following, the MOST accurate statement regarding components of atopy is that", "options" : "[\"allergic rhinitis is not a risk factor for the development of asthma\", \"children who wheeze before 1 year of age are at higher risk for persistent asthma compared with children who begin wheezing after 6 years of age\", \"early child care exposure reduces the risk for the development of asthma\", \"exclusive breastfeeding longer than 6 months significantly reduces asthma incidence beyond 6 years of age\", \"maternal dietary restriction during breastfeeding prevents the development of atopy\"]"}
{"id" : 162, "question_text" : "A 14-year-old boy is brought to the emergency department after being struck by a car. On arrival, he is unresponsive and hypotensive. You intubate him endotracheally, place two large-bore intravenous lines, and infuse 3 L of 0.9% saline. Following these measures, his heart rate is 100 beats/min and blood pressure is 100/60 mm Hg. On secondary survey, you find a large swelling on the back of his head, a distended abdomen, blood at the urethral meatus, guaiac-positive stool, and a right femur fracture. Of the following, the procedure that is CONTRAINDICATED in this patient is", "options" : "[\"diagnostic peritoneal lavage\", \"femoral traction splint placement\", \"orogastric tube placement\", \"retrograde urethrography\", \"urethral catheter placement\"]"}
{"id" : 163, "question_text" : "You are called to the emergency department to see a 5-day-old infant, who has presented because of bile-stained emesis. When the infant was born at term following an uncomplicated pregnancy and delivery, he weighed 3,300 g. He was sent home at 36 hours of age. Since discharge, he has been nursing every 2 to 3 hours at home, but he recently developed apparent discomfort postprandially. His mother has observed no stools since discharge. This morning, he began to spit up after feeding, and the last emesis was bile-stained. Upon arrival at the emergency department, the infant appeared alert but irritable and had moderate, generalized abdominal distension. The emergency department physician obtained an upright abdominal radiograph. Of the following, the MOST appropriate next step is", "options" : "[\"abdominal computed tomography scan\", \"contrast enema\", \"rectal suction biopsy\", \"surgical decompression\", \"upper gastrointestinal tract radiographic series\"]"}
{"id" : 164, "question_text" : "You have been following a 16-year-old girl for symptoms of irritability, loss of interest in activities, and decreased appetite. She has experienced these symptoms every day for several weeks. She has stopped attending band practice, which she previously enjoyed. You offer treatment with a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy. Her mother asks you how long her daughter will need to take the SSRI before determining if it is effective.\n\nOf the following, the MOST appropriate timeframe to assess medication efficacy is", "options" : "[\"1 to 2 days\", \"1 to 2 weeks\", \"4 to 6 weeks\", \"8 to 10 weeks\", \"12-14 weeks\"]"}
{"id" : 165, "question_text" : "A 15-year-old girl is brought to your office after \"passing out\" while she was participating in a band program outside on an 80.0°F day. She recalls feeling lightheaded, then awakening surrounded by her bandmates. The reported duration of the episode was 1 minute. She has had one similar episode in the past. She has no underlying medical problems, and there is no family history of seizures or heart disease. Currently, her temperature is 37.3°C, heart rate is 84 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 98/64 mm Hg. The remainder of her findings, including those of cardiovascular and neurologic examinations, are normal.\n\nOf the following, the MOST appropriate next step in her evaluation is", "options" : "[\"cardiac event monitoring\", \"computed tomography scan of the brain\", \"electrocardiography\", \"electroencephalography\", \"tilt table testing\"]"}
{"id" : 166, "question_text" : "The father of a 3-week-old baby calls for an urgent appointment because he has noted blood in her last two diapers. When he arrives, he shows you two diapers, each of which contains a dime-sized spot of blood. The baby is thriving on human milk. She is active and has gained 500 g over her birthweight. The father states that the blood seems to be coming from her vagina. He also is concerned about asymmetric swelling of the infant's breast, which is not accompanied by redness.\n\nOf the following, this constellation of signs and symptoms is BEST characterized by exposure to maternal", "options" : "[\"cortisol\", \"estrogen\", \"oxytocin\", \"progesterone\", \"prolactin\"]"}
{"id" : 167, "question_text" : "A 6-year-old previously healthy boy presents with the recent development of nocturnal dyspnea. On questioning of his parents, you discover that the child has experienced exercise intolerance, two episodes of syncope while running, poor appetite, and a cough without congestion over the past year. His physical examination reveals a heart rate of 120 beats/min, respiratory rate of 26 breaths/min, gallop rhythm, III/VI high-pitched blowing systolic murmur at the apex, hepatomegaly, and diminished pulses. Chest radiography documents an enlarged cardiac silhouette with pulmonary vascular congestion (Item Q57), and echocardiography demonstrates a regurgitant mitral valve with a dilated left ventricle and markedly reduced systolic contractility.\n\nOf the following, the MOST likely cause for this child's dilated cardiomyopathy is", "options" : "[\"a congenital mitral valve abnormality\", \"Duchenne muscular dystrophy\", \"Friedreich ataxia\", \"rheumatic heart disease\", \"sickle cell disease\"]"}
{"id" : 168, "question_text" : "A 17-year-old boy presents with the complaint of an intermittent spinning sensation with nausea. He first noted the symptoms this morning when he rolled out of bed. He is a competitive hockey player and had received a hard blow to the side of his head during a game last night. He is not experiencing dizziness in your office. Physical examination findings are normal. Neurologic examination shows normal mental status, with normal visual fields and equally reactive and symmetric pupils. Extraocular movements are full, with normal horizontal and vertical tracking (visual pursuits), and there is no nystagmus or reported double vision. Facial sensation and movements are symmetric. Hearing is intact to finger rub bilaterally. Tongue and palate movements are normal.\n\nOf the following, these findings are MOST consistent with", "options" : "[\"aneurysm of the posterior communicating artery\", \"benign paroxysmal positional vertigo\", \"complex migraine\", \"orthostatic hypotension\", \"schwannoma of the vestibular nerve\"]"}
{"id" : 169, "question_text" : "A couple who is planning to bring their child to you for care, present for a prenatal consultation at 28 weeks' gestation. After reviewing basic information about your practice, the wife explains that she is one of six children, four of whom are currently alive. She had a sister and a brother who both died between the ages of 3 and 4 years. Although normal at birth, both children had progressive loss of milestones beginning at about 1 year of age, with hypotonia and later severe muscle weakness, difficult-to-control seizures, visual loss, and eventual death. No other individuals in the extended family had such problems. The woman is concerned about this family history and wishes to know possible risks for her children as well as advice about testing for her newborn.\n\nOf the following, you are MOST likely to tell her that her affected siblings probably had", "options" : "[\"an autosomal dominant condition with incomplete penetrance, and the risk to her unborn child may be as high as 50%\", \"an autosomal recessive condition, and the risk to her unborn child is probably low\", \"a mitochondrial condition, and the risk to her unborn child may be as high as 100%\", \"an X-linked dominant condition, and the risk to her unborn child may be as high as 50%\", \"an X-linked recessive condition, and the risk to her unborn child may be as high as 50% if she gives birth to a son\"]"}
{"id" : 170, "question_text" : "A 17-year-old sexually active girl presents for a follow-up evaluation after her third episode of a urinary tract infection. She is currently asymptomatic. The results of renal ultrasonography and voiding cystourethrography are negative. She asks you how to prevent further episodes.\n\nOf the following, you are MOST likely to advise her to", "options" : "[\"drink cranberry juice frequently\", \"increase her daily water intake\", \"make sure to void after intercourse\", \"self-medicate with antibiotics for 3 days when symptomatic\", \"use single-dose postcoital antibiotic prophylaxis\"]"}
{"id" : 171, "question_text" : "During morning teaching rounds, while discussing oxygenation and ventilation, a medical student asks you if capillary blood gas measurement is an acceptable substitute for arterial blood gas measurement. You inform her that with one exception, properly performed capillary blood gas testing has been shown to correlate well with results of arterial blood gas testing in several recent studies.\n\nOf the following, the correlation between capillary and arterial blood gas readings is MOST likely to be decreased in patients who have", "options" : "[\"bradycardia\", \"hyperthermia\", \"hypotension\", \"hypothermia\", \"tachypnea\"]"}
{"id" : 172, "question_text" : "During a 14-year-old girl's annual health supervision visit, you learn that she has not yet had menarche. During most of the visit, the girl's mother speaks for her and states that her daughter is a straight A student and has many friends. The mother is not worried about the delay in her daughter's menarche but does raise concerns that she does not exercise on a regular basis. Mid-parental height is at the 50th percentile. Physical examination of the well but thin-appearing girl reveals a weight of 35 kg (3rd percentile); height of 160 cm (50th percentile); and normal findings on eye, ear, nose, heart, lung, abdomen, and extremities evaluation. She has a Sexual Maturity Rating of 3 for pubic hair and 2 for breast development.\n\nOf the following, the MOST appropriate next step in the evaluation of this patient is to", "options" : "[\"measure luteinizing and follicle-stimulating hormones\", \"obtain a bone age radiograph\", \"obtain a diet history\", \"perform a karyotype\", \"schedule a follow-up appointment in 2 months\"]"}
{"id" : 173, "question_text" : "A child walks into the examination room, accompanied by his parents. He points to a box of crayons that he notices on a nearby shelf. You offer him a paper and the crayons. You then draw a vertical line and a cross, which he successfully copies. You ask him to draw a person. He draws two circles, one for the head and one for the body. He then stops drawing and says, \"Look at me\" while he balances on his foot for 3 seconds.\n\nOf the following, these developmental milestones are MOST typical for a child whose age is", "options" : "[\"24 months\", \"30 months\", \"36 months\", \"48 months\", \"60 months\"]"}
{"id" : 174, "question_text" : "You are seeing a 12-year-old boy for follow-up of problematic handwashing and bathing routines. He has been receiving cognitive behavior therapy for 12 weeks and has had minimal improvement. He has always been somewhat of a perfectionist and rigid, but recently has begun to have persistent fears of germs. The routines are time-consuming and embarrassing, sometimes causing him to be late for school. He is otherwise healthy, although he is beginning to have significant skin irritation on his hands.\n\nOf the following, the BEST next course of action is to initiate", "options" : "[\"alprazolam treatment\", \"clomipramine treatment\", \"propranolol treatment\", \"risperidone treatment\", \"sertraline treatment\"]"}
{"id" : 175, "question_text" : "A 5-year-old boy who is otherwise well presents with an area of hair loss; there is some scale and several pustules (Item Q66). The area does not fluoresce on exposure to a Woods lamp. The remainder of his physical examination findings are normal.\n\nOf the following, the MOST appropriate therapy is", "options" : "[\"oral clindamycin\", \"oral griseofulvin\", \"oral ivermectin\", \"topical ketoconazole\", \"topical selenium sulfide\"]"}
{"id" : 176, "question_text" : "A 3-month-old male infant presents with poor feeding and occasional vomiting. He has no history of fever, cough, irritability, constipation, or diarrhea. He has approximately 12 wet diapers per day. On physical examination, the afebrile infant has a heart rate of 130 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 94/50 mm Hg. He has tacky mucous membranes and a capillary refill time of 2 seconds; all other findings are normal. Laboratory evaluation reveals:\n• Sodium, 160 mEq/L (160 mmol/L)\n• Potassium, 3.7 mEq/L (3.7 mmol/L)\n• Chloride, 122 mEq/L (122 mmol/L)\n• Bicarbonate, 16 mEq/L (16 mmol/L)\n• Glucose,100 mg/dL (5.6 mmol/L)\n• Osmolality, 345 mOsm/kg\n• Blood urea nitrogen, 34 mg/dL (12.1 mmol/L)\n• Creatinine, 0.6 mg/dL (53.0 mcmol/L)\n\nOf the following, the MOST likely urine specific gravity and urine osmolality for this patient are", "options" : "[\"Urine Specific Gravity: 1.001, Urine Osmolality: 80 mOsm/kg\", \"Urine Specific Gravity: 1.010, Urine Osmolality: 300 mOsm/kg\", \"Urine Specific Gravity: 1.015, Urine Osmolality: 400 mOsm/kg\", \"Urine Specific Gravity: 1.020, Urine Osmolality: 600 mOsm/kg\", \"Urine Specific Gravity: 1.030, Urine Osmolality: 1,200 mOsm/kg\"]"}
{"id" : 177, "question_text" : "A 12-month-old boy presents with a 7-month history of a worsening skin rash. The rash is pruritic and involves his neck, anterior and posterior trunk, antecubital and popliteal fossae, and hands and feet. Use of a moisturizer and topical corticosteroid has resulted in some improvement. The remainder of his past medical history is unremarkable. On physical examination, you observe multiple erythematous, lichenified patches and diagnose severe atopic dermatitis.\n\nOf the following, the MOST helpful next step is to", "options" : "[\"eliminate milk, eggs, soy, and wheat from the diet\", \"measure serum immunoglobulins (IgG, IgA, and IgM)\", \"perform aeroallergen allergy testing\", \"perform food allergy testing\", \"start oral corticosteroids\"]"}
{"id" : 178, "question_text" : "A 13-year-old girl comes to the office with a 4-day history of a brownish, foul-smelling vaginal discharge. She reports that the discharge has been associated with perineal itching and burning with urination. She has had no fever, abdominal pain, or other constitutional symptoms. She denies sexual activity and reports that her last menstrual period was 1 week ago. Her physical examination findings are normal, except for mild labial erythema and the presence of a scant, watery, malodorous discharge at the vaginal opening.\n\nOf the following, the MOST appropriate next step is to", "options" : "[\"obtain bacterial cultures of the discharge\", \"obtain urine for nucleic acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae\", \"perform a pelvic examination\", \"prescribe clotrimazole cream\", \"recommend sitz baths\"]"}
{"id" : 179, "question_text" : "You are seeing a 15 month-old boy who has been placed in foster care. He was born to a 22-year-old human immunodeficiency virus (HIV)-positive woman who had a history of intravenous drug use. His birthweight was 2,850 g. The child experienced no neonatal complications and, at 13 months of age, was found to be HIV-negative and hepatitis C antibody-positive. At the time of his office visit today, the boy appears well and demonstrates no abnormal physical findings. Based upon his perinatal exposure, you obtain the following laboratory studies:\n• Hemoglobin, 12.5 g/dL (125 g/L)\n• White blood cell count, 6.5x103/mcL (6.5x109/L) (40% neutrophils, 56% lymphocytes, 4% eosinophils)\n• Aspartate aminotransferase, 30 units/L (normal, 5 to 30 units/L)\n• Alanine aminotransferase, 35 units/L (normal, 10 to 30 units/L)\n• Hepatitis C RNA (PCR), 1x104 copies/mL\n\nOf the following, the MOST appropriate next management step includes", "options" : "[\"follow-up in 6 months\", \"interferon therapy\", \"lamivudine therapy\", \"liver biopsy\", \"pegylated interferon and ribavirin therapy\"]"}
{"id" : 180, "question_text" : "A term infant is delivered by repeat elective cesarean section complicated by oligohydramnios. Mild bilateral pelviectasis was noted on prenatal ultrasonography. Artificial rupture of the membranes at delivery reveals scant meconium-stained fluid. The infant initially has a strong cry, but she develops escalating respiratory distress and cyanosis requiring endotracheal intubation in the delivery room. Upon arrival in the nursery, she is placed on the ventilator, with the following settings: peak inspiratory pressure of 26 mm Hg, positive end-expiratory pressure of 6 mm Hg, rate of 40 breaths/min, and FiO2 of 100%. Physical examination reveals central cyanosis, a full anterior fontanelle, II/VI systolic murmur at the left lower sternal border, and slightly diminished breath sounds bilaterally. A right radial arterial blood gas reveals:\n• pH, 7.10\n• PCO2, 70 mm Hg\n• PCO2, 26 mm Hg\n• Base excess, -7 mmol/L\n• Bicarbonate, 22 mmol/L\n\nOf the following, the MOST appropriate next study is", "options" : "[\"chest radiography\", \"echocardiography\", \"head ultrasonography\", \"renal ultrasonography\", \"tracheal aspirate\"]"}
{"id" : 181, "question_text" : "A previously well 22-month-old child has had the onset of pallor, jaundice, and dark urine over the past 2 days. His parents report no fever, vomiting, or diarrhea. He continues to take fluids well, but he has been very fatigued. Physical examination of the pale child reveals marked scleral icterus, temperature of 38.2°C, heart rate of 132 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 92/44 mm Hg. He has a nonradiating II/VI systolic murmur audible at the left upper sternal border, clear lungs, and splenomegaly 3 cm below the left costal margin. He has 4+ hemoglobinuria. Other laboratory test results include:\n• Hemoglobin, 5.8 g/dL (58 g/L)\n• White blood cell count, 14.8x103/mcL (14.8x109/L)\n• Platelet count, 240x103/mcL (240x109/L)\n• Spherocytes, nucleated red blood cells, and polychromasia on peripheral blood smear\n• Reticulocyte count, 15% (0.15)\n• Serum creatinine, 0.6 mg/dL (53.0 mcmol/L)\n\nOf the following, the additional laboratory test that is MOST likely to show an abnormal result is", "options" : "[\"antistreptolysin O titer\", \"direct antiglobulin (Coombs) test\", \"fecal occult blood\", \"hepatitis B surface antigen\", \"urine culture\"]"}
{"id" : 182, "question_text" : "A 2-month-old boy presents for a health supervision visit. Physical examination reveals a normally growing and thriving infant whose left testis is easily palpable but whose right testis cannot be palpated. The remainder of his physical examination results are normal.\n\nOf the following, the MOST appropriate approach is to", "options" : "[\"order chromosomal studies to confirm genetic sex\", \"order pelvic ultrasonography\", \"plan for surgical exploration at 6 months of age\", \"plan for surgical exploration at 2 years of age\", \"refer the child immediately for urgent surgical consultation\"]"}
{"id" : 183, "question_text" : "You are seeing a 4-week-old previously healthy infant in your office because of concern about poor feeding. On questioning, the parents report that the child has developed grunting respirations associated with feedings, diaphoresis, pallor, and prolonged periods of sleep. On physical examination, the boy's heart rate is 160 beats/min, respiratory rate is 55 breaths/min, blood pressure in the right arm is 75/48 mm Hg, blood pressure in the left leg is 88/55 mm Hg, and oxygen saturation is 95%. He exhibits tachypnea, rales and retractions, a II/VI low-pitched holosystolic murmur across the precordium (Item Q74), and a palpable liver 2 cm below the right costal margin. Of the following, the MOST likely explanation for the child's findings of congestive heart failure is", "options" : "[\"aortic valve stenosis\", \"coarctation of the aorta\", \"tetralogy of Fallot\", \"transposition of the great arteries\", \"ventricular septal defect\"]"}
{"id" : 184, "question_text" : "The parents of an 11-year-old girl have become concerned about their daughter's waning strength. She has always been a strong competitive swimmer, but for the past 2 years, her race times have not improved. They state that she seems to have progressive difficulty pulling her body out of the pool, and at this summer's first swim competition, her younger sister's freestyle time was faster than hers. There is no family history of diseases causing progressive weakness. On physical examination, the girl has normal mental status, cranial nerves, and muscle bulk and tone. Reflexes are 1+. She has 4/5 strength in neck flexors, deltoids, and hip flexors and extensors and 5/5 strength in distal muscles. Of the following, the MOST useful initial diagnostic test for this girl is", "options" : "[\"brain magnetic resonance imaging\", \"cervical spine magnetic resonance imaging\", \"electromyography\", \"nerve conduction velocities\", \"serum creatine kinase\"]"}
{"id" : 185, "question_text" : "During a health supervision visit for a 5-year-old girl, her mother reports that she herself is currently 16 weeks pregnant. She expresses concern about this pregnancy because her brother and two of her maternal uncles died from complications of hemophilia A. She was told at the time of her most recent ultrasonographic examination that she is carrying a male fetus. She asks if you can tell her the chances that her son will be affected with hemophilia A. Of the following, the chance that her son will be affected is CLOSEST to", "options" : "[\"12.5%\", \"25%\", \"50%\", \"75%\", \"90%\"]"}
{"id" : 186, "question_text" : "An 18-year-old college student who has a history of attention-deficit/hyperactivity disorder (ADHD) presents to your office as a new patient, requesting a renewal prescription for methylphenidate. You note that her current supply, according to the empty bottle that she hands you, should be refilled in 2 weeks. She fills out a release of information form for her prior physician, but that person cannot be reached today. When you ask why she takes this medication, she replies, \"It helps me pay attention.\" When you ask why the bottle is empty, she states, \"The pills spilled in the sink.\" Of the following, the MOST appropriate next step is", "options" : "[\"ask for a urine sample to perform a urine drug screen\", \"ask her to return in 1 to 2 weeks to give you adequate time to contact the previous prescribing physician\", \"complete a brief medical history and write a prescription for a 1-month supply\", \"complete an inventory to assess risk for alcohol and recreational drug use and write the requested prescription for 1 month\", \"have her complete a Vanderbilt Diagnostic Rating Scale form\"]"}
{"id" : 187, "question_text" : "A 16-year-old girl presents to the emergency department with right upper quadrant abdominal pain. She has no fever or other systemic symptoms. The pain began a few days after her last menstrual period, which was heavier than usual. The pain is not related to meals and not accompanied by any scapular or shoulder pain. She does complain of intermittent dysuria. On physical examination, the girl is in mild distress from the pain. Her vital signs are normal, and her body mass index is 21.2. You hear normal bowel sounds. Palpation of her abdomen reveals diffuse tenderness that is accentuated in the right upper quadrant, with no rebound. A pregnancy test is negative. Urinalysis and urine culture results are pending. Of the following, the MOST appropriate next step is", "options" : "[\"abdominal ultrasonography\", \"abdominal upright radiography\", \"complete blood count\", \"emergency surgical consultation\", \"pelvic examination\"]"}
{"id" : 188, "question_text" : "You are evaluating a 2-month-old infant in the emergency department whose parents state that she has had trouble breathing for the past week. The infant was born at term via vaginal delivery and had no prenatal or neonatal complications. The parents explain that for the past couple of days, she appears to be breathing fast and seems to \"suck her chest in when she breathes.\" Physical examination reveals a thin infant in moderate respiratory distress whose temperature is 37.0°C, heart rate is 150 beats/min, respiratory rate is 50 breaths/min, blood pressure is 74/48 mm Hg, and oxygen saturation is 94% in room air. Her lungs are clear to auscultation, but she has suprasternal and subcostal retractions. She also \"bobs\" her head with inspiration. The nurse was able to suction the nasopharynx by passing a suction catheter through each nostril, but there was no improvement in the infant's respiratory status. You order chest radiography (Item Q79). Of the following, the MOST likely cause of this infant's symptoms is", "options" : "[\"bronchomalacia\", \"choanal atresia\", \"mediastinal tumor\", \"pneumonia\", \"pneumothorax\"]"}
{"id" : 189, "question_text" : "An 8-year-old girl presents for evaluation of \"neck swelling.\" Her mother reports that the swelling began approximately 1 year ago and has progressed with time. The swelling is not causing any pain. On physical examination, the girl's thyroid gland is diffusely enlarged, has a cobblestone texture, but has no discrete nodules (Item Q80). Findings for all other systems are within normal parameters. Free thyroxine and thyroid-stimulating hormone measurements are normal. Of the following, the BEST next step in the evaluation of this patient is to", "options" : "[\"assess thyroglobulin\", \"assess thyroid peroxidase antibodies\", \"assess thyroid-stimulating immunoglobulins\", \"order neck ultrasonography\", \"perform a thyroid biopsy\"]"}
{"id" : 190, "question_text" : "A 7-year-old child who has quadriplegia uses a wheelchair for mobility. He requires assistance for eating and dressing due to his delay in motor skills. He has difficulty articulating his words. His parents are concerned that he is becoming increasingly frustrated due to his difficulty expressing his needs. They ask your guidance in helping him to become a more effective communicator. Of the following, the MOST appropriate intervention is to", "options" : "[\"evaluate him for an amplification system\", \"evaluate him for an augmented communication device\", \"focus on improving his fine motor skills\", \"refer him for behavioral therapy\", \"teach him American sign language\"]"}
{"id" : 191, "question_text" : "An 11-month-old boy presents to your office with a 5-day history of fever, nasal congestion, conjunctivitis, and the development of a rash over the past 24 hours. The rash began on his head and neck and spread to his trunk (Item Q82) and extremities. The family recently returned from a trip to Ireland. His past medical history is unremarkable, and his immunizations are up to date. Of the following, the BEST test for diagnosing this child's condition is", "options" : "[\"measles immunoglobulin (Ig) M serology\", \"nasal aspirate for viral culture\", \"rubella IgM serology\", \"skin biopsy\", \"throat culture for group A Streptococcus\"]"}
{"id" : 192, "question_text" : "You are examining a 6-day-old infant who was born at 36-1/7 weeks' gestation to a 19-year-old primigravida by cesarean section due to preterm labor. The mother had no prenatal care. Apgar scores were 7 and 8 at 5 and 10 minutes, respectively. The infant was stable in room air until today, when she developed apnea requiring intubation, bradycardia, and profound hypotension. On physical examination, the intubated infant appears pale. Auscultation of the lungs reveals diffuse rhonchi. The liver is palpable 4 cm below the costal margin. Laboratory findings include: White blood cell count, 5.6x103/mcL (5.6x109/L) with 20% neutrophils, 68% lymphocytes, and 12% monocytes; Hemoglobin, 10 g/dL (100 g/L); Platelet count, 60x103/mcL (60x109/L); Aspartate aminotransferase, 455 units/L; Alanine aminotransferase, 538 units/L. Cerebrospinal fluid examination reveals: White blood cells, 10/mm3 with 80% lymphocytes and 20% monocytes; Red blood cells, 300/mm3; Protein, 89 mg/dL (0.89 g/L); Glucose, 57 mg/dL (3.2 mmol/L). A chest radiograph demonstrates diffuse pneumonitis. Of the following, the test MOST likely to yield the patient's diagnosis is", "options" : "[\"blood culture for virus\", \"cerebrospinal fluid Gram stain\", \"human immunodeficiency virus Western blot\", \"Mycoplasma polymerase chain reaction\", \"rubella serology\"]"}
{"id" : 193, "question_text" : "A 5-year-old girl presents with mild flank pain. She has no history of fever, trauma, gross hematuria, frequency, urgency, or dysuria. Physical examination of the afebrile child reveals a heart rate of 90 beats/min, respiratory rate of 20 breaths/min, blood pressure of 106/62 mm Hg, and normal growth parameters. There are no other findings of note. A dipstick urinalysis reveals a specific gravity of 1.020; pH of 8.5; 2+ protein; and negative for blood, leukocyte esterase, and nitrite. A urine protein-to-creatinine ratio performed on this specimen is subsequently reported as 0.02. Of the following, the MOST likely explanation for this girl's urinary findings is", "options" : "[\"alkaline urine\", \"minimal change disease\", \"orthostatic proteinuria\", \"urinary tract infection\", \"urolithiasis\"]"}
{"id" : 194, "question_text" : "An 18-year-old boy requires a computed tomography scan with intravenous contrast for an upcoming surgery. During his preoperative physical examination, he states that he experienced diffuse urticaria and tongue angioedema when he underwent a previous imaging study that required intravenous contrast. Of the following, the BEST method to prevent future contrast reactions is to", "options" : "[\"administer 1 L intravenous normal saline before the procedure\", \"perform desensitization to the contrast agent\", \"pretreat with oral antihistamines and corticosteroids\", \"use a contrast agent that has a low iodine content\", \"use a high-osmolar contrast agent\"]"}
{"id" : 195, "question_text" : "An 18-month-old boy is brought to the emergency department after being found in his grandfather's room with several open pill bottles. The family reports that they removed two unidentifiable tablets from his mouth and found 23 more scattered on the floor. The medications include terazosin, simvastatin, aspirin, acetaminophen, and allopurinol. The sleepy but arousable child has a temperature of 37.0°C, heart rate of 160 beats/min, respiratory rate of 24 breaths/min, and blood pressure of 66/34 mm Hg. The remainder of his physical examination findings are normal. Of the following, the medication that is MOST likely to be the cause of this child's clinical findings is", "options" : "[\"acetaminophen\", \"allopurinol\", \"aspirin\", \"simvastatin\", \"terazosin\"]"}
{"id" : 196, "question_text" : "A 16-year-old boy presents to your office with a history of increasing irritability, low mood, social withdrawal, a decline in school performance, and decreased energy despite a marked increase in sleep. These symptoms began approximately 1 year ago, when his father lost his job and the family had to move. He has no history of substance use. The boy began counseling 3 months ago but has not improved. Findings on physical examination are unremarkable. You administer a Patient Health Questionnaire-9 (PHQ-9), which supports the diagnosis of depression, and you decide to suggest treatment with a medication. Of the following, the BEST choice for management is", "options" : "[\"bupropion\", \"clomipramine\", \"fluoxetine\", \"paroxetine\", \"trazodone\"]"}
{"id" : 197, "question_text" : "You are seeing a 15-year-old girl because of abdominal pain. She was well until 6 months ago, when she began complaining of epigastric discomfort occurring at any time of the day. She has been awakened several times at night because of pain. Because of the severity of discomfort, she visited the local emergency department 3 days ago, and the following study results were obtained: Hemoglobin, 13.8 g/dL (138 g/L); White blood cell count, 8.5x103/mcL (8.5x109/L); Erythrocyte sedimentation rate, 10 mm/hr; Liver function studies, normal; Amylase, 45 units/L (normal, 10 to 50 units/L); Helicobacter pylori antibody, positive. She denies diarrhea, constipation, fevers, or weight loss. She has experienced occasional nausea and two or three episodes of vomiting, most recently this morning. Her menses are regular. Physical examination of the well-developed, well-nourished adolescent reveals moderate, direct abdominal tenderness in the epigastrium and the left upper quadrant. Rectal examination yields no findings of note, with an empty ampulla, and the examining glove tests negative for occult blood. Of the following, the MOST appropriate next step is", "options" : "[\"abdominal ultrasonography\", \"13C-urea breath test\", \"lansoprazole, amoxicillin, and clarithromycin therapy\", \"stool H pylori antigen testing\", \"upper gastrointestinal tract endoscopy\"]"}
{"id" : 198, "question_text" : "You are performing a follow-up evaluation on a 4-year-old boy in whom anemia was diagnosed during a Head Start® screening. He has been receiving 3 mg/kg per day of elemental iron for the past 6 weeks. His mother reports no changes in activity or appetite. He drinks two to three glasses of milk each day and eats a relatively diverse diet. His growth parameters are in the 75th percentile, and his physical examination findings are normal. Results of laboratory tests include: Hemoglobin. 9.4 g/dL (94 g/L), Hematocrit, 29% (0.29), Mean corpuscular volume, 66 fL, Red cell distribution width, 12.2%, Red blood cell count, 5.8 x 106/mcL (5.8 x 1012/L), Reticulocyte count, 1% (0.01), Ferritin, 54 ng/mL (121.3 pmol/L) (normal, 7 to 140 ng/mL [15.7 to 314.6 pmol/L]). Of the following, the MOST appropriate next step is", "options" : "[\"obtain direct and indirect antiglobulin (Coombs) tests\", \"obtain hemoglobin electrophoresis\", \"perform a bone marrow aspirate\", \"repeat the course of iron\", \"transfuse with packed red blood cells\"]"}
{"id" : 199, "question_text" : "A 17-year-old boy presents for a preparticipation sports physical examination for high school varsity football. He denies sexual activity, but examination of his genital area reveals marks consistent with excoriation due to scratching. You also note debris on the skin under the pubic hair and attached to the pubic hair. Of the following, the MOST appropriate initial treatment for this condition is", "options" : "[\"oral ivermectin\", \"oral trimethoprim-sulfamethoxazole\", \"topical lindane\", \"topical malathion\", \"topical permethrin\"]"}
{"id" : 200, "question_text" : "You are called to the emergency department to assess a 7-day-old infant who has presented with poor perfusion and respiratory collapse. He has been well-appearing but slightly dusky since birth. Pulse oximetry reveals an oxygen saturation of 90% in the right arm but 55% in the left leg. His blood pressures are symmetric but diffusely reduced. Although he has no obvious cardiac murmur, he does exhibit a gallop rhythm, his liver is enlarged, and his extremities are cool, with reduced pulses. Of the following, the MOST likely diagnosis for this infant is", "options" : "[\"coarctation of the aorta\", \"dilated cardiomyopathy due to viral myocarditis\", \"hypertrophic cardiomyopathy due to gestational diabetes\", \"hypoplastic left heart syndrome\", \"transposition of the great arteries\"]"}
{"id" : 201, "question_text" : "You note an upcoming health supervision visit appointment for a 10-year-old child who has myelomeningocele complex. You are seeing him for the first time after your partner, who previously cared for him, retired. In preparation for the visit, you review the child's medical history and some background on this complex condition. The boy had an open spinal dysraphism repaired at birth. He also had herniation of the cerebellar vermis (a Chiari II malformation) that required surgical decompression and hydrocephalus that necessitated a ventriculoperitoneal shunt. The boy has been stable for 3 years, but according to your reading, he is at risk for acute deterioration due to shunt malfunction or new problems in the brainstem or upper or lower spinal cord. Of the following, the finding that is MOST indicative of potential neurological deterioration in this child is", "options" : "[\"double vision\", \"facial weakness\", \"gait dysfunction\", \"impulsive behavior\", \"unilateral headache\"]"}
{"id" : 202, "question_text" : "A 2-year-old boy in your practice has clinical signs of rickets; laboratory testing reveals a low phosphorus, normal calcium, elevated alkaline phosphatase, low-normal 1,25-dihydroxyvitamin D3, and high normal parathyroid hormone values. You refer him to a pediatric endocrinologist who suspects that he has X-linked dominant hypophosphatemic rickets. Of the following, the history that is MOST suggestive of the X-linked dominant form of hypophosphatemic rickets is that", "options" : "[\"his father has significant short stature, genu varum, and recurrent dental abscesses\", \"his mother and maternal aunt have mild short stature and his maternal grandfather has severe genu varum\", \"his parents are second cousins (their grandfathers are brothers)\", \"neither parent has signs of rickets, but his mother's brother and one of her maternal uncles were diagnosed with rickets\", \"the number of affected males in the extended family history is approximately twice that of affected females\"]"}
{"id" : 203, "question_text" : "You are seeing a 17-year-old boy for the first time because of symptoms of burning on urination and occasional staining of his underwear. On physical examination, you note scant clear fluid at his urethral meatus but no other genital findings. He has had three sexual partners in the past 6 months and uses condoms intermittently. You obtain a urine specimen to test for sexually transmitted infections. He has no allergies to any medications. You are concerned that he may not return for the test results. Of the following, the BEST choice for treatment for this boy is", "options" : "[\"ampicillin\", \"ampicillin and doxycycline\", \"benzathine penicillin and doxycycline\", \"ceftriaxone and azithromycin\", \"levofloxacin\"]"}
{"id" : 204, "question_text" : "You are called to the infusion center to evaluate a 15-year-old girl who just received a transfusion of two units of packed red blood cells over 4 hours for anemia due to her underlying acute lymphocytic leukemia. Before starting her transfusion, her temperature was 37.0°C, heart rate was 80 beats/min, respiratory rate was 16 breaths/min, blood pressure was 110/70 mm Hg, and oxygen saturation was 97% in room air. As the transfusion was completed, she began to feel short of breath and developed chills, headache, nausea, and vomiting. Currently, her temperature is 38.5°C, heart rate is 100 beats/min, respiratory rate is 26 breaths/min, blood pressure is 105/65 mm Hg, and oxygen saturation is 95% in room air. You discuss the apparent transfusion reaction with the patient and her parents. Of the following, the information you are MOST likely to share with the family is that", "options" : "[\"fevers are always associated with a hemolytic reaction\", \"fevers are the most common reaction seen\", \"leukocyte reduction filters can eliminate the risk of a reaction with future transfusions\", \"the incidence is approximately 25%\", \"washed blood cell products can eliminate the risk of a reaction with future transfusions\"]"}
{"id" : 205, "question_text" : "A 9-year-old girl presents with a 2-month history of diarrhea and weight loss. A thorough review of systems reveals that she has been having difficulty sleeping at night for the past month. On physical examination, her heart rate is 95 beats/min, blood pressure is 121/85 mm Hg, weight is 22 kg, and height is 132 cm. You palpate a firm enlarged thyroid gland without nodules. Laboratory studies reveal a free thyroxine (FT4) value of 2.4 ng/dL (30.9 pmol/L) (normal, 0.9 to 1.6 ng/dL [11.6 to 20.6 pmol/L]) and thyroid-stimulating hormone (TSH) value of less than 0.01 mIU/L (normal, 0.5 to 4.0 mIU/L). Of the following, the next BEST step in the management of this patient is to", "options" : "[\"assess thyroid-stimulating immunoglobulins\", \"perform I-123 uptake scan\", \"repeat FT4 and TSH measurements in 1 week\", \"start methimazole\", \"start propylthiouracil\"]"}
{"id" : 206, "question_text" : "The mother a 10-year-old girl whom you have been seeing since birth calls you because of concerns that her daughter might have depression. When they arrive at the office, one of your office assistants asks both the mother and child to complete a Child Depression Inventory (CDI). The mother's inventory scores are borderline significant and the child's scores are below the cutoff for depression. When you interview the girl in her mother's presence, she admits to trouble sleeping, difficulty concentrating on her schoolwork, and no longer enjoying school. Physical examination of the quiet but cooperative girl yields normal findings. Of the following, the next BEST step in care is to", "options" : "[\"administer the Patient Health Questionnaire-9 (PHQ-9)\", \"interview the child alone regarding other possible symptoms of depression\", \"prescribe a trial of fluoxetine therapy\", \"reassure the mother that her child does not have depression based on results of the CDI\", \"schedule a follow-up visit in about 1 month for reassessment\"]"}
{"id" : 207, "question_text" : "A young mother brings in her 12-month-old child for a health supervision visit. The child is breastfeeding well and tolerating solids. She has a vocabulary of 5 words and is able to follow simple directions. The grandmother, who also is in attendance, is concerned that the child is tongue-tied and worries that she will not be able to speak correctly. On physical examination, you notice a short lingual frenulum. The mother asks if her infant is \"all right.\" Of the following, the BEST response is to", "options" : "[\"reassure the family that this is normal\", \"recommend that the child begin to use a cup\", \"refer the child for a frenulectomy\", \"send the child for an otolaryngology consultation\", \"send the child for speech evaluation\"]"}
{"id" : 208, "question_text" : "You are evaluating a newborn whose mother has known hepatitis C infection. The mother asks when the baby should be tested to determine if the infection has been transmitted to her infant. Of the following, the BEST course of action is", "options" : "[\"nucleic acid amplification testing (NAAT) for hepatitis C genome at 2 months of age\", \"NAAT for hepatitis C genome before discharge from the nursery\", \"serial liver enzyme testing\", \"serologic testing for hepatitis C antibodies at 12 months of age\", \"serologic testing for hepatitis C antibodies before discharge from the nursery\"]"}
{"id" : 209, "question_text" : "A pregnant woman has recently been exposed to varicella-zoster virus and is concerned about the risk to her fetus if she develops varicella-zoster infection. Of the following, the most accurate information to share with this mother is that", "options" : "[\"her infant is at high risk of death if the infection occurs during active labor at term\", \"her infant is at highest risk of damage to the heart if the infection occurs between 13 to 20 weeks' gestation\", \"most mothers infected in the first trimester experience fetal loss\", \"transplacental transfer of antibody is ineffective in modifying the disease in the term newborn\", \"ultrasonography can be used to exclude infection in the fetus after 20 weeks' gestation\"]"}
{"id" : 210, "question_text" : "You are examining a 1-day-old term male infant during rounds in the newborn nursery and palpate a right upper quadrant abdominal mass. The remainder of the examination findings are normal. The infant's mother is an otherwise healthy 22-year-old gravida 1, para 1, woman who received no prenatal care. You note on the chart that the infant voided at 6 hours of age. Of the following, the MOST likely diagnosis in this infant is", "options" : "[\"posterior urethral valves\", \"ureterocele\", \"ureteropelvic junction obstruction\", \"urolithiasis\", \"Wilms tumor\"]"}
{"id" : 211, "question_text" : "A 14-year-old boy who has seasonal allergic rhinitis and moderate persistent asthma is currently receiving allergen immunotherapy. Today in the clinic, he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical examination, he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. His oropharynx appears normal and without tongue or uvula edema. Vital signs include a room air pulse oximetry reading of 97%, blood pressure of 130/70 mm Hg, and heart rate of 90 beats/minute. Of the following, the MOST appropriate next action is to administer", "options" : "[\"a short-acting beta-2 agonist nebulization\", \"an oral antihistamine\", \"an oral corticosteroid\", \"intramuscular epinephrine\", \"supplemental oxygen via face mask\"]"}
{"id" : 212, "question_text" : "A 14-year-old boy is brought to the emergency department by emergency medical services after he fell 30 feet out of a tree. At the scene, he was unconscious. The paramedics immobilized his cervical spine, endotracheally intubated him, began mechanical ventilation with 100% oxygen, and inserted two intravenous catheters. On arrival at the emergency department, his temperature is 36.5°C, heart rate is 140 beats/min, blood pressure is 80/60 mm Hg, and oxygen saturation is 100%, and he is being ventilated at 15 breaths/min. Physical examination reveals a Glasgow Coma Scale score of 5 and a right femur deformity. His abdomen is nondistended and his breath sounds are equal bilaterally. Following rapid infusion of two 20-mL/kg 0.9% saline fluid boluses, his heart rate is 70 beats/min and his blood pressure is 76/45 mm Hg. Of the following, the MOST likely explanation for the boy's persistent hypotension is", "options" : "[\"blood loss from the femur fracture\", \"epidural hematoma\", \"hemothorax\", \"liver laceration\", \"spinal cord injury\"]"}
{"id" : 213, "question_text" : "A 14-year-old girl presents with painless rectal bleeding. The well-appearing child's height and weight are both between the 10th and 25th percentiles. A digital rectal examination demonstrates normal anatomy, and stool is positive for occult blood. Upon further questioning, the girl's father states that he also experienced rectal bleeding as a child and had \"a few\" polyps removed at age 12 years. At that time, his parents were told that the polyps were benign and that no further follow-up was required. He has been asymptomatic since then. The girl's initial laboratory study results show a hemoglobin of 12.5 g/dL (125 g/L), an albumin of 3.8 g/dL (38 g/L), and a C-reactive protein of less than 1.0 mg/dL. You refer the child for colonoscopy. Several pedunculated polyps in the descending colon are identified at colonoscopy and removed by electrocautery. Histologic findings are typical for a juvenile (inflammatory) polyp. Of the following, the girl MOST likely will require", "options" : "[\"colonoscopy annually\", \"colonoscopy every 5 years until age 45\", \"perinuclear antineutrophil cytoplasmic antibody (pANCA) assay\", \"phosphatase and tensin homolog (PTEN) mutation analysis\", \"stool occult blood testing annually\"]"}
{"id" : 214, "question_text" : "You are called to the newborn nursery to evaluate a term newborn for abdominal distention. The infant was born 12 hours ago by vaginal delivery. The pregnancy was complicated by gestational diabetes and polyhydramnios. Spontaneous rupture of the membranes occurred 1 hour before delivery with copious amniotic fluid that appeared to be lightly meconium-stained. The infant is breastfeeding well and has passed one stool since birth. Her mother describes the infant as spitting up about a teaspoon of \"green stuff\" twice in the past hour. Physical examination reveals an active, alert infant who has a moderately distended abdomen that is not tender to palpation. The rectum appears patent. You obtain a radiograph of the abdomen. Of the following, the MOST appropriate next step is", "options" : "[\"abdominal computed tomography scan\", \"abdominal ultrasonography\", \"contrast enema\", \"lateral abdominal radiograph with the infant prone\", \"upper gastrointestinal radiographic series\"]"}
{"id" : 215, "question_text" : "An intern asks you to evaluate a 4-day-old infant who has a rash. On physical examination, the healthy-appearing infant has a rash on the trunk and extremities that is comprised of erythematous macules, each of which has a central papule or vesicle (Item Q108). A Gram stain of the lesion shows white blood cells but no organisms and a Wright stain shows numerous eosinophils.\n\nOf the following, the MOST likely diagnosis is", "options" : "[\"congenital candidiasis\", \"erythema toxicum\", \"herpes simplex virus infection\", \"staphylococcal folliculitis\", \"transient neonatal pustular melanosis\"]"}
{"id" : 216, "question_text" : "The mother of an 8-year-old boy brings him in for follow-up care 6 weeks after a motor vehicle crash in which he sustained minor abrasions and contusions. The mother notes that her son is healing well, and she is pleased that he does not have any significant scarring. However, she comments that he has not been himself lately and is driving her \"nuts.\" He has been whiny and easily tearful, and all he wants to do is play with some old toy cars he found in the basement. He refused to go to school the last two Mondays, stating he had a stomachache and begging to stay home. He has begun to come into his parents' room at night, complaining that he had a \"scary dream\" and can't fall asleep. For the past few weeks, he has not wanted to go to his friend's house to play. On physical examination, the boy's abrasions are healed and he has no residual bruising or scarring. His vital signs and other findings on physical examination, including abdominal evaluation, are within normal limits. He is quiet but cooperative, he has his fists in his pockets, and he makes adequate eye contact. He shrugs his shoulders when asked why he doesn't want to visit his friend or why he suddenly doesn't like going to school. His energy is \"fine\" and his appetite is \"good.\" He says that he would just rather stay home and leans into his mother, burying his head in her shoulder and crying silently.\n\nOf the following, the MOST likely diagnosis for this boy is", "options" : "[\"major depressive disorder\", \"normal behavior\", \"oppositional defiant disorder\", \"posttraumatic stress disorder\", \"separation anxiety disorder\"]"}
{"id" : 217, "question_text" : "You diagnose an interrupted aortic arch in a newborn. You order an infusion of prostaglandin E1 to maintain patency of the ductus arteriosus.\n\nOf the following, the physiologic benefits of this medication MOST likely are due to increased", "options" : "[\"pulmonary blood flow via left-to-right ductal shunting\", \"pulmonary blood flow via right-to-left ductal shunting\", \"pulmonary vasodilatory effects\", \"systemic blood flow via left-to-right ductal shunting\", \"systemic blood flow via right-to-left ductal shunting\"]"}
{"id" : 218, "question_text" : "During the hottest week of the summer, a 6-month-old previously healthy infant presents to the emergency department via ambulance in tonic-clonic status epilepticus. After two doses (each 0.05 mg/kg) of intravenous lorazepam, the seizure continues. The bedside glucose measurement is normal, as is a noncontrast head computed tomography scan.\n\nOf the following, the MOST likely cause of the child's prolonged seizure is", "options" : "[\"hyperthyroidism\", \"hypocalcemia\", \"hypomagnesemia\", \"hyponatremia\", \"pyridoxine deficiency\"]"}
{"id" : 219, "question_text" : "You are examining a 6-year-old girl who is new to your practice. Past medical history reveals that she had a normal head circumference at birth but experienced head growth deceleration over time. Her development was relatively normal until she was about 1 year of age but has regressed since then. She developed a seizure disorder when she was three years old. Her mother reports that her daughter has an abnormal breathing pattern (intermittent hyperventilation and breath-holding) and a stiff, awkward gait.\n\nOf the following, the MOST likely diagnosis for this girl is", "options" : "[\"Angelman syndrome\", \"duplication 15q11\", \"phenylketonuria\", \"Rett syndrome\", \"Smith-Lemli-Opitz syndrome\"]"}
{"id" : 220, "question_text" : "You are evaluating a 13-year-old boy who has had intermittent low back pain and stiffness for the past 3 months. He also has some ankle pain but no fever or other complaints. He plays soccer but does not recall any particular injuries. On physical examination, you note some tenderness of his sacroiliac joints. He has normal lower extremity strength, sensation, and reflexes and negative results on a straight leg-raising test. There is moderate tenderness to palpation over the insertion of his Achilles tendon. He has no skin or eye findings and no other joint findings. Spinal radiographs are read as normal.\n\nOf the following, the BEST next step is", "options" : "[\"acetaminophen use as needed\", \"corticosteroid injections in the Achilles tendon\", \"evaluation for spondyloarthropathies\", \"heat to his back and bed rest\", \"screening for sexually transmitted infections\"]"}
{"id" : 221, "question_text" : "You are providing moderate sedation to a 9-month-old infant who weighs 10 kg to allow complete transthoracic echocardiography. The child underwent an uncomplicated repair of a large ventricular septal defect 1 week ago, has no allergies, and has been appropriately fasting. Your health evaluation before administering the sedative reveals no abnormal physical findings, except for a well-healed sternotomy scar. His temperature is 37.0°C, heart rate is 120 beats/min, respiratory rate is 25 breaths/min, blood pressure is 90/55 mm Hg, and oxygen saturation is 98% in room air. You order 0.5 mg (0.05 mg/kg) of midazolam, which the nurse administers intravenously. Shortly after administration, the child develops apnea, with a decrease in blood pressure to 75/40 mm Hg and no change in heart rate. As you reposition the airway and begin bag-valve-mask ventilation, the nurse reports that an error had been made and that 5 mg (0.5 mg/kg) of midazolam was administered inadvertently.\n\nOf the following, the MOST appropriate next step is administration of", "options" : "[\"atropine\", \"epinephrine\", \"fentanyl\", \"flumazenil\", \"naloxone\"]"}
{"id" : 222, "question_text" : "A 9-year-old boy presents with a 2- to 3-month history of increased urination, intermittent back pain, and constipation. There are no other findings of note on his history, and the only abnormality noted on physical examination is mild hyporeflexia. Among the screening laboratory results are total calcium of 12.1 mg/dL (3.0 mmol/L) and phosphorus of 1.7 mg/dL (0.55 mmol/L).\n\nOf the following, the test that is MOST likely to establish the diagnosis is", "options" : "[\"serum alkaline phosphatase\", \"serum ionized calcium\", \"serum parathyroid hormone\", \"serum parathyroid hormone-related protein\", \"urinary calcium/creatinine ratio\"]"}
{"id" : 223, "question_text" : "A 7-year-old girl is having behavioral problems in school. Her academic skills are strong, but she is impulsive and has difficulty staying on task and remaining quiet while the teacher is talking. When the students line up, she pushes to be at the head of the line. At home, her parents have problems getting her to comply with their requests. She needs frequent reminders to sit and do her homework.\n\nOf the following, the MOST appropriate next step is to", "options" : "[\"begin a trial of stimulant medication\", \"complete Vanderbilt questionnaires\", \"have the parents institute a token economy behavior plan\", \"obtain a thyroid function test\", \"refer the child for psychoeducational testing\"]"}
{"id" : 224, "question_text" : "A 3-year-old girl is admitted to the intensive care unit with the acute onset of fever, altered mental status, and nuchal rigidity. She, her 1-year old brother, and her 4-year-old sister have not received immunizations because of parental religious objection. Cerebrospinal fluid evaluation reveals a white blood cell count of 2.45x103/mcL (2.45x109/L) with 98% polymorphonuclear neutrophils, glucose of 3 mg/dL (0.2 mmol/L), and protein of 266 mg/dL (2.7 g/L). Culture results are pending.\n\nOf the following, the culture result that MOST strongly indicates the need for chemoprophylaxis for this child's siblings is", "options" : "[\"enterovirus\", \"Haemophilus influenzae type b\", \"nontypeable Haemophilus influenzae\", \"Streptococcus pneumoniae\", \"West Nile virus\"]"}
{"id" : 225, "question_text" : "A healthy term newborn has done well in the nursery and is ready for discharge. While speaking with the new mother, you learn that her brother has a coughing illness accompanied by fever, weight loss, and hemoptysis. He often stays at his sister's home. No other family members, including the infant's mother, are ill.\n\nOf the following, the next BEST management step for the newborn is to", "options" : "[\"isolate the infant and the mother\", \"obtain a chest radiograph\", \"place a tuberculin skin test\", \"separate the infant from the uncle\", \"start isoniazid therapy\"]"}
{"id" : 226, "question_text" : "You are examining a newborn who has wrinkling of the abdominal wall skin. His mother recalls her obstetrician mentioning that her \"fluid was low.\" The infant was born at 37 weeks' gestation, and his birthweight was appropriate for gestational age.\n\nOf the following, the MOST likely additional findings expected in this infant are cryptorchidism and", "options" : "[\"bilateral hydronephrosis\", \"hypospadias\", \"nephrocalcinosis\", \"polycystic kidney disease\", \"unilateral renal agenesis\"]"}
{"id" : 227, "question_text" : "You are scheduled to see an 11-year-old girl for a health supervision visit. In the past she was seen by your partner who recently retired. Her medical records reveal that she has been taking risperidone, clonidine, and methylphenidate for almost 2 years. You notice that her weight has increased over the past year. Her mother states that her daughter has been in good health and has not yet achieved menarche. On physical examination, you note Sexual Maturity Rating (SMR) 3 pubic hair and breast tissue and mild acne. Her body mass index (BMI) is elevated and pulse and blood pressure are normal. Her review of systems is negative for abnormal involuntary movements, muscle stiffness, fainting or shortness of breath. There is no family history of cardiac disease or sudden unexplained death.\n\nOf the following, the MOST appropriate tests to obtain for a patient taking these medications are", "options" : "[\"fasting glucose, liver enzymes, and cholesterol/lipid profile\", \"fasting glucose, thyroxine, and electrocardiogram\", \"prolactin, fasting glucose, and cholesterol/lipid profile\", \"risperidone concentration, liver enzymes, and fasting glucose\", \"thyroxine, lipid profile, and serum creatinine\"]"}
{"id" : 228, "question_text" : "A-14 year-old girl presents with a 4-year history of recurrent infections. Her parents state that it seems she is on antibiotics almost every other month for the treatment of otitis media, sinusitis, or pneumonia. During a recent hospitalization for lobar pneumonia, the inpatient team measured serum immunoglobulins (Igs), which showed:\n• Low IgG of 54 mg/dL (0.54 g/L) (normal range, 700 to 1,500 mg/dL [7 to 15 g/L])\n• Absent IgA at <7.5 mg/dL (75 mg/L) (normal range, 15 to 200 mg/dL [150 to 2,000 mg/L])\n• Low IgM of 10 mg/dL (100 mg/L) (normal range, 50 to 300 mg/dL [500 to 3,000 mg/L])\n\nDespite the recurrent infections, the girl is otherwise growing and developing appropriately and has no other specific medical concerns.\n\nOf the following, the MOST appropriate next laboratory test is", "options" : "[\"flow cytometry for B lymphocytes, T lymphocytes, and natural killer cells\", \"genetic analysis for mutations of the Bruton tyrosine kinase (Btk) gene\", \"lymphocyte proliferation assay of peripheral blood mononuclear cells to mitogens\", \"measurement of antibody responses to protein and polysaccharide vaccines\", \"measurement of IgG subclasses (IgG1, IgG2, IgG3, IgG4)\"]"}
{"id" : 229, "question_text" : "A 2-year-old boy is brought to the emergency department after his mother found him with an open bottle of toilet bowl cleaner. She reports that he had spilled some on his shirt and had some on his face, but she does not know if he drank any of it. The child is awake and alert, and his vital signs are normal. He is drooling slightly, but examination of his oropharynx reveals no lesions.\n\nOf the following, the MOST appropriate next step is to", "options" : "[\"administer activated charcoal\", \"administer syrup of ipecac\", \"perform gastric lavage\", \"provide no further treatment\", \"refer the boy to a gastroenterologist for urgent endoscopy\"]"}
{"id" : 230, "question_text" : "You are caring for an 18-year-old girl who has a presumptive diagnosis of cyclic vomiting syndrome. Extensive gastroenterologic and neurologic evaluations have failed to establish an alternative diagnosis. You began prophylactic treatment with amitriptyline several months ago, and the frequency of vomiting episodes has decreased from every 4 to 6 weeks to every 8 to 10 weeks. During these episodes, vomiting usually persists for 48 to 72 hours and has required hospitalization for intravenous hydration on two occasions in the past year. The girl's parents want to know if any treatment is available to abort these episodes at home.\n\nOf the following, the best available evidence suggests that the MOST appropriate treatment is", "options" : "[\"cyproheptadine\", \"erythromycin\", \"ondansetron\", \"propranolol\", \"sumatriptan\"]"}
{"id" : 231, "question_text" : "You are called to attend the delivery of a preterm infant at 32 weeks gestational age. The mother presented with preterm labor 12 hours ago. Tocolytic therapy and the administration of antenatal corticosteroids were begun at that time. Due to unknown group B Streptococcus status, the mother also was begun on ampicillin. Labor has now progressed to imminent vaginal delivery.\n\nOf the following, the tocolytic agent MOST likely to affect the neonatal resuscitation of this infant is", "options" : "[\"indomethacin\", \"magnesium sulfate\", \"nifedipine\", \"ritodrine\", \"terbutaline\"]"}
{"id" : 232, "question_text" : "The parents of a 22-month-old boy are concerned because he appears pale. Approximately 3 weeks ago he had a viral illness with fever and respiratory symptoms, from which he recovered in 6 days. Since then, he has had no fever, rashes, or complaints of discomfort. His appetite has been fair and activity level has decreased minimally. On physical examination, the generally well-appearing but somewhat pale boy has a temperature of 37.2°C, heart rate of 132 beats/min, and respiratory rate of 20 breaths/min. He has no lymphadenopathy, and his liver and spleen are not enlarged. Laboratory findings are:\n\nHemoglobin, 6.8 g/dL (68 g/L)\nWhite blood cell count, 7.2x103/mcL (7.2x109/L) with normal differential count\nPlatelet count, 402x103/mcL (402x109/L)\nMean corpuscular volume, 78 fL\nRed cell distribution width, 11.5%\nReticulocyte count, 0.5% (0.005)\nLactate dehydrogenase and red blood cell adenosine deaminase, normal\nDirect antiglobulin (Coombs) test, negative\n\nOf the following, the MOST appropriate treatment for this patient at this time is", "options" : "[\"close observation\", \"erythropoietin\", \"iron\", \"prednisone\", \"red blood cell transfusion\"]"}
{"id" : 233, "question_text" : "A mother brings her 14-year-old daughter to see you because of hair loss of several weeks' duration. On physical examination, you see an area of relative alopecia located at the vertex within which are hairs of varying lengths (Item Q126). There is no erythema or scaling of the scalp, and no \"black dot\" hairs are apparent. During the evaluation, you note that the child seems very shy and that she bites her fingernails.\n\nOf the following, the MOST likely diagnosis is", "options" : "[\"alopecia areata\", \"nevus sebaceus\", \"tinea capitis\", \"traction alopecia\", \"trichotillomania\"]"}
{"id" : 234, "question_text" : "You are evaluating a 10-year-old boy for a rash and fatigue. He recently returned from visiting family in South Africa, where he experienced an illness characterized by fever and sore throat 2 weeks ago. On physical examination, he is afebrile and his heart rate is 100 beats/min, respiratory rate is 28 breaths/min, and blood pressure is 110/65 mm Hg. He has a macular, erythematous rash on his trunk. In addition, you note a III/VI blowing systolic murmur at the apex as well as a II/VI long diastolic murmur at the left lower sternal border. Twelve-lead electrocardiography reveals sinus rhythm with first-degree atrioventricular block. Echocardiography documents valve dysfunction. Of the following, the MOST likely explanation for this child's diastolic murmur is", "options" : "[\"aortic valve insufficiency\", \"aortic valve stenosis\", \"mitral valve insufficiency\", \"mitral valve stenosis\", \"pulmonary valve stenosis\"]"}
{"id" : 235, "question_text" : "A 4-year-old boy has had two fairly similar, brief episodes within the past month consisting of abrupt arrest of ongoing behavior, glassy-eyed staring, and lip smacking, followed by confusion and sleepiness for 1 hour. He has had no fevers or other signs of illness at the time of either event. Findings on his medical and developmental histories are otherwise normal. Physical and neurologic examination results are normal. Brain magnetic resonance imaging yields normal results, and electroencephalography shows no abnormalities. Of the following, the MOST appropriate treatment for this boy is", "options" : "[\"carbamazepine\", \"ethosuximide\", \"felbamate\", \"phenobarbital\", \"phenytoin\"]"}
{"id" : 236, "question_text" : "You diagnose an atrial septal defect, bilateral hydronephrosis, and clubfeet in a newborn female. Cytogenetic analysis reveals an unbalanced translocation between the short arm of chromosome 2 and the long arm of chromosome 8 designated as – 46, XX , der (2), t(2;8) (p24; q24), resulting in a loss of genetic material from the top of chromosome 2 and a duplication of genetic material from the bottom of chromosome 8. The newborn has three healthy siblings, and the family history is negative for congenital anomalies or recurrent pregnancy losses. The parents ask about the risks for having another child with this condition. Of the following, you are MOST likely to advise them that the risks for recurrence", "options" : "[\"are as high as 50% because most unbalanced translocations are passed down from a balanced translocation carrier\", \"are between 1% and 5% because of risks for gonadal mosaicism in an otherwise normal parent\", \"are negligible since the parents and sibs are healthy and there is no history of recurrent miscarriages\", \"are probably between 20% and 30% because of a higher risk for miscarriage in fetuses who have unbalanced translocations\", \"cannot be determined unless chromosome studies are performed on both parents\"]"}
{"id" : 237, "question_text" : "A 14-year-old girl presents to the office for a routine health supervision visit. Her mother, who had her menarche at age 13 years, asks if she should be concerned that her daughter has not started menstruating yet. Chart review confirms that the adolescent began breast development at age 10½ years. She has been tracking along the 5th to 10th percentile for height and weight since entering puberty. Her father's growth spurt occurred around age 16 years. The girl is at Sexual Maturity Rating (SMR) 4 for breast development and SMR 5 for pubic hair development and has normal external genitalia. The remainder of her physical examination findings are normal. Of the following, the MOST appropriate next step is", "options" : "[\"follow-up evaluations every 6 months for 1 year\", \"hand and wrist radiograph for bone age\", \"luteinizing hormone and follicle-stimulating hormone assessment\", \"pelvic ultrasonography\", \"thyroid function testing\"]"}
{"id" : 238, "question_text" : "A 15-year-old girl is recovering in the pediatric ward of a hospital after an intentional overdose of acetaminophen. She admits she wanted to die because of her shame over her first sexual activity and the conflict it has caused with her parents. Her father states he is very \"disappointed\" in her and plans to have her work with their youth minister, who \"made an example\" of her to the congregation when she attempted to date in the past. She took \"extra\" aspirin a few days before this attempt, although her family is unaware of this. She timed the current suicide attempt for when she thought no one would be able to bring her to the hospital. She denies substance use or other psychiatric disturbance. You have decided that she no longer needs inpatient medical treatment. She tells you she is very embarrassed by the incident and is asking to go home. Of the following, the MOST appropriate course of action is to", "options" : "[\"prescribe a selective serotonin reuptake inhibitor and send the girl home\", \"pursue acute inpatient psychiatric hospitalization\", \"pursue admission to a long-term residential psychiatric facility\", \"send the girl home and arrange for counseling with her youth minister\", \"send the girl home with plans for office follow-up with her primary care physician in 1 week\"]"}
{"id" : 239, "question_text" : "You are teaching a group of medical students in the well baby nursery. One of them asks about pain perception in newborns and if pain medications are needed before circumcision. Of the following, the MOST accurate statement regarding pain perception in term newborns is that", "options" : "[\"neonatal pain fibers are fully myelinated at birth\", \"neonates are at increased risk of pain wind-up (hypersensitivity)\", \"neonates are incapable of perceiving pain\", \"neonates lack opioid receptors at birth\", \"sensory nervous system development begins at 12 weeks of gestation\"]"}
{"id" : 240, "question_text" : "A 4-year-old boy who has severe recurrent asthma and an allergy to cockroaches has had poor disease control despite inhaled fluticasone propionate 220 mcg twice a day for the previous 4 months. He most recently required 4 weeks of prednisone at 2 mg/kg per day to manage asthma symptoms and avoid hospitalization. After moving to a new home, his asthma symptoms improved dramatically, and he discontinued both the fluticasone and the prednisone. When he presents today, his mother states that he has not suffered any further asthma exacerbations, but he has developed nausea and severe fatigue. Of the following, the MOST appropriate treatment for this boy is to", "options" : "[\"begin hydrocortisone at 10 mg/m2 per day\", \"begin hydrocortisone at 50 mg/m2 per day\", \"restart both fluticasone at 220 mcg/day and prednisone at 2 mg/kg per day\", \"restart fluticasone at 220 mcg twice a day\", \"restart prednisone at 5 mg/kg per day\"]"}
{"id" : 241, "question_text" : "A 3-year-old child is showing evidence of significant delay in his expressive and receptive language; other aspects of his development are normal. His hearing has been tested and is normal. You review the situation with his mother. Of the following, the MOST appropriate action is to", "options" : "[\"have the boy evaluated for an augmented communication device\", \"have the boy return for a follow-up visit in 6 months\", \"have the mother begin to teach him simple signs to minimize his frustration\", \"refer the boy for a psychoeducational evaluation\", \"refer the boy for speech evaluation and therapy as indicated\"]"}
{"id" : 242, "question_text" : "A 4-year-old boy is brought to your office for treatment of a dog bite to his right hand that occurred several hours ago. A neighbor's dog bit the child when he was playing near the dog's food dish. Physical examination reveals several bite marks on the dorsum of his hand that have broken the skin. According to your records, the boy developed a diffuse pruritic rash after receiving amoxicillin for a streptococcal pharyngitis 6 months ago. The records confirm that his tetanus immunization status is up to date. Of the following, the MOST appropriate antibiotic coverage for this child is", "options" : "[\"amoxicillin-clavulanate\", \"azithromycin and trimethoprim-sulfamethoxazole\", \"cefdinir\", \"ciprofloxacin\", \"clindamycin and trimethoprim-sulfamethoxazole\"]"}
{"id" : 243, "question_text" : "A 2-year-old girl who has no significant exposure history presents with a 4-week history of progressive right neck swelling. On physical examination, her temperature is 37.0°C and weight is 12 kg (50th percentile). She has a 3x2-cm area of swelling of the right anterior neck that is mildly fluctuant and tender to palpation. The overlying skin is purplish and thin. There is no hepatosplenomegaly or diffuse lymphadenopathy or other findings of note on the remainder of the physical examination. A tuberculin skin test read at 48 hours measures 5 mm of induration. Of the following, the MOST appropriate next step is to", "options" : "[\"initiate clindamycin and trimethoprim-sulfamethoxazole therapy\", \"initiate isoniazid and rifampin therapy\", \"obtain a chest radiograph\", \"perform an excisional biopsy of the lymph node\", \"perform needle aspiration of the lymph node\"]"}
{"id" : 244, "question_text" : "A 3-year-old boy presents with difficulty voiding. His mother states that he appears fussy and seems to strain when trying to void. He is otherwise well and has no history of fever, vomiting, difficulty feeding, swelling, or gross hematuria. He does have a history of acute pyelonephritis at 10 months of age. Ultrasonography and voiding cystourethrography (VCUG) results were reported as normal. His mother noted that he had some visible blood in his urine immediately after undergoing his VCUG, which cleared several hours later. The boy was toilet trained at 2½ years of age. He has had no recent urinary tract infections. Physical examination reveals an uncircumcised male who has easily retractable foreskin and no sacral dimples or hair tufts on the back. Urinalysis results include a specific gravity of 1.020; pH of 6; and no blood, protein, leukocyte esterase, or nitrite. Microscopy is negative. Of the following, the MOST likely explanation for this boy's difficulty voiding is", "options" : "[\"bladder stone\", \"cystitis\", \"neurogenic bladder\", \"posterior urethral valves\", \"urethral stricture\"]"}
{"id" : 245, "question_text" : "You are evaluating a 3-month-old boy who was born at 38 weeks' gestation and has experienced chronic diarrhea and recurrent pneumonia, although his growth and development have been normal. During a recent hospitalization for pneumonia, a chest radiograph demonstrated a right lower pneumonia but absence of a thymic shadow. You suspect severe combined immunodeficiency and discuss the case with an immunologist. Of the following, the MOST appropriate initial screening test for this child is", "options" : "[\"antibody response to polysaccharide vaccines\", \"antibody response to protein vaccines\", \"complete blood count\", \"immunoglobulin G subclasses\", \"T-cell receptor excision circles\"]"}
{"id" : 246, "question_text" : "A 14-year-old softball player comes to the emergency department after being struck in the eye by a pitch. She is awake and alert, complaining of right eye and face pain. She has obvious swelling and ecchymosis around her right orbit. Her extraocular movements are normal on the left, but she is unable to look up with her right eye. Her globe is intact, vision is 20/20 in both eyes, and pupils are equally round and reactive; no corneal injuries are apparent on fluorescein examination. Of the following, the injury that BEST explains this girl's physical findings is", "options" : "[\"epidural hematoma\", \"intracranial contusion\", \"LeFort fracture, type 1\", \"right orbital floor fracture\", \"right temporal skull fracture\"]"}
{"id" : 247, "question_text" : "A 17-year-old boy is referred to you by his school because of obesity. He has been in good health, except for a rapid increase in weight for the past 2 years. During that time, his parents have noted a change in his behavior, and they are concerned about his poor school performance. Because of declining grades and some difficulty in concentrating on his studies, the young man recently was diagnosed with attention-deficit disorder and has been treated with methylphenidate. Physical examination demonstrates a well-developed, obese adolescent, whose height is 170 cm and weight is 80 kg. The only other findings of note are a firm liver edge palpated 2 cm below the right costal margin and a palpable spleen tip. Initial laboratory results include: Hemoglobin, 13.0 g/dL (130 g/L); Aspartate aminotransferase, 60 units/L (normal, 10 to 30 units/L); Alanine aminotransferase, 55 units/L (normal, 10 to 30 units/L); Alkaline phosphatase, 280 units/L (normal, 10 to 140 units/L); Bilirubin, 3.5 mg/dL (59.9 mcmol/L); Erythrocyte sedimentation rate, 30 mm/hr. Because of these results, you obtain the following additional studies: Hepatitis A antibody, negative; Hepatitis B surface antibody, positive; Hepatitis B surface antigen, negative; Hepatitis C antibody, negative; Alpha-1-antitrypsin, 220 mg/dL (40.5 mcmol/L) (normal, 150 to 350 [27.6 to 64.4 mcmol/L]); Serum ceruloplasmin, 22 mg/dL (220 mg/L) (normal, 20 to 60 [200 to 600 mg/L]). Of the following, the MOST appropriate next study is", "options" : "[\"abdominal ultrasonography\", \"Epstein-Barr virus titers\", \"liver biopsy\", \"serum copper measurement\", \"slit lamp examination\"]"}
{"id" : 248, "question_text" : "During a routine health supervision visit, a mother relates that her sister recently gave birth to an infant who had hypoplastic left heart syndrome. She has just found out she is 6 weeks pregnant with her second child and is very worried because she has learned that other members of her family have had children with heart problems over the past three generations. She would like to know how her baby can be assessed prenatally for heart problems. Of the following, you are MOST likely to advise her that a fetal heart defect can best be diagnosed by", "options" : "[\"amniocentesis\", \"chorionic villus sampling\", \"fetal magnetic resonance imaging\", \"maternal serum alpha-fetoprotein concentrations\", \"prenatal level 2 ultrasonography\"]"}
{"id" : 249, "question_text" : "You are seeing a 17-year-old boy in your office for suture removal following a laceration to the left index finger. He reports that he cut himself while operating a meat slicer at a local deli, where he has worked since dropping out of school. You have not seen him in your office for 2 years. He has a past history of attention-deficit/hyperactivity disorder, which you briefly treated with methylphenidate. On physical examination, in addition to a healing, sutured 2-cm finger laceration, you observe tachycardia and injected conjunctivae bilaterally. The boy appears nervous and has difficulty recalling details of the accident at work. You obtain a psychosocial history that includes family functioning, drug history, sexual history, peer interaction, and mood and anxiety assessment. Upon further questioning, he admits to daily marijuana use for more than 2 years. Of the following, the MOST appropriate next step is to", "options" : "[\"advise him to stop use and follow up in 1 month\", \"arrange urine drug testing\", \"notify his parents of his marijuana use\", \"obtain a more detailed substance use history\", \"resume methylphenidate therapy\"]"}
{"id" : 250, "question_text" : "A 7-year-old girl complains of 1 day of dysuria, vaginal itching, and perineal pain without fever or vomiting. She does not have urgency, frequency, or enuresis, but she does report a light yellow discharge. She denies any type of trauma, including sexual abuse. Her vital signs and abdominal examination findings are normal, and she has no flank tenderness. Perineal inspection shows a minimal amount of mucoid vaginal discharge and moderate erythema of the vestibule. There is no evidence of trauma. A urine dipstick evaluation is negative except for trace leukocyte esterase. Of the following, the MOST appropriate next step in the evaluation/treatment of this patient is", "options" : "[\"a course of oral antibiotics for urinary tract infection\", \"application of bland emollients as needed for symptom relief\", \"topical anticandidal cream for 7 days\", \"urine testing for gonorrhea and chlamydia\", \"vaginoscopy\"]"}
{"id" : 251, "question_text" : "A 12-year-old girl presents to your office 2 weeks after the onset of a viral respiratory illness. She recovered from the illness 8 days ago, but she now complains of chest pain, shortness of breath, and fatigue. On physical examination, her heart rate is 110 beats/min, respiratory rate is 28 breaths/min, blood pressure is 75/45 mm Hg, and oxygen saturation is 95%. The pale girl exhibits tachypnea, muffled heart tones without an obvious murmur, a palpable liver 3 cm below the right costal margin, and poor peripheral pulses. She has minimal palpable chest discomfort when sitting, but the pain on palpation increases when she is supine. Electrocardiography reveals ST-segment abnormalities and diffusely reduced voltages. Chest radiography is shown in image (Item Q145). Of the following, the MOST likely diagnosis is", "options" : "[\"endocarditis\", \"myocardial infarction\", \"myocarditis\", \"pericarditis\", \"tachyarrhythmia\"]"}
{"id" : 252, "question_text" : "A 12-year-old girl who has idiopathic partial epilepsy that has been well controlled with carbamazepine for 1 year develops an ear infection. Because she is allergic to penicillin, an urgent care physician prescribes a course of azithromycin. Three days later, she presents to the emergency department with vomiting and dizziness. On physical examination, she has end-gaze nystagmus in both horizontal directions and a broad-based gait. Of the following, the MOST likely explanation for this girl's clinical findings is", "options" : "[\"carbamazepine toxicity\", \"confusional migraine\", \"otitic hydrocephalus\", \"postictal presentation\", \"unilateral labyrinthitis\"]"}
{"id" : 253, "question_text" : "A 10-year-old girl and her 14-year-old brother in your practice both had phenylketonuria (PKU) diagnosed at birth. With early identification and initiation of dietary restriction, both children have done well academically and socially. Their mother is looking ahead to their college years and asks about recommendations regarding ongoing dietary management. Of the following, you are MOST likely to tell her that dietary restriction can be lifted after age 15 years", "options" : "[\"for both children\", \"but must be reinstituted for the girl before she becomes pregnant\", \"but must be reinstituted for the girl during pregnancy\", \"for the boy only\", \"for neither child\"]"}
{"id" : 254, "question_text" : "You are seeing a 13-year-old girl, in whom you diagnosed anorexia nervosa approximately 18 months ago, for a follow-up visit. She had started to restrict her food intake about 6 months before her first visit. There was no history of binging or purging. She had become progressively more isolated from her friends and was very anxious and irritable. Currently, her mother states that she is doing well at school and has one friend. She is eating everything but still in small quantities. She has not had menarche yet but is otherwise asymptomatic. Her mother had her menarche at age 12½ years. On physical examination, the girl has normal vital signs, a body mass index of 17.4, and no focal findings. When her father comes in after your examination, he is very upset that she is not \"cured after all this time\" and that they still have to supervise her meals and eating habits. You discuss the usual course of this illness and prognosis with him. Of the following, the factor MOST likely to be associated with a poor prognosis for this girl is", "options" : "[\"absence of binging and purging\", \"comorbid psychiatric illness\", \"early onset of illness (<14 years)\", \"good family support\", \"short duration of illness\"]"}
{"id" : 255, "question_text" : "You are discussing the upcoming gastric tube placement and Nissen fundoplication surgery with the physician parents of one of your patients, who has spinal muscular atrophy type I. The boy is 8 months old and has been receiving enteral feeding through a nasogastric tube. It has been difficult to control his gastroesophageal reflux medically, and the nasogastric tube interferes with achieving a consistent face mask seal when he uses noninvasive continuous positive airway pressure at night. His parents are concerned about the anesthesia because they have heard that there is an association between neuromuscular disorders and malignant hyperthermia. Of the following, the information regarding malignant hyperthermia that you are MOST likely to share with these parents is that", "options" : "[\"DNA testing can identify all susceptible patients\", \"it occurs most commonly in adults\", \"it occurs only with the use of halothane\", \"it usually is inherited in an autosomal recessive pattern\", \"the mortality rate is less than 5%\"]"}
{"id" : 256, "question_text" : "A 16-year-old boy presents to your office for his annual health supervision visit. His past medical history includes chemotherapy and radiation therapy to the head and neck for Hodgkin lymphoma diagnosed when he was 11 years old. Following his therapy, he has done extremely well, with normal growth and development. The only medication he takes is levothyroxine. On physical examination, you palpate a 1.25-cm nontender, mobile nodule in the lower left lobe of his thyroid. Of the following, the next BEST step is to", "options" : "[\"increase his thyroid hormone replacement\", \"perform an I-123 scan\", \"refer him for biopsy of the nodule\", \"refer him for resection of the nodule\", \"refer him for thyroid ultrasonography\"]"}
{"id" : 257, "question_text" : "A 7-year-old child is squinting when looking at books and complaining of difficulty seeing the blackboard in his first-grade classroom. Of the following, the MOST appropriate test of visual acuity for this child is the", "options" : "[\"Allen card test\", \"cross cover test\", \"HOTV matching test\", \"Snellen letter test\", \"tumbling E test\"]"}
{"id" : 258, "question_text" : "A 4-year-old girl who has a chronic tracheostomy due to subglottic stenosis is admitted to your hospital with increased respiratory distress, purulent tracheal secretions, and fever. A Gram stain of tracheal secretions reveals numerous white blood cells and gram-negative rods. Of the following, the BEST choice for empiric antibiotic therapy for this child is", "options" : "[\"ampicillin-sulbactam\", \"azithromycin\", \"clindamycin\", \"piperacillin-tazobactam\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 259, "question_text" : "A 15-year-old girl presents to your office with her mother, who reports that the girl is not acting like her usual self. The girl's mood is euphoric, and she is talking incessantly about herself, telling everyone that she will be graduating from high school early and attending a prestigious college. She recently went on shopping spree with her mother's credit card. She has been distracted in school and not able to pay attention in class. According to the mother, her daughter has only slept 3 hours the past few nights. She has no history of illicit drug use, and results of a urine drug screen are negative. Detailed psychosocial history reveals no apparent trigger for this episode or any hallucinatory phenomena. Findings on physical examination are normal. Of the following, the MOST likely diagnosis is", "options" : "[\"adjustment disorder of adolescence\", \"attention-deficit/hyperactivity disorder\", \"bipolar disorder\", \"hyperthyroidism\", \"schizoaffective disorder\"]"}
{"id" : 260, "question_text" : "A 10-month-old male infant presents to the emergency department with his third buttock abscess in the past 3 months. Each infection has occurred in a different place on his buttocks. He was treated previously with bedside incision and drainage and oral cephalexin, and no cultures were sent. On physical examination, he has a temperature of 38.0°C, heart rate of 110 beats/min, and respiratory rate of 30 breaths/min. He does not appear toxic and has moist mucous membranes. The lateral aspect of his left buttock, along the border of his diaper, has a 3x3-cm area of erythema, warmth, induration, and central fluctuance. The remainder of his physical examination findings are within normal parameters. Of the following, the MOST appropriate antimicrobial therapy for this patient is", "options" : "[\"amoxicillin\", \"ceftriaxone\", \"cephalexin\", \"clindamycin\", \"doxycycline\"]"}
{"id" : 261, "question_text" : "A 9-month-old girl is brought to the clinic for a follow-up visit after an episode of acute pyelonephritis due to Escherichia coli 1 month ago. She was treated with intravenous antibiotics for 48 hours and discharged with a prescription for trimethoprim/sulfamethoxazole (TMP/SMX) for an additional 8 days. Upon completion of her treatment doses of antibiotics, she was started on TMP/SMX as a prophylactic agent. Three weeks after hospital discharge, she underwent voiding cystourethrography, which revealed grade II reflux on the left side. Review of systems today reveals good urine output and one soft stool per day. Of the following, the MOST appropriate next step is to", "options" : "[\"change TMP/SMX to amoxicillin\", \"continue TMP/SMX\", \"discontinue prophylactic antibiotics\", \"prescribe oxybutynin chloride\", \"prescribe polyethylene glycol\"]"}
{"id" : 262, "question_text" : "You are evaluating a 2-week-old boy for his first health supervision visit after he was discharged from the hospital following an uneventful birth. The parents are concerned because their son has been having noisy breathing during both inspiration and expiration for the past week, which is increasing in frequency. They report that he is eating well and has not had fever or nasal congestion. On physical examination, you note that the infant has regained his birthweight but has inspiratory stridor. A chest radiograph demonstrates normal lung fields without infiltration or consolidation. The heart size is normal, but the aortic arch is right-sided. Of the following, the MOST likely explanation for the neonate's stridor is", "options" : "[\"gastroesophageal reflux\", \"laryngomalacia\", \"subglottic laryngeal web\", \"vascular ring\", \"vocal cord paralysis\"]"}
{"id" : 263, "question_text" : "A 13-year-old wrestler comes to the office with an injury to his right ear. He reports that his ear struck the mat during practice, and it became swollen shortly thereafter. He was not wearing his protective head gear when this occurred. On physical examination, you note that the right external ear is markedly swollen (Item Q157) and the normal architecture of the pinna is distorted. His tympanic membrane is intact. Of the following, the MOST appropriate next step in the treatment of this patient's injury is to", "options" : "[\"apply a pressure dressing over the ear\", \"apply ice packs to ear\", \"aspirate the blood from the hematoma\", \"prescribe acetaminophen for pain\", \"prescribe antibiotics\"]"}
{"id" : 264, "question_text" : "You are asked to see a 16-year-old boy who has jaundice. He was well until 2 months ago, when he developed symptoms of an upper respiratory tract infection and scleral icterus was noted. At that time, blood tests showed: Hemoglobin, 14.5 g/dL (145 g/L); Albumin, 4.2 g/dL (42 g/L); Aspartate aminotransferase, 20 units/L; Alanine aminotransferase, 22 units/L; Bilirubin (total), 4.5 mg/dL (76.9 mcmol/L); Bilirubin (conjugated), 0.2 mg/dL (3.4 mcmol/L). His respiratory symptoms resolved after 1 week and his jaundice cleared. At his office visit today, he appears well and is anicteric. Physical examination demonstrates no abnormalities. Follow-up laboratory evaluation documents: Hemoglobin, 14.2 g/dL (142 g/L); Albumin, 4.3 g/dL (43 g/L); Aspartate aminotransferase, 22 units/dL; Alanine aminotransferase, 20 units/dL; Bilirubin (total), 2.4 mg/dL (41.0 mcmol/L); Bilirubin (conjugated), 0.1 mg/dL (1.7 mcmol/L). Of the following, the elevated bilirubin in this patient MOST likely results from", "options" : "[\"alpha-1-antitrypsin deficiency\", \"Crigler-Najjar syndrome\", \"Dubin-Johnson syndrome\", \"Gilbert syndrome\", \"hepatitis A infection\"]"}
{"id" : 265, "question_text" : "You are attending a delivery at term for a woman who received limited prenatal care. Upon reviewing the chart while awaiting the delivery, you find that she first presented for prenatal care at the beginning of the second trimester. Limited screening was done, but you note that the maternal serum alpha-fetoprotein concentration measured at 16 weeks' gestation was described as \"low.\" Ultrasonography was scheduled, but the mother did not show up for the appointment. She was lost to follow-up after that time, and no further was performed. Of the following, the MOST likely potential diagnosis for the infant is", "options" : "[\"anencephaly\", \"omphalocele\", \"spina bifida\", \"tracheoesophageal fistula\", \"trisomy 21\"]"}
{"id" : 266, "question_text" : "A 7-year-old girl is brought to your clinic with complaints of vaginal bleeding for 2 days. The child is appropriately grown, with height and weight in the 50th percentile. She has had no chronic diseases, is taking no medications, has no skin conditions, and is using no topical creams. She denies any trauma or sexual abuse. She has felt well and has had no respiratory or gastrointestinal symptoms, although two family members recently had diarrhea. The mother's menarche was at age 12 years. On physical examination, the well-appearing girl has no breast or pubic hair development or skin lesions. Perineal inspection reveals only a small amount of vaginal discharge that is blood-tinged, with otherwise normal findings for a prepubertal girl. Of the following, the MOST appropriate diagnostic test is", "options" : "[\"computed tomography scan of the brain\", \"follicle-stimulating hormone/luteinizing hormone measurement\", \"karyotype\", \"pelvic examination under anesthesia\", \"vaginal culture for Shigella\"]"}
{"id" : 267, "question_text" : "A young mother in your practice presents for the 6-month health supervision visit for her third child whom she is breastfeeding. The older children are 2 and 4 years of age. The 4-year-old child recently required extensive dental extractions and capping of the deciduous teeth. You note that the 2-year-old is carrying a baby bottle of juice in the examination room. The infant you are examining has two lower incisors. Of the following, the MOST appropriate advice to give this mother about her children's dental health is to", "options" : "[\"await eruption of the upper incisors before arranging a dental appointment for the infant\", \"begin brushing the baby's teeth with toothpaste\", \"continue breastfeeding the infant because it may prevent caries\", \"offer juice only from a cup to the 2-year-old child\", \"reassure her that dental caries are not hereditary\"]"}
{"id" : 268, "question_text" : "A 5-year-old boy presents to the emergency department 30 minutes after he ingested some of his mother's tricyclic antidepressant. Over the ensuing hour of observation in the emergency department, he develops lethargy, irritability, and autonomic nervous system findings of mydriasis, dry mouth, and urinary retention. Within 3 hours of ingestion, these symptoms have resolved. Of the following, the MOST appropriate next step in management is", "options" : "[\"chest radiography and arterial blood gas\", \"discharge home without further evaluation\", \"electrocardiography and continuous cardiac monitoring\", \"serum electrolytes assessment\", \"tricyclic serum drug concentration assessment and discharge home\"]"}
{"id" : 269, "question_text" : "The mother of a 7-year-old boy brings in her son because he has been staring off into space in his second-grade classroom. The teacher is concerned that he may be having seizures. Of the following, the feature of staring spells that is MOST consistent with absence epilepsy is", "options" : "[\"body rocking\", \"greater than 1 minute duration\", \"interruption of play\", \"limb twitching\", \"preserved responsiveness\"]"}
{"id" : 270, "question_text" : "A mother brings her 11-year-old son to your office after he refused to go to school due to periumbilical abdominal pain for the third time this week. The abdominal pain is not associated with diarrhea, vomiting, fever, or bloody stools. He has missed an average of 2 to 3 days of school per week over the past few months. According to the mother, his pain is less severe on weekends, does not wake him from sleep, and is not associated with weight loss. She states that he is an average student, and on further questioning, he denies problems with other children in the school or bullying. On physical examination, the boy is afebrile and his height and weight are at the 25th percentile for age. Abdominal examination reveals no guarding, tenderness, rebound, or organomegaly. Occult stool blood testing yields negative results. You order a complete blood count, erythrocyte sedimentation rate, and urinalysis and tell the mother you would like to see them in 1 week to discuss test results. As you are leaving the room, the mother requests a note from you for the school to provide home tutoring. Of the following, the MOST appropriate next best step in management is to", "options" : "[\"create a rapid return-to-school plan for the child\", \"recommend that the child change schools\", \"refer the child to a gastroenterologist\", \"start a trial of proton pump inhibitors\", \"write the note for the child as requested by the mother\"]"}
{"id" : 271, "question_text" : "A 2-year-old boy in your practice is doing well because of immediate institution of dietary galactose restriction following the diagnosis of classic galactosemia at 14 days of age. Although he initially had mild jaundice, his liver function is normal, and the mild cataracts noted in infancy seem to have resolved. His parents ask about long-term developmental and medical consequences of galactosemia. Of the following, you are MOST likely to tell them that", "options" : "[\"affected individuals are at high risk for the development of cataracts in early adulthood\", \"affected men have significant risks for infertility\", \"affected school-age children are at risk for learning disabilities\", \"dietary nonadherence is associated with long-term neurologic deficits\", \"preschool children on dietary restriction rarely have any speech delays\"]"}
{"id" : 272, "question_text" : "You are sharing the results of laboratory testing with the mother of a set of fraternal twins aged 16 years and at Sexual Maturity Rating 5. The girl has a hemoglobin (Hgb) of 12.2 g/dL (122 g/L), with a mean corpuscular volume (MCV) of 85 fL. The boy's Hgb is 13.1 g/dL (131 g/L), with an MCV of 80 fL. They both are active adolescents and, other than occasional complaints of tiredness, are asymptomatic. Of the following, the MOST appropriate interpretation of the evaluation is that", "options" : "[\"both adolescents have iron deficiency anemia\", \"both adolescents need folic acid supplements\", \"the boy is anemic and needs iron medication\", \"the girl is anemic and needs iron medication\", \"the results are normal in both adolescents\"]"}
{"id" : 273, "question_text" : "You are caring for a 16-year-old girl who was admitted to the hospital for sepsis. She required 40 mL/kg of isotonic fluid in the emergency department for hypotension, but she says that she now feels \"much better.\" She is laughing with her mother about \"getting out of a couple of days of school and catching up on my TV shows.\" Her temperature is 38.2°C, heart rate is 90 beats/min, respiratory rate is 35 breaths/min, blood pressure is 100/60 mm Hg, and oxygen saturation is 98% on 1 L of oxygen via nasal cannula. An arterial blood gas shows a pH of 7.28, PaCO2 of 30 mm Hg, and PaO2 of 100 mm Hg. Of the following, the MOST likely cause of the patient's tachypnea is her", "options" : "[\"anxiety\", \"fever\", \"metabolic acidosis\", \"metabolic alkalosis\", \"pain\"]"}
{"id" : 274, "question_text" : "A 12-year-old girl presents with a 2-week history of nausea, headache, and increased thirst. Her growth chart is shown in image (Item Q168). Review of systems yields no findings of note except for recurrent yeast infections and one episode of enuresis over the past 6 months. Urine dipstick shows large glucose and negative nitrites, leukocyte esterase, and ketones. Blood glucose measures 224 mg/dL (12.4 mmol/L). Of the following, the MOST appropriate initial treatment for this patient is", "options" : "[\"acarbose\", \"insulin\", \"metformin\", \"chlorpropamide\", \"rosiglitazone\"]"}
{"id" : 275, "question_text" : "An 8-year-old boy in your practice has attention-deficit/hyperactivity disorder and learning issues. He currently is receiving specialized educational services and methylphenidate for his attention difficulties and hyperactivity. He does well with the structure that is in place at school but has issues with compliance at home when completing his homework. His parents seek guidance in establishing a behavioral modification approach for him at home. Of the following, the BEST intervention is", "options" : "[\"extinction\", \"habit reversal\", \"spanking\", \"stress anxiety reduction procedures\", \"token economy\"]"}
{"id" : 276, "question_text" : "A 2-year-old boy who received a diagnosis of congenital hydrocephalus and underwent ventriculoperitoneal (VP) shunt placement at 1 month of age presents with a 2-day history of decreased activity, fever, and vomiting. Fluid obtained from his VP shunt reveals: White blood cell count, 77/mm3 with 90% neutrophils and 10% lymphocytes; Red blood cell count, 45/mm3; Glucose, 32 mg/dL (1.7 mmol/L); Protein, 185 mg/dL (1.85 g/L). Gram stain reveals gram-positive cocci in clusters. You are consulted about the selection of empiric antibiotic therapy pending further neurosurgical evaluation. Of the following, the MOST appropriate agent for empiric therapy is", "options" : "[\"cefazolin\", \"ceftriaxone\", \"nafcillin\", \"trimethoprim-sulfamethoxazole\", \"vancomycin\"]"}
{"id" : 277, "question_text" : "A previously healthy 7-year-old boy presents with a 2-day history of progressive right knee pain and swelling and increasing difficulty bearing weight. He reports falling on the playground 1 week ago but was \"fine\" after the fall. On physical examination, his temperature is 39.0°C, heart rate is 120 beats/min, and respiratory rate is 25 breaths/min. He is lying on a stretcher, obviously uncomfortable. His right knee is swollen and warm, but there is no significant overlying erythema or effusion. Movement of the knee joint is moderately painful, but he can tolerate the maneuver. The lateral aspect of the distal femur is tender to palpation. His mucous membranes are moist and lungs are clear. His abdomen is benign. There are no other findings of note on the remainder of his examination. His white blood cell count is 25.0x103/mcL (25.0x109/L), with 75% polymorphonuclear leukocytes, 20% lymphocytes, and 5% monocytes. Blood culture results are pending. Of the following, the MOST likely pathogen causing this patient's illness is", "options" : "[\"Haemophilus influenzae type b\", \"Kingella kingae\", \"Salmonella non-typhi\", \"Staphylococcus aureus\", \"Streptococcus agalactiae\"]"}
{"id" : 278, "question_text" : "An 8-year-old boy presents with cola-colored urine without blood clots. He was well until 2 days ago, when he developed a sore throat with upper respiratory tract infection symptoms. He denies any dysuria, frequency, urgency, flank pain, or trauma. On physical examination, his temperature is 37.8°C, heart rate is 84 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 118/78 mm Hg. He has no costovertebral tenderness, abdominal tenderness, or edema. The urinalysis reveals: Specific gravity, 1.025; pH, 6.0; 3+ blood; 3+ protein; 1+ leukocyte esterase; Nitrite, negative. Microscopy shows more than 100 red blood cells/high-power field (hpf) and 5 to 10 white blood cells/hpf. Other laboratory findings include: Blood urea nitrogen, 24 mg/dL (8.6 mmol/L); Creatinine, 0.9 mg/dL (79.6 mcmol/L); Complement component 3 (C3), 140 mg/dL (normal, 80 to 200 mg/dL); Complement component 4 (C4), 30 mg/dL (normal, 16 to 40 mg/dL); Antinuclear antibody, negative. Of the following, the MOST likely diagnosis is", "options" : "[\"acute pyelonephritis\", \"immunoglobulin A glomerulonephritis\", \"postinfectious glomerulonephritis\", \"urolithiasis\", \"viral cystitis\"]"}
{"id" : 279, "question_text" : "A 16-year-old boy presents to your office with a history of bilateral nasal congestion. Initially he thought he had a viral illness and bought an over-the-counter nasal decongestant. His symptoms improved at first, but despite using the nasal spray regularly for 2 weeks, his nasal congestion has persisted. On physical examination, the boy appears healthy but is having obvious difficulty breathing through his nose. A nasal examination shows \"beefy-red\" turbinates, with friability of the nasal mucosa. Of the following, the MOST likely reason for the patient's symptoms is", "options" : "[\"allergic rhinitis\", \"nasal polyposis\", \"nonallergic rhinitis with eosinophilia\", \"rhinitis medicamentosa\", \"vasomotor rhinitis\"]"}
{"id" : 280, "question_text" : "A 15-year-old baseball player presents to the office after being struck in the face by a pitch. He reports that he had a profuse nosebleed immediately after the event, and now his nose is swollen and it is hard to breathe through his left nostril. On physical examination, the bridge of his nose is markedly swollen and there are ecchymoses developing under both eyes. A clot is visible in the right nostril and a purple swelling is visible on the medial aspect of his left nostril. Of the following, the MOST appropriate next step in the treatment of this patient is to", "options" : "[\"apply a warm pack to his nose\", \"pack both nostrils to prevent further epistaxis\", \"prescribe phenylephrine nose drops\", \"prescribe prophylactic antibiotics\", \"refer him immediately to an otolaryngologist\"]"}
{"id" : 281, "question_text" : "The mother of an 8-year-old boy calls you to seek advice after her son told her that he had been videotaped yesterday by an older boy while changing out of his swimming suit in the locker room at the local pool. Two other young boys were taped at the same time by the video on the older boy's cell phone. Immediately after the child told his mother, she called 911 and police were dispatched to the scene. The police confiscated the cell phone and verified that the young boys had been videotaped. After interviewing all parties involved, a teenage boy who did the taping was arrested and placed into juvenile custody. The mother reports that her son had difficulty falling asleep last night, but he is acting normally today. Of the following, the BEST next step to take is to", "options" : "[\"advise the mother to maintain normal routines\", \"arrange for a videotaped interview of the boy\", \"prescribe clonidine to aid in sleeping\", \"prescribe fluoxetine to help prevent posttraumatic stress disorder\", \"refer the family to a mental health specialist for evaluation\"]"}
{"id" : 282, "question_text" : "A mother brings in her 5-week-old infant girl because of feeding difficulties. The baby weighed 3,300 g when born at term, and she has breastfed exclusively. Approximately 2 weeks ago, the parents noted that the baby became increasingly irritable, particularly during feedings, and she began spitting-up 4 to 6 times per day. Physical examination demonstrates a well-developed, alert but irritable infant whose weight is 3.85 kg, heart rate is 180 beats/min, and respiratory rate is 70 breaths/min. Lung sounds are clear. On physical examination, you note a hyperdynamic precordium and a grade 2/6 holosystolic cardiac murmur. Chest auscultation yields normal results. You palpate a firm liver edge 5.0 cm below the right costal margin. The spleen is not palpable. You also note a 2x2-cm hemangioma on the abdominal wall. Results of laboratory tests include: Hemoglobin, 9.8 g/dL (9.8 g/L); White blood cell count, 4.8x103/mcL (4.8x109/L); Platelet count, 80x103/mcL (80x109/L); Peripheral blood smear, Burr cells and schistocytes noted; Electrolytes, normal; Bilirubin, 1.6 mg/dL (27.4 mcmol/L). Chest radiography demonstrates mild cardiomegaly. Of the following, the study that is MOST likely to demonstrate the cause of this infant's symptoms is", "options" : "[\"abdominal ultrasonography\", \"acid alpha-glucosidase assay\", \"bone marrow aspiration\", \"Coombs test\", \"echocardiography\"]"}
{"id" : 283, "question_text" : "During your evaluation at 48 hours after birth, you note that an infant consistently holds her head tilted to the left. She was delivered at term by cesarean section due to breech presentation. No difficulties were described with the extraction at delivery. On physical examination, the infant holds her head tilted to the left with her chin deviated to the right (Item Q177). She has normal tone, strength, reflexes, and movement in all four extremities. You palpate a mass within the left sternocleidomastoid muscle. Of the following, the MOST appropriate initial management strategy is to", "options" : "[\"consult orthopedic surgery for a sternocleidomastoid muscle release\", \"initiate therapy with onabotulinumtoxinA\", \"obtain clavicular radiography\", \"obtain magnetic resonance imaging of the head and neck\", \"order physical therapy for stretching of the neck muscles\"]"}
{"id" : 284, "question_text" : "A 17-year-old boy comes to your office for an employment physical. On physical examination, you note thoracic kyphosis. He has been healthy and has no history of trauma or surgery. He cannot correct the kyphosis voluntarily by standing straight. There are no other findings of note. Radiographs of his thoracic spine show wedging of three consecutive anterior vertebral bodies at the apex of the curve. Of the following, the MOST important indication for surgical treatment of his kyphosis is", "options" : "[\"absence of the deformity at birth\", \"history of well-controlled mild persistent asthma\", \"intermittent back pain not limiting activity\", \"sixty-five degrees of kyphosis using the Cobb technique\", \"unacceptable aesthetic appearance\"]"}
{"id" : 285, "question_text" : "A couple who is new to the community comes to you for a prenatal visit. They live in a home with a private well and have questions about the safety of providing well water to their newborn. Of the following, you are MOST likely to advise them to use", "options" : "[\"boiled tap water\", \"bottled distilled water\", \"bottled drinking water\", \"filtered tap water\", \"tap water\"]"}
{"id" : 286, "question_text" : "An overweight 14-year-old girl presents to your office for the first time for a health supervision visit. She has a strong family history of early myocardial infarctions and hypercholesterolemia. Her father has a total cholesterol of 290 mg/dL (7.5 mmol/L), and her paternal grandfather (who died of a heart attack at 54 years of age) had a total cholesterol of 325 mg/dL (8.4 mmol/L). You measure the girl's total serum cholesterol, which reveals a value of 220 mg/dL (5.7 mmol/L). Of the following, the MOST appropriate step in the initial management of this child's condition is", "options" : "[\"assessment for evidence of diabetes mellitus\", \"assessment of a fasting lipid profile\", \"initiation of an exercise program and low-fat diet\", \"initiation of lipid-lowering pharmacologic therapy\", \"repeat measurement of total serum cholesterol in 6 months\"]"}
{"id" : 287, "question_text" : "A 17-year-old girl presents for evaluation after a first generalized tonic-clonic seizure, which occurred the morning after she was up late at a party. You suspect juvenile myoclonic epilepsy, a form of epilepsy that may present with seizures in adolescence. Of the following, the feature, if present, that is MOST consistent with this diagnosis is", "options" : "[\"brief, rapid jerks noted in the mornings\", \"cortical dysplasia on brain magnetic resonance imaging\", \"multiple hypopigmented skin macules\", \"partial discharges on electroencephalography\", \"positive toxicology screen for marijuana\"]"}
{"id" : 288, "question_text" : "You are treating an 18-month-old child in whom glycogen storage disease type 1 (GSD1 or von Gierke disease) was diagnosed at 2 months of age when she presented to the emergency department with a hypoglycemic seizure and hepatomegaly. With prompt diagnosis and intervention, her condition improved significantly, and she is doing well on overnight nasogastric cornstarch supplements, with decreased hepatomegaly and rare episodes of symptomatic hypoglycemia. Her parents have questions about future medical complications of GSD1 in addition to hypoglycemia and hepatomegaly. Of the following, the MOST common long term medical problem found in children with GSD1 despite optimal treatment is", "options" : "[\"chronic constipation\", \"decreased growth rate\", \"precocious puberty\", \"splenomegaly\", \"thrombophlebitis\"]"}
{"id" : 289, "question_text" : "You are seeing a 15-year-old sexually active girl who complains of vague lower abdominal pain and a vaginal discharge. She has no systemic symptoms but has experienced intermittent dysuria over the past week. She believes that she needs only a prescription for a yeast infection because she was treated for this a few weeks ago but the discharge did not resolve completely. Of the following, the MOST appropriate next step is to", "options" : "[\"obtain a vaginal swab for a wet mount evaluation only\", \"perform a speculum and bimanual examination\", \"perform an external genital inspection only\", \"provide an antifungal prescription\", \"send a urine specimen for culture only\"]"}
{"id" : 290, "question_text" : "You are caring for an 8-year-old girl who was involved in a motor vehicle-pedestrian crash. Despite maximal medical and surgical therapy, she developed intractable intracranial hypertension, and she now has fixed and dilated pupils as well as an absence of corneal, cough, and gag reflexes. Her temperature is 36.0°C, heart rate is 90 beats/min, respiratory rate is 25 breaths/min on the mechanical ventilator, blood pressure is 95/60 mm Hg, and oxygen saturation is 96%. She is in a cervical collar due to a suspected cervical spine injury, and her tympanic membranes are ruptured bilaterally. Results of the apnea test (absence of respiratory movements and a rise in PaCO2 after temporarily disconnecting the ventilator) are consistent with brain death. Of the following, the MOST commonly used ancillary test to support the diagnosis of brain death in this situation is", "options" : "[\"cerebral blood flow studies\", \"electroencephalography\", \"magnetic resonance imaging of the brain\", \"somatosensory evoked potentials\", \"transcranial Doppler ultrasonography\"]"}
{"id" : 291, "question_text" : "A 15-year-old girl presents for evaluation of irregular menses. She had menarche at 12 years of age but has had irregular periods ever since. She has had a period every 2 to 3 months for the past year. She has a strong family history of irregular menses and type 2 diabetes. She is 160 cm tall and weighs 85 kg. Her blood pressure is 135/85 mm Hg. Hemoglobin A1c measures 5.3% (0.053). A urine pregnancy test is negative. No other laboratory evaluations have been obtained in the past 5 years. Of the following, the next BEST step in managing this patient is to measure", "options" : "[\"estradiol\", \"fasting blood glucose\", \"fasting lipids\", \"luteinizing and follicle-stimulating hormones\", \"postprandial glucose\"]"}
{"id" : 292, "question_text" : "For the past 2 years, you have been providing medications for a 9-year-old girl in whom you diagnosed attention-deficit/hyperactivity disorder (ADHD) using parent and teacher assessments and family history. You have sequentially prescribed methylphenidate, dextroamphetamine, and currently atomoxetine. All have yielded the same benefits on her inattention and impulsivity but have not improved her occasional aggressive behaviors. Today her mother brings her in, saying that she has had a significant worsening in her aggression and is now getting into fights at school. When asked about the most recent incident, the girl replies, \"Sheryl was making faces at me for days, so I hit her, and it serves her right.\" The mother describes her daughter as being chronically vindictive at home, aggressively \"paying back\" her siblings as much as several days later when she feels she has been wronged. The mother reports no major changes in the household and no traumatic or bullying incidents for the girl. She indicates that her husband has a history of anger management difficulties. Of the following, the MOST appropriate next step in care is to", "options" : "[\"add guanfacine to the girl's regimen\", \"have the mother and teacher complete the Vanderbilt Diagnostic Rating Scale\", \"prescribe risperidone at bedtime\", \"refer the family for behavior management training\", \"wean the girl off the atomoxetine and initiate a trial of lisdexamfetamine\"]"}
{"id" : 293, "question_text" : "A 4-month-old infant comes to your office for a health supervision visit. When you pass through the waiting room, you observe his young mother prop the infant's bottle while he is in his stroller. Of the following, the MOST appropriate action is to", "options" : "[\"advise the mother to prop only bottles containing water\", \"discuss the advantages of holding her baby during feedings\", \"explain that the child is too young to have the bottle propped\", \"recommend that the mother obtain a bottle sling\", \"tell the mother that a bottle should not be propped when the infant is falling asleep\"]"}
{"id" : 294, "question_text" : "A 4-month-old boy presents with his second episode of oral thrush. He is growing and developing normally and has had no other infections. He was born at term by cesarean section. The pregnancy was complicated by maternal diabetes that was managed with diet. There were no problems in the nursery, and he was discharged with his mother, who is a nurse, at 2 days of age. His umbilical cord fell off at 2 weeks of age. He has been exclusively breastfed. He has received his 2-month and 4-month vaccines without significant reaction and has received no medications except for oral multivitamins. The mother has a history of eczema, but there is no history of immune deficiency disorder on either side of the family. After discussing the diagnosis with the mother, she asks about risk factors for recurrent episodes of thrush. Of the following, the factor that is MOST likely to be associated with an increased risk for recurrent oral thrush is", "options" : "[\"breastfeeding\", \"cesarean section\", \"contaminated vitamin dropper\", \"maternal eczema\", \"maternal gestational diabetes\"]"}
{"id" : 295, "question_text" : "You are examining a 3-week-old preterm infant who was born at 26 weeks' gestation and is receiving continuous positive airway pressure (CPAP) respiratory support. He has had increasing episodes of apnea and bradycardia over the past 12 hours. On physical examination, his temperature is 37.0°C, heart rate is 150 beats/min, and respiratory rate is 50 breaths/min on CPAP pressure support of 6 mm Hg with an FiO2 0.35. The infant has a flat and soft anterior fontanelle, moist mucous membranes, normal heart and lung sounds, and benign findings on abdominal examination. His extremities are mildly warm, and his left knee is swollen without noticeable erythema. Range of motion of the left knee is mildly decreased compared with the right. A clean and dry dressing covers a peripherally inserted central venous catheter in the right arm. The white blood cell count is 9.0x103/mcL (9.0x109/L), with 55% polymorphonuclear leukocytes, 10% band forms, 30% lymphocytes, and 5% monocytes. Cerebrospinal fluid evaluation reveals 15 white blood cells/mm3 with 80% lymphocytes, 10% polymorphonuclear leukocytes, and 10% monocytes; protein of 70 mg/dL; and glucose of 60 mg/dL. Urinalysis yields normal results. Blood, cerebrospinal fluid, and urine specimens have been sent for cultures. A magnetic resonance imaging study reveals increased signal in the left knee. You order broad-spectrum intravenous antibiotics. Of the following, the next BEST step is", "options" : "[\"arthrocentesis of the left knee\", \"bone scan of the left knee\", \"radiograph of the left knee\", \"removal of the central venous catheter\", \"ultrasonography of the left knee\"]"}
{"id" : 296, "question_text" : "You recently diagnosed Burkitt lymphoma in one of your patients. He is an 8-year-old boy, and his pediatric oncologist is planning to treat him with CODOX-M (cyclophosphamide, doxorubicin, vincristine, methotrexate intravenously and cytarabine and methotrexate intrathecally) for cycles 1 and 3 and IVAC (ifosfamide, etoposide, cytarabine intravenously and methotrexate intrathecally) for cycles 2 and 4. As her son's longstanding pediatrician, the boy's mother asks you about the adverse effects of the therapy. Because her cousin is undergoing dialysis, she asks you specifically which medication is most likely to damage her son's kidneys. Of the following, the MOST nephrotoxic medication being prescribed is", "options" : "[\"cyclophosphamide\", \"cytarabine\", \"doxorubicin\", \"etoposide\", \"ifosfamide\"]"}
{"id" : 297, "question_text" : "A 12-year-old boy has a 3-year history of worsening nasal congestion and anosmia. He has a history of allergic rhinitis, but his usual medications no longer control his symptoms. On physical examination, you see a polyp in his right naris. Sinus computed tomography scan demonstrates opacification of his right maxillary sinus, with hyperattenuation of the mucin. Of the following, the MOST likely cause for this boy's sinus symptoms is", "options" : "[\"allergic fungal sinusitis\", \"allergic rhinitis\", \"chronic bacterial sinusitis\", \"cystic fibrosis\", \"primary ciliary dyskinesia\"]"}
{"id" : 298, "question_text" : "A 7-year-old boy is brought to the emergency department after being poked in the left eye while he and his friends were playing with pointed sticks. He reports that the injury occurred approximately 2 hours ago and that the pain is worsening. He states that the light hurts his eye and that he has been unable to see clearly with that eye since the injury. On physical examination, the boy appears uncomfortable and is holding his left eye closed. There is marked epiphora and conjunctival injection. His extraocular movements are intact, but his left pupil is elliptically shaped and poorly reactive to light. He can discern only light with his left eye. You decide to consult an ophthalmologist. Of the following, the MOST appropriate next step, while waiting for the ophthalmologist to arrive, is to", "options" : "[\"administer an oral dose of ibuprofen\", \"apply topical antibiotic ointment to the eye\", \"have the child lay on the bed with his head elevated 45 degrees\", \"place an occlusive eye patch over the left eye\", \"sedate the child with ketamine\"]"}
{"id" : 299, "question_text" : "You are evaluating a 15-year-old girl for primary amenorrhea. She was well until 7 years of age, at which time she was diagnosed with type 1 diabetes mellitus. Her diabetic control has been good for the past 2 years, with an acceptable hemoglobin A1C reading 6 weeks ago. Both the girl and her mother are concerned about her delayed menarche. The girl also reports experiencing irregular bowel habits and intermittent abdominal discomfort for the past year, with occasional loose stools. The mother has been diagnosed with irritable bowel syndrome. Physical examination of the well-appearing, thin adolescent shows a height of 162 cm, weight of 45 kg, and Sexual Maturity Rating of 3. There are no other findings of note on the remainder of the physical examination. Of the following, the test that is MOST helpful in determining the cause of this girl's symptoms is", "options" : "[\"abdominal magnetic resonance imaging\", \"human leukocyte antigen typing\", \"pelvic ultrasonography\", \"serum follicle-stimulating hormone and luteinizing hormone assessment\", \"tissue transglutaminase antibody assessment\"]"}
{"id" : 300, "question_text" : "You are speaking with the mother of a newborn at 18 hours after birth. She is worried about the pustules on her son's neck and upper chest. She has read about methicillin-resistant Staphylococcus aureus on the Internet and is concerned that he has this infection. Upon physical examination, the alert and active infant has multiple milky white pustules that are 2-mm in diameter on the neck and upper chest; there is no warmth or erythema around the lesions. In addition, there are several faint brownish macules, many of which have a rim of scale.", "options" : "[\"congenital candidiasis\", \"erythema toxicum neonatorum\", \"miliaria crystallina\", \"staphylococcal folliculitis\", \"transient neonatal pustular melanosis\"]"}
{"id" : 301, "question_text" : "A 14-year-old girl first developed redness across the bridge of her nose and on her cheeks about 3 months ago. Subsequently, the rash spread to involve more of her face as well as her hands. She now reports increasing fatigue and some weakness; she has difficulty climbing stairs and has needed help brushing her hair. She has had no fever or joint swelling. Physical examination of the appropriately developed teen reveals normal vital signs; a heliotrope rash involving the eyelids, nasal bridge, and cheeks; and erythematous scaling papules on the extensor surfaces of her metacarpal, phalangeal, and interphalangeal joints. She has weakness and tenderness of the proximal musculature and must employ the Gower maneuver to arise from sitting. Of the following, the test that is MOST likely to contribute to the diagnosis is", "options" : "[\"cranial computed tomography scan\", \"edrophonium (Tensilon\\u00ae) test\", \"electroneurography\", \"magnetic resonance imaging of proximal muscles\", \"skin biopsy\"]"}
{"id" : 302, "question_text" : "The mother of an 11-year-old girl brings in her daughter because she noted white-to-pale yellow vaginal discharge on the girl's cotton underwear when doing the laundry. The child denies discomfort or itching. The mother notes that the girl likes to take bubble baths. Results of a careful interview raise no concerns about sexual abuse or activity. Physical examination reveals normal vital signs with no fever and normal head, eyes, ears, nose, and throat findings without pharyngitis or conjunctivitis. She has Sexual Maturity Rating 3 breast development and normal genitourinary examination findings, with normal hymenal tissue, pink vaginal mucosa, and scant white discharge. No tenderness is elicited on abdominal examination. Of the following, the MOST likely cause of this girl's discharge is", "options" : "[\"chlamydial infection\", \"nonspecific vulvovaginitis\", \"physiologic leukorrhea\", \"streptococcal vaginitis\", \"vaginal candidiasis\"]"}
{"id" : 303, "question_text" : "You are seeing a 10-year-old girl for follow-up evaluation of behavior problems and recurrent abdominal pain. Her mother reports that she continues to be irritable most of the time, even with friends, she has problems falling asleep, and she \"talks back\" when pressed to complete tasks such as getting dressed in the morning. She adds that symptoms have been ongoing for a couple of months, stating \"last summer she wasn't like this.\" The girl's teacher reports that she has been quiet and withdrawn in class. The girl's abdominal pain is daily and periumbilical in location. She admits to decreased appetite, denies nausea, and reports one soft bowel movement per day. Physical examination, including neurologic evaluation, shows no findings of note other than periumbilical tenderness to deep palpation. The girl exhibits no guarding, masses, or organomegaly. Of the following, the MOST appropriate next diagnostic step is to", "options" : "[\"collect a stool sample for bacterial culture\", \"complete a Child Depression Inventory\", \"complete a Connors Parent Rating Scale short form\", \"measure her ceruloplasmin\", \"obtain abdominal radiography\"]"}
{"id" : 304, "question_text" : "A 5-year-old boy presents to the emergency department with a 5-day history of fever, bilateral conjunctivitis, cracked and red lips, a strawberry tongue, and swelling of the dorsal surfaces of his hands and feet. On physical examination, you identify unilateral, nontender cervical lymphadenopathy. Laboratory assessment yields an elevated erythrocyte sedimentation rate and C-reactive protein value with sterile pyuria. Of the following, the MOST appropriate initial therapy for this child is", "options" : "[\"dependent upon the presence or absence of coronary artery involvement\", \"high-dose aspirin alone if coronary arteritis is absent\", \"immune globulin intravenous and high-dose aspirin irrespective of echocardiographic findings\", \"immune globulin intravenous and low-dose aspirin if echocardiography shows the absence of coronary arteritis\", \"immune globulin intravenous if echocardiography identifies dilated coronary arteries\"]"}
{"id" : 305, "question_text" : "A 9-year-old boy has had 3 days of progressive difficulty walking. This morning he had difficulty combing his hair and began complaining of back pain. He has had no urinary or fecal incontinence. In the emergency department, he is afebrile and has normal vital signs. Physical examination yields normal results, with no pain or swelling of his joints. His neurologic examination shows normal mentation, normally reactive pupils with full extraocular movements, and no nystagmus. He has slight weakness of eye closure. Upper limbs have normal bulk and tone but mild weakness, with the shoulders worse than the elbows or wrists. He cannot arise unassisted from the floor and has weakness at the hips, knees, and ankles. He is areflexic. Concerned about his subacute generalized weakness, you obtain a forced vital capacity, which is greater than 2 L. Of the following, the test that is MOST likely to clarify the diagnosis is", "options" : "[\"cerebrospinal fluid testing for protein concentrations\", \"edrophonium (Tensilon\\u00ae) testing\", \"electromyography of the upper limbs\", \"fecal testing for botulinum spores\", \"magnetic resonance imaging of the spine\"]"}
{"id" : 306, "question_text" : "A 2-year-old girl presents to the emergency department with what is eventually diagnosed as a hypocalcemic seizure. Administration of oral calcitriol improves her serum calcium concentration. Laboratory testing documents an extremely low parathyroid hormone value. The girl has a history of a cleft palate that was repaired at 6 months of age and an incidental finding of a right-sided aortic arch noted on routine chest radiograph. She is otherwise healthy and doing well developmentally. Of the following, the MOST likely test to confirm her underlying diagnosis is", "options" : "[\"echocardiography\", \"fluorescence in situ hybridization for a 22q deletion\", \"magnetic resonance imaging of the brain\", \"routine karyotype\", \"ultrasonography of the neck\"]"}
{"id" : 307, "question_text" : "A 14-year-old girl, who has experienced irregular bleeding since menarche at age 11 years, presents with painless menstrual bleeding of 14 days' duration. She is using 8 to 10 super-pads per day. She says she was told that her period could be irregular in the first few years, but she is feeling tired and is upset with the number of days of bleeding. The only finding of note on physical examination is mild pallor. Her heart rate is 82 beats/min and blood pressure is 120/80 mm Hg, with no postural changes. Laboratory tests show a hemoglobin of 9.4 g/dL (94 g/L) with a normal platelet count, prothrombin time, partial thromboplastin time, and von Willebrand panel. Of the following, the MOST appropriate treatment for this girl is", "options" : "[\"a course of iron therapy and an iron-rich diet\", \"a daily dose of oral progesterone pills\", \"combined oral contraceptive pills\", \"gynecologic referral for a dilatation and curettage\", \"tracking with a menstrual calendar and follow-up appointment in 3 months\"]"}
{"id" : 308, "question_text" : "You are called to evaluate a 2-year-old girl in the emergency department who has septic shock. She has received 80 mL/kg of normal saline since her arrival 45 minutes ago as well as appropriate antibiotics. On physical examination, her heart rate is 140 beats/min, respiratory rate is 30 breaths/min, and blood pressure is 65/40 mm Hg. She appears lethargic but arouses with vigorous stimulation. Her extremities are cool, it is difficult to feel peripheral pulses, and her capillary refill time is 5 seconds. Of the following, the MOST appropriate next step is initiation of an infusion of", "options" : "[\"dobutamine\", \"dopamine\", \"milrinone\", \"norepinephrine\", \"vasopressin\"]"}
{"id" : 309, "question_text" : "During the annual health supervision visit for an 11-year-old boy, his mother advises you that over the last year he has had considerable pubertal development, with rapid linear growth and both testicular and penile enlargement. On physical examination, you note that his height is above the 95th percentile for his age and confirm that his testicular volume is 12 mL (3.5 cm in length) bilaterally. A bone age radiograph demonstrates skeletal maturity of 14 years. Of the following, his upper-to-lower segment ratio would be expected to be CLOSEST to", "options" : "[\"0.9\", \"1.1\", \"1.3\", \"1.5\", \"1.7\"]"}
{"id" : 310, "question_text" : "A 15-month-old boy bangs his head when he gets upset and does not get his way as well as when he falls asleep in his crib. He currently says about five words and is ambulating independently. His parents are concerned that he will seriously hurt himself and are puzzled about how to decrease this behavior. Of the following, the MOST appropriate next step is to", "options" : "[\"have the child fitted for a soft helmet\", \"have the parents hold him when he begins to bang his head\", \"instruct the parents to ignore the behavior\", \"monitor the child for possible autism\", \"refer the boy for an early intervention evaluation\"]"}
{"id" : 311, "question_text" : "A 16-year-old boy presents with bilateral cervical lymphadenitis, fatigue, and hepatosplenomegaly. Laboratory studies show: White blood cell count, 8.2x103/mcL (8.2x109/L) with 32% neutrophils, 61% lymphocytes, and 7% atypical lymphocytes; Heterophile antibodies, negative; Epstein-Barr virus antibodies, negative; Cytomegalovirus antibodies, negative; Toxoplasma immunoglobulin M, positive. As you are reviewing the diagnosis with the patient and his family, they ask where he might have acquired this infection. Of the following, the MOST likely source of this patient's infection is", "options" : "[\"contaminated cat litter\", \"fecal-oral transmission from an infected food handler\", \"ingestion of undercooked meat\", \"respiratory droplets from an infected classmate\", \"scratch from an infected kitten\"]"}
{"id" : 312, "question_text" : "A 10-month-old previously healthy female infant presents with a 3-day history of fever and rash that started on her trunk and spread to her extremities. Blisters developed on her abdomen today. On physical examination, her temperature is 38.0°C, heart rate is 110 beats/min, and respiratory rate is 35 breaths/min. She has mild facial edema and perioral crusting. Her mucous membranes are mildly dry but without lesions. An erythematous, sunburn-like eruption is present on her trunk and extremities and is accentuated in the flexor creases. The rash is warm to the touch and mildly painful. There are two flaccid bullae on the abdomen and a circular erosion on the chest at the site of prior monitor lead placement. Of the following, the test MOST likely to establish the diagnosis is a", "options" : "[\"blood culture\", \"creatinine phosphokinase assessment\", \"hepatic transaminase assessment\", \"serum antibody test\", \"skin biopsy\"]"}
{"id" : 313, "question_text" : "A 15-year-old girl presents with gross hematuria (bright red blood with clots) accompanied by sharp left-sided back pain. She denies fever, dysuria, frequency, urgency, or trauma. On physical examination, her temperature is 37.3°C, heart rate is 90 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 116/72 mm Hg. You note no costovertebral angle tenderness, suprapubic tenderness, or edema. Urinalysis reveals: Specific gravity, 1.020; pH, 6; 3+ blood; Trace protein; Leukocyte esterase, negative; Nitrite, negative. Microscopy documents 20 to 50 red blood cells/high-power field (hpf) and 5 to 10 squamous epithelial cells/hpf. Abdominal ultrasonography shows mild dilation of the collecting system on the left, with some debris in the bladder. You suspect urolithiasis. Of the following, the study that is MOST likely to establish the diagnosis is", "options" : "[\"abdominal computed tomography scan\", \"diethylene-triamine-penta-acetic acid (DTPA) furosemide renal scan\", \"magnetic resonance urography\", \"random urine sample for calcium and creatinine\", \"24-hour urine collection for calcium and creatinine\"]"}
{"id" : 314, "question_text" : "The parents of an 8-year-old patient call for an appointment because they are concerned that she may have an anxiety problem. The father explains that other family members receive treatment for anxiety. Your office procedure is to have parent and initial teacher Vanderbilt Diagnostic Rating Scale forms completed before all visits for possible mental health problems. The scores obtained for this girl indicate the presence of possible anxiety or depression. Further history obtained upon questioning increases your suspicion of a mental health problem. Of the following, the MOST appropriate next step is to", "options" : "[\"administer the National Institute of Mental Health Diagnostic Interview for Children \\u2013 IV (DISC \\u2013 IV)\", \"administer the Pediatric Symptom Checklist\", \"complete syndrome-specific scales for anxiety and depression\", \"recommend cognitive behavioral therapy for an anxiety disorder\", \"refer the child for play therapy\"]"}
{"id" : 315, "question_text" : "A mother brings her 3-year-old daughter in for evaluation. She enrolled her daughter in child care 1 week ago. Over the past 3 days, the child has experienced yellowish rhinorrhea and cough. Her appetite has remained good, and her highest temperature has been 37.3°C. On physical examination, the child is interactive and playful. Her tympanic membranes are normal bilaterally, but yellowish rhinorrhea is visible in both nares. The remainder of the physical examination findings are unremarkable. You order a sinus radiograph series, which shows bilateral maxillary mucosal thickening with opacification of the ethmoid sinuses. Of the following, the MOST appropriate next therapy is", "options" : "[\"amoxicillin orally\", \"azithromycin orally\", \"ceftriaxone intramuscularly\", \"observation\", \"trimethoprim-sulfamethoxazole orally\"]"}
{"id" : 316, "question_text" : "A 10-year-old girl presents with right wrist pain. According to her mother, the girl has been complaining of this pain for 2 weeks, and the pain has persisted despite administration of daily ibuprofen. The girl cannot recall any recent injury and has had no fever or other systemic symptoms. She is right-handed and participates in gymnastics and soccer. Physical examination of her wrist reveals no redness or swelling, but she has moderate tenderness diffusely over the radial aspect and pain with wrist flexion and extension. She has no snuff-box tenderness and her hand is neurovascularly intact. You obtain radiographs of the wrist. Of the following, the MOST likely explanation for this child's wrist pain is", "options" : "[\"a navicular fracture\", \"a sprain\", \"an overuse injury\", \"osteomyelitis\", \"septic arthritis\"]"}
{"id" : 317, "question_text" : "An 8-month-old girl presents to your office because of poor growth. She was born at 36 weeks' gestation and had a birthweight of 2.5 kg. No problems were noted during the neonatal period, and early growth and development were normal. However, at the age of about 3 months, she was hospitalized because of purulent otitis media. Since that time, she has been treated on two more occasions for otitis media. Over the past month, her parents have noted that the baby has two to three large, foul-smelling, bulky stools per day, and she has failed to gain weight. Her developmental milestones are normal for age, and there are no findings of note on the family history. Physical examination of the alert, well-hydrated infant shows a weight of 6.4 kg, length of 66 cm, and palpable liver edge 3.0 cm below the right costal margin. Initial laboratory study results include: Hemoglobin, 10.8 g/dL (108 g/L); White blood cell count, 3.0x103/mcL (3.0x109/L) (15% neutrophils, 75% lymphocytes, 10% monocytes); Platelet count, 50x103/mcL (50x109/L); Alanine aminotransferase, 61 units/L (normal, up to 30 units/L); Albumin, 3.8 g/dL (38 g/L); Prothrombin time, 12.5 seconds; International Normalized Ratio, 1.1. Of the following, the study that is MOST likely to establish the diagnosis for this infant is", "options" : "[\"genetic testing\", \"liver biopsy\", \"serum amylase\", \"sweat chloride test\", \"tissue transglutaminase antibody assay\"]"}
{"id" : 318, "question_text" : "You are called by a neonatologist regarding the transfer of a convalescing preterm infant from the tertiary hospital to your care at the community hospital. The 4-week-old infant was born at 29 weeks' gestation, weighing 1,100 g. He required mechanical ventilation for 1 week for respiratory distress syndrome and needed supplemental oxygen therapy for 1 additional week after extubation. He received indomethacin treatment for a patent ductus arteriosus (PDA), with his last cardiac echocardiography 4 days ago showing closure of the PDA. Head ultrasonography revealed a right-sided grade I intraventricular hemorrhage 1 week after birth. He is now breathing room air and tolerating nasogastric feedings of fortified human milk. Of the following, the MOST important consultant to have available at the community hospital for this infant is a pediatric", "options" : "[\"audiologist\", \"cardiologist\", \"neurologist\", \"ophthalmologist\", \"pulmonologist\"]"}
{"id" : 319, "question_text" : "During a health supervision visit, you note that an 18-month-old boy has erosions of the medial portions of his maxillary central incisors and brown discoloration of several teeth. He was born at term following an uncomplicated pregnancy and has been well, except for two episodes of otitis media that were successfully treated with amoxicillin. His physical examination findings are otherwise normal. Of the following, the MOST likely factor contributing to this boy's findings is", "options" : "[\"amoxicillin exposure\", \"enamel hypoplasia\", \"excessive fluoride exposure\", \"exclusive breastfeeding\", \"maternal oral colonization with Streptococcus mutans\"]"}
{"id" : 320, "question_text" : "You are seeing a 14-month-old boy for a follow-up visit for anemia. When he was 12 months old, his hemoglobin value was 10 g/dL (100 g/L). Further testing at 13 months revealed a mean corpuscular volume of 62 fL on complete blood count, with the remainder of the red blood cell indices and the smear within normal limits. Reticulocyte count was 0.5% (0.005). When you review the child's diet, his mother reports that he drinks 40 oz of cow milk per day and his favorite food is macaroni and cheese. He eats little meat and few vegetables. Of the following, the BEST recommendation for management of this child's condition is to", "options" : "[\"encourage replacement of some cow milk with fruit juice\", \"prescribe a chewable multivitamin with iron tablet once daily\", \"prescribe therapeutic ferrous sulfate drops three times daily\", \"resume use of infant formula until his hemoglobin increases\", \"switch from cow milk to a 30 kcal/oz cow milk-based nutritional supplement\"]"}
{"id" : 321, "question_text" : "You are called to the delivery room to assess a newborn who has a heart rate of 60 beats/min. On physical examination, you determine that the infant is in no distress and has no other findings of note apart from the profound bradycardia. You recommend observation in the neonatal intensive care unit and order 12-lead electrocardiography. Upon questioning the mother, you learn that she has Sjögren syndrome. Of the following, the MOST likely nature of the rhythm disturbance experienced by the infant is", "options" : "[\"blocked premature atrial contractions\", \"first-degree atrioventricular block\", \"second-degree atrioventricular block\", \"sinus bradycardia\", \"third-degree atrioventricular block\"]"}
{"id" : 322, "question_text" : "A 6-month-old girl presents to the urgent care clinic with vomiting, fussiness, and head tilt. She had a similar episode 1 month ago. She was born at term with no complications and has been otherwise healthy. She is a good eater and has no diarrhea or other gastrointestinal problems. Developmentally she has been on track and currently she sits independently. On physical examination, her head shape is normal and the circumference is 43 cm. Growth parameters are otherwise normal. The pale, fussy infant has a soft abdomen with normal bowel sounds. When placed in a sitting position, her head tilts to the left. Sternocleidomastoid muscles feel symmetric in size. After you straighten her head and neck, she resumes the tilted posture. Her eyes are normally aligned, visual tracking is normal and full, there is no nystagmus, and facial movements are symmetric during crying. Tone in vertical suspension is normal, as are reflexes. Muscle bulk is also normal, with no distal muscle wasting or fasciculations. Of the following, the condition that BEST explains this constellation of findings is", "options" : "[\"brainstem glioma\", \"congenital muscular torticollis\", \"dystonia musculorum deformans\", \"left fourth nerve palsy\", \"paroxysmal torticollis of infancy\"]"}
{"id" : 323, "question_text" : "You are seeing a new patient for a 2-month health supervision visit. According to medical records that the mother brings with her, the infant was born at term, weighing 7 lb 2 oz. In the newborn period she had no episodes of hypoglycemia and was discharged home with her mother at 2 days of age. On physical examination, you note right-sided hemihyperplasia, with increased girth and length of her right arm and leg as well as mild overgrowth of the right half of the thorax and abdomen. You find no evidence of underlying subcutaneous vascular defects; there is no macroglossia, umbilical hernia, or ear lobe creases that are common in children who have Beckwith-Wiedemann syndrome. Of the following, the MOST important screening test for this child is", "options" : "[\"chest radiography\", \"fasting blood glucose\", \"limb radiography\", \"renal ultrasonography\", \"urinary catecholamine screening\"]"}
{"id" : 324, "question_text" : "You are seeing a 16-year-old girl for the first time who complains of amenorrhea. The mother's menarche was at age 12 years. The girl developed pubic hair at age 11 years and breast buds at age 12 years. She has no other symptoms. The mother reports that the girl eats well and has been active all her life. Physical examination reveals a height of 57 in, weight of 89 lb, body mass index of 19.3, breast tissue at Sexual Maturity Rating (SMR) 2, and pubic hair at SMR 4. A urine pregnancy test shows negative results. Laboratory results include: luteinizing hormone of 10 mIU/mL (normal adult female, 2 to 95 mIU/mL), follicle-stimulating hormone of 42 mIU/mL (normal adult female, 1 to 30 mIU/mL), and prolactin of 27 ng/mL (normal, 5 to 23 ng/mL). Of the following, the MOST likely cause of this girl's primary amenorrhea is", "options" : "[\"congenital adrenal hyperplasia\", \"excessive exercise\", \"imperforate hymen\", \"prolactinoma\", \"Turner syndrome\"]"}
{"id" : 325, "question_text" : "During a health supervision visit, the mother of 8-year-old girl and 10-year-old boy tells you that the children have been receiving counseling for anxiety for 3 months. The mother has a history of anxiety, and she has responded well to sertraline. She reports that the boy is not making much progress in therapy and asks you if a medication trial would be appropriate for him. Of the following, the MOST appropriate initial response is to", "options" : "[\"advise the mother to give the current therapist more time to see if an improvement occurs\", \"ask the boy if he wants a new therapist\", \"obtain consent from the mother to contact the therapist\", \"prescribe sertraline for the boy\", \"refer the family to another therapist\"]"}
{"id" : 326, "question_text" : "You are evaluating an 18-month-old boy who was pulled from a swimming pool (water temperature of 15.0°C) after an estimated 5 minutes of submersion. Cardiopulmonary resuscitation (CPR) was initiated at the scene, and the boy was transported to the emergency department while undergoing advanced cardiac life support. Spontaneous circulation was restored in the emergency department after a total of 20 minutes of CPR. On initial physical examination, the boy was comatose, with mildly reactive pupils and abnormal flexion with painful stimuli. He had no spontaneous eye opening. He has now been in the pediatric intensive care unit receiving mechanical ventilation and maximal intensive care support for 12 hours. At this point, he exhibits briskly reactive pupils, spontaneous eye opening, and purposeful withdrawal from pain. Of the following, the prognostic factor that is BEST associated with a favorable neurologic outcome for this boy is", "options" : "[\"establishment of a perfusing rhythm in the emergency department\", \"improvement in neurologic examination findings within 24 hours\", \"submersion time of less than 20 minutes\", \"total CPR time of less than 30 minutes\", \"water temperature of less than 18.0\\u00b0C\"]"}
{"id" : 327, "question_text" : "A 12-year-old boy presents for evaluation of short stature. His mother reports that he has been growing but that he is not keeping up with the growth rates of his peers. His mother is 160 cm tall (~63 in) and his father is 172 cm tall (~68 in). With the exception of his relative short stature, his medical history is unremarkable, and he takes no medications. His growth curve is shown in image (Item Q221). A bone age radiograph demonstrates a skeletal maturity of 10 years. The boy asks if he will \"always be short.\" You advise him that the best way to estimate his potential for growth is to calculate his midparental target height and compare it to his current height and his skeletal maturity. Of the following, the BEST estimate of his midparental target height is", "options" : "[\"162.5 cm (64 in)\", \"167.5 cm (66 in)\", \"172.5 cm (68 in)\", \"177.5 cm (70 in)\", \"182.5cm (72 in)\"]"}
{"id" : 328, "question_text" : "A 17-year-old boy comes to your office for medication management of his attention-deficit/hyperactivity disorder (ADHD). He explains that he is considering stopping his medication before his last year in high school. His parents are upset because they are fearful that his academic success will diminish and that he may make poor social choices. His parents ask about the long-term outcome for ADHD. Of the following, the MOST appropriate response is that", "options" : "[\"certain features of ADHD (risk taking, fast-paced approach, outgoing style) may be advantageous in some occupations\", \"longitudinal studies have not found elevated anxiety or mood disorders among adults who have ADHD\", \"males who have ADHD have a greater ability to handle stressful situations\", \"more than 75% of children who have ADHD no longer have inattention or have a need for stimulant medications in adulthood\", \"studies have not found a higher rate of divorce among adults who have ADHD\"]"}
{"id" : 329, "question_text" : "A 3-year-old boy presents with a temperature of 39.5°C and a first-time generalized seizure. Over the past 3 days, he has had 8 to 10 loose, liquid stools and abdominal pain. He attends child care, and several other children in the center have been reported to have diarrhea. Of the following, the MOST likely cause of this child's illness is infection with", "options" : "[\"Campylobacter jejuni\", \"rotavirus\", \"Salmonella enteritidis\", \"Salmonella typhi\", \"Shigella flexneri\"]"}
{"id" : 330, "question_text" : "You are examining a 2-week-old term infant who was born at home to a mother who had no prenatal care. On physical examination, you note moderate bilateral conjunctival injection, eye discharge, and periorbital edema. The infant is afebrile and otherwise doing well. The remainder of the physical examination findings are normal. Of the following, the MOST appropriate antibiotic therapy for this infant is", "options" : "[\"amoxicillin\", \"doxycycline\", \"erythromycin\", \"levofloxacin\", \"sulfamethoxazole\"]"}
{"id" : 331, "question_text" : "A 3-week-old term infant presents with vomiting, increased fussiness, and poor weight gain. In answer to your questioning, his mother states he has a vigorous suck, decreased tearing, and several wet diapers per day. The infant is formula-fed. On physical examination, he is fussy and difficult to console. His weight is 2.9 kg (birthweight was 3.2 kg), temperature is 37.3°C, heart rate is 180 beats/min, respiratory rate is 40 breaths/min, and blood pressure is 76/36 mm Hg. His anterior fontanelle is flat and mucous membranes are tacky. His chest is clear to auscultation, he has tachycardia without murmurs, and he has no abdominal masses. Skin evaluation reveals reduced turgor, and capillary refill time is approximately 3 to 4 seconds. Laboratory results include: sodium of 168 mEq/L (168 mmol/L), potassium of 3.5 mEq/L (3.5 mmol/L), chloride of 130 mEq/L (130 mmol/L), and bicarbonate of 20 mEq/L (20 mmol/L). Urinalysis shows a specific gravity of 1.002, pH of 5.5, and otherwise negative results. Of the following, the MOST likely diagnosis for this patient is", "options" : "[\"Bartter syndrome\", \"diabetes insipidus\", \"Fanconi syndrome\", \"Gitelman syndrome\", \"improper formula preparation\"]"}
{"id" : 332, "question_text" : "A 6-year-old boy who has moderate persistent asthma has experienced more frequent asthma symptoms as well as nasal congestion and headaches for the past 4 weeks. Recently, he went to the dentist because of upper tooth pain, but the dentist stated his examination findings were normal, and there was no evidence of dental caries. Of the following, the MOST likely cause for the boy's symptoms is", "options" : "[\"allergic rhinitis\", \"bacterial sinusitis\", \"migraine headache\", \"nonallergic rhinitis\", \"viral upper respiratory tract infection\"]"}
{"id" : 333, "question_text" : "A 14-year-old girl presents to the office with right wrist pain after falling on her outstretched hand while roller skating 2 hours ago. On physical examination, you note minimal swelling of her right wrist and point tenderness at the base of the first metacarpal. Her hand is neurovascularly intact. You obtain radiographs of her right wrist and forearm, which do not reveal any fracture. Of the following, the MOST appropriate next step in this patient's management is", "options" : "[\"ice and acetaminophen for pain\", \"magnetic resonance imaging of the wrist and forearm\", \"no further intervention\", \"orthopedic follow-up evaluation if pain persists for more than 1 week\", \"a thumb spica splint\"]"}
{"id" : 334, "question_text" : "You are seeing a 18-month-old boy because of poor growth and inadequate weight gain. He weighed 3,100 g at birth, following a term, uncomplicated pregnancy and delivery. The baby was breastfed exclusively until 10 months of age, when he was weaned to whole cow milk and a mixed solid food diet. At 13 months, he developed several loose bowel movements per day, and his diet was adjusted to include lactase-treated milk (1% milk fat). Since that time, although he has gained weight slowly, he continues to have two to three loose bowel movements per day. Over the past several weeks, he has developed \"eczema,\" with sharply demarcated, dry, scaly patches appearing prominently in the periorificial and acral areas (Item Q228). His mother reports that the child has also experienced recent hair loss. His height and weight have crossed from the 25th to the 10th percentiles. Of the following, this child's symptoms are MOST likely the consequence of", "options" : "[\"cow milk protein allergy\", \"essential fatty acid deficiency\", \"gluten-sensitive enteropathy\", \"Hartnup disease\", \"zinc deficiency\"]"}
{"id" : 335, "question_text" : "You are evaluating a 28 weeks gestational age infant who was recently discharged from the neonatal intensive care unit after a 4-month hospital stay. She was delivered prematurely due to severe pregnancy-induced hypertension and intrauterine growth restriction, with a birthweight of 700 g (3rd percentile). She had a complicated hospital course that included severe respiratory distress syndrome and necrotizing enterocolitis, with prolonged periods of parenteral nutrition and poor weight gain. She now is breathing room air and receiving oral feeding of 150 mL/kg per day of human milk fortified to 24 kcal/oz. Her weight in your office is 2,500 g (<3rd percentile). Her parents have many concerns about her small size and neurodevelopmental outcome. Of the following, the MOST appropriate counseling for this family is that", "options" : "[\"early growth deficits are not associated with poor neurodevelopmental outcomes\", \"feeding strategies that provide 90 kcal/kg per day maintain optimal growth\", \"higher protein intake after birth improves neurodevelopmental indices at 18 months\", \"increased amounts of lipid after hospital discharge support brain development\", \"nutrition in the second year after birth is critical to neurodevelopmental outcome\"]"}
{"id" : 336, "question_text" : "You are seeing a 9-year-old prepubertal boy for the first time for a health supervision visit. The father mentions that the boy is playing competitive tennis, and his coach would like him to start a strength training program to improve his sports performance. The child has a past history of a murmur, but the father does not know any further details. The boy is currently asymptomatic and his examination findings are normal. Of the following, the MOST appropriate advice to provide the father about strength training is that", "options" : "[\"evidence shows that strength training affects growth plates adversely and impairs linear growth\", \"specific strength-training exercises should be learned initially with no or low resistance\", \"the most commonly reported adverse affects of strength training are injuries to joint structures such as ligaments\", \"the risk of injury to children in supervised strength training programs exceeds the risk of injury in team sports\", \"to be effective, the athlete must participate in strength training four or more times per week\"]"}
{"id" : 337, "question_text" : "A 2-year-old boy who has trisomy 21 has been plagued by middle ear infections for several months. You last saw him days ago and prescribed high-dose amoxicillin at 80 mg/3kg per day for recurrent otitis media. Today he has a new onset of drainage from the ear and continued fussiness and nocturnal awakening. Although his tympanic membranes are always difficult to see through his tiny canals, today purulent drainage occludes the membrane completely. You decide to discontinue the amoxicillin therapy. Of the following, the BEST course of action for this patient is to", "options" : "[\"administer intramuscular ceftriaxone\", \"administer one dose of intramuscular ampicillin\", \"begin topical fluoroquinolone otic drops\", \"begin trimethoprim-sulfamethoxazole\", \"refer him for urgent placement of tympanostomy tubes\"]"}
{"id" : 338, "question_text" : "A previously healthy 15-year-old boy presents to the emergency department with a 60-minute history of tachycardia. He describes a rapid heart rate without irregularity, slight light-headedness, anxiety, and mild shortness of breath. He can suppress the tachycardia transiently by performing a Valsalva maneuver. On physical examination, the only finding of note is his heart rate of 230 beats/min. Twelve-lead electrocardiography demonstrates tachycardia with a ventricular rate of 220 beats/min (Item Q232). You elect to initiate therapy in an effort to convert the tachycardia to sinus rhythm. Of the following, the BEST choice for initial pharmacologic therapy is", "options" : "[\"adenosine continuous drip infusion\", \"adenosine intravenous bolus\", \"amiodarone intravenous infusion\", \"digoxin orally\", \"propranolol orally\"]"}
{"id" : 339, "question_text" : "In late summer, a 14-year-old previously healthy boy presents to the emergency department in convulsive status epilepticus. Vital signs show low-grade fever. The seizures persist despite administration of two doses of lorazepam and 20 mg/kg fosphenytoin intravenously. The child is given 20 mg/kg phenobarbital, intubated endotracheally, and brought to the intensive care unit for further management. Computed tomography scan yields normal results. Lumbar puncture shows 15 white blood cells, 3 red blood cells, and normal glucose and protein concentrations. Stat electroencephalography shows continuing electrographic seizures. A midazolam infusion is started, and 20 mg/kg acyclovir is administered. Of the following, the MOST likely diagnosis is", "options" : "[\"acetaminophen ingestion\", \"aneurysmal hemorrhage\", \"encephalitis\", \"idiopathic status epilepticus\", \"mitochondrial disease\"]"}
{"id" : 340, "question_text" : "You are called to attend the delivery of a newborn male who had been monitored carefully prenatally for moderate oligohydramnios. Prenatal ultrasonography suggested bilateral cystic dysplastic kidneys, with no other congenital anomalies identified. Of the following, the MOST likely immediate life-threatening problem in this infant is", "options" : "[\"bladder outlet obstruction\", \"cardiac arrhythmias\", \"liver failure\", \"renal failure\", \"respiratory failure\"]"}
{"id" : 341, "question_text" : "A 17-year-old girl is brought to the emergency department by her parents because of vomiting. She has no fever, headache, abdominal pain, or diarrhea. She says that over the past 3 years she has periods of time when she vomits and then she is fine for a while. She denies inducing the vomiting. Her periods are regular, and her last one was 2 weeks ago. On physical examination, you note normal vital signs, a body mass index of 28.5, a small subconjunctival hemorrhage on the right eye, and slight enlargement of her parotid glands bilaterally. Laboratory results reveal a normal complete blood count and erythrocyte sedimentation rate, amylase of 75 U/L, and lipase of 1 U/L. Her pregnancy test is negative, and a urinalysis has a specific gravity of 1.030 with trace protein and ketones. Of the following, the MOST likely explanation for these findings is", "options" : "[\"acute pancreatitis\", \"bulimia nervosa\", \"cyclic vomiting\", \"diabetic ketoacidosis\", \"ectopic pregnancy\"]"}
{"id" : 342, "question_text" : "You are called to evaluate an 8-year-old boy who fell while climbing a tree and landed on the left side of his abdomen on a fence. He did not lose consciousness, was transported to the emergency department by emergency medical services, and complains of left-sided shoulder pain and tenderness over the left side of his abdomen. On physical examination, he has a heart rate of 125 beats/min, respiratory rate of 27 breaths/min, and blood pressure of 105/70 mm Hg. His oxygen saturation by pulse oximetry is 85% while receiving 2 L/min oxygen via a nasal cannula. His heart rhythm is normal with no murmurs, he has clear and equal breath sounds, and his abdomen is mildly distended, with abrasions, ecchymosis, and tenderness in the left upper quadrant. Results of laboratory studies from 2 hours ago include: Serum sodium, 140 mEg/L (140 mmol/L); Serum potassium, 4 mEq/L (4 mmol/L); Serum chloride, 105 mEq/L (105 mmol/L); Hematocrit, 30% (0.3); Blood urea nitrogen, 12.0 mg/dL (4.3 mmol/L); Serum creatinine, 0.6 mg/dL (53.0 mcmol/L); Aspartate aminotransferase, 75 units/L; Alanine aminotransferase, 45 units/L; Amylase, 40 units/L; Lipase, 35 units/L. Of the following, the BEST test to evaluate for abdominal injury in this boy is", "options" : "[\"abdominal radiograph\", \"computed tomography scan of the abdomen with contrast\", \"computed tomography scan of the abdomen without contrast\", \"diagnostic peritoneal lavage\", \"focused abdominal sonography for trauma (FAST)\"]"}
{"id" : 343, "question_text" : "A 14-year-old girl presents for her annual health supervision visit. She has no complaints, and her review of systems reveals no findings of note. However, her mother is concerned that her daughter has not yet had menarche. The girl's height is at the 5th percentile and her weight is at the 25th percentile. On physical examination, she has Sexual Maturity Rating (SMR) 1 breast development and SMR 3 pubic hair. Examination of the external genitalia reveals a patent vagina and pink mucosae. Of the following, the BEST next step in evaluation of this patient is to", "options" : "[\"measure serum estradiol\", \"obtain a karyotype\", \"perform a bone age radiograph\", \"reassure the family and see them again in 1 year\", \"re-examine her in 6 months\"]"}
{"id" : 344, "question_text" : "An 8-year-old boy is having attention difficulties in his third-grade classroom. He has undergone psychoeducational testing and has not had a learning disability identified. His parents and teachers have completed Vanderbilt rating forms, and the results are significant for inattention and impulsivity. You are considering starting the child on medication to treat his attention-deficit/hyperactivity disorder. Of the following, the MOST significant historical information that would affect your decision to start treatment with a stimulant medication is", "options" : "[\"absence epilepsy in his 6-year-old sister\", \"bipolar disorder in his paternal uncle\", \"mild motor tic in the child\", \"myocardial infarction in the paternal grandfather at the age of 65 years\", \"sudden death of his 15-year-old brother while playing basketball\"]"}
{"id" : 345, "question_text" : "A 3-year-old child who lives in Philadelphia presents to the local emergency department in August with a 2-day history of fever, decreased oral intake, and sore throat, followed by the onset of a rash today. He attends a day camp, where he swims daily, but he has no history of travel. Physical examination reveals a temperature of 39.5°C, heart rate of 120 beats/min, respiratory rate of 22 breaths/min, and oxygen saturation of 100% in room air. He is alert and verbal. His pharynx is erythematous without exudate and neck is supple without significant adenopathy. His lungs are clear. He has a regular heart rhythm without murmur, rub, or gallop; his pulses are full and equal; and his capillary refill is less than 2 seconds. Abdominal and neurologic examinations reveal no findings of note. He has scattered petechiae on his abdomen and extremities. Laboratory results include: White blood cell count, 12.4x103/mcL (12.4x109/L) with 48% neutrophils, 39% lymphocytes, 11% monocytes, and 2% eosinophils; Hemoglobin, 13.6 g/dL (136 g/L); Hematocrit, 39% (0.39); Platelet count, 229x103/mcL (229x109/L). Of the following, the BEST test to diagnose this child's condition is", "options" : "[\"blood culture\", \"bone marrow aspiration\", \"serology for Rocky Mountain spotted fever\", \"throat and rectal viral cultures\", \"throat culture for group A Streptococcus\"]"}
{"id" : 346, "question_text" : "A 4-year-old boy presents with a 4-day history of worsening right eyelid swelling and redness after a mosquito bite. On physical examination, his temperature is 38.0°C, heart rate is 100 beats/min, and respiratory rate is 25 breaths/min. His right eyelid is markedly swollen, red, and tender, and he is unable to open it fully. His conjunctivae are clear, and extraocular movements are not limited. There is no proptosis. Visual acuity is difficult to assess fully but appears normal. There are no other physical findings of note. The white blood cell count is 19.0x103/mcL (19.0x109/L), with 55% polymorphonuclear leukocytes, 20% band forms, 20% lymphocytes, and 5% monocytes. Of the following, the MOST appropriate antibiotic for this patient is", "options" : "[\"ampicillin-sulbactam\", \"cefazolin\", \"clindamycin\", \"doxycycline\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 347, "question_text" : "You are seeing a 10-year-old girl who has systemic lupus erythematosus (SLE) for a health supervision visit. You diagnosed SLE when she was 8 years old, based on an initial presentation of idiopathic thrombocytopenic purpura and a positive antinuclear antibody test and the subsequent development of arthritis and a positive anti-double-stranded DNA test. She is currently doing well in school and has no concerns about her memory or problem-solving skills. The only finding of note on her physical examination is a slight erythematous rash in a malar distribution. Of the following, the MOST useful screening test for other organ involvement in this girl is", "options" : "[\"Coombs test\", \"erythrocyte sedimentation rate\", \"magnetic resonance imaging of the brain\", \"urinalysis\", \"Venereal Disease Research Laboratory (VDRL) testing\"]"}
{"id" : 348, "question_text" : "A 12-year-old girl is admitted to the intensive care unit with anaphylactic shock after being stung by a wasp. She was playing outside when she was stung twice on her arm. Within 10 minutes, she developed abdominal pain and dyspnea. Her parents attempted to administer an oral antihistamine, but the girl vomited and then collapsed. Emergency medical services arrived in 10 minutes to find an unresponsive child whose initial systolic blood pressure was 60 mm Hg. They administered intravenous fluids and two doses of epinephrine, which improved the girl's level of consciousness and blood pressure. Her parents, who are physicians, have many questions about wasp stings and what can be done to prevent reactions in the future. Of the following, you are MOST likely to advise the parents that", "options" : "[\"Hymenoptera immunotherapy decreases the risk of anaphylaxis with future stings to approximately 30%\", \"Hymenoptera immunotherapy is contraindicated due to the severity of the girl's sting reaction\", \"initial allergy testing should be performed within 2 weeks after the sting reaction\", \"serum tryptase should be measured 1 to 2 weeks after the reaction\", \"the girl's future risk for anaphylaxis to a wasp sting is less than 10% per sting\"]"}
{"id" : 349, "question_text" : "Emergency medical services personnel bring a 3-month-old infant to the emergency department in status epilepticus. The mother reports that the infant was well when she put her to sleep approximately 4 hours ago and that she found her seizing when she checked on her 20 minutes ago. On initial physical examination, the infant's temperature is 35.6°C, heart rate is 175 beats/min, respiratory rate is 45 breaths/min, blood pressure is 90/60 mm Hg, and pupils are equally round and reactive. She is having equally symmetric, generalized tonic-clonic movements of her extremities. Her bedside glucose determination is 145 mg/dL (8.0 mmol/L). After two doses of midazolam, the seizure activity stops. A head computed tomography scan is read as normal, and further testing is initiated. Of the following, the assessment that is MOST likely to yield abnormal results for this infant is", "options" : "[\"cerebrospinal fluid\", \"serum ammonia\", \"serum calcium\", \"serum sodium\", \"skeletal survey\"]"}
{"id" : 350, "question_text" : "You are asked to see a 6-week-old infant who has just been hospitalized because of an apparent life-threatening event. The baby was delivered via cesarean section at term following an uncomplicated pregnancy because of failure of labor progression. He weighed 3,200 g. He was started on cow milk protein-based formula at birth. At about 2 weeks of age, he developed postprandial emesis, and these episodes have increased so that the baby spits up once or twice after each feeding. He currently consumes 6 oz of formula every 3 to 4 hours. Several hours ago, immediately after feeding, the baby appeared to be choking, stopped breathing, and developed perioral cyanosis. He expelled formula from his nose and mouth. The parents called 911, and the infant was brought to the emergency department, where he appeared active and alert and had a weight of 4,400 g. The infant was admitted for evaluation and observation. Of the following, the MOST appropriate next step is", "options" : "[\"barium esophagography\", \"intraesophageal pH monitoring\", \"lansoprazole administration\", \"ranitidine administration\", \"reduced feeding volumes\"]"}
{"id" : 351, "question_text" : "You are called by an obstetric colleague about the antibiotic of choice for intrapartum prophylaxis for group B Streptococcus (GBS) infection. A 22-year-old primigravida has presented in labor at 39 weeks' gestation. She is currently afebrile with intact membranes. Her prenatal records demonstrate a positive GBS screening result at 36 weeks' gestation. Upon questioning, the woman states that she has a \"penicillin allergy\" that manifests with a faint rash but no anaphylaxis, angioedema, or urticaria. Of the following, the MOST appropriate antibiotic for intrapartum prophylaxis for this patient is", "options" : "[\"azithromycin\", \"cefazolin\", \"clindamycin\", \"erythromycin\", \"vancomycin\"]"}
{"id" : 352, "question_text" : "A 16-month-old girl is brought to the emergency department because of persistent crying for several hours. She has had clear rhinorrhea, cough, and an undocumented fever for 3 days. She has had adequate oral intake, has vomited twice, and has had no diarrhea. She has no underlying medical conditions and no exposures. Current medications include acetaminophen and an over-the-counter cough and cold medicine. Physical examination reveals an agitated, crying child, who is inconsolable. Her temperature is 37.8°C, heart rate is 192 beats/min, respiratory rate is 36 breaths/min, blood pressure is 122/78 mm Hg, and oxygen saturation is 98%. The remainder of physical examination findings are normal. Complete blood count, electrolytes, urinalysis, and cerebrospinal fluid studies yield normal results. Electrocardiography shows sinus tachycardia. Of the following, the MOST likely cause of this child's symptoms is", "options" : "[\"acetaminophen overdose\", \"early meningitis\", \"intussusception\", \"myocarditis\", \"reaction to cold and cough medicine\"]"}
{"id" : 353, "question_text" : "A 7-year-old boy comes to the emergency department complaining of back pain for the past 3 weeks after falling on the playground. A few days after the onset of pain, he was evaluated at an urgent care center, where the examination and plain radiographs were reported to be normal. After initially improving, the pain has become progressively worse, and recently he developed fever. On physical examination, his vital signs are normal except for a temperature of 38.3°C. He seems mildly uncomfortable and has difficulty climbing onto the examination table because of the pain. Examination of the back reveals tenderness over the midline lumbar region and spasm of the paraspinal muscles. Findings on neurologic examination are normal. A complete blood count reveals a white blood cell count of 15.0x103/mcL (15.0x109/L) with 76% polymorphonuclear leukocytes, 21% lymphocytes, and 3% bands. The erythrocyte sedimentation rate is 45 mm/hr. Of the following, the BEST test to establish the diagnosis for this child is", "options" : "[\"abdominal ultrasonography\", \"blood culture\", \"bone scan\", \"computed tomography scan of the spine\", \"magnetic resonance imaging of the spine\"]"}
{"id" : 354, "question_text" : "A 10-year-old girl presents to your office with fever, shortness of breath, and a recent history of pharyngitis. Physical examination reveals tenderness of the left ankle without swelling or redness, nontender nodules on the elbows and knees, rales across both lung bases, and a II/VI high-pitched blowing systolic ejection murmur at the apex. An antistreptolysin O titer is elevated, and 12-lead electrocardiography identifies first-degree atrioventricular block. Echocardiography shows thickened mitral valve leaflets with severe mitral regurgitation. Of the following, the MOST appropriate treatment for this patient is", "options" : "[\"erythromycin and aspirin\", \"erythromycin and corticosteroids\", \"penicillin, furosemide, and aspirin\", \"penicillin, furosemide, and corticosteroids\", \"penicillin, furosemide, aspirin, and corticosteroids\"]"}
{"id" : 355, "question_text" : "An otherwise healthy 2-year-old child has mild unilateral ptosis on the right. On questioning, the mother believes this eyelid always has been slightly droopy. A picture of the child from infancy confirms this. On physical examination, the child has equal pupil sizes in light and dark and normal pupil reactions. Extraocular movements are full and conjugate. Physical examination findings are otherwise normal. Of the following, the MOST likely diagnosis is", "options" : "[\"congenital ptosis\", \"Horner syndrome\", \"Kearns-Sayre syndrome\", \"myasthenia gravis\", \"orbital tumor\"]"}
{"id" : 356, "question_text" : "You are examining a 6-year-old girl who is new to your practice during a health supervision visit. You note that she has a low posterior hairline and a rather short neck with decreased range of motion, and her mother explains that she has a condition known as Klippel-Feil syndrome. Her father also has this condition, and the mother explains that it \"runs on my husband's side of the family.\" A radiography report provided by the mother confirms cervical vertebral fusion abnormalities consistent with Klippel-Feil syndrome. Of the following, the MOST likely additional clinical feature to expect in this patient is", "options" : "[\"conductive hearing loss\", \"kyphosis\", \"Madelung deformity\", \"microtia\", \"Sprengel anomaly\"]"}
{"id" : 357, "question_text" : "The parents of a 15-year-old boy would like your help in sending their son to a drug rehabilitation facility. He disagrees and feels he can stop use of illicit drugs on his own. He reportedly started smoking and drinking at age 12 years. His mother recently found drug paraphernalia in his room, prompting the visit. He tells her that his friend asked him to hold these items for him but they are not his. In deciding on a plan, you review risk factors. Of the following, this boy's prognosis is MOST influenced by", "options" : "[\"age at which substance use began\", \"duration of substance use\", \"his current age\", \"peer substance use\", \"types of substances used\"]"}
{"id" : 358, "question_text" : "You are seeing a 4-month-old infant who has a 4-hour history of inconsolable crying and frequent bile-colored emesis. His mother reports that he has had no stools today. He was born at term via vaginal delivery with no prenatal or neonatal complications. Results of his 2-month health supervision visit were within normal parameters, and he received the appropriate immunizations at that time. Physical examination today reveals a well-nourished child in distress whose temperature is 37.0°C, heart rate is 160 beats/min, respiratory rate is 45 breaths/min, blood pressure is 78/50 mm Hg, and oxygen saturation is 95% in room air. His lungs are clear to auscultation. His perfusion is decreased peripherally. Abdominal examination documents a markedly distended abdomen, minimal bowel sounds, and diffuse pain. You order abdominal radiography. Of the following, the MOST likely cause of this child's symptoms is", "options" : "[\"appendicitis\", \"gastroenteritis\", \"Mallory-Weiss tear\", \"necrotizing enterocolitis\", \"volvulus\"]"}
{"id" : 359, "question_text" : "The mother of an 8-year-old boy in whom you diagnosed type 1 diabetes 2 months ago calls your office for advice. There has been a gastroenteritis outbreak in the boy's school, and 2 days ago he developed fever, vomiting, and diarrhea. He no longer is interested in eating, although he is able to drink. She reports his blood glucose measurement as 205 mg/dL (11.4 mmol/L). His insulin regimen includes 15 units of glargine insulin administered daily at bedtime and aspart insulin administered before meals (1 unit per 15 g carbohydrate) and for correction of high blood glucose (1 unit for every 25 mg/dL [1.39 mmol/L] above 125 mg/dL [6.9 mmol/L]). Of the following, the MOST appropriate next step is to", "options" : "[\"administer 0.1 units/kg of regular insulin subcutaneously\", \"administer 0.1 units/kg per hour of regular insulin intravenously\", \"administer 4 units of subcutaneous aspart insulin based on his blood glucose\", \"check for urine ketones\", \"discontinue glargine until he is able to eat normally\"]"}
{"id" : 360, "question_text" : "The parents of a 24-month-old boy express concern about three recent episodes that occurred 2 hours after the boy fell asleep. He sat up straight and let out a blood-curdling scream. The boy recently started a child care program twice a week, and his parents are concerned that he may be getting sick from the other toddlers in his program. Of the following, the BEST response is to", "options" : "[\"obtain a throat culture\", \"reassure the parents that the events are benign\", \"send the child for behavioral therapy\", \"send the child for electroencephalography\", \"send the child for polysomnography\"]"}
{"id" : 361, "question_text" : "A 15-year-old girl presents to your clinic on the weekend with a complaint of left lower jaw pain that developed over the past 24 hours. She also describes increased sensitivity to hot and cold on that side. On physical examination, you note tenderness localized to a lower left molar and a tender 1.5-cm submandibular lymph node on that side. She has otherwise been well and has no known drug allergies. You advise her to see her dentist the next day. Of the following, the MOST appropriate antibiotic for treating this infection pending dental evaluation is", "options" : "[\"azithromycin\", \"cefdinir\", \"doxycycline\", \"penicillin VK\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 362, "question_text" : "A 10-year-old girl presents to the emergency department with a 1-week history of sore throat, fever, chest pain, and progressive left-sided neck pain and swelling. On physical examination, her temperature is 40.0°C, heart rate is 130 beats/min, respiratory rate is 34 breaths/min, blood pressure is 90/60 mm Hg, and oxygen saturation is 70% in room air. You undertake emergent endotracheal intubation and fluid resuscitation. The left side of her neck is notably swollen, and auscultation of the chest reveals rhonchi throughout, with decreased breath sounds in the bases bilaterally. A white blood cell count is 30.0x103/mcL (30.0x109/L), with 80% polymorphonuclear leukocytes, 15% lymphocytes, and 5% monocytes. Plain radiography of the chest reveals bilateral air space disease and effusions. Computed tomography scan of the neck documents a retropharyngeal abscess extending toward the mediastinum. Of the following, the MOST appropriate antimicrobial to include in this girl's therapy is", "options" : "[\"ampicillin\", \"ampicillin-sulbactam\", \"cefepime\", \"doxycycline\", \"gentamicin\"]"}
{"id" : 363, "question_text" : "You are evaluating a 7-year-old girl who had end-stage renal disease caused by renal hypoplasia/dysplasia and underwent renal transplantation 18 months ago. She had been receiving peritoneal dialysis from birth until the time of transplantation. At present, she is maintained on a combination of prednisone, mycophenolate mofetil, and tacrolimus. She has had two previous episodes of rejection that required medical treatment with pulse methylprednisolone. Because of the two rejection episodes, her maintenance steroid dose is approximately 50% higher than usual. During her health supervision visit today, the girl's mother raises concern that her daughter is the smallest child in the second grade. In reviewing her growth charts, you realize that while receiving dialysis, the girl was at the 5th percentile for linear growth, but now she is at less than the 3rd percentile. Of the following, the MOST likely cause for this child's growth impairment is", "options" : "[\"corticosteroid exposure\", \"end-stage renal disease of 7 years' duration\", \"malnutrition\", \"metabolic acidosis due to tacrolimus\", \"vitamin D deficiency\"]"}
{"id" : 364, "question_text" : "A 15-year-old boy was stung by a hornet and experienced anaphylaxis with urticaria, dyspnea, and throat swelling. He states that he has been stung a number of times in the past but only experienced local pain and erythema at the sting site. His parents are worried because he spends a lot of time hiking and camping with friends. Of the following, the MOST accurate statement regarding Hymenoptera allergy is that", "options" : "[\"additional Hymenoptera testing is not required if initial blood test results are negative\", \"Hymenoptera allergy testing should be performed only to the insect identified by the patient\", \"Hymenoptera immunotherapy is generally prescribed for 1 to 2 years before discontinuation\", \"immunotherapy is not recommended for children younger than 16 years of age who experience only cutaneous symptoms\", \"this boy's risk for anaphylaxis to a future Hymenoptera sting is approximately 5% to 10%\"]"}
{"id" : 365, "question_text" : "A 5-year-old boy is brought to the emergency department after being struck by a car while running across the street. The paramedics report that he ran out from between two parked cars, and witnesses estimate the car was traveling at 40 mph. He was thrown approximately 30 feet and was unconscious immediately after the impact. The paramedics immobilized his cervical spine, administered oxygen using a nonrebreather mask, placed a 20-gauge intravenous line in his right antecubital fossa, and transported him to the emergency department. Physical examination upon arrival reveals moderate respiratory distress with a respiratory rate of 58 breaths/min and diffuse retractions, a heart rate of 140 beats/min, blood pressure of 72/38 mm Hg, and oxygen saturation of 90% on 100% oxygen. Auscultation of the lungs documents absent breath sounds diffusely over the right hemithorax. His abdomen is moderately distended and tender in the right upper quadrant. Of the following, the MOST appropriate next step is to", "options" : "[\"begin a dopamine infusion at 15 mcg/kg per minute\", \"infuse 20 mL/kg 0.9% saline rapidly\", \"obtain a chest radiograph\", \"obtain an abdominal computed tomography scan\", \"perform needle decompression of the right chest\"]"}
{"id" : 366, "question_text" : "A 10-month-old girl presents to your office because of diarrhea, irritability, and a fall-off in her weight gain. She was born at term to a 28-year-old gravida 1, para 1, woman following an uncomplicated pregnancy and delivery and had a birthweight of 2,900 g. She was exclusively breastfed for the first 2 months after birth. At 2 months of age, human milk was supplemented with cow milk protein-based formula. Because of increasing problems with postprandial emesis and \"colicky\" symptoms, human milk feeding was discontinued and several formula changes were attempted. At 6 months of age, she was started on a soy protein formula thickened with rice cereal because of symptoms suggesting gastroesophageal reflux. Since that time, her mother has noted an increased frequency and reduced consistency of the baby's stools. The infant now passes six to eight loose-to-watery bowel movements per day. Physical examination of the alert, well-developed, somewhat thin-appearing infant shows a length of 72 cm and a weight of 8.0 kg. The only additional finding of note is an erythematous and eroded diaper dermatitis. Of the following, the MOST appropriate diagnostic test for this infant is a", "options" : "[\"breath hydrogen test\", \"d-xylose absorption study\", \"lactose tolerance test\", \"tissue transglutaminase antibody\", \"zinc measurement\"]"}
{"id" : 367, "question_text" : "You are examining a 4-kg, 37-week gestational age infant 46 hours after birth. She was born to a 30-year-old woman who has type 1 diabetes. The infant's sibling had jaundice but did not require phototherapy. The infant has been bottle feeding well, with six wet diapers and two stools over the past day. Her current weight is 3.8 kg. On physical examination, she has a large right cephalohematoma and jaundice that extends from her face caudally to her trunk. Her total serum bilirubin measures 11.0 mcg/dL (188.1 mcmol/L) and the conjugated serum bilirubin is 0.2 mg/dL (34.2 mcmol/L). Of the following, the MOST significant risk factor for the development of severe hyperbilirubinemia in this patient is", "options" : "[\"bottle feeding\", \"cephalohematoma\", \"current serum bilirubin concentration\", \"macrosomia due to maternal diabetes\", \"sibling who had jaundice\"]"}
{"id" : 368, "question_text" : "You are seeing a 16-year-old boy in your office for a sports preparticipation examination. He has no complaints, but his parent asks about a rash that has been present for several months. On physical examination, you note a rash on his neck and upper back composed of hypopigmented macules. Of the following, the MOST likely cause of the rash is", "options" : "[\"Borrelia burgdorferi\", \"Malassezia\", \"nickel dermatitis\", \"parvovirus B19\", \"Streptococcus pyogenes\"]"}
{"id" : 369, "question_text" : "A 14-year-old boy presents for a preparticipation sports evaluation for baseball. He plays shortstop. His mother is very concerned about his playing because of the injuries she has heard about in professional and collegiate athletes. You explain to her that appropriate equipment, including a batting helmet, is needed to provide protection for her son. Of the following, the LARGEST percentage of baseball injuries can be prevented by also using", "options" : "[\"a mouth guard\", \"a protective cup\", \"elbow pads\", \"knee pads\", \"polycarbonate goggles\"]"}
{"id" : 370, "question_text" : "You are called to examine an otherwise well-appearing term 2-hour-old infant whom the nurse has noted to be dusky. On physical examination, he has cyanosis of the distal extremities of the hands and feet, his mucous membranes and his trunk are pink, his lungs are clear, and he has no organomegaly. His cardiac examination reveals no murmurs, rubs, or clicks, and his pulses are symmetric. Of the following, the MOST likely pulse oximetry reading obtained on the foot of this infant is", "options" : "[\"54% to 63%\", \"64% to 73%\", \"74% to 83%\", \"84% to 93%\", \"94% to 100%\"]"}
{"id" : 371, "question_text" : "A 3,100-g term infant, who was born via an uncomplicated, spontaneous vaginal delivery, has two episodes of nonsuppressible, pedaling movements of limbs with eye deviation and apnea during the first postnatal day. On physical examination, the infant has normal vital signs, appears well, and has a normal head circumference. After administration of a loading dose of 20 mg/kg of phenobarbital, no further episodes occur. Head computed tomography scan shows blood along the posterior rim of both occipital lobes but is otherwise normal. A lumbar puncture shows 340 red blood cells. Of the following, the MOST likely cause of the infant's seizure is", "options" : "[\"neonatal stroke\", \"prenatal trauma\", \"sinus venous thrombosis\", \"subarachnoid hemorrhage\", \"subdural hemorrhage\"]"}
{"id" : 372, "question_text" : "A 6-year-old child presents for a health supervision visit. His growth parameters show that his height and weight are both between the 50th and 75th percentiles for age. You note that his head appears rather large, and when you plot his head circumference on a special curve for older children, it is well above the 98th percentile for age and at the 50th percentile for a 15-year-old boy. When you review his growth chart, you note that his head circumference has been consistently above the 98th percentile. He has some frontal bossing and a slightly scooped nasal bridge, but otherwise completely normal physical exam. He has been quite healthy, with normal developmental milestones, and there are no developmental concerns at this time. When you measure the parents' heads, you note that the mother's head circumference is normal, but the head circumference of the father is greater than the 98th percentile for an adult male. Of the following, the MOST likely cause for the boy's macrocephaly is", "options" : "[\"basal cell nevus syndrome\", \"benign familial macrocephaly\", \"Cowden syndrome\", \"neurofibromatosis type 1\", \"tuberous sclerosis\"]"}
{"id" : 373, "question_text" : "You are seeing a 17-year-old boy whose mother is concerned that he is not eating as well as before and appears to be losing weight. He is upset at being brought in and states that he is just stressed in preparing for his upcoming examinations and not sleeping as well as usual. On physical examination, the boy's blood pressure is 130/95 mm Hg, heart rate is 95 beats/min, and body mass index is 19.7. He appears restless and has cold and sweaty palms, mildly dilated pupils, very active bowel sounds, and hyperactive reflexes. Of the following, the MOST likely cause for this boy's weight loss is", "options" : "[\"anxiety disorder\", \"eating disorder\", \"hyperthyroidism\", \"sleep disorder\", \"stimulant abuse\"]"}
{"id" : 374, "question_text" : "You have administered a benzodiazepine and ketamine combination to a 2-year-old boy in the emergency department to allow placement of a thoracostomy tube by another physician for a suspected empyema. On physical examination, the boy's eyes are closed and do not open to verbal commands or stimulation. His temperature is 37.0°C, heart rate is 110 beats/min, spontaneous respiratory rate is 10 breaths/min, blood pressure is 80/50 mm Hg, and while assisting him with bag-valve-mask ventilation and head positioning, oxygen saturation is 95% by pulse oximetry. The child does not respond to verbal commands but does reach for his side when lidocaine is injected at the planned thoracostomy tube site. Of the following, the level of sedation achieved for this boy is BEST defined as", "options" : "[\"conscious sedation\", \"deep sedation\", \"general anesthesia\", \"minimal sedation\", \"moderate sedation\"]"}
{"id" : 375, "question_text" : "During a health supervision visit, the mother of a 24-month-old boy reports that her son \"uses a lot of words and has a great memory.\" However, when you call his name, he does not respond, and when his mother asks, \"You want milk?\" he repeats, \"You want milk.\" He then starts to recite the script from a movie he watched. In his chart, you note that results of a previous audiology evaluation were normal. On a general developmental screening questionnaire that his mother completed, he was below the \"cut-off\" for both typical communication and personal social development. He also scored in the risk range on the parent-completed autism-specific screening questionnaire. You refer him to a developmental-behavioral specialist, whose next available appointment is in 3 months. Of the following, the MOST appropriate next step for this boy is to", "options" : "[\"order baseline electroencephalography\", \"provide information to his mother about language stimulation activities\", \"refer him for a central auditory processing evaluation\", \"refer him for early intervention services\", \"refer him for evaluation for an augmented communication device\"]"}
{"id" : 376, "question_text" : "A 17-year-old boy is brought to the emergency department with a 1-day history of a temperature of 39.6°C, progressive lethargy, and a petechial rash. On physical examination, the arousable but sleepy boy has a temperature of 40.4°C, heart rate of 180 beats/min, respiratory rate of 26 breaths/min, and blood pressure of 90/62 mm Hg. Scattered petechiae are visible, with confluent areas on the lower extremities. Of the following, the BEST choice for initial antibiotic therapy is", "options" : "[\"ampicillin-sulbactam\", \"clindamycin and trimethoprim-sulfamethoxazole\", \"doxycycline and ceftriaxone\", \"vancomycin and ceftriaxone\", \"vancomycin and nafcillin\"]"}
{"id" : 377, "question_text" : "A 10-year-old girl presents with a history of chronic sinusitis unresponsive to appropriate nasal hygiene and multiple courses of appropriate antibiotic therapy. She complains of ongoing nasal congestion, purulent nasal discharge, headache, and facial pain. Evaluations for allergy and immunodeficiency have yielded negative results. On physical examination, she has a temperature of 38.0°C, heart rate of 90 beats/min, and respiratory rate of 22 breaths/min. Her weight is 33 kg (50th percentile) and height is 138 cm (50th percentile). You note purulent nasal discharge and tenderness to palpation of the maxillary sinuses. Oropharyngeal examination reveals moderately large tonsils and foul-smelling breath. Flexible endoscopy of the nasopharynx documents enlarged nasal turbinates without polyps and bilateral adenoidal hypertrophy. Of the following, the next BEST step to consider in this patient's management, before performing endoscopic sinus surgery, is", "options" : "[\"adenoidectomy\", \"decongestants\", \"intranasal steroids\", \"repeat immune evaluation\", \"tonsillectomy\"]"}
{"id" : 378, "question_text" : "A 6-year-old girl presents for a health supervision visit that was scheduled as a follow-up appointment after she had an elevated blood pressure at an urgent care facility during an evaluation for abdominal pain. Her abdominal pain has resolved. Her mother recalls the blood pressure in the urgent care center as 135/90 mm Hg. The girl has had two urinary tract infections with fever in the past, and her father had hypertension diagnosed at age 45 years. On physical examination, the girl's temperature is 37.3°C, heart rate is 90 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 146/86 mm Hg. A repeat blood pressure reading is 142/88 mm Hg. The four limb blood pressures are: 142/88 mm Hg in the right arm, 144/84 mm Hg in the left arm, 156/100 mm Hg in the right leg, and 160/96 mm Hg in the left leg. You find no cardiac murmurs, abdominal bruits, or edema. Femoral pulses are 2+ and symmetrical bilaterally. Renal ultrasonography shows the left kidney to be 8.5 cm with normal corticomedullary differentiation and the right kidney to be 5.5 cm with increased echogenicity. Of the following, the MOST likely cause for this patient's elevated blood pressure is", "options" : "[\"coarctation of the aorta\", \"essential hypertension\", \"renal artery stenosis\", \"renal hypoplasia/dysplasia\", \"renal scarring from prior pyelonephritis\"]"}
{"id" : 379, "question_text" : "A 14-year-old girl was brought to the emergency department after she complained of difficulty breathing. She had been helping her family pack their household items for an upcoming move. Every time she was near a cardboard box she noticed a \"funny smell\" and experienced difficulty breathing. Her vital signs, including room air pulse oximetry and respiratory rate, are normal, but she points to her neck and states that it is \"hard to get air in.\" Her oropharynx is without edema, and her lungs are clear to auscultation without crackles or wheezing. After observation for 15 minutes, her symptoms resolve and the girl is discharged. Of the following, the MOST likely cause for this girl's symptoms is", "options" : "[\"asthma exacerbation\", \"gastroesophageal reflux\", \"hereditary angioedema\", \"nonallergic rhinitis\", \"vocal cord dysfunction\"]"}
{"id" : 380, "question_text" : "A 15-year-old boy is brought to the emergency department by emergency medical services personnel after crashing his all-terrain vehicle into a tree. The paramedics found him under the vehicle, responding appropriately to commands. Following extrication, they immobilized his cervical spine, administered 100% oxygen by a nonrebreather mask, and inserted two intravenous catheters. On arrival at the emergency department, his temperature is 36.5°C, heart rate is 140 beats/min, respiratory rate is 42 breaths/min, blood pressure is 80/60 mm Hg, and oxygen saturation is 86%. He has a Glasgow Coma Scale score of 14, bilateral femur deformities, marked right-sided chest wall tenderness, and crepitus. In addition, when he inhales, you note that his chest wall on the right appears to \"sink in.\" Of the following, the MOST appropriate next step is to", "options" : "[\"administer morphine for analgesia\", \"obtain a chest radiograph with dedicated views of the ribs\", \"obtain computed tomography scan of the chest\", \"perform intubation and mechanical ventilation\", \"perform needle decompression of the right chest\"]"}
{"id" : 709, "question_text" : "A 1-year-old boy with no drug allergies has pain, swelling, and erythema 10 hours after being bitten on the forearm by his pet cat. His temperature is 38°C and vital signs are normal for his age. On physical examination, there is an area of erythema, swelling, and tenderness on the posterior aspect of the right forearm (Item Q1). You note 2 puncture sites in the center of this area. Flexion and extension of the elbow and wrist are mildly limited by pain. The remainder of the physical examination findings is normal. Of the following, the MOST appropriate antimicrobial agent for this patient is", "options" : "[\"amoxicillin-clavulanate\", \"azithromycin\", \"clindamycin\", \"dicloxacillin\", \"levofloxacin\"]"}
{"id" : 710, "question_text" : "You are seeing a 16-year-old girl for her annual health supervision visit. The girl has become a vegan, and her mother is concerned about possible nutritional deficiencies. The girl has no symptoms and has not lost any weight in the last 6 months. Her menses are regular and her physical examination findings are unremarkable. Of the following, the girl's diet puts her at GREATEST risk of a deficiency of", "options" : "[\"calcium\", \"iron\", \"vitamin A\", \"vitamin B12\", \"vitamin D\"]"}
{"id" : 711, "question_text" : "A 12-year-old Chinese-American boy complains of gas, bloating, and diarrhea for the past 3 months. He has no nocturnal symptoms and denies weight loss. His recent history is significant only for a family trip to mainland China to visit his grandparents 2 months ago. Physical examination demonstrates a well-developed, well-nourished adolescent. The remainder of the examination is unremarkable, except for a nontender, tympanitic, slightly distended abdomen with active bowel sounds. His stool is watery, however occult blood test results are negative and the pH is 5.0. Of the following, the test that you are MOST likely to recommend is a", "options" : "[\"72-hour fecal fat\", \"lactose breath test\", \"lactulose breath test\", \"small intestinal biopsy for disaccharidase levels\", \"stool for ova and parasites\"]"}
{"id" : 712, "question_text" : "A newborn is determined to have Leber congenital amaurosis, which causes congenital blindness. There are no other abnormalities and no indication of central nervous system involvement. The parents ask how this diagnosis will affect their infant's development. Of the following, the MOST appropriate statement about development in this child is", "options" : "[\"language development will be persistently delayed\", \"preserved hearing will allow this child to develop typically\", \"reaching for objects is likely to be delayed\", \"sitting independently is likely to be delayed\", \"social development will be typical\"]"}
{"id" : 713, "question_text" : "A previously healthy, 3-year-old girl developed a high fever and has trouble breathing since this morning. On physical examination, the child appears \"toxic\" and is leaning forward in her mother's lap. Her temperature is 40.0°C, heart rate is 138 beats/min, respiratory rate is 37 breaths/min, blood pressure is 96/62 mm Hg, and oxygen saturation on room air is 94% by pulse oximetry. You arrange rapid transfer to the local hospital and consultation with a pediatric anesthesiologist and otolaryngologist. The otolaryngologist updates you on the condition of your patient and lets you know that a large \"cherry red\" epiglottis was seen on visualization in the operating room. Of the following, the image MOST consistent with your patient's diagnosis is", "options" : "[\"Item Q5A\", \"Item Q5B\", \"Item Q5C\", \"Item Q5D\", \"Item Q5E\"]"}
{"id" : 714, "question_text" : "A 15-year-old female patient calls to request that you call in a prescription for emergency contraception. Her last sexual activity was 4 days ago, and her partner did not use a condom. Of the following, the BEST choice for emergency contraception for this girl is", "options" : "[\"intrauterine device placement\", \"levonorgestrel\", \"mifepristone\", \"ulipristal acetate\", \"Yuzpe regimen\"]"}
{"id" : 715, "question_text" : "A 4-year-old boy is being evaluated for a 6-cm abscess on his buttocks with surrounding erythema. An incision and drainage is performed that yields approximately 15 mL of purulent material. Therapy with clindamycin is recommended, pending culture and sensitivity results, because there is a high incidence of community-acquired methicillin-resistant Staphylococcus aureus in the area. Of the following, the adverse reaction MOST often associated with this treatment is", "options" : "[\"anemia\", \"diarrhea\", \"glomerulonephritis\", \"hepatitis\", \"scalded skin syndrome\"]"}
{"id" : 716, "question_text" : "A 7-year-old boy presents to your office with a 3 -day history of fever and joint pain. His parents recall a sore throat 3 weeks ago. Findings on physical examination reveal swelling and erythema of his right knee and ankle. Yesterday, he had swelling and erythema of his right wrist and left knee that have since resolved. His temperature is 38.7°C, and the remainder of his vital signs is normal. Examination of his skin reveals a rash (Item Q8). His erythrocyte sedimentation rate is 30 mm/h and a rapid streptococcal test result is negative. Of the following, the MOST appropriate therapy for this patient is", "options" : "[\"azithromycin\", \"ceftriaxone\", \"naproxen\", \"penicillin G\", \"prednisone\"]"}
{"id" : 717, "question_text" : "A 2 year-old boy is brought to your office by his parents. The child is having difficulties both at home and at his child care center. His parents report that he often makes noises, but rarely does this seem like he is making an attempt to communicate. The parents feel that he is able to hear them, but he either does not understand them or chooses not to respond. They feel he is not as interactive with them as his older sibling had been at the same age. The boy usually plays by himself and does not appear to be interested in joining group activities at child care. He becomes very frustrated when he does not get his way. He typically makes poor eye contact. The staff at his child care center is having difficulties managing his behaviors. Of the following, the MOST appropriate intervention at this time is to perform", "options" : "[\"an electroencephalogram\", \"a fragile X syndrome genetic test\", \"a mercury level test\", \"a modified checklist for autism in toddlers (M-CHAT)\", \"thyroid function tests\"]"}
{"id" : 718, "question_text" : "A neonate was born at 35 weeks of gestation to a 23-year-old primigravida by spontaneous vaginal delivery that was complicated by prolonged rupture of the membranes and no prenatal care. The mother presented completely dilated and rapidly delivered a vigorous neonate. Tachypnea is noted 2 hours after birth. The mother described leaking copious clear fluid 36 hours before delivery. Her prenatal screens, including group B streptococcus status, were unknown at the time of delivery, and no antibiotics were given to the mother. Physical examination reveals a neonate with a temperature of 36.3°C, heart rate of 120 beats/min, respiratory rate of 76 breaths/min, right-arm blood pressure of 41/23 mm Hg (mean blood pressure, 29 mm Hg), and right-hand oxygen saturation of 95% on room air. The remainder of the evaluation is remarkable for a capillary refill of 4 seconds, a soft 2/6 systolic murmur at the left lower sternal border, and mild retractions. After obtaining blood and cerebrospinal fluid cultures, antibiotic therapy is initiated with ampicillin and gentamicin. Of the following, the MOST appropriate next step in management is to", "options" : "[\"administer 10 mL/kg albumin bolus\", \"continue to monitor cardiorespiratory status\", \"initiate dopamine\", \"provide supplemental oxygen\", \"start prostaglandin El\"]"}
{"id" : 719, "question_text" : "A 5-year-old girl presents to the emergency department with pallor and jaundice. Her mother states that the girl was in her usual state of health until 3 days ago, when she began to have fever, cough, and decreased activity. On physical examination, her oral temperature is 37.5°C, pulse rate is 120 beats/ min, respiratory rate is 24 breaths/min, and blood pressure is 100/60 mm Hg. The child is pale with icteric sclerae. Her breath sounds are normal, and there is no hepatosplenomegaly or lymphadenopathy. The remainder of the examination is normal. Laboratory test results reveal: • White blood cell count, 13,500/µL (13.5 x 109/L), with 40% polymorphonuclear leukocytes, 53% lymphocytes, 5% monocytes, and 2% eosinophils • Hemoglobin, 4.0 g/dL (40 g/L) • Mean corpuscular volume, 85/µm3 (85 fL) • Platelet count, 402 x 103/µL (402 x 109/L) • Reticulocyte count, 12% (0.12) Of the following, the MOST likely cause of this child's anemia is", "options" : "[\"autoimmune hemolytic anemia\", \"congenital erythrocyte hypoplasia (Blackfan-Diamond anemia)\", \"glucose-6-phosphate dehydrogenase deficiency\", \"parvovirus B19 infection\", \"transient erythroblastopenia of childhood\"]"}
{"id" : 720, "question_text" : "A 10-year-old boy is at school when his teacher notices that he is staring out the window. She can't get him to stop staring or respond to her, so he is brought to the emergency department. No other children had similar symptoms. On arrival, his physical examination reveals a temperature of 37.2°C, blood pressure of 100/60 mm Hg, heart rate of 85 beats/min, and a respiratory rate of 20 breaths/min. The boy is awake and seems restless. He follows one-step commands (eg, \"take off your shoes\"), but does not follow two-step commands. He knows his name, but not where he is. The remainder of the physical examination findings is unremarkable. Results of computed tomography of the head without contrast, serum sodium and glucose, and serum and urine toxicology testing are normal. As you are completing your examination, the boy's parents arrive and report no known ingestions at home, no history of seizures or headaches, and no similar prior events. The boy is adopted and no family history is known. After 2 hours of observation, he is alert and responding normally to commands, but complains of a headache and vomits. Of the following, the MOST likely diagnosis is", "options" : "[\"acute psychosis\", \"carbon monoxide poisoning\", \"confusional migraine\", \"postictal state\", \"pseudotumor cerebri\"]"}
{"id" : 721, "question_text" : "A 4-year-old girl presents to your office for a health super-vision visit. Her parents are very worried about the appearance of her ankles. When she is sitting, the feet and ankles appear normal. However, when she walks, the parents observe that her ankles protrude inward and she seems to have \"very flat feet\" The child does not report any pain and has not had difficulty keeping up with her peers at play. The appearance of the girl's feet and ankles when standing on her toes is shown (Item Q13). The remainder of the examination is normal. Of the following, the MOST appropriate management is", "options" : "[\"physical therapy for ankle strengthening\", \"reassure the family regarding the physical findings\", \"refer the girl to orthopedic surgery for possible surgical correction\", \"use of rigid 3/ length custom shoe inserts\", \"use of soft, full-length custom shoe inserts\"]"}
{"id" : 722, "question_text" : "You are seeing a 2-year-old girl for a routine health super-vision visit. Her mother tells you that she is thinking about becoming pregnant, but she was diagnosed last year with bipolar disorder and is currently maintained on lithium. Her psychiatrist feels that lithium is her best option for medical management and has discouraged her from stopping this medication. She asks your advice about another pregnancy. Of the following, you are MOST likely to tell her that", "options" : "[\"the decision whether to discontinue lithium requires a risk-benefit assessment since the risk of fetal anomaly is relatively low\", \"lithium is a potent teratogen and she should not consider a pregnancy while on this medication\", \"lithium use is primarily associated with cardiac and limb defects, which can be detected on second trimester ultrasonography\", \"she can resume lithium after delivery and may breastfeed without concern because little is excreted into breast milk\", \"she should discontinue lithium throughout the first trimester of pregnancy to avoid any adverse fetal effects\"]"}
{"id" : 723, "question_text" : "A 2-year-old boy is brought to the emergency department by ambulance. Thirty minutes ago, his mother discovered him eating pills from a pillbox at his grandparents' house and called 911. The boy's mother states that the pillbox contained a 1-week supply of his grandparents' daily medications. She did not count how many tablets remained in the box before the ambulance arrived, but she states, \"I think only a couple were missing:' Both grandparents take \"blood pressure medicine\" and that the grandfather takes \"a pill for his nerves\" The boy is well-appearing and playful. His vital signs are normal for his age, and you note no abnormalities on physical examination. The mother states that she now feels \"silly for panicking over nothing. ' She asks you how soon she can take her son home. Of the following, the BEST next step in managing this patient is", "options" : "[\"administration of activated charcoal at 1 g/kg\", \"administration of intravenous normal saline at 20 mL/kg\", \"discharge the boy after educating his mother about signs and symptoms to observe for at home\", \"observe the boy in the emergency department for development of symptoms over the next 6 hours\", \"perform gastric lavage to remove ingested pill fragments from the stomach\"]"}
{"id" : 724, "question_text" : "A 19-month-old boy is seen in your office for follow-up after a diagnosis of anemia. One month ago, iron supplementation was initiated for treatment. At that time, his hemoglobin was 9.1 g/dL (91 g/L), hematocrit was 28% (0.28), and the mean corpuscular volume was 67 fL. Today, his hemoglobin is 11 g/dL (110 g/L), hematocrit is 33% (0.33), and the mean corpuscular volume is 71 fL. He eats a varied diet and continues to breastfeed well. His growth is normal. Of the following, the BEST plan for management today is", "options" : "[\"continue iron supplementation for 3 months\", \"encourage more meat in the child's diet\", \"have the mother take a multivitamin with iron tablet daily\", \"offer reassurance and discontinue the iron supplementation\", \"suggest weaning the child from breastfeeding\"]"}
{"id" : 725, "question_text" : "The parents of a 4-year-old boy have questions about their son's food allergies and what foods he will need to avoid when he starts kindergarten next year. They were advised that he was allergic to milk, egg, and soy products on blood testing (serum specific IgE) performed in infancy as part of an evaluation of atopic dermatitis. His eczema worsened when he consumed milk, but he has never eaten egg or soy. He has been strictly avoiding all these foods, and he outgrew his atopic dermatitis 2 years ago. You discuss your plan to reevaluate the status of the boy's food allergies with his parents. Of the following and according to the natural history of food allergies, the MOST appropriate response is to advise the parents that in kindergarten their son may", "options" : "[\"be able to tolerate eggs but not milk and soy products\", \"be able to tolerate milk and soy products but not egg products\", \"be able to tolerate milk, egg, and soy products\", \"need to avoid all milk, egg, and soy products\", \"need to avoid egg and soy products but not milk products\"]"}
{"id" : 726, "question_text" : "A 15-year-old boy is seen for a health supervision visit. The patient is healthy with normal growth parameters and development. He has no significant past medical or past surgical history. Physical examination and vital signs are unremarkable. His urine analysis in the office reveals a specific gravity of 1.010, a pH of 6.0, 4+ protein, and no blood, leukocyte esterase, or nitrites. His parents recall that their son had protein in his urine during a sports physical last year. Of the following, the BEST next step in management is", "options" : "[\"evaluation by a nephrologist\", \"evaluation of a first morning urine sample\", \"quantitative urine protein estimation in a 24-hour urine sample\", \"recheck at the next health supervision visit\", \"urine microalbumin estimation in a 24-hour urine sample\"]"}
{"id" : 727, "question_text" : "A family living in the United States comes to your office for the initial medical evaluation of their 2-year-old daughter who they recently adopted from Southeast Asia. The limited past medical history is unremarkable. The parents report that the child is eating, voiding, and stooling normally, and they have no specific concerns about her health or behavior. On physical examination, vital signs are normal for age, and growth parameters are in the 25th percentile for age. Complete physical examination findings are normal. The peripheral white blood cell count is 15,000/µL (15.0 x 109/L), with 40% polymorphonuclear neutrophils, 20% lymphocytes, 10% monocytes, and 30% eosinophils. Hemoglobin is 10 g/dL (100 g/L), and platelet count is 260 x 103/µL (260 x 109/L). Of the following, the test that is MOST likely to yield an abnormal result is", "options" : "[\"hepatitis B antigen test\", \"human immunodeficiency virus antibody test\", \"stool culture\", \"stool for ova and parasites\", \"tuberculin skin test\"]"}
{"id" : 728, "question_text" : "A 17-year-old, sexually active boy has complaints of intermittent burning with urination for the last 2 weeks. He says he sometimes sees some staining on his underwear but has not noticed any penile discharge or genital lesions. He reports that he has never had a sexually- transmitted infection and that he always uses condoms. He is otherwise healthy and has no systemic complaints, hematuria, or urgency. On physical examination, he is at sexual maturity rating 5 for pubertal development. Other than some moistness at the urethral meatus, his genital examination findings are normal. Of the following, the organism MOST likely responsible for this boy's symptoms is", "options" : "[\"Chlamydia trachomatis\", \"Escherichia coli\", \"Mycoplasma genitalium\", \"Neisseria gonorrhoeae\", \"Ureaplasma urealyticum\"]"}
{"id" : 729, "question_text" : "A 14-year-old girl complains of nausea and right shoulder pain. She was well until 6 weeks ago, when she began to experience pain and swelling of the right knee while on vacation. She was evaluated at a local hospital, diagnosed with Lyme disease on the basis of her history and physical examination, and started on a course of ceftriaxone. Since that time, she has had some exercise intolerance and occasional knee pain. Recently, she has experienced postprandial nausea, without vomiting and for the past week has had discomfort in her right shoulder. She denies vomiting, diarrhea, jaundice, and abdominal pain. Physical findings demonstrate a well-developed, well-nourished adolescent. The remainder of the physical examination is unremarkable. You order laboratory tests that produce the following results: • Hemoglobin, 12.8 g/dL (128 g/L) • White blood cell count, 6,500/µL (6.5 x 109/L) • Aspartate aminotransferase, 125 U/L; reference range, ≤40 U/L • Alanine aminotransferase, 35 U/L; reference range, ≤30 U/L • Total bilirubin, 2.0 mg/dL (34.2 pmol/L) Results of the girl's urinalysis are normal. Of the following, the MOST appropriate next step in evaluating this patient is", "options" : "[\"abdominal ultrasonography\", \"magnetic resonance cholangiopancreatography\", \"serum \\u03b3-glutamyltransferase\", \"upper gastrointestinal endoscopy\", \"Western blot testing for Lyme disease\"]"}
{"id" : 730, "question_text" : "Foot abnormalities are noted in a full-term newborn who is otherwise healthy. The ankle and forefoot are in cavus and adductus position, with the hindfoot varus and the ankle plantar flexed (equinus) (Item Q22). This condition cannot be corrected with positioning passively. Of the following, the MOST appropriate management plan is", "options" : "[\"immediate referral to orthopedics for manipulation and serial casting\", \"observation with follow-up in 1 month to determine if flexibility improves\", \"physical therapy consult to teach the parents stretching exercises for the foot and ankle\", \"placement in a bar and brace orthotic to hold feet abducted and dorsiflexed\", \"referral to orthopedics at 1 month of age for anticipated tendon release surgery\"]"}
{"id" : 731, "question_text" : "A 15-year-old boy who is a patient in your practice collapsed during physical education class. He had no heart rate when he was first assessed, and cardiopulmonary resuscitation (CPR) was initiated promptly. An automatic external defibrillator was attached and detected an initial rhythm of ventricular fibrillation. A single shock was delivered with return of circulation and shallow breathing. The patient was transported to the local hospital and is now in the pediatric intensive care unit and receiving mechanical ventilation. After seeing patients in the office, you go to the hospital to check on the boy's condition and talk with his parents. The father, who is an internal medicine physician, asks you if their son should be \"cooled\" as a therapy to help preserve brain function. Of the following, the MOST accurate statement regarding therapeutic hypothermia following cardiac arrest is that", "options" : "[\"the goal temperature should be below 30\\u00b0C\", \"it has been demonstrated to be beneficial for all age groups\", \"it has been demonstrated to be effective only after traumatic brain injury\", \"it should be continued for a minimum of 5 days\", \"there are no completed randomized pediatric trials in this age group\"]"}
{"id" : 732, "question_text" : "A 5-year-old girl is noted to have breast budding. She has no pubic hair, axillary hair, deepening of her voice, or acne. Laboratory evaluation reveals an elevated baseline luteinizing hormone level of 4.6 mIU/mL (4.6 IU/L). Brain magnetic resonance imaging shows a large pineal gland cyst (Item Q24). Her mother is worried her daughter will have menses at a very young age. Of the following, the BEST treatment for managing precocious puberty in this patient is", "options" : "[\"hydrocortisone\", \"leuprolide acetate\", \"medroxyprogesterone acetate\", \"observation\", \"tamoxifen\"]"}
{"id" : 733, "question_text" : "An 8-year-old boy is seen in the emergency department with a fever, depressed mental status, vomiting, and a stiff neck. Two days ago, he was involved in a motor vehicle accident and hit his head on the dashboard. His past medical history is unremarkable and immunizations are up to date. On physical examination, the boy is febrile (up to 39.3°C) and difficult to arouse. He has clear rhinorrhea and nuchal rigidity. Cerebrospinal fluid examination reveals the following: • White blood cells, 2,100/pL (2.1 x 109/L), with 93% neutrophils • Glucose, 10 mg/dL (0.6 mmol/L) • Protein, 180 mg/dL (1.8 g/L) Gram stain reveals pleomorphic gram-negative rods. Of the following, the BEST antibiotic to treat this organism is", "options" : "[\"ampicillin\", \"cefazolin\", \"ceftriaxone\", \"clindamycin\", \"vancomycin\"]"}
{"id" : 734, "question_text" : "A 15-year-old, African-American boy is seen in your office with fever, rash, and joint pain. The patient has had 2 weeks of joint swelling and intermittent low-grade fevers. A facial rash has been present for 7 days. On physical examination, he has swollen, tender metacarpal phalangeal joints bilaterally, bilateral knee swelling, warmth, and pain with range of motion, oral ulcers, and a rash (Item Q26). Of the following, the test MOST likely to establish the diagnosis is", "options" : "[\"anti-double-stranded DNA antibody\", \"antinuclear antibody\", \"erythrocyte sedimentation rate\", \"monospot\", \"rheumatoid factor\"]"}
{"id" : 735, "question_text" : "A 9-year-old girl who has been living in her current foster home for the past 2 months is brought to your office by the foster parents. The couple is concerned because the girl has been \"hearing and seeing things\" around the house that aren't actually there. A few nights prior to the visit, she became very distressed and afraid, stating that she saw a man looking in her second-floor bedroom window. She hears her name being called and becomes distressed about hearing doors slamming when neither has occurred. The girl occasionally wakes up from nightmares. On several occasions, the foster parents have seen her appear to \"space out\" for several minutes during the day, after which she appears scared and states that she had been thinking about \"bad things. ' She occasionally has dramatic and apparently unprovoked mood swings and often has a negative mood. At other times she can engage normally and can get along well with other children. Although they were provided no details, the foster parents were told that the girl witnessed domestic violence in her biological parents' home and that there is a family history of a mental health disorder. Results of her physical examination are within normal limits. Her interaction with you in the office is age appropriate. Of the following, the MOST likely cause of this girl's symptoms is", "options" : "[\"bipolar disorder\", \"depression\", \"posttraumatic stress disorder\", \"schizophrenia\", \"seizure disorder\"]"}
{"id" : 736, "question_text" : "A mother well known to your practice has just presented to the hospital with premature rupture of the membranes at 24 weeks' gestation. The medical student shadowing you in the office asks you if there is a clinical variable that is associated with improved survival and outcome at this very early gestational age. Of the following, the BEST response to the student's question is", "options" : "[\"antenatal corticosteroids\", \"antenatal magnesium sulfate\", \"male sex\", \"multiple gestation\", \"small for gestational age\"]"}
{"id" : 737, "question_text" : "A 10-year-old girl who has undergone a cardiac transplant 8 months ago is now hospitalized with fever and adenopathy. A biopsy of the lymph node shows post-transplant lymphoproliferative disease. Of the following, the medication MOST likely to be associated with the development of this patient's symptoms is", "options" : "[\"enalapril\", \"fluticasone\", \"prednisone\", \"tacrolimus\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 738, "question_text" : "A 5-year-old boy complains of headache and neck pain and lies down for a nap. An hour later, his father tries to rouse him, but the boy can only mumble. He is brought to the emergency department, where on physical examination his blood pressure is 125/90 mm Hg, heart rate is 78 beats/ min, respiratory rate is 14 breaths/min, and temperature is 37.4°C. The boy briefly opens his eyes but otherwise does not respond during the examination. There is no sign of head injury, no nuchal rigidity, and no rashes. Neurologic examination shows that the pupils are round and equally reactive to light, the limbs are flaccid, the deep tendon reflexes are brisk, and the toes are upgoing on plantar stimulation. The parents report that all medications in the home are secured and deny any ingestions. Computed tomography of the head without contrast is obtained (Item Q30). Of the following, the MOST likely cause of his symptoms is", "options" : "[\"arterial ischemic stroke\", \"arteriovenous malformation\", \"brain abscess\", \"choroid plexus carcinoma\", \"vein of Galen aneurysmal malformation\"]"}
{"id" : 739, "question_text" : "A 12-year-old female ice hockey player presents to your office for a preparticipation physical evaluation. This is her first visit with your practice. Her parents bring a copy of her medical records for your review. She would like to play in a hockey game later that day. Of the following, the only ABSOLUTE contraindication to participation would be", "options" : "[\"absence of one ovary\", \"blood pressure reading at the 90th percentile for her age\", \"history of a seizure disorder\", \"a soft systolic ejection murmur that disappears with standing\", \"temperature of 38.8\\u00b0C\"]"}
{"id" : 740, "question_text" : "In the regular nursery, you are examining a full-term new-born who was born yesterday evening. You note that he has proximal limb shortening. Because of your concerns about possible achondroplasia, you order a skeletal survey, which confirms this clinical diagnosis. You meet with the parents and discuss these findings and potential medical problems in infants and children with achondroplasia. Of the following, before discharge from the hospital, you are MOST likely to recommend", "options" : "[\"DNA analysis for an FGFR3 mutation\", \"head ultrasonography\", \"magnetic resonance imaging of the thoracic and lumbar spine\", \"polysomnography\", \"renal ultrasonography\"]"}
{"id" : 741, "question_text" : "You are taking weekend telephone calls for your practice when the father of a 12-year-old boy calls to let you know he is driving his son to the local hospital. The boy was working in the family garage when he drank an unknown substance out of a plastic bottle that he mistakenly thought contained water. Since swallowing some of the substance, the boy has complained of severe throat pain, burning pain in his chest, difficulty swallowing, and nausea. The father tells you that his son is drooling and that he can see a few white \"sores\" on his tongue and the roof of his mouth. Of the following, the MOST likely substance to cause the boy's symptoms and physical findings is", "options" : "[\"antifreeze (ethylene glycol)\", \"furniture polish (hydrocarbon)\", \"insecticide (organophosphate)\", \"toilet bowl cleaner (sodium hydroxide)\", \"weed killer (glycophosphate)\"]"}
{"id" : 742, "question_text" : "A 16-month-old girl is seen for evaluation of a limp. For the past day, she has been crying and refusing to bear full weight on her left leg. She is afebrile and has no other symptoms. There is no known trauma, but the mother states that she is an active toddler. On physical examination, there is no erythema, bruising, warmth, or swelling of the extremity or joints. The patient cries when you attempt to have her bear weight. She has full range of motion at the hips, knees, and ankles but cries when you palpate the left lower leg. You obtain a radiograph of the left leg (Item Q34). Of the following, the MOST likely diagnosis is", "options" : "[\"ankle sprain\", \"neuroblastoma\", \"osteomyelitis\", \"toddler's fracture\", \"transient synovitis\"]"}
{"id" : 743, "question_text" : "A 2-year-old boy in your office is receiving an albuterol nebulizer treatment along with oxygen supplementation. He has been given albuterol every 1 to 2 hours at home to treat his cough and wheeze since his exacerbation began 6 hours ago. The boy's mother is concerned that he is excessively shaky and irritable. On his initial physical examination, he had an oxygen saturation of 85% on room air and a respiratory rate of 60 breaths/min with intercostal retractions and use of accessory muscles. On auscultation, he had loud wheezing in both lung fields. He has received an albuterol nebulizer treatment with oxygen and now has a heart rate of 120 beats/min, a respiratory rate of 40 breaths/min, and oxygen saturation of 97%. He has a mild tremor, minimal use of accessory muscles, and faint expiratory wheezing in both lung bases. Of the following, the adverse effect this boy is MOST likely to experience is", "options" : "[\"arrhythmia\", \"hypocalcemia\", \"hypoglycemia\", \"hypokalemia\", \"seizure\"]"}
{"id" : 744, "question_text" : "A 3-month-old female infant presents to your office for follow-up of pyelonephritis diagnosed 2 months ago. After treatment of her urinary tract infection, she had a contrast voiding cystourethrogram (VCUG) that showed narrowing of the distal urethra and a normal urinary stream upon voiding (Item Q36). Her physical examination is unremarkable. She is currently on oral amoxicillin for urinary tract infection prophylaxis. Of the following, the MOST appropriate next step in the management of this patient is", "options" : "[\"intravenous pyelography\", \"referral to urology for surgical correction\", \"repeat urine culture\", \"repeat VCUG in 1 year\", \"stop prophylactic antibiotics\"]"}
{"id" : 745, "question_text" : "A 2-day-old, term neonate discharged at 24 hours of age is brought into the emergency department because the mother has developed a rash (Item Q37A and Item C37B). The infant is afebrile and has normal vital signs for age. Findings on physical examination are unremarkable. Of the following, the BEST next step in the management of this patient is to administer", "options" : "[\"immune globulin intravenous\", \"oral acyclovir\", \"parenteral foscarnet\", \"varicella vaccine\", \"varicella-zoster immune globulin\"]"}
{"id" : 746, "question_text" : "The mother of a 17-year-old girl made an appointment for her daughter to see you for a gynecologic examination. She learned that her daughter had 2 Chlamydia infections in the past year and requests that her daughter be \"fully tested\" and have a Papanicolaou (Pap) smear. The girl is otherwise healthy and asymptomatic today. She has received 3 doses of quadrivalent human papillomavirus (HPV) vaccine. Of the following, the advice you are MOST likely to provide is that Pap smear testing should be", "options" : "[\"deferred until the girl reaches 18 years of age\", \"deferred until the girl reaches 21 years of age\", \"performed today because it has been requested\", \"performed today because of the girl's history of Chlamydia infection\", \"unnecessary because the girl has been immunized against HPV\"]"}
{"id" : 747, "question_text" : "A 13-year-old boy is seen in the emergency department with a complaint of \"something stuck in my chest. ' He was well until eating dinner, which is when the symptom occurred. The problem was relieved after he drank a large glass of apple juice. The past medical history demonstrates that he has been taking oral tetracycline for facial acne and is trying to lose weight. He does not complain of odynophagia, heartburn, or regurgitation. The boy's parents report that he seems to eat very slowly and drinks copious amounts of water with his meals. His body mass index is 27, but all physical examination findings are normal. Of the following, the MOST appropriate next step you recommend is", "options" : "[\"abdominal ultrasonography\", \"esophageal manometry\", \"esophageal pH study\", \"upper gastrointestinal endoscopy\", \"videofluoroscopic swallowing study\"]"}
{"id" : 748, "question_text" : "A 6-week-old infant is being discharged after a hospitalization for an apparent life-threatening event (ALTE). He was born at term and had no medical problems before this event. During the hospitalization, no underlying cause for the ALTE was found, and he remained well, had a normal physical examination, and had no further events. His parents ask about home apnea monitoring. Of the following, the MOST accurate information to give these parents is", "options" : "[\"the benefits of home monitoring to the infant outweigh the negative psychosocial effects on parents\", \"the psychosocial changes the parents will experience are likely to remain constant during the entire time the infant is monitored\", \"the parents are likely to experience early increases in depression and hostility once home monitoring is instituted\", \"the parents are likely to experience increases in depression starting about 6 months after home monitoring is instituted\", \"the parents are likely to report feeling that home monitoring of their infant is not helpful\"]"}
{"id" : 749, "question_text" : "A 15-year-old girl was admitted to the hospital 3 days ago for a large left-sided pneumonia with associated pleural effusion (Item Q41). At the time of admission, she was started on ceftriaxone and placed on oxygen via nasal cannula. Over the last 3 days, she has had daily fevers along with a persistent cough. Her vital signs this morning are temperature 39.0°C, heart rate 100 beats/min, and respiratory rate 35 breaths/ min. Her oxygen saturation is 94% on 3 liters/min of oxygen via nasal cannula. Daily chest radiographs, which are unchanged since admission, demonstrate the persistence of the pneumonia and pleural effusion. On physical examination, she has mild respiratory distress, prolonged expiration, and unchanged decreased breath sounds over the left side of her chest. She has a grade 2/6 systolic ejection murmur. Of the following, the MOST appropriate next step is", "options" : "[\"bronchoscopy with bronchoalveolar lavage\", \"echocardiogram\", \"open lung biopsy\", \"sputum culture\", \"video-assisted thoracoscopic surgery (VATS)\"]"}
{"id" : 750, "question_text" : "During a health supervision visit, a 7-year-old girl is noted to be growing poorly. She has had a minimal increase in height during the last 2 years, but her weight continues to track at the 25th percentile (Item Q42). The mother reports that her daughter is a picky eater but is otherwise well. The girl has no constipation, diarrhea, or other signs of malabsorption. Her parents are not concerned because her mother is 5 feet, 1 inch (155 cm) tall and her father is 5 feet, 6 inches (168 cm) tall, and both had delayed puberty and had growth spurts in their late teenage years. Of the following, the MOST likely diagnosis is", "options" : "[\"constitutional delay of growth\", \"Crohn disease\", \"familial short stature\", \"hypothyroidism\", \"inadequate caloric intake\"]"}
{"id" : 751, "question_text" : "A 17-year-old girl in your practice returned 3 weeks ago from a semester as an exchange student in Ghana. She complains of having mild abdominal discomfort since she returned. The discomfort has progressed to severe abdominal pain in association with the development of grossly bloody stools. She has had intermittent, low-grade fever (up to 38.2°C) and reports a 4- to 5-pound weight loss. On physical examination, she appears uncomfortable but nontoxic. Her abdominal examination reveals increased bowel sounds and diffuse tenderness without rebound. There is no enlargement of the liver or spleen. Of the following, the MOST likely cause of this patient's symptoms is infection with", "options" : "[\"Entamoeba histolytica\", \"enterotoxigenic Escherichia coli\", \"Escherichia coli 0157:H7\", \"Giardia intestinalis\", \"rotavirus\"]"}
{"id" : 752, "question_text" : "A previously healthy, 5-year-old boy presents to your office with a 3-day history of bilateral knee pain and swelling. This morning, he developed a rash over his buttocks and lower extremities. There is no history of trauma or recent illness. On physical examination, he is well-appearing. His vital signs are unremarkable. He has bilateral knee swelling and a palpable rash (Item Q44). Of the following, the MOST likely diagnosis is", "options" : "[\"infectious mononucleosis\", \"Henoch-Schonlein purpura\", \"erythema infectiosum\", \"exanthem subitum\", \"meningococcemia\"]"}
{"id" : 753, "question_text" : "An 8-year-old boy is seen in your office for problem behavior. He will not stay in his seat at school, does not pay attention well in class, and does not seem to be learning as expected. Last year, he was treated with methylphenidate followed by dextroamphetamine with no significant effect. He is becoming increasingly disruptive in class and refusing to do work. Notes are now being sent home repeatedly reporting aggressive behavior with others. Upon questioning, you learn that there appears to be no new social stressors, he has not been bullied, and there is no particular family disruption. His school and home behavior have worsened each year, but he is far less disruptive at home. According to his mother, he achieved his early motor milestones at the expected times. His physical examination is unremarkable, with no dysmorphic features, and normal vision and hearing. Of the following, the MOST appropriate next step is to", "options" : "[\"perform a blood lead level test\", \"recommend an electroencephalogram\", \"recommend genetic testing\", \"recommend a psychoeducational evaluation\", \"refer the boy for evaluation of possible child abuse\"]"}
{"id" : 754, "question_text" : "During morning rounds, the nurse informs you that a 3.8-kg neonate has just been delivered by caesarean section due to breech presentation. The pregnancy was notable for well-controlled maternal type I diabetes. The maternal glycated hemoglobin A,, values ranged between 5% to 6% before conception and during pregnancy. Level II screening ultrasonography done at 18 weeks of gestation was normal. Your assessment at 40 minutes after birth reveals a pink, well-perfused neonate with normal tone, strong suck, and good color. Cardiac examination reveals a grade 1/6 systolic murmur at the left lower sternal border with a preductal oxygen saturation of 97% on room air. The mother is anxious to breastfeed. Of the following, the MOST appropriate next step in management is to immediately", "options" : "[\"determine blood glucose concentration\", \"initiate breastfeeding\", \"obtain a chest radiograph\", \"perform an echocardiogram\", \"supplement with formula\"]"}
{"id" : 755, "question_text" : "A medical student is working with you in clinic. He is preparing to see a 2-month-old infant whose older sister has sickle cell disease. The infant's medical record has the results of the state newborn screen, which shows the hemoglobin fractionation to be an F, A, S pattern. Of the following, the MOST appropriate counseling for the family of this patient is that the infant", "options" : "[\"has a less severe phenotype of sickle cell disease\", \"has the most common form of sickle cell disease\", \"has sickle cell trait\", \"must be referred to a hematologist immediately\", \"must be retested at 4 to 6 months of age for a definitive diagnosis\"]"}
{"id" : 756, "question_text" : "You are evaluating a 4-year-old boy who complains of \"bouncing eyes:' His mother reports seeing his eyes jiggle for a few seconds at a time. There are no abnormal head, neck, trunk, or limb movements. He is awake during these episodes and complains that his eyes are \"bouncing. \" On physical examination, the pupils are round and equally reactive to light, and eye movements are conjugate and intact in all directions. On downward gaze, there is downward nystagmus. The remainder of his physical examination findings, including hair and skin, are unremarkable. Of the following, the MOST likely diagnosis is", "options" : "[\"Chiari I malformation\", \"congenital nystagmus\", \"neurofibromatosis type 1\", \"phenytoin ingestion\", \"spasmus nutans\"]"}
{"id" : 757, "question_text" : "A 14-year-old girl presents to your office for a preparticipation physical evaluation for the school soccer team. During a recent ophthalmologic examination, she was noted to have a corrected visual acuity of 20/20 in the right eye and 20/50 in the left eye. Of the following, the MOST appropriate recommendation for this patient would be that she", "options" : "[\"does not need any special eye protection when playing soccer\", \"should not participate in soccer due to her poor visual acuity on the left side\", \"should wear hard contact lenses to protect her eyes during soccer\", \"should wear her regular glasses secured to the head with a strap while playing soccer\", \"should wear sports goggles with polycarbonate lenses when playing soccer\"]"}
{"id" : 758, "question_text" : "A full-term newborn was delivered after an uneventful pregnancy to a gravida 2, para 2 woman by normal spontaneous vaginal delivery. His birth weight is 3,150 g. Findings on physical examination are unremarkable except for bilateral ear pits and a small branchial sinus on the left neck with no drainage noted. Of the following, prior to discharge, you are MOST likely to order a(n)", "options" : "[\"complete blood cell count\", \"complete metabolic profile\", \"echocardiogram\", \"head ultrasonography\", \"renal ultrasonography\"]"}
{"id" : 759, "question_text" : "A 16-year-old boy is brought to the emergency department following an all-terrain vehicle (ATV) collision. He was driving the vehicle at a high rate of speed when he lost control and crashed into a tree. He was not wearing a helmet and sustained significant trauma to his forehead and face. The boy experienced an initial loss of consciousness at the time of the accident, but he is now awake and has a Glasgow Coma Score of 14. His airway, breathing, and circulation are fully intact. Computed tomography of his head and facial bones reveals fractures involving both the anterior and posterior tables of his frontal sinus. Of the following, the BEST next step in management is", "options" : "[\"antibiotic therapy\", \"decongestants\", \"irrigation of the nasal passages with sterile saline\", \"observation in the hospital\", \"surgical consultation\"]"}
{"id" : 760, "question_text" : "A 6-year-old boy is having problems in school. As part of the evaluation for special education services, the school performed a full individual evaluation. On a standardized achievement test, his IQ score is 60. His birth history, past medical history, and physical examination are unremarkable. Hearing and vision screen are normal. Parents report the patient has some early language developmental delay, but they deny any regression of milestones. There is a family history of some adults with learning difficulties. Of the following tests, the BEST next step is to perform", "options" : "[\"electroencephalogram\", \"genetic testing\", \"magnetic resonance imaging of the brain\", \"serum amino acids\", \"urine for cytomegalovirus\"]"}
{"id" : 761, "question_text" : "A 9-year-old girl presents with symptoms of an itchy, raised rash. The rash started 2 weeks ago, but she has had similar episodes intermittently for the previous 4 months. The rash consists of multiple erythematous, slightly elevated lesions ranging in size from a dime to a golf ball (Item Q53). The lesions resolve in a few hours without bruising or discoloration. Diphenhydramine as needed and daily cetirizine help minimize the frequency and severity of her symptoms, but she still gets breakthrough episodes. Her parents have not found any association of the eruption with foods, cosmetics, or medications. At times, the rash occurs after the girl becomes hot and sweaty. The parents have heard that food allergies might be a trigger for their daughter's episodes and wonder if she should undergo testing. Of the following, the MOST appropriate response is to", "options" : "[\"order allergen- specific IgE tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives\", \"order allergen- specific IgG4 tests to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives\", \"reassure the parents that allergy testing is not needed; an undiscovered allergy to foods or food additives is unlikely to be the cause\", \"recommend an elimination diet of home-cooked rice or oats, chicken or turkey, and vegetables for a trial period of 2 weeks\", \"refer them to an allergist for skin testing to milk, egg, soy, wheat, fish, shellfish, peanuts, nuts, and food additives\"]"}
{"id" : 762, "question_text" : "A 7-year-old boy has significant daytime and nocturnal enuresis since birth. Physical examination reveals a temperature of 37.8°C, heart rate of 76 beats/min, respiratory rate of 16 breaths /min, blood pressure of 98/50 mm Hg, and normal growth parameters. He has a tuft of hair above the gluteal cleft. His urinalysis demonstrates a specific gravity of 1.005, pH of 6.0, and no blood, leukocyte esterase, protein, or nitrites. Of the following, the MOST likely cause of enuresis in this patient is", "options" : "[\"bladder dysfunction\", \"central diabetes insipidus\", \"chronic renal failure\", \"nephrogenic diabetes insipidus\", \"urinary tract infection\"]"}
{"id" : 763, "question_text" : "A 3-year-old boy diagnosed with pneumonia 3 days ago returns to your office with ongoing fever and cough. Because he received amoxicillin for otitis media 1 month ago, you prescribed an oral third-generation cephalosporin. His mother reports that he has been taking the medication but that he will not eat. He has been drinking some fluids and seems to have normal urine output. He has not been vomiting, and his cough is nonproductive. On physical examination, his temperature is 39°C, heart rate is 130 beats/min, respiratory rate is 40 breaths/min, and blood pressure is 90/45 mm Hg. Oxygen saturation is 98% in room air. His mucous membranes are mildly dry, but capillary refill is less than 2 seconds. He is mildly tachypneic without retractions or nasal flaring. Auscultation of his lungs reveals good air entry throughout with diffuse crackles. He is tachycardic but has no murmur. The remainder of his physical examination findings are normal. A white blood cell count is 10.0 x 101/µL (10.0 x 10'/L), with 30% polymorphonuclear leukocytes, 55% lymphocytes, and 15% monocytes. You obtain a chest radiograph (Item Q55). Of the following, the MOST appropriate next step in the management of this patient is to", "options" : "[\"add azithromycin to his regimen\", \"admit him for intravenous ceftriaxone\", \"discontinue antibiotics\", \"obtain a chest computed tomography scan\", \"send a blood culture\"]"}
{"id" : 764, "question_text" : "You are seeing a 15-year-old boy for a health supervision visit. His parents complain that he has been irritable lately and spends too much time playing his guitar and hanging out with his friends. He seems less interested in family activities and his grades have dropped from A+'s to B's in most subjects. They ask that you screen him for drug use. The boy is upset with this conversation and says his parents don't give him any breathing space. Of the following, the BEST next step is to", "options" : "[\"advise the parents to restrict the boy's privileges until his grades improve\", \"interview the boy alone to discuss his school, peer, and family functioning\", \"obtain a psychiatric consultation to evaluate the boy for depression\", \"obtain a urine drug screen per the parents' request\", \"reassure the parents that this is normal adolescent behavior\"]"}
{"id" : 765, "question_text" : "An 8-year-old boy is brought to the emergency department because of hematemesis. He has recently been experiencing upper respiratory tract symptoms, including cough and nasal congestion, which have been treated by his parents using an over-the-counter cold preparation. Upon awakening this morning, he ate normally. Several hours later he complained of abdominal pain and vomited several times. The vomitus contained both bright red blood and clots. He was brought to the emergency department, where his temperature is 38°C, heart rate is 130 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 80/40 mm Hg. He appears pale, his liver edge is palpated at the right costal margin, and the spleen tip is palpated 2.5 cm below the left costal margin. Of the following, the MOST likely cause of this child's bleeding is", "options" : "[\"esophageal varices\", \"Helicobacter pylori- associated gastritis\", \"Mallory-Weiss tear\", \"nasopharyngeal bleeding\", \"nonsteroidal anti-inflammatory drug-induced ulcer\"]"}
{"id" : 766, "question_text" : "A 10-month-old has been hospitalized for the third time for persistent vomiting and weight loss. His length and head circumference are at the 50th percentile, while his weight is at less than the 3rd percentile. His history and physical examination do not suggest a clear cause for his symptoms, and past evaluations, including infectious disease, neurology, immunology, and gastroenterology consults, have not yielded a diagnosis. His mother is friendly with the staff and doctors and has readily agreed to all suggested diagnostic studies. Of the following, the MOST appropriate next step in this infant's management is to", "options" : "[\"do a thorough review of all medical records with a multidisciplinary team, including a child abuse specialist\", \"exclude all other potential organic causes before considering a factitious cause\", \"initiate total parenteral nutrition to improve caloric intake and support growth\", \"obtain a pediatric surgery consult for fundoplication and gastric tube insertion\", \"obtain a psychiatric evaluation to determine if the parent has an intention to injure the child\"]"}
{"id" : 767, "question_text" : "You are evaluating a 15-year-old boy in the emergency department who collided with a parked car while sledding. The accident was witnessed by his friends who report that the patient was not wearing a helmet and was unresponsive after impact. Emergency medical service providers intubated the boy at the scene and report that he moved all extremities in response to stimulation. The boy has a temperature of 37.6°C and a heart rate of 120 beats/min and is being mechanically ventilated at a rate of 20 breaths/min. He has received 1 small dose of fentanyl for agitation and presumed pain. His pupils are 2 mm in size and equal. A large area of swelling over his right temporal area is noted, and computed tomography of his head is shown (Item Q59). During ongoing observation, you note that his right pupil becomes markedly dilated and unresponsive to light. He now only moves his right arm and leg in response to stimulation. Of the following, the MOST likely cause of the pupillary finding is", "options" : "[\"compression of the fourth cranial nerve\", \"compression of the third cranial nerve\", \"disruption of sympathetic nerve activity\", \"inflammation of the second cranial nerve\", \"narcotic stimulation of opiate receptors\"]"}
{"id" : 768, "question_text" : "You are called by your state newborn screening program for a low total thyroxine (T4) level found on newborn screening. The level was drawn 24 hours after a term, healthy female neonate was born. Pregnancy was uncomplicated, and there was no maternal history of thyroid disease. Repeat testing in your office at 7 days after birth shows a thyroid-stimulating hormone level of 200 mIU/L and a low free thyroxine (FT4) level of 0.2 ng/dL (2.57 pmol/L) in this otherwise healthy girl. Her weight is 3 kg. Findings on physical examination are unremarkable. Of the following, the BEST next step in the management of this patient is to", "options" : "[\"begin treatment with levothyroxine (LT4)\", \"begin treatment with liothyronine (LT3)\", \"measure serum thyroglobulin level\", \"order a thyroid radionuclide uptake and scan\", \"order thyroid ultrasonography\"]"}
{"id" : 769, "question_text" : "A 17-year-old boy in your practice has an 18-mm induration response to a tuberculin skin test that was placed as part of a precollege physical examination. He is clinically well, with no cough, night sweats, fever, or weight loss. He is well-appearing and findings on his physical examination are unremarkable. He lives with his parents and 14-year-old sister, all of whom are reported as healthy. He immigrated to the United States from India at 3 years of age. He received a Bacillus Calmette-Guerin vaccine as an infant. He has not travelled internationally since immigrating into the United States. His grandparents visited from India 6 months ago but are reportedly healthy. Of the following, the BEST next step in management of this patient is to", "options" : "[\"begin isoniazid preventive therapy\", \"obtain a chest radiograph\", \"order an interferon-y release assay\", \"repeat the tuberculin skin test in 6 months\", \"repeat the tuberculin skin test in 2 weeks\"]"}
{"id" : 770, "question_text" : "A 10-year-old girl presents to your office with a lesion diagnosed 4 years ago as a nevus simplex (salmon patch) on her back. Recently, the lesion has enlarged, darkened, and developed an area that is hard and white (Item Q62). Of the following, the BEST diagnosis based on the clinical findings is", "options" : "[\"lichen scleroses\", \"localized scleroderma\", \"neurofibromatosis\", \"tinea versicolor\", \"vitiligo\"]"}
{"id" : 771, "question_text" : "A 16-year-old boy complains of a depressed mood of 3 months' duration associated with loss of interest in previously enjoyed activities, low energy, poor appetite, difficulty concentrating, and thoughts of hopelessness. He has started to have some suicidal thoughts but has no history of suicidal plans or attempts. His school performance has been significantly worsening over the past 3 months. The boy goes to bed around 11:00 PM in a quiet, dark room but does not fall asleep until 4:00 AM. He wakes at 6:00 or 7:00 AM. Shortly before he developed his current depressed mood, he had a 1-week period of elevated mood with a high energy level and a decreased need for sleep. He was disruptive in class during that time, which resulted in disciplinary action by his teacher. For the past 6 weeks, the boy has been seeing a psychologist who has referred him to you for consideration of a medication trial because of his worsening condition. While awaiting an available appointment with a child psychiatrist, you decide to initiate a medication trial. Of the following, the MOST appropriate treatment strategy is to initiate:", "options" : "[\"amitriptyline\", \"fluoxetine\", \"lamotrigine\", \"lorazepam\", \"valproic acid\"]"}
{"id" : 772, "question_text" : "A neonate is being assessed for increasing work of breathing. The infant was born weighing 2.8 kg at 36 weeks of gestation to a 32-year-old primigravida by urgent caesarean section due to severe preeclampsia. Artificial rupture of membranes occurred at delivery and revealed clear amniotic fluid. He emerged vigorous, with the development of grunting, retracting, and flaring at 30 minutes after birth. The neonate required initiation of a 30% oxygen hood two hours after birth to maintain oxygen saturation values greater than 94%. His clinical status was unchanged until 12 hours after birth, when his oxygen requirement escalated to 40% and was accompanied by increased grunting and retracting. Physical examination reveals a neonate with moderate grunting and retractions who has a temperature of 37°C, heart rate of 140 beats/min, respiratory rate of 76 breaths/min, blood pressure of 60/36 mm Hg, and a pulse oximetry reading of 90% in a 40% oxygen hood. The examination is notable for diminished breath sounds bilaterally. The white blood cell count is 12,000/pL (12.0 x 109/L), with 50% polymorphonuclear leukocytes, 5% bands, 30% lymphocytes, and 15% monocytes. You order a chest radiograph (Item Q64). Of the following, the MOST likely cause of this neonate's signs and symptoms is", "options" : "[\"cystic adenomatoid malformation\", \"group B streptococcal pneumonia\", \"respiratory distress syndrome\", \"retained fetal lung liquid syndrome\", \"total anomalous pulmonary venous return\"]"}
{"id" : 773, "question_text" : "A 3-year-old girl suddenly refuses to walk. There is no reported history of injury or ingestions. She has been well, although several children in her preschool class have been absent because of illness. Physical examination shows a temperature of 37.8°C, blood pressure of 88/62 mm Hg, heart rate of 96 beats/min, and respiratory rate of 20 breaths/min. She is crying loudly but calms down when her mother holds her. The girl's neck is supple and there are no skin lesions. Her neurologic examination shows conjugate eye movements in all directions. She has strong, symmetric facial movements when crying and strong, symmetric limb movements when she is resisting examination. After being calmed again, her deep tendon reflexes are found to be absent. She can sit independently, but, when placed standing, she wobbles, immediately adopts a wide-based stance, refuses to take steps, and collapses to the floor while crying. Results of magnetic resonance imaging of the brain with and without contrast are normal. Of the following, the MOST likely diagnosis is", "options" : "[\"acute cerebellar ataxia\", \"ataxia telangiectasia\", \"Friedreich ataxia\", \"Guillain-Barre syndrome\", \"opsoclonus-myoclonus-ataxia syndrome\"]"}
{"id" : 774, "question_text" : "A 16-year-old boy is seen for a sports preparticipation physical evaluation. He is an 11th grader preparing for the wrestling season, and he would like to wrestle at a weight class that is lower than his current weight. His parents ask you to counsel him about safe weight control practices during the wrestling season. Upon review of his records, you note that this teenager has consistently been around the 70th percentile for weight and the 50th percentile for height. Of the following, the statement MOST appropriate to include in your discussion with this boy is that", "options" : "[\"athletes at his age and grade level should not implement a weight loss plan for sports\", \"an athlete's build does not significantly affect his or her performance, except for athletes in the extreme ranges for body composition\", \"cycling between higher and lower weights will lead to an increased metabolic rate and make weight control easier\", \"he should plan his training and weight loss to achieve between 5% and 10% body fat\", \"mild hypohydration will allow him to safely reduce his weight before events and will not interfere with performance\"]"}
{"id" : 775, "question_text" : "While examining a 2-year-old for a routine health supervision visit at least 18 hyperpigmented macules greater than 0.5 cm in diameter are noted on her trunk and extremities. No axillary or inguinal freckles are noted and no subcutaneous or cutaneous lesions suggestive of neurofibromas are observed. Findings on examination by a pediatric ophthalmologist are normal, with good visual acuity in both eyes and no Lisch nodules noted. The history is negative for anyone else in the family with cafe au lait spots or other signs of neurofibromatosis. Of the following, you are MOST likely to tell her parents that", "options" : "[\"she has neurofibromatosis because she has more than 6 cafe au lait spots\", \"she possibly has neurofibromatosis because she is only 2 years old and other findings are likely to appear over time\", \"she probably does not have neurofibromatosis because the family history is negative for neurofibromatosis\", \"she probably does not have neurofibromatosis because she has no cutaneous findings other than the spots\", \"she probably has neurofibromatosis because she has 18 spots, which is significantly greater than the minimum number of 6\"]"}
{"id" : 776, "question_text" : "An 8-year-old girl presents for evaluation shortly after falling down her front porch steps and landing on her outstretched left arm. A complete physical examination is remarkable only for mild swelling and tenderness over the midportion of her left forearm. Arm radiographs are shown (Item Q69). Of the following, the MOST likely diagnosis is a", "options" : "[\"buckle fracture\", \"greenstick fracture\", \"metaphyseal chip fracture\", \"Salter\\u2013Harris type I fracture\", \"spiral fracture\"]"}
{"id" : 777, "question_text" : "A 20-month-old girl is being evaluated for low-grade fever and upper respiratory symptoms that have been present for 3 days. In addition, her parents noted drainage from the right ear this morning. This is her first episode of ear drainage since surgery. The child had tympanostomy tubes placed 3 months ago for persistent middle ear effusion with conductive hearing loss following acute otitis media. She had 3 episodes of otitis media prior to the surgery and has had no serious systemic infections. She attends child care and is fully immunized. On physical examination, you note purulent drainage from the right tympanostomy tube. Of the following, the BEST next step in management is", "options" : "[\"culture and sensitivity of the drainage\", \"evaluation for immunodeficiency\", \"oral antimicrobial therapy\", \"topical antifungal therapy\", \"topical steroid therapy\"]"}
{"id" : 778, "question_text" : "A 9-year-old girl is seen in the emergency department for an asthma exacerbation. She received 3 breathing treatments at home, 20 minutes apart, before coming to the emergency department. On physical examination, she has a respiratory rate of 40 breaths/min, an oxygen saturation of 92% on room air, intercostal and suprasternal retractions, and bilateral expiratory wheezes. Her peak expiratory flow is 40% of the predicted value. You administer a nebulized albuterol treatment. Of the following, the best NEXT step in the management of this patient is to", "options" : "[\"add ipratropium bromide to the nebulized albuterol\", \"observe her to assess response to albuterol\", \"order heliox administration\", \"order a loading dose of an oral corticosteroid\", \"order subcutaneous terbutaline\"]"}
{"id" : 779, "question_text" : "A 1-year-old with genitourinary malformations recently underwent corrective urological surgery and was discharged home in stable condition with an indwelling urinary catheter. The patient presents 10 days after discharge with fever and vomiting. Physical examination is significant only for a febrile infant (40.1°C) with mild dehydration. The urine is cloudy, and a spot urine test strip analysis shows a pH of 6.0, specific gravity of 1.040, 4+ leukocyte esterase, and no nitrites, blood, or protein. The patient is admitted to the hospital and parenteral antibiotics are started. Of the following, the MOST appropriate empiric antibiotic choice for this patient is intravenous", "options" : "[\"ampicillin\", \"ampicillin and ceftriaxone\", \"ceftriaxone\", \"cefuroxime and gentamicin\", \"gentamicin\"]"}
{"id" : 780, "question_text" : "A 10-year-old boy has a fever, rash, and facial swelling. Just before the onset of these symptoms, he had a 4-day period of low-grade fever and cough, for which he took an over-the-counter cough medication. On physical examination, his temperature is 38.5°C, heart rate is 85 beats/min, and respiratory rate is 18 breaths/min. He has nonpruritic, erythematous macules and patches on his face, chest, arms, and back, as well as facial swelling (Item Q73). He has mild nasal congestion, and auscultation of his lungs reveals coarse scattered rales bilaterally. The remainder of his physical examination findings is normal. Of the following, the MOST likely cause of the boy's illness is", "options" : "[\"adverse drug effect\", \"group A Streptococcus infection\", \"herpes simplex virus infection\", \"influenza virus infection\", \"Mycoplasma pneumoniae infection\"]"}
{"id" : 781, "question_text" : "An adolescent girl is being treated for a Chlamydia infection that was discovered on routine screening. She is asymptomatic and believes she acquired the infection from a previous partner. After addressing antibiotic treatment for the girl and her current partner, you discuss prevention of future infections. Of the following, the MOST effective prevention message for her at this time is to", "options" : "[\"begin and consistently use hormonal contraception\", \"douche after sexual intercourse\", \"maintain a monogamous relationship\", \"undergo frequent testing for sexually transmitted infections\", \"use condoms consistently\"]"}
{"id" : 782, "question_text" : "An 11-year-old girl presents to your office because of left knee pain. She was in her usual state of health until 1 month ago, when she began experiencing pain in her right knee that was associated with limitation in motion. This problem resolved, but she is now complaining of similar symptoms in her left knee. Her parents also are concerned because she occasionally complains of periumbilical abdominal pain and they have noticed a decrease in her appetite. The child has 4 to 6 bowel movements per week, which are occasionally loose but without blood or mucus. The family has recently started to purchase all of their groceries at a local organic food market, and they have increased their consumption of whole grains. On physical examination, you note that her height and weight percentiles have steadily decreased over the past 3 years from the 25th percentile to the 10th percentile. Physical examination demonstrates a well-appearing girl, and there is mild swelling of her left knee without warmth, redness, or limitation of range of motion. Abdominal examination shows mild, direct tenderness to palpation in the right lower quadrant and periumbilical regions. You obtain the following laboratory test results: • Hemoglobin, 10.3 g/dL (103 g/L) • White blood cell count, 7,500/µL (7.5 x 109/L) • Erythrocyte sedimentation rate, 36 mm/h • Aspartate aminotransferase, 24 U/L; reference range,<40 U/L • Alanine aminotransferase 14 U/L; reference range,<30 U/L • Albumin, 3.2 g/dL (32 g/L) Of the following, the MOST appropriate next diagnostic test is", "options" : "[\"abdominal ultrasonography\", \"antineutrophil cytoplasmic antibody (ANCA)\", \"colonoscopy\", \"small-bowel radiographic series\", \"tissue transglutaminase antibody\"]"}
{"id" : 783, "question_text" : "While examining a term neonate in the newborn nursery, it is noted that the red reflex is markedly less bright on one side than it is on the other. The remainder of the physical examination, including growth parameters, is normal. You have requested an ophthalmologic evaluation, but you are considering whether additional evaluation is needed. Of the following, the information MOST likely to be helpful in determining the cause of this abnormality is that the", "options" : "[\"infant's father has a history of a cataract at birth\", \"infant's mother is rubella nonimmune\", \"infant's mother is being treated for hypothyroidism\", \"maternal serum \\u03b1-fetoprotein levels were elevated during the pregnancy\", \"mother smoked an average of 4 cigarettes per day during the pregnancy\"]"}
{"id" : 784, "question_text" : "A 3-year-old boy is brought to the emergency department (ED) 30 minutes after ingesting one of his grandmother's medications. The boy's mother reports that the grandmother takes medications for depression and hypertension. During the first hour of being monitored in the ED, the boy becomes increasingly lethargic and develops mydriasis and a dry mouth. You notice on the cardiopulmonary monitor that his heart rate is 130 beats/min and he now appears to have a prolonged QRS duration. An electrocardiogram demonstrates a QRS duration of 110 milliseconds, right axis deviation, and prolonged PR and QT intervals. Of the following, the MOST likely medication ingested by the patient is", "options" : "[\"amitriptyline\", \"clonidine\", \"fluoxetine\", \"labetalol\", \"nicardipine\"]"}
{"id" : 785, "question_text" : "A 17-year-old boy develops altered mental status and is rapidly brought to the emergency department. Four days ago, he complained of polyuria, polydipsia, and fatigue. He has lost 4.5 kg of body weight in the last week. Vital signs taken in the emergency department show a blood pressure of 146/53 mm Hg, pulse rate of 133 beats/min, and respiratory rate of 16 breaths/min. He is afebrile. His body mass index is 30. His current medications include olanzapine, 20 mg once daily, started a few weeks ago for schizophrenia, and sertraline and valproic acid, both of which he has taken for a long time. Initial laboratory evaluation shows a glucose level of 660 mg/dL (36.6 mmol/L), serum sodium of 161 mEq/L (161 mmol/L), potassium of 4.8 mEq/L (4.8 mmol/L), and bicarbonate of 23 mEq/L (23 mmol/L). Of the following, the MOST likely diagnosis is", "options" : "[\"diabetic ketoacidosis\", \"hyperglycemic hyperosmolar syndrome\", \"maturity onset diabetes of the young\", \"medication overdose\", \"toxic ingestion\"]"}
{"id" : 786, "question_text" : "A 16-year-old boy is brought to the emergency department with a 1-day history of illness characterized by a diffuse, erythematous rash, nausea and vomiting, 3 loose stools, marked abdominal pain, and increasing confusion. A week ago, he cut his hand climbing a fence but did not seek medical attention. Physical examination reveals a temperature of 39.2°C; heart rate of 130 beats/min; blood pressure of 80/50 mm Hg; respiratory rate of 24 breaths/min; diffuse erythematous, blanching rash; supple neck without significant adenopathy; and a laceration on the right hand with surrounding erythema and edema. Head, eyes, ears, nose, and throat examination reveal injected sclerae and inflamed lips and tongue. Lungs are clear to auscultation. Cardiac auscultation reveals tachycardia without murmur, rub, or gallop. Upon neurologic examination, the boy is sleepy and difficult to arouse. The laboratory test results are as follows: • White blood cell count, 14,400/µL (14.4 x 109/L), with 80% neutrophils, 8% band neutrophils, and 12% lymphocytes • Hemoglobin, 11.0 g/dL (110 g/L) • Hematocrit, 34.6% (0.34) • Platelets, 86 x 103/µL (86 x109/L) • Sodium, 132 mEq/L (132 mmol/L) • Potassium, 4.6 mEq/L (4.6 mmol/L) • Chloride, 106 mEq/L (106 mmol/L) • Bicarbonate, 16 mEq/L (16 mmol/L) • Blood urea nitrogen, 52 mg/dL (18.6 mmol/L) • Creatinine, 2.3 mg/dL (203.3 4mol/L) • Alanine aminotransferase, 128 U/L • Aspartate aminotransferase, 211 U/L • Total bilirubin, 2.2 mg/dL (37.6 µmol/L) • Direct bilirubin, 0.6 mg/dL (10.3 µmol/L) He is infused with 20 mL/kg of intravenous normal Saline Of the following, the BEST initial therapy for this boy's condition is", "options" : "[\"cefazolin\", \"dobutamine\", \"immune globulin intravenous\", \"pentoxifylline\", \"vancomycin\"]"}
{"id" : 787, "question_text" : "A 3-year-old girl presents for a routine health supervision visit. She was recently diagnosed with juvenile idiopathic arthritis. Her mother asks why the rheumatologist has referred her to an ophthalmologist. Of the following, the BEST indication for ophthalmology referral is", "options" : "[\"assessment for corneal abrasions\", \"assessment of depth perception\", \"evaluation for cataracts\", \"screening for eye infections before starting a new treatment\", \"screening for uveitis\"]"}
{"id" : 788, "question_text" : "A girl with depression has stalled in her progress with cognitive behavioral therapy. She has chronic insomnia that is negatively affecting her mood and uses social media excessively overnight. Which intervention would be most appropriate?", "options" : "[\"St. John's Wort herbal supplements\", \"Dietary changes to improve mood\", \"Discontinuing all use of electronic devices in her room at night\", \"Daytime naps to improve overnight sleep\", \"Transferring psychotherapy to a different counselor\"]"}
{"id" : 789, "question_text" : "A term neonate appears dusky and cyanotic 4 hours after birth. He was born by spontaneous vaginal delivery and nursed well. Physical examination reveals clear lungs and normal cardiac examination. Pulse oximetry shows 78% on room air and 82% in 100% oxygen hood. Arterial blood gas in 100% hood shows pH 7.32, PCO2 40, PO2 33, bicarbonate 19, base deficit -4. What is the MOST likely cause of the neonate's findings?", "options" : "[\"group B streptococcal pneumonia\", \"methemoglobinemia\", \"persistent pulmonary hypertension of the newborn\", \"polycythemia\", \"transposition of the great arteries\"]"}
{"id" : 790, "question_text" : "A 3-year-old boy is brought to the office with a firm, smooth, nontender mass on the right side of the abdomen. He has no fever, vomiting, diarrhea, abdominal pain, or dysuria. Laboratory tests show mild anemia, elevated platelet count, and hematuria. CT scan shows a right-sided renal mass. What is the MOST likely diagnosis?", "options" : "[\"hepatoblastoma\", \"neuroblastoma\", \"renal abscess\", \"renal cell carcinoma\", \"Wilms tumor\"]"}
{"id" : 791, "question_text" : "An 8-year-old girl has a seizure at school lasting about 2 minutes. She was healthy all her life with no family history of seizures. EEG shows right and left centrotemporal spikes consistent with benign rolandic epilepsy. What is the MOST appropriate advice to provide the girl's parents?", "options" : "[\"brain damage is common even after a single seizure\", \"children who have epilepsy should not participate in contact sports\", \"children who have epilepsy should not take baths alone\", \"risk of sudden death is high in children who have epilepsy\", \"their daughter will likely need lifelong seizure medications\"]"}
{"id" : 792, "question_text" : "A 9-year-old girl has an acute right ankle injury from rolling her ankle during basketball 3 days ago. She has mild swelling and bruising over the lateral aspect of the ankle with point tenderness over the lateral malleolus. Radiographs are normal. What is the MOST likely diagnosis?", "options" : "[\"avulsion fracture involving the distal fibula\", \"grade 1 ankle sprain involving the posterior talofibular ligament\", \"peroneal tendinitis\", \"Salter\\u2013Harris type I fracture of the fibula\", \"talar dome fracture\"]"}
{"id" : 793, "question_text" : "A child with phenylketonuria (PKU) identified on newborn screening has been on a low-phenylalanine diet with excellent weight gain and normal developmental milestones. Parents are concerned about potential problems with growth, cognitive development, and risks to a developing fetus. With proper treatment, which statement is MOST likely accurate?", "options" : "[\"normal bone mineral densities in adulthood if maintained on the PKU diet\", \"normal cognitive development if the diet is well managed until 10 years of age\", \"normal height and head circumference measurements if maintained on the PKU diet\", \"no teratogenic effects in her offspring if phenylalanine levels are well-controlled\", \"some neurocognitive or psychosocial deficits in childhood despite good dietary management\"]"}
{"id" : 794, "question_text" : "A 4-year-old girl has a 1-cm vertical laceration to her upper lip extending approximately 4 mm beyond the vermillion border from a fall into a bookshelf corner. The laceration is not through and through and not actively bleeding. What is the MOST appropriate response regarding treatment?", "options" : "[\"absorbable suture material should be used for the best possible outcome\", \"consultation with a plastic surgeon may be required to achieve an acceptable outcome\", \"lidocaine should be infiltrated liberally around the wound edges to provide adequate analgesia\", \"suture placement is not needed since the laceration primarily involves a mucosal surface\", \"use of a cyanoacrylate tissue adhesive would be a good option for laceration repair given the patient's young age\"]"}
{"id" : 795, "question_text" : "During routine examination of a well 4-year-old boy, a bifid uvula is noted. On palpation of the soft palate, a submucous cleft palate is suspected. Of the following, this child is at GREATEST risk for which complication?", "options" : "[\"conductive hearing loss\", \"dental anomalies\", \"dysphagia\", \"problems with articulation\", \"recurrent sinusitis\"]"}
{"id" : 796, "question_text" : "A resident asks if formoterol can be used as rescue therapy for asthma. You explain the differences in kinetics between short-acting β-agonists (SABAs) and long-acting β-adrenergic agonists (LABAs). Which statement is MOST accurate?", "options" : "[\"LABAs have bronchodilating effects lasting up to 6 hours\", \"levoalbuterol is a SABA modified to have the same duration of action as a LABA\", \"regular use of LABAs can lead to dimunition of bronchoprotective effect\", \"regular use of SABAs does not lead to dimunition of bronchoprotective effect\", \"SABAs have bronchodilating effects lasting up to 2 hours\"]"}
{"id" : 797, "question_text" : "An 8-year-old boy with multiple café au lait spots, peripheral neurofibromas, and axillary freckling is seen for routine health supervision. His blood pressure is 150/90 mm Hg. Urinalysis shows 1+ blood with 2-5 RBCs per high-power field. Serum electrolytes are normal. What is the MOST likely cause of elevated blood pressure?", "options" : "[\"acute nephritis\", \"chronic renal failure\", \"pseudoaldosteronism (Liddle syndrome)\", \"pseudohypoaldosteronism (Gordon syndrome)\", \"renal artery stenosis\"]"}
{"id" : 798, "question_text" : "A 7-year-old girl presents with 3 days of fever, headache, myalgias, vomiting, and a rash on her ankles and feet after a camping trip to North Carolina. She is ill-appearing with temperature 39.5°C, heart rate 135 beats/min, blood pressure 90/55 mm Hg. Laboratory findings show WBC 5,600/µL, hemoglobin 10 g/dL, platelets 75 x 103/µL, AST 55 U/L, sodium 128 mEq/L, potassium 3.0 mEq/L. What is the MOST appropriate antimicrobial therapy?", "options" : "[\"chloramphenicol\", \"ciprofloxacin\", \"doxycycline\", \"penicillin\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 799, "question_text" : "A 15-year-old girl is seen as follow-up from an ED visit for vulvar pain. Testing confirms herpes simplex virus type 2. She was given pain medication but no antiviral medication pending test results. Physical examination reveals scattered shallow ulcers on the vulva. What is the BEST course of action?", "options" : "[\"oral acyclovir for an initial infection\", \"oral acyclovir suppressive therapy\", \"oral acyclovir to begin with the next recurrence\", \"topical acyclovir for the current infection\", \"topical acyclovir to begin with the next recurrence\"]"}
{"id" : 800, "question_text" : "A 16-year-old girl with hemoglobin SS disease who has undergone cholecystectomy presents with acute onset of abdominal pain, fever, and vomiting. She is icteric with right upper quadrant and epigastric tenderness. Laboratory tests show total bilirubin 18.5 mg/dL, direct bilirubin 10.8 mg/dL, amylase 650 U/L, lipase 900 U/L. Abdominal ultrasound shows dilated common bile duct without intrahepatic ductal dilatation and edematous pancreas. What is the MOST appropriate next step?", "options" : "[\"abdominal computed tomography\", \"endoscopic retrograde cholangiopancreatography\", \"hepatobiliary scintigraphy\", \"magnetic resonance cholangiopancreatography\", \"percutaneous transhepatic cholangiography\"]"}
{"id" : 801, "question_text" : "You are giving a presentation to a community group about environmental effects on pediatric health. One participant asks about the effects of air pollution in developing countries. Which statement are you MOST likely to make?", "options" : "[\"adult men are most susceptible to air pollution effects in the developing world because of occupational exposures\", \"air pollution causes proven respiratory effects in industrialized nations but has not been shown to be a health hazard in the developing world\", \"exposure to household air pollution caused by burning plant or animal materials for cooking fuel increases a child's risk of developing pneumonia\", \"the health effects of air pollution in the developing world are primarily restricted to congested urban areas\", \"in the developing world, outdoor air pollution accounts for a greater impact on health and disability than does indoor air pollution\"]"}
{"id" : 802, "question_text" : "A 4-month-old boy with atrioventricular septal defect underwent cardiac catheterization today in preparation for surgical repair in 2 weeks. His oxygen saturation is 80% on 1 L/min oxygen via nasal cannulae. Shortly after examination, he becomes acutely agitated with rapid decrease in oxygen saturation to 65%, heart rate 145 beats/min, and blood pressure 80/55 mm Hg. Of the following, the treatment MOST likely to improve his oxygen saturation is", "options" : "[\"albuterol nebulized treatment\", \"epinephrine infusion\", \"naloxone intravenously\", \"sodium bicarbonate bolus intravenously\", \"supplemental oxygen administration\"]"}
{"id" : 803, "question_text" : "A 2-year-old girl has intermittent facial spasms. She has been treated with levothyroxine since the first week after birth for elevated TSH on newborn screening. Serum calcium is 4.5 mg/dL with PTH 103 pg/mL (reference 10-65 pg/mL). Radiographic studies reveal shortened metacarpals and subcutaneous nodules. Her mother is healthy but also has multiple subcutaneous nodules. What is the MOST LIKELY diagnosis?", "options" : "[\"hypoparathyroidism\", \"hypopituitarism\", \"multiple endocrine autoimmune syndrome\", \"pseudohypoparathyroidism\", \"vitamin D resistance\"]"}
{"id" : 804, "question_text" : "A 16-year-old boy has a 4-week history of progressive coughing spells that began with an upper respiratory infection. He has had difficulty sleeping over the past week because of the progression of the cough. His family recently moved and has no record of his immunizations. Diagnostic test results are pending. Of the following agents, the BEST antibiotic for treating this patient is", "options" : "[\"amoxicillin\", \"ciprofloxacin\", \"doxycycline\", \"erythromycin\", \"trimethoprim-sulfamethoxazole\"]"}
{"id" : 805, "question_text" : "A 6-year-old boy is seen in the emergency department with fever and knee swelling of 1 day's duration. Physical examination reveals a warm, erythematous, swollen knee with decreased range of motion due to pain. His temperature is 40°C and heart rate is 110 beats/min; the remainder of his physical examination findings and vital signs are within normal limits. A complete blood cell count reveals a white blood cell count of 15,000/µL (15.0 x 109/L) and platelets of 412.0 x 109/µL (412.0 x 109/L). The erythrocyte sedimentation rate is 50 mm/h. Arthrocentesis reveals white synovial fluid, a white blood cell count of 80,000/µL (80.0 x 109/L), and a red blood cell count of 0.1 x 103/µL (0.1 x 109/L). Gram stain and culture results are pending. Of the following, the BEST antibiotic choice is", "options" : "[\"cefepime\", \"cefotaxime\", \"doxycycline\", \"nafcillin\", \"penicillin G\"]"}
{"id" : 806, "question_text" : "In your office, you are seeing a 16-year-old girl who for the past month has had symptoms of depression, including insomnia, irritability, loss of ability to concentrate, decreased physical activity, and worsening of academic performance. She recently started seeing a psychologist who has referred her to you for consideration of starting a medication to treat the depression because of the severity of her symptoms. The patient and her mother are interested in starting a medication today. You decide to start fluoxetine, a selective serotonin reuptake inhibitor. Of the following, the BEST next step in management is to", "options" : "[\"ask the patient and her family to help monitor for any new irritability or self-harm thoughts\", \"instruct the patient she must avoid pregnancy while taking fluoxetine\", \"order a complete blood cell count to be performed in 2 months\", \"order a serum sodium blood test in 4 weeks\", \"schedule the patient for a follow-up in 4 weeks\"]"}
{"id" : 807, "question_text" : "You are called to attend the vaginal delivery of a woman who presented completely dilated at 29 weeks of gestation. The newborn emerges limp without any respiratory effort. After gently suctioning and drying the newborn, you begin bag-mask ventilation with 30% oxygen. A pulse oximetry probe is placed on the right hand. The heart rate slowly begins to rise over 100 beats/min after 30 seconds of effective ventilation, and the pulse oximeter reads 90% oxygen saturation. The infant begins to have weak spontaneous respiratory effort associated with deep retractions. A decision is made to intubate, and a 3 min endotracheal tube is placed on the first attempt. At 5 minutes after birth, the newborn continues to require positive pressure ventilation with 30% oxygen. The newborn is centrally pink with a heart rate of 140 beats/ min and continues with a weak spontaneous respiratory effort while intubated. The newborn has some flexion and grimaces upon intramuscular injection of vitamin K. Of the following, the MOST appropriate Apgar score to assign at 5 minutes is", "options" : "[\"5\", \"6\", \"7\", \"8\", \"9\"]"}
{"id" : 808, "question_text" : "A 5-year-old boy is hospitalized for hypoxia and respiratory distress associated with bacterial pneumonia. He is receiving supplemental oxygen and parenteral antibiotics. On the second hospital day, you are called to his bedside because he is noted to be pale. His oral temperature is 37.9°C, pulse rate is 110 beats/min, respiratory rate is 28 breaths/ min, and blood pressure is 100/55 min Hg. On examination, the child is alert and pale. He has mildly icteric sclerae and a grade 2/6 systolic ejection murmur. The remainder of the physical examination is normal. The following are the results of the child's laboratory tests: White blood cell count, 16,500/µL (16.5 x 109/L), with 62% polymorphonuclear leukocytes, 30% lymphocytes, 7% monocytes, and 1% eosinophils; Hemoglobin, 5.0 g/dL (50 g/L); Mean corpuscular volume, 80/µm3 (80 fl,); Platelet count, 445 x 103/uL (445 x 109/L); Reticulocyte count, 10% (0.10); Direct antiglobulin test (direct Coombs), positive for IgG, negative for C3; Indirect antiglobulin test (indirect Coombs), negative upon review of his medical record, his hemoglobin on admission was 10.5 g/dL (105 g/L). Of the following, the MOST likely cause of the acute anemia in this child is", "options" : "[\"aplastic crisis\", \"cold agglutinin disease\", \"hemolytic uremic syndrome\", \"inconclusive because of conflicting Coombs results\", \"warm agglutinin autoimmune hemolytic anemia\"]"}
{"id" : 809, "question_text" : "A 16-year-old boy has had constant daily headache for 1 month. The headache is all over his head; it comes and goes but never fully resolves. The pain worsens with coughing, sneezing, and laughing. He has mild nausea and photophobia and ringing in his ears. He reports that his vision \"grays out\" sometimes but he does not have tunnel vision or visual loss. His past medical history is notable for acne, asthma, and attention-deficit/hyperactivity disorder (ADHD). He is currently taking oral isotretinoin for his acne, oral montelukast and inhaled fluticasone for his asthma, and atomoxetine for his ADHD. He also takes vitamin B12 supplements and riboflavin as natural remedies for headache. There is no family history of migraine. On physical examination, his weight is 65 kg, height is 178 cm, and blood pressure is 102/76 mm Hg. His funduscopic examination is shown in Item Q102 (both eyes exhibit similar findings). The remainder of his physical examination findings is normal. Results of magnetic resonance imaging of the brain are normal. Lumbar puncture is performed in the lateral decubitus position with legs extended, and the opening pressure is 340 mm H20. Cerebrospinal fluid protein is 13 mg/dL and glucose is 64 mg/dL, and there are 3 white blood cells/µL and 204 red blood cells/ 4L. Of the following, the medication MOST likely to cause the boy's symptoms and signs is", "options" : "[\"atomoxetine\", \"isotretinoin\", \"montelukast\", \"riboflavin\", \"vitamin B12\"]"}
{"id" : 810, "question_text" : "You are counseling a couple whose 6-month-old son has Down syndrome and is scheduled for a ventricular septal defect (VSD) repair. He is otherwise well and has been gaining weight appropriately while taking digoxin and furosemide for mild congestive heart failure. The parents ask about complications and whether their child's Down syndrome will put him at greater risk than children who undergo VSD repair and do not have Down syndrome. Of the following, you are MOST likely to tell the parents that their son is at", "options" : "[\"greater risk for anoxic brain injury\", \"greater risk for postoperative fatal arrhythmia\", \"greater risk for postoperative respiratory complications\", \"greater risk for postoperative seizures\", \"no greater risk of perioperative complications\"]"}
{"id" : 811, "question_text" : "The mother of a 4-year-old boy brings him to your office because he \"looks flushed and is acting strangely.\" There is no history of trauma or recent illness. The boy has been healthy and takes no medications. His symptoms began 1 hour ago. His mother is concerned that he has meningitis because earlier in the morning, another child at his preschool was sent home with fever and headache. The boy has a temperature of 38. VC, heart rate of 156 beats/min, blood pressure of 120/84 mm Hg, and respiratory rate of 28 breaths/min. The boy appears anxious. He is intermittently picking at his shirt and skin. He looks toward his mother when she speaks to him, but he seems confused and does not respond to questions in a coherent manner. On physical examination, his skin is warm and flushed and mucous membranes are dry. His pupils are both 6 mm in diameter and minimally reactive. You find no signs of traumatic injury or meningismus. His abdomen is soft and nontender, although his bowel sounds are diminished. As you are interviewing the mother further about the boy's activities prior to symptom onset, his older sister interrupts and states that she saw her brother eating some \"candy\" out of their mother's purse earlier today. The mother acknowledges that she keeps a variety of over-the-counter medications in her purse to \"be ready for emergencies\" Of the following, the medication MOST likely to cause the patient's signs and symptoms is", "options" : "[\"acetaminophen\", \"aluminum hydroxide\", \"chlorpheniramine\", \"loperamide\", \"simethicone\"]"}
{"id" : 812, "question_text" : "The parents of a 4-month-old male infant are concerned about his left foot. They report that the infant has appeared \"pigeon-toed\" since birth. On examination, you note medial deviation of the forefoot and the lateral border of the foot is convex. You are able to easily move the foot to a neutral position and abduct the forefoot past the midline (Item Q105). Of the following, the BEST initial management is", "options" : "[\"immediate referral to orthopedics for probable surgical correction\", \"radiologic imaging of the foot\", \"serial manipulation and casting\", \"stretching maneuvers of the forefoot\", \"ultrasonography of the hips\"]"}
{"id" : 813, "question_text" : "The parents of a 3-year-old boy would like him tested for allergies. The parents report that the boy has had worsening symptoms of itchy eyes, sneezing fits, and nasal congestion since the family got a new dog 1 year ago. The parents would like the boy tested to determine if they need to give the dog away. They are reluctant to stop the boy's daily antihistamine and are disappointed to learn that skin testing cannot be performed while taking this medication. You decide to obtain blood-specific IgE testing. However, the parents have read on the internet that the \"scratch test\" is a better test. Of the following, you are MOST likely to advise the parents that in this situation, blood-specific IgE testing is", "options" : "[\"comparable to skin testing\", \"less expensive and better tolerated by children than skin testing\", \"more accurate than skin testing\", \"the only testing that can be done because he is too young for skin testing\", \"a preliminary test and you will obtain skin testing to confirm the results\"]"}
{"id" : 814, "question_text" : "A 17-year-old boy has recently been diagnosed as having autosomal dominant polycystic kidney disease. His parents have done some research and are worried about the risk of associated cerebral aneurysms and intracerebral bleeding. Of the following, you are MOST likely to advise them that the boy", "options" : "[\"can have magnetic resonance angiography\\u2013based screening irrespective of his renal function\", \"has 50% risk for having cerebral aneurysm\", \"has a higher risk for intracerebral bleed if the size of the aneurysm is more than 7 mm\", \"will need routine yearly screening for identifying cerebral aneurysms\", \"will need surgical correction if an asymptomatic cerebral aneurysm is detected\"]"}
{"id" : 815, "question_text" : "An 18-year-old homeless girl presents to the emergency department because she \"cannot see\" in her left eye. She complains of slowly progressive decreased visual acuity and the recent development of \"floaters.\" She also reports chronic diarrhea and skin problems. On physical examination, her temperature is 36.5°C, heart rate is 65 beats/min, respiratory rate is 14 breaths/min, and blood pressure is 85/55 min Hg. The examination is notable for a cachectic girl who answers questions appropriately. Funduscopic examination reveals retinitis with extensive areas of hemorrhage and white retinal exudates (Item Q108). Visual acuity is 20/30 in the right eye and 20/400 in the left eye. The oropharyngeal examination reveals white palatal plaques. Auscultation of the lungs reveals coarse breath sounds bilaterally with normal effort. Her abdomen is mildly tender to palpation; the liver and spleen are palpable 3 cm to 4 cm below the costal margins. Neurologic examination is grossly unremarkable except for visual acuity. Examination of the skin reveals multiple erythematous, eroded papules consistent with insect bites that are not healing well. Of the following, the MOST likely cause of this patient's vision loss is infection with", "options" : "[\"Bartonella henselae\", \"Candida albicans\", \"cytomegalovirus\", \"Epstein\\u2013Barr virus\", \"Mycobacterium avium\"]"}
{"id" : 816, "question_text" : "An 18-year-old girl is in your office for evaluation of abdominal pain. You diagnose her as having pelvic inflammatory disease (PID). She is using an oral contraceptive but takes the pills erratically, and her partner does not always use condoms. She has no fever or systemic symptoms at this time. You prescribe outpatient antibiotics. You discuss the reasons why adherence with the medication regimen is important. In order to help with adherence, you suggest a number of techniques. Of the following, the MOST effective strategy to enhance adherence would be to", "options" : "[\"have her mark a calendar each time she takes her pills\", \"have her mother supervise medication administration\", \"have her place alarm reminders on her cell phone\", \"have her take the medicines with meals\", \"stress the possible long-term consequences of untreated PID\"]"}
{"id" : 817, "question_text" : "An 8-year-old boy is seen for a health supervision visit. Since his last appointment, he has been well and has had a good appetite and normal development. His only complaint is a recent upper respiratory tract infection for which his parents treated him symptomatically. The boy's parents tell you that he vomited several times last month, and on one occasion, he awoke at night and vomited a large amount of yellow-green, clear fluid. Since then he has been completely asymptomatic. Physical examination demonstrates a well-appearing child, and the remainder of the examination is completely unremarkable. Of the following, you are MOST likely to recommend", "options" : "[\"abdominal ultrasonography\", \"referral for upper gastrointestinal endoscopy\", \"routine follow-up in 6 months, or sooner if symptoms recur\", \"surgical referral\", \"upper gastrointestinal tract radiographic series\"]"}
{"id" : 818, "question_text" : "Parents bring in their 6-year-old daughter because her toes turn in when she walks. They are concerned because imaging studies have not been performed and treatment has not been prescribed. Examination of this appropriately grown child is notable for moderate intoeing and 90° of internal rotation of both hips when she is in the prone position (Item Q111). There is no evidence of metatarsus adductus or tibial torsion. Aside from the intoeing, she has a normal gait. Of the following, the MOST appropriate next step in the care of this child is to", "options" : "[\"counsel the family that a substantial portion of children with this condition will require surgical intervention as they grow older\", \"obtain a computed tomography scan to define precisely the femoral neck anatomy\", \"prescribe twist cables and corrective shoes\", \"reassure the parents that this child has a good prognosis for resolution as the child matures\", \"refer to orthopedics because the intoeing has not corrected by 6 years of age\"]"}
{"id" : 819, "question_text" : "You are evaluating a 2-year-old girl whose parents report that she began choking while playing near a table where a box of thumbtacks was located. The choking episode was not improved by her father pounding on her back, but the girl remained conscious while being transported to the emergency department. She has a temperature of 37.0°C, heart rate of 130 beats/min, respiratory rate of 36 breaths/min, and blood pressure of 80/50 mm Hg. Her oxygen saturation is 93% by pulse oximetry on room air. The child is in mild respiratory distress and has bilateral wheezing. Her parents state that she has no history of asthma. You suspect that she has aspirated a thumbtack. Of the following, the MOST likely complication for this patient would be", "options" : "[\"bronchial stricture\", \"bronchiectasis\", \"pneumothorax\", \"pulmonary infection\", \"tracheal perforation\"]"}
{"id" : 820, "question_text" : "You are called about an 8-year-old boy with ulcerative colitis who developed fever (up to 39.4°C). He is currently at home, and he is still taking oral feedings well. Among his medications, he was taking prednisone daily for 4 months and completed tapering off the medication 1 week ago. A recent morning serum cortisol level was 0.4 µg/dL (11nmol/L) (normal range, 8-19 µg/dL [221-524 nmol/L]). His body surface area is 1 m'. He has an appointment with you tomorrow. Of the following, the BEST step in the management of this patient is to start 3-times-daily treatment with", "options" : "[\"dexamethasone, 10 mg orally\", \"fludrocortisone, 10 mg orally\", \"hydrocortisone, 10 mg orally\", \"prednisone, 10 mg orally\", \"prednisolone, 10 mg orally\"]"}
{"id" : 821, "question_text" : "As part of an evaluation for a small for gestational age (SGA) infant, Toxoplasma serology reveals the presence of IgG and IgM antibodies in the infant's specimen. The baby's weight is at less than the fifth percentile, and weight and head circumference are at the 10th percentile. The remainder of the baby's physical examination is unremarkable, including a normal liver span and normal neurologic examination findings for age. Confirmatory laboratory tests, including cerebrospinal fluid examination, computed tomography scan of the head, and ophthalmologic and audiologic examinations are ordered. In discussing potential for treatment with the parents pending the results of the evaluations, the parents raise concerns regarding the potential toxicities of prolonged sulfa-drug treatment. They ask what their child's long-term risks are if the infant is infected with toxoplasma and not treated. Of the following, the adverse outcome MOST likely to be seen in this infant is", "options" : "[\"attention-deficit disorder\", \"dental deformities\", \"hearing loss\", \"hepatitis\", \"visual loss\"]"}
{"id" : 822, "question_text" : "A 9-year-old girl presents to your office for her annual health supervision visit. She has no significant medical history or complaints and is growing normally. Her physical examination, including vital signs, is unremarkable. Her mother was recently diagnosed with systemic lupus erythematous (SLE). Per the mother's request, an antinuclear antibody test was performed on the child, resulting in a low-positive titer. Of the following, the BEST information you can provide the mother is that her daughter", "options" : "[\"has a confirmed diagnosis of SLE\", \"has a high likelihood of developing autoimmune diseases\", \"has an infection\", \"most likely does not have SLE\", \"will develop lupus later in life\"]"}
{"id" : 823, "question_text" : "You are seeing a 15-year-old, 55-kg boy in your office for a health supervision visit. He has no significant findings on physical examination. Within your review of adolescent risk behaviors, he revealed that he smokes cigarettes but denied abusing any other substances. One of his parents and several close friends also smoke cigarettes. He says he will usually smoke one-half pack per day, but sometimes will smoke up to one pack per day. The boy states that he sometimes wishes he could quit smoking but so far has not tried to reduce his cigarette use. Of the following, the BEST next best action would be to", "options" : "[\"ask him to tell you his reasons he wishes to quit smoking\", \"ask his parents to put pressure on him to quit smoking\", \"prescribe the nicotine transdermal patch\", \"prescribe sustained-release bupropion\", \"prescribe varenicline\"]"}
{"id" : 824, "question_text" : "You are assessing a term neonate who was born by vaginal delivery that was complicated by shoulder dystocia and thick meconium. The neonate emerged limp and apneic. No meconium was found below the vocal cords after the initial intubation and suctioning were performed. The neonate required resuscitation with bag-mask ventilation for 2 minutes. Apgar scores assigned were 1 at one minute (1 for heart rate) and 6 at five minutes (2 for heart rate, 2 for respiratory effort, 1 for color, 0 for tone, and 1 for reflex irritability). Examination reveals an alert newborn with mild retractions and decreased tone, with a temperature of 36.7°C, heart rate of 110 beats/min, respiratory rate of 80 breaths/ min, blood pressure of 64/40 min Hg, and oxygen saturation of 95% on room air. An arterial blood gas obtained 20 minutes after delivery reveals a pH of 7.22, PaCO2 of 51 min Hg, PaO2 of 60 min Hg, bicarbonate of 19 mEq/L (19 mmol/L), and base deficit of -7. Of the following, the MOST appropriate next step in management for this neonate is", "options" : "[\"intravenous bolus of 10 mL/kg normal saline\", \"intravenous infusion of 1 mEq/kg sodium bicarbonate\", \"intubation for mechanical ventilation\", \"observation of cardiorespiratory status\", \"placement in a 100% oxygen hood\"]"}
{"id" : 825, "question_text" : "A 16-year-old boy in your care was recently diagnosed with osteosarcoma. His paternal grandfather died of brain cancer at 60 years of age, his father survived adrenocortical carcinoma at 30 years of age, and the father's brother had a soft tissue sarcoma at 35 years of age. The patient's mother is well; no cancer has been seen on her side of the family. The parents ask you about the risk of cancer in their daughter. Of the following, the MOST appropriate response would be that the", "options" : "[\"cancer predisposition pattern appears to be X-linked, so it is unlikely that the daughter would be at increased risk\", \"daughter may have an increased risk of developing breast cancer\", \"daughter should receive yearly imaging for brain cancers when she reaches adulthood\", \"daughter will likely need a bone marrow transplant in her lifetime\", \"family's history is unlikely to be related to any cancer syndrome because the cancer types are different\"]"}
{"id" : 826, "question_text" : "A 3-year-old boy was playing in the park with his family. He ran into his mother's legs, fell to the ground without hitting his head, and started crying. The mother picked him up, noticed he wasn't moving his arms, and brought him to the emergency department. On physical examination, his blood pressure is 108/62 min Hg, heart rate is 110 beats/min, respiratory rate is 40 breaths/min (while crying), and temperature is 37.8°C; there is no nuchal rigidity, meningismus, or tenderness to palpation of the spinous processes, and skin evaluation is normal. His neurologic examination shows an alert, crying toddler; his eyes move conjugately in all directions, and his facial movements are strong and symmetric. There is flaccid paralysis of his upper extremities with normal movements of his lower extremities. Deep tendon reflexes are absent in his arms, he has normal patellar reflexes, and his toes extend on plantar stimulation. The boy's gait is unremarkable. Of the following, the MOST appropriate next diagnostic test to perform is", "options" : "[\"computed tomography of the brain\", \"electromyography and nerve conduction study\", \"lumbar puncture\", \"magnetic resonance imaging of the brain\", \"magnetic resonance imaging of the spine\"]"}
{"id" : 827, "question_text" : "A 12-year-old boy presents to your office with his parents for evaluation of right shoulder pain. The boy reports that his pain began 3 weeks ago during tennis practice. He plays approximately 10 hours of tennis each week and experiences pain when he serves the ball. On physical examination, you note tenderness over the proximal humerus and pain with resisted shoulder elevation. The remainder of the physical examination is normal. You obtain radiographs; the patient's anteroposterior shoulder radiograph is shown (Q120). Of the following, the MOST appropriate statement to include in your discussion with this family is that this child", "options" : "[\"does not have a structural injury and can return to all tennis activities\", \"had an injury to the biceps tendon that resulted from a single forceful motion\", \"has an injury to the glenoid labrum that resulted from a single forceful motion\", \"has an injury to the proximal humerus growth plate that resulted from repetitive overhead motion\", \"has an injury to the rotator cuff that resulted from repetitive overhead motion\"]"}
{"id" : 828, "question_text" : "You are examining a female neonate born following an uneventful pregnancy to a gravida 3, para 3 woman by repeat cesarean section. The neonate weighs 3.3 kg. A chest radiograph ordered as part of an evaluation for transient tachypnea shows vertebral anomalies and scoliosis. The remainder of the examination is unremarkable. The infant is breastfeeding well and has no other obvious problems. Of the following, this neonate is MOST at risk for", "options" : "[\"cardiopulmonary compromise\", \"a connective tissue disorder\", \"a cytogenetic abnormality\", \"a genitourinary anomaly\", \"a neuromuscular disorder\"]"}
{"id" : 829, "question_text" : "During a health supervision visit, the parents of a 6-month-old girl express concern about her \"birthmarks\" She had a few flat reddish tan lesions on her body that appeared shortly after birth, and she has developed more since that time (Item Q122A). These lesions are present on her trunk, extremities, and scalp (Item Q12213, page Q-31). Her palms and soles are not involved. The parents report that these \"birthmarks\" sometimes become larger and redder. They attribute this to the girl being overheated or upset. The lesions do not appear to be tender, and the girl is otherwise well. On physical examination, you make the diagnosis by rubbing a lesion on the girl's lower back. Of the following, the MOST likely diagnosis is", "options" : "[\"bed bug bites\", \"cafe au laic macules\", \"chronic urticaria\", \"erythema nodosum\", \"urticaria pigmentosa\"]"}
{"id" : 830, "question_text" : "You are seeing a 14-year-old boy who has asthma. Over each of the past 2 years, he has experienced 3 to 4 exacerbations that required emergency department visits and oral corticosteroid bursts. You prescribed a daily moderate-dose inhaled corticosteroid (ICS), but the boy admits to taking it only when symptoms worsen. He had no asthma exacerbations 2 years ago when he was using daily ICS. He rates his symptoms as \"well controlled\" on the asthma control test but is not taking part in any physical activity since it triggers his symptoms. He does not feel his lungs \"open up\" when taking the daily ICS and would rather use albuterol daily, since that seems to make him feel better. Of the following, you are MOST likely to encourage the boy to", "options" : "[\"limit physical activity and initiate daily montelukast\", \"use albuterol as needed and recommend daily peak expiratory flow meter monitoring\", \"use the ICS daily and albuterol as needed\", \"use the ICS only during worsening symptoms\", \"use twice daily scheduled albuterol along with montelukast\"]"}
{"id" : 831, "question_text" : "The parents of a 10-year-old girl present to your office for a second opinion. The girl has been having asymptomatic microscopic hematuria for the last 18 months. Her records show a normal physical examination on regularly documented visits, normal renal ultrasonography, and a normal serum chemistry (most recently checked 1 month ago). She has multiple urine analyses showing 4+ blood by urine test strips and 20 to 50 red blood cells per high-power field (HPF). There is no family history of autoimmune diseases or renal failure. Her physical examination reveals that her temperature is 37.9°C, heart rate is 76 beats/min, respiratory rate is 17 breaths/min, and blood pressure is 110/60 min Hg. She has normal growth parameters and a normal physical examination. Her urinalysis demonstrates a specific gravity of 1.035, a pH of 6.0, 4+ blood, and no leukocyte esterase, protein, or nitrites. Her urine microscopy shows 50 to 100 red blood cells/HPF, less than 5 white blood cells/HPF, and no crystals or bacteria. Of the following, you are MOST likely to inform the parents that", "options" : "[\"asymptomatic microscopic hematuria is uncommon in schoolchildren\", \"persistent microscopic hematuria indicates significant risk for renal failure in the future\", \"proteinuria would increase her risk for progressive renal disease\", \"she will need a renal biopsy for evaluation of her hematuria\", \"she will need a urology referral\"]"}
{"id" : 832, "question_text" : "A 10-month-old male infant presents with a several-month history of poor weight gain, fevers, persistent upper respiratory tract infections, recurrent diarrhea, and persistent diaper candidiasis. His maternal grandmother is his caregiver and reports that the patient's mother recently died from \"an infection. \" On physical examination, he is afebrile and vital signs are normal for age. The boy's head circumference and length are at the 20th percentile, but weight is at less than the 5th percentile for age. He has nasal congestion, clear rhinorrhea, oral thrush, and dull tympanic membranes. Auscultation of the lungs reveals coarse breath sounds bilaterally with normal effort. The results of the cardiovascular examination are normal. The abdomen is soft, with the liver and spleen palpated 4 cm and 3 cm below the costal margins, respectively. The patient has normal genitalia with diaper dermatitis consistent with candidiasis. You palpate lymph nodes of less than 0.5 cm in the neck and groin. The peripheral white blood cell count is 4,000/µL (4.0 x 109/L), with 80% polymorphonuclear neutrophils, 10% lymphocytes, and 10% monocytes. His hemoglobin level is 10 g/dL (100 g/L) and platelet count is 280 x 103/µL (280 x 109/L). You are concerned that the patient has an immunodeficiency. Of the following, the test MOST likely to establish the patient's diagnosis is a(n)", "options" : "[\"antigen detection assay\", \"complement activity test\", \"enzyme immunoassay\", \"polymerase chain reaction assay\", \"viral culture\"]"}
{"id" : 833, "question_text" : "A 13-year-old boy presents for a routine health supervision visit. He is very concerned about a lump on his chest that appears to be increasing in size. You have not seen him in 2 years, and your last note indicates that the results of his examination were normal. He appears well, has normal vital signs, and has a body mass index of 25. He is very embarrassed and reluctantly allows you to examine him. You find a slightly tender, rubbery mass under his right areola that measures approximately 2 cm in diameter. The remainder of his examination, including a genital examination, is unremarkable. He is at sexual maturity rating 2/3. Of the following, the MOST appropriate next step in this boy's management is to", "options" : "[\"discuss normal development\", \"obtain an endocrinology consult\", \"obtain ultrasonography of the mass\", \"refer him to a plastic surgeon for excision of the mass\", \"suggest that treatment for the mass is weight loss\"]"}
{"id" : 834, "question_text" : "An 18-year-old, African-American young man comes to your office with a recent history of weight loss. He was well until 1 month ago, when he returned from a camping trip with his friends. During the trip, they ran out of bottled water and drank from a mountain stream near their campsite. Also while camping, he developed an infected cut on his arm and was prescribed clindamycin at a local emergency department. Since returning home, he has been complaining of vague, generalized abdominal discomfort that is associated with 2 to 3 semiformed stools per day. His bowel movements do not contain visible blood or mucus. He denies vomiting, fevers, or joint pains. He does not like dairy products and tries to avoid them. Review of his past records indicates that he has lost 1.5 kg of body weight since his last office visit 6 months ago. Of the following, the organism MOST likely responsible for this young man's symptoms is", "options" : "[\"Blastocystis hominis\", \"Campylobacter jejuni\", \"Clostridium difficile\", \"Cryptosporidium species\", \"Giardia intestinalis\"]"}
{"id" : 835, "question_text" : "A 3-month-old infant from your practice has died suddenly and unexpectedly in the sleep environment. Law enforcement and the medical examiner are investigating the death. You are considering what involvement you should have with this family. Of the following, the BEST description of your role is to", "options" : "[\"arrange a meeting only if the parents request it\", \"arrange to meet with the family and surviving siblings\", \"discuss grief issues only if the parents report a concern\", \"leave the medical examiner to review the autopsy and investigation with the family\", \"provide medical records to law enforcement but avoid discussing the case with the family\"]"}
{"id" : 836, "question_text" : "While at the hospital, you visit the family of a 6-weekold boy who has been recovering in the cardiac intensive care unit after undergoing a stage I Norwood procedure for hypoplastic left heart syndrome. The surgery and postoperative course have gone well, and the patient is being fed standard formula through a nasoenteric tube. The bedside nurse informs you that the infant has developed large bilateral pleural effusions (Item Q129A) this morning and has had bilateral thoracostomy tubes placed (Item Q129B) with a significant amount of milky white fluid that tests positive for a large amount of triglycerides and a predominance of lymphocytes. Of the following, the MOST likely diagnosis in this patient is", "options" : "[\"chylothorax\", \"empyema\", \"heart failure\", \"hemothorax\", \"lymphoma\"]"}
{"id" : 837, "question_text" : "An 11-year-old girl is seen for evaluation of short stature. Her past medical history is significant for swelling of her right foot, noted at birth, that never resolved. She also had a lisp that required speech therapy, and pressure equalization tubes placed 4 times for recurrent otitis media. Her height is at the first percentile, well below her midparental target height at the 90th percentile. Physical examination reveals a high-arched palate, bilateral short fourth metacarpals, and moderate edema of the right foot. Of the following, the MOST likely diagnosis is", "options" : "[\"Noonan syndrome\", \"pseudohypoparathyroidism\", \"Russell-Silver syndrome\", \"Turner syndrome\", \"Williams syndrome\"]"}
{"id" : 838, "question_text" : "A 4-month-old infant is seen in the emergency department with a 2-week history of progressive coughing associated with duskiness. Nasopharyngeal swab is positive for pertussis. The nurse who was caring for the child prior to the diagnosis was not wearing a mask during extensive contact with the infant. She reports receiving a booster dose of diphtheria-pertussis-tetanus vaccine 6 years ago. Of the following, the MOST appropriate treatment for this nurse is", "options" : "[\"azithromycin for 5 days\", \"a booster dose of diphtheria-pertussis-tetanus vaccine\", \"erythromycin for 7 days\", \"no treatment necessary\", \"trimethoprim-sulfamethoxazole for 7 days\"]"}
{"id" : 839, "question_text" : "A 2-year-old girl presents to your office after 5 days of fever (up to 38.3°C). Three days ago, she was seen in the emergency department and started on amoxicillin for the diagnosis of otitis media. On physical examination, the patient is irritable and has injection of the conjunctiva bilaterally without dis-charge, dry cracked lips, a red tongue, a fine papular rash, and a unilateral, 2-cm cervical lymph node (Item Q132). The following are the results of laboratory tests for the girl: • White blood cell count, 16,000/µL (16 x 109/L), with 55% polymorphonuclear leukocytes, 40% lymphocytes, and 5% monocytes • Platelets, 340 x 103/µL (340 x 109/L) • Erythrocyte sedimentation rate, 45 mm/h, • C-reactive protein, 30.1 mg/L (287.6 nmol/L) • Aspartate transaminase, 200 U/L • Alanine transaminase, 235 U/L Of the following, the MOST likely diagnosis is", "options" : "[\"herpes gingivostomatitis\", \"Kawasaki disease\", \"pharyngoconjunctival fever\", \"Stevens-Johnson syndrome\", \"toxic shock syndrome\"]"}
{"id" : 840, "question_text" : "A 4-year-old boy presents with a 5-day history of fever, bilateral conjunctival injection without exudate, erythema and edema of the lips, cervical lymphadenopathy, a polymorphous exanthem, and edema of the hands and feet. Laboratory studies show an elevated erythrocyte sedimentation rate, elevated C-reactive protein, leukocytosis with neutrophil predominance, mild thrombocytosis, mildly elevated liver transaminases, and sterile pyuria. Of the following, the MOST likely diagnosis is?.", "options" : "[\"Disseminated herpes simplex virus infection\", \"Kawasaki disease\", \"Pharyngoconjunctival fever\", \"Stevens-Johnson syndrome\", \"Toxic shock syndrome\"]"}