Pediatric Emergencies

1.

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A three-year-old child presents to the Emergency Department with acute onset of

stridor and tachypnea. Discuss your approach to this patient including important
aspects of the history and physical exam, the differential diagnosis and management
principles.

2. A previously healthy, fully immunized two-year-old boy presents to the emergency

room at midnight following the sudden onset of a barky cough and increased work of
breathing. What is the most likely diagnosis? How would you manage this patient?
3.

A three-year-old boy presents to the Emergency Department with worsening cough,

wheezing and shortness of breath. He has difficulty talking in the Emergency
Department. How would you manage this child?

4. A two-year-old child presents with the abrupt onset of cough, wheeze and tachypnea.
He is afebrile. Physical exam reveals diminished air exchange and wheezing on the
right. What is the most likely cause of this patients finding? How would you proceed
to evaluate and treat this patient? What anticipatory guidance should this encounter
generate?
5.

A four-year-old girl is brought to the Emergency Department following the acute

onset of cough, increased work of breathing and tachypnea while at a friends
birthday party. What is your differential diagnosis? How would you evaluate and
manage this patient?

6.

A five-year-old boy presents following a dog bite on the back of his hand. What is the
initial management for this patient? How would your management change if this were
a superficial wound on his leg? What if the bite was from a cat?

7.

A twelve-year-old boy presents with scrotal pain. He has associated nausea and
vomiting but no fever. On examination, the left hemiscrotum is enlarged and slightly
bluish in hue. It is exquisitely tender to palpation. What is your differential
diagnosis? What is the first step in evaluation and management?

8.

The mother of an eighteen-month-old calls to say her child has pulled splattered hot
tea across his face and chest. How would you counsel her?

9.

A two year-old girl is bitten by a bat while playing in her yard in the early evening.
Would you recommend rabies prophylaxis?
Prevention

10. A ten-year-old boy is seen with a severe headache after falling from his bicycle. He
was not wearing a helmet. What advice would you give him?

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Newborn Exam

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Health Supervision
11. What topics are important to cover in a prenatal visit?
12. In the nursery, parents are informed that blood needs to be drawn from their newborn
for screening tests. Describe to the parents what these are and why they are
performed. What tests are routinely performed in your state? How are the results
transmitted to the parents?
13. A newborn has an APGAR score of 5 at one minute and 9 at five minutes. What are
the components of the APGAR score? How is the APGAR score used?
14. The mother of a newborn infant asks your advice about why she should breast-feed
her infant. She will need to return to work in 8 weeks and wonders if she should just
bottle feed. How would you counsel her?
15. A mother with no prenatal care and a history of known substance abuse just delivered
a baby at term. What special medical and social concerns do you have about caring
for this infant? What evaluations and treatments are necessary before discharge?
16. The parents of a newborn boy ask your opinion about whether the baby should be
circumcised. How should you counsel these parents?
17. What anticipatory guidance would you give the parents of a healthy, full-term, first
born infant at the time of discharge from the newborn nursery?
18. You are unable to see a red reflex when examining the eyes of a newborn. Discuss
the causes and your approach to this patient.
19. A term female is delivered via c-section because a frank breech presentation. What
features of the history and physical examination would support your concern about
development hip dysplasia in this child?
20. The breast-feeding mother of a 4-week-old infant is concerned that her baby is not
gaining enough weight. Her mother-in-law has encouraged her to start formula
supplements. The babys birth weight was 3500 g. His current weight is 4300 g.
How would you evaluate this infant and counsel the mother? What cultural beliefs
might be important to discuss.
Prevention
21. The parents of a newborn want to know why their infant has to face the rear window
in the car seat and ride only in the back seat. What would you say to them? What are
the different car restraints recommended based on age and size?

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Prevention
22. The parents of a two-month-old girl ask why their child has to be immunized. None
of their friends, family members, or neighbors has ever had hepatitis B virus
infection, tetanus, diphtheria or polio. What would you say to them?
23. List and discuss safety issues that should be discussed with parents at the newborn
visit, 9 month visit, 2 year visit and 6 year visit.
Health Supervision
24. A two-month old girl is brought to the office for a well child examination. The
mother is concerned about the potential complications of immunizing her child.
How would you address this issue? What if the mother refused immunizing her
child?
25. A four-month old boy is seen for a well child examination. Following his first set of
immunizations he had a temperature of 103 for 12 hours and was extremely
irritability. The parents are concerned about giving the next set of immunizations.
How would you address their concerns?
26. A twelve month-old child is seen for a health maintenance visit He is due to receive
his vaccines. On exam he has a temperature of 100.4 F and a runny nose. Should he
still be immunized? What are the absolute contraindications to immunizations?
27. The parents of a previously healthy nine-month-old girl want to know why a
hemoglobin was checked. How would you answer their concern? What are the
common etiologies of anemia at this age? How would you evaluate an abnormal
hemoglobin level?
28. The mother of a twelve-month-old girl, living in a house built four years ago, wants to
know why her daughter should undergo lead testing. How would you respond to her
concerns? What are the risk factors for lead poisoning? How do you treat an elevated
lead level?
29. The parents of a previously healthy three-year-old boy would like their son tested for
tuberculosis. What are the indications for tuberculosis testing? What are the
measurements of a positive PPD? How do you interpret a positive PPD in children
who had a BCG vaccine?
Possible Impaired Vision
30. The parents of a four-month-old are concerned because her eyes cross. What are your
concerns? How would you evaluate this patient?

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Child Advocacy
31. You live in a small town and note that many children have dental caries. You find out
that the water supply is not fluoridated. How would you proceed with this child?
Professional Conduct
32. The mother of a six-year-old boy is upset that you examined his testicles and penis
during a well-child examination. She feels that this part of the examination is private
and best left to family discussions. What would you say to her?

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33. A fifteen-month-old boy says no recognizable words. His parents are concerned and
wonder if he needs speech therapy. How would you respond to their concerns? How
would you evaluate this child?
34. An infant rolled over at four month, sat unassisted at six months, but at one year he is
unable to sit alone or stand. His parents are quite concerned and ask if this is normal.
How would you evaluate this patient?
35. The parents of a nine-month-old infant are concerned because she is not sitting. She
has increased tone, brisk deep tendon reflexes, and scissoring of her lower
extremities. She can grasp a rattle, but does not reach for objects. She coos and has a
social smile. What would you tell her parents? What important information should
you obtain from the history?
36. A nine month-old child has a head circumference of < 5th percentile. Her height and
weight are at the 25th percentile. How would you evaluate this child
37. The parents of fourteen month-old-boy born at 30 weeks gestational age are
concerned he is not walking. He sat alone at nine months and says two to three words
in addition to Mama and Dada. How would you counsel these parents?
38. A six-month-old infant is seen for a well child examination. His height and weight
have remained at the 25th percentile but his head circumference has gone from the 25th
percentile to greater than the 95th percentile over the past four months. What would
you be most concerned about? How would you evaluate this child?
Behavior
39. The parents of a three-year-old boy are concerned that he is not yet toilet trained.
How would you counsel them? What are the signs that indicate that a child may be
ready for toilet training?
40. A sixteen-month-old boy has had several episodes of breath holding leading to
cyanosis and becoming limp for a few seconds. They occur when he is angry or
upset. What is the most likely diagnosis? How would you counsel the parents? What
work-up may be warranted?
41. The parents of a three-month-old girl are surprised that she is not yet sleeping through
the night. What would you tell them?
42. The parents of a 3 year-old are concerned that their daughter still uses a pacifier.
What advice would you give them?
43. The parents of a 5-year-old boy are concerned about their child because he frequently
awakes screaming, appears frightened, is difficult to console, and does not appear to
be aware of his surroundings. How would you counsel the parents?

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44. A seven-year-old boy is still wetting the bed at night. How would you evaluate the
patient and counsel him and his family? What treatment modalities are available for
enuresis and when should they be implemented?
45. The parents of a seven-year-old boy receive a call from the childs teacher because he
is having difficulty following directions and behaving in class. She feels he has a
short attention span and is very distractible. How should you proceed? What are
possible etiologies of why a child is demonstrating these behaviors?
46. The parents of a two-year-old ask how to control their sons temper tantrums.
Describe how you would address this situation and what advice you would give.
Health Supervision
47. The parents of a 14-month-old girl feel that she is not developing at the same pace her
older brother did. How would you evaluate her development? What tools are
available for developmental screening?
Prevention
48. During a routine office visit the father of a six-year-old boy states that he recently
purchased a new shotgun for hunting. What questions would you consider asking the
father about storing the gun? What advice would you give to help prevent an injury?
Chronic Disability
49. The parents of an eighteen-month-old boy are concerned because he is not yet
walking. He has lower extremity hypertonia and hyperreflexia. What important
historical information should you gather? How would you counsel the parents?
Child Advocacy
50. A nine-year-old boy with learning disabilities and poor school performance is seen in
the clinic. How would you work with the school to increase the likelihood that he
gets the services that he needs?

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Endocrinology/ Growth & Development

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51. The parents of a three year-old girl are concerned because their daughter has
developed pubic hair. How would you evaluate this child?
52. The parents of a three year-old girl have noticed that she has developed bilateral
breast tissue. How would you evaluate this child?
53. The mother of a ten-year-old girl wants to know when she might start her periods.
What would you tell her? When would you expect her to have regular periods once
she starts menstruating?
54. A 14 year-old female has not started her periods. What important information should
you gather from the history and physical examination?
55. A fifteen-year-old boy is concerned that he is not yet developing facial hair and is
now considerably shorter than most of his peers. How would you evaluate and
counsel him?
56. A twelve-year-old boy complains that he is the shortest person in his class. He is 54
inches tall. He wants to know if he should take a growing medicine. What
additional information do you need from the history and physical examination before
counseling him regarding his growth potential? What are the indications for using
growth hormone in children?

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57. A sixteen-year-old boy presents to your clinic with polyuria and weight loss over the
past three weeks. Describe the important aspects of the history and physical exam,
diagnostic considerations, differential diagnosis and basic management principles
58. A fourteen-year-old girl with previously well-controlled insulin dependent diabetes
mellitus presents in diabetic ketoacidosis for the third time in the past six months.
What are the issues that might be adversely affecting her diabetes control?
59. A nine-year-old child with diabetic ketoacidosis has the following electrolytes: Na+
132, K+ 5.4, Cl- 103 and Bicarb 9. What is the anion gap? As the fluid deficit is
corrected what is likely to happen for the serum K? How should this be managed?
Prevention
60. A nine-year-old boy has been at the 95% for weight or more for the past three years
and at the 10% for height during the same time. What are the long-term health
consequences of this condition? How would you counsel the patient and the family?

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Nutrition

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61. Parents of a newborn infant want to know the advantages and disadvantages of breastfeeding compared to bottle-feeding. How would you counsel them?
62. A mother who is chooses not to breast-feed her child wants to know what types of
formula are available and which would be appropriate for her child? What are the
indications for using Soy protein formulas?
63. A mother is concerned that her five-day-old infant is not breast-feeding well. What
historical or physical examination findings would help you investigate her concerns?
How does the mother know that she is producing milk? What additional resources
may be available to help support this mother?
64. A three-month-old full-term infant, who was 3000 g. at birth, now weighs 3420 g.
Her height velocity has been normal. Her parents want to know if this is an adequate
weight gain. What would you tell them? What are the common causes of poor
weight gain at this age? How would you evaluate the infant?
65. A healthy four-month-old breast-fed child presents for a well-child examination. The
parents want to know when he can begin solid foods and when he should be weaned
from breast milk. When the mother decides to stop nursing, how would you advise
her to stop?
66. A healthy two-month-old infant, who is being breast-fed, is seen in your office for a
routine visit. The mother asks about the need for vitamin and fluoride
supplementation in her infant. Discuss which supplements should be considered and
at what age. What if she is feeding formula?
67. A one month-old born at term weighing 3.3 kg presents for a well child visit. Today
his weight is 4.0 kg, length 53 cm, and head circumference is 39 cm. He is taking
four ounces of Enfamil with iron every 3-4 hours. Is this adequate weight gain?
What are the caloric requirements for neonates and young infants?
68. A 9-month-old is drinking formula. Her parents ask if they can change from formula
to cows milk as they could save a lot of money. How would you counsel them?
69. The health conscious parents of a healthy, non-obese 15-month-old ask if they can
switch her to nonfat milk, as they are concerned about obesity and heart disease. How
would you counsel them?
70. An eighteen-month-old is drinking 48 ounces of whole milk a day. Is this
appropriate? How would you discuss this with the parents? What complication might
you see in this child?

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71. A five-year-old boy is now at the 95th percentile for weight and 50th percentile for
height whereas previously he had been at the 50th percentile for both height and
weight. How would you counsel him and his family? Include the consequences of
childhood obesity in your discussion.
72. In evaluating a four-year-old child, you discover that there is a strong family history
of diabetes and the father had a heart attack at age 35. How would you counsel the
patient and his family?
73. The parents of a 14 year-old female who is a competitive runner are concerned that
she has been tired, has stopped menstruating, and has been diagnosed with shin
splints. How would you counsel them?
Behavior
74. The parents of a two-year-old are concerned because he refuses to eat. What
additional information do you need? How would you evaluate him and counsel his
family?
Prevention
75. A six-month-old boy is seen for a routine health care supervision visit. The parents
want to know what types of foods he can eat. What foods should he not be offered?

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Nutrition
76. A thirteen-year-old girl wants to go on a diet. Her birthday was last week. Her
current weight is 45 kg and height is 157 cm. What is her BMI? How would you
evaluate and counsel her?
Professional Conduct and Attitudes
77. Brothers aged 10 and 16 present for a routine health care supervision visit with their
mother. How would you interview these patients? How would your interview
strategy or questions differ?
78. A previously healthy sixteen-year-old girl presents for a routine health care
supervision visit with her mother. When you ask the mother to leave the room she
refuses. How would you approach this situation?
Middle Adolescence
79. A fourteen-year-old female is seen in the clinic with her mother for acute onset of
dysuria and urinary frequency. How would you evaluate and manage this patient?
80. The parents of a previously healthy fifteen-year-old male bring him to you for a visit.
The previous weekend he returned home from a party confused and combative. They
are asking for your advice. Describe your approach to this clinical problem.
81. A fifteen-year-old-boy had been an honor student and is now failing most of his
classes. He seems withdrawn from his parents and friends. He quit the soccer team
after a fight with his coach. Describe your approach to the evaluation of this
adolescent. What confidentiality issues does this pose and what are the rules
regarding them?
Nutrition
82. A fifteen-year-old wrestler comes in for an annual visit and wants to know your views
on supplements and vitamins. How would you counsel him? What are the important
questions to ask in your history and what should you check on your physical
examination?
83. A fifteen year-old female comes to your clinic with complaints of bilateral leg pain.
On physical examination, you notice that she has lost fifteen pounds since her last
visit one year ago and she has missed her last six periods. Her BMI is 15. How
would you evaluate this patient?

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Prevention/ STD
84. A sixteen-year-old girl presents for a routine health care supervision visit. She has
had two sexual partners and has used birth control inconsistently. What advice would
you give to help prevent a sexually transmitted disease or pregnancy?
85. A sixteen-year-old girl presents with fever and lower abdominal pain but denies
urinary urgency or frequency. She is sexually active and uses condoms infrequently.
How would you evaluate this patient?
86. A sixteen-year-old boy presents with a chief complaint of urethral discharge. He
states that he notices it most in the morning. He has mild burning with urination. On
examination, you note mucoid discharge at the urethral meatus and slightly enlarged
inguinal nodes. What other historical questions do you need to ask? What laboratory
testing will you order?
Late Adolescence
87. The parents of a fifteen-year-old boy bring him to your clinic after he threatened to
take a bunch of pills. Although his affect seems depressed, he is not currently
suicidal. Explain your approach to this young man, including important history,
physical exam findings, diagnostic studies, management principles and advice to his
parents.
88. During a routine health care visit a fifteen-year-old girl with a history of depression
confides to you that she would like to end her life. What should you do?
89. A seventeen-year-old female sees you for a pre-college physical. Describe your
approach to history, physical exam and guidance/counseling.
Professional Conduct and Behavior
90. During a routine health care supervision visit of a sixteen-year-old girl, the mother
pulls you aside to tell you that she is very concerned about her daughters behavior
and demands to know if the daughter is using drugs or having sex. What are you
ethical and legal obligations? What would you tell the mother?
91. A fourteen-year-old female well known to your practice makes an appointment to see
you alone regarding a desire for contraception. What advice would you give her?
What are her rights to confidentiality? What are your responsibilities to inform her
parents?

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Fluid and Electrolyte Management__________________ ____________

92. A nine-month-old infant has diarrhea and signs of moderate dehydration. His
electrolytes are Na+ 162, K+ 5.6, Cl- 122, and bicarbonate 12. During IV rehydration
the patient has a generalized seizure. What is the probable cause of the seizure? How
should it be treated? How could this complication have been avoided?
93. A seven-month-old infant has had fever, vomiting and diarrhea for the past 24 hours.
What are the symptoms and physical findings to help you decide if the infant is
dehydrated?
94. A three-year-old girl has had forty-eight hours of fever, vomiting and diarrhea. How
would you evaluate her hydration status? Discuss management principles based on
diagnosis and physical exam findings
95. A six-year-old girl admitted for elective surgery and she is made NPO. She weighs 21
kg and is 135 cm. tall. Write the orders for her IV fluids prior to surgery.
96. A two-year-old has sustained a severe closed head injury and is comatose. He
weights 14 kg. What factors need to be considered when calculating his daily water
requirements? How will you follow this patients clinical course to adjust fluids
appropriately?
97. An infant weighing 8 kg is estimated to be 12% dehydrated. What fluids should you
start initially? What laboratory tests should be ordered immediately? What is the
calculated fluid deficit and how should it be replaced? What IV solution(s) should be
used?
98. A two-month-old infant is brought to the Emergency Department because of seizures.
He has had diarrhea for five days and has been fed only water and diluted apple juice.
What might be the cause of the seizures and how should they be treated?
99. A nine-month-old infant has vomiting and diarrhea. He has dry mucous membranes
and decreased tearing and urination. After your assessment, you would like to try oral
rehydration. What liquids, what quantity, and how often should the mother give the
fluids to the infant?
100. A nine-month-old girl present with two days of vomiting and diarrhea. She is listless
and her heart rate is 210. What is the most appropriate initial management of this
child?

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101. A two-week-old presents with a fever of 101 F. She has been feeding a little less
than normal and there has been no vomiting or diarrhea. Her physical exam is normal.
What makes this patient concerning and why? How would you evaluate and manage
this patient?
102. A six-month-old has had a high fever for three days and has been seen in your office
for the last two days. He has had a normal exam on both of those visits. On the fourth
day he breaks out with an erythematous macular-papular rash all over shortly after his
fever breaks and he is very fussy. What is the most likely diagnosis? How would you
manage this patient?
103. A seven-month-old girl presents to your office with a one day history of fever to 103
F, mild irritability, and poor feeding. The physical exam is normal without any
localizing findings. What are your concerns? How would you evaluate and manage
this patient?
104. An eight-year-old presents with a fever of 102 F and headache. He has positive
meningeal signs including nuchal rigidity. What other physical findings would you try
to elicit? How would you evaluate and manage this patient?
105. A seven-year-old girl presents to your office with a history of two days of cough,
coryza, conjunctivitis and a fever to 103 F. Today she developed a red macularpapular rash that started on her face and neck and it is spreading caudally. What are
your concerns? How would you evaluate and manage this patient?
106. A four-year-old boy presents with a five-day history of fever and rash. He has
received acetaminophen and amoxicillin without improvement. He is very irritable
with a temperature of 103.6 F, bilateral non-purulent conjunctivitis, enlarged cervical
nodes, puffy hands and a maculopapular rash. What is the most likely diagnosis?
How would you evaluate and manage this patient?
107. A sixteen-year-old male presents with fever, fatigue and sore throat for a four days.
Discuss what aspects of physical exam and lab data that will help establish a
diagnosis.
108. A six-year-old presents with a fever, headache, sore throat, and raised, rough, red rash
in his trunk and abdomen. There are no symptoms of a URI. What is the most likely
diagnosis? How would you evaluate and manage this patient?
109. A nine-year-old presents with a sore throat and fever of 101 F. He has a cough and
runny nose. There are small minimally tender anterior cervical lymph nodes and a red
pharynx without exudate. What is your differential diagnosis? How would you
evaluate and manage this patient?

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110. A fourteen-year-old female present with fever, headache and sore throat. She has
exudates on her tonsils, an erythematous posterior pharynx, enlarged posterior
cervical lymph nodes and a palpable spleen. What is your most likely diagnosis?
How would you manage this patient?
Lymphadenopathy
111. A six-year-old, previously healthy, girl presents with a 3 by 5 cm tender anterior
cervical lymph node. What historical and physical examination information is
essential to develop an appropriate differential diagnosis?
Therapeutics
112. An eleven-year-old has a sore throat. She has fever and a headache. Her pharynx is
red and there are petechiae on the soft palate. The rapid streptococcal test is positive.
How would you treat this child? When can she return to school?
113. A four-year-old girl has urinary urgency and dysuria. A clean catch urine shows 50100 white blood cells, 5-10 red blood cells, and positive nitrites and leukocyte
esterase. How would you manage this child? If the urine culture was positive, what
further evaluations would you do?
114. The mother of a one year-old girl with a fever of 39 C asks if she should give her
child medicine for the fever. What other information should you gather from the
mother? What is the appropriate dose of acetaminophen OR ibuprofen and how often
should it be administered?

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Therapeutics
115. An eighteen-month-old has bilateral injected conjunctiva with purulent drainage.
There are no other physical findings. How would you manage this patient?
Otalgia
116. An eight-month-old male with a four-day history of URI symptoms presents with
fever, irritability and pulling at his left ear for the past 24 hours. What physical
findings would be consistent with an acute otitis media? How would you treat this
patient? How would your management change if the patient were 3 year-old?
117. A fifteen-month-old was treated for acute otitis media three weeks ago. Today, both
tympanic membranes look dull, gray, and have poor mobility. The parents are
concerned that his hearing appears abnormal. How would you manage this patient?
What if these findings were still present four months later?
118. An eleven year-old presents in July with left ear pain. He has been afebrile and there
has been drainage from the canal. He refuses to let you touch his ear. What is your
diagnosis? How would you treat this patient?
119. A ten-year-old swimmer complains of otalgia and ear discharge. His right external
ear canal is filled with a purulent discharge. There is pain on touching the pinna and
he wont allow you to inspect inside the ear. Discuss your diagnosis and initial
treatment plan. What measures could prevent this from recurring?
Therapeutics
120. A three-year-old has acute otitis media. She is not allergic to any medications.
Which if any antibiotics would you prescribe and why? What treatments could you
offer this patient to alleviate the pain?
Nasal Discharge
121. A seven-year-old presents with two weeks of coughing and nasal congestion
following a URI. The cough is worse at night and frequently awakens him. His
mother says he has also developed bad breath. What is your differential diagnosis and
how would you manage this patient? When would further workup/imaging be
warranted?
122. A ten-year-old presents with a headache, nasal discharge and a mild cough. He is
afebrile now and his examination is unremarkable. How would you manage this
patient?

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123. An eleven-year-old has springtime nasal congestion and itchy eyes which have
become more of a problem over the last three years. How would you manage this
child?
124. A sixteen-month-old presents with a history of nasal discharge for the past week
presents with a swollen red eye and fevers to 103 F. What are you most concerned
about? What physical findings are important to look for in this patient? How would
you proceed if you could not visualize the globe because of the swelling?
Optional
125. A three-year-old presents with runny nose, mild irritability, with temperature of 99 F
over the past forty-eight hours. Other than clear nasal discharge his examination is
unremarkable. How would manage this child? What advice would you give the
parents?
126. After informing the mother of a two-year-old infant that the child has a viral infection
and no specific treatment is necessary, the mother demands antibiotics for the child.
How would you respond?
Impaired Hearing
127. The parents of a two-year-old boy are concerned that he doesnt appear to hear. How
would you evaluate the patient and counsel the parents?

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128. A previously healthy 5-month infant presents with a cough and increased respirations.
On physical exam, she is pink, there are diffuse wheezes, and a few crackles. There
are mild intercostal and subcostal retractions. She is taking oral fluids well and is well
hydrated. The O2 saturation is 99% in room air. How would you manage this
patient?
129. A six-month-old former 28-week premature infants presents with URI symptoms,
cough, and poor oral intake. She is tachypneic with retractions and diffuse crackles
and wheezes. A CXR shows bilateral perihilar streakiness and hyperinflation.
Discuss your differential diagnosis. What diagnostic and therapeutic interventions are
warranted? What preventive measures would you recommend for this patient?
130. A one-month-old infant with a one-week history of cough and congestion now
presents with paroxysms of cough associated with blue spells. He is afebrile with a
normal examination between paroxysms of coughing. A CXR is normal. Discuss
your differential diagnosis. How would you evaluate and manage this patient?
131. A two-month-old afebrile infant with a history of conjunctivitis at 10 days of age
presents with a staccato cough and tachypnea. Physical exam reveals bilateral
crackles and mild retractions. A CXR shows patchy densities and hyperinflation. A
CBC has an increased numbers of eosinophiles. Discuss your differential diagnosis.
How would you manage this patient?
132. A ten-month-old girl present with recurrent pneumonia and failure to thrive. She has
thrush and numerous axillary and inguinal nodes. How would you evaluate this
patient?
133. A four-year-old presents with a cough for 3-4 days following a URI. He has had a fever to
104 F for twenty-four hours. Exam reveals crackles on the right. What other physical
finding should you try to elicit? What would you expect the CXR to show? What are the
potential etiologies? How would you manage this patient?
134. A twelve-year-old boy presents with a three-day history of cough, chest pain and fever
of 101 F. Physical exam reveals diffuse bilateral crackles. A CXR shows diffuse
interstitial markings. Discuss your differential diagnosis. What could be causing the
chest pain? How would you manage this patient?
135. An eleven-year-old presents with frequent episodes of a coughing illness often
triggered by colds. What is the most likely diagnosis? How would you manage this
patient?

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Lower Respiratory Tract Infection/ Cough____

__________ Page 2 of 2

Chronic Illness and Disability

136. Smoke, dust and exercise trigger asthma attacks in an eleven-year-old boy with
asthma. Both of his parents smoke and he would like to play basketball on the school
team. Discuss the medical management of this child. How would you negotiate an
asthma care plan with the child and family?
137. A seventeen-month-old girl is diagnosed with cystic fibrosis after her third
hospitalization for pneumonia. Her mother is pregnant. What are the short and long
term implications for this girl? What are the implications for the family including the
unborn child?
Therapeutics
138. A thirteen-year-old has had a persistent cough without other complaints or findings
for the past week. It is not interfering with sleep. How would you manage this child?
139. A known asthmatic complains of worsening cough and wheezing, unresponsive to
inhaled albuterol. How would you manage this patient?
140. A six year-old boy has been coughing particularly at night for 3 days. On physical
examination he has diffuse wheezes. There is no history of reactive airway disease.
Discuss your initial assessment and treatment?
141. A sixteen-year-old presents with cough and shortness of breath following exertion.
This is affecting his ability to play soccer. What is the most likely diagnosis? How
would you manage this patient?
Health Supervision
142. A twelve-month-old child has been taking 2 mg/kg/day of oral prednisone for the past
three days for asthma. He is due for his routine immunizations. Would you modify
his immunization schedule? What if he had been taking 2 mg./kg./day for the past
three weeks?

End of First Half

Midterm Exam

86

Musculoskeletal

___________ ______________

Limb and Joint Pain

143. A fourteen-year-old male presents for a football sports physical. What are the
important points to cover in the history and physical exam?
Prevention
144. A twelve-year-old girl presents for a pre-participation sports physical examination.
What are the key components of the sports history and physical examination?
Limb and Joint Pain
145. During a routine physical examination, you notice a curvature of the spine in a
fourteen year-old female. What other information is important to document on your
physical examination? How would you evaluate this patient?
146. A fifteen-year-old girl badly twisted her ankle while playing basketball earlier in the
day. What advice would you give her? What are the indications for a radiograph?
How would the management change if this were 6 year- old boy?
147. An athletic twelve-year-old boy complains of pain just below the right knee when
running and playing soccer. There is no joint swelling or redness. There is pain on
palpating the right tibial tuberosity. Discuss the most likely cause and treatment.
148. A fourteen-month-old girl presents with the sudden onset of fever and refusal to walk.
Discuss your differential diagnosis and evaluation of this child.
149. A five-year-old present with a swollen red knee. Discuss your differential diagnosis
and evaluation of this child. How would your differential diagnosis change if he later
developed swelling of the knee and wrist?
150. A fifteen year old, slightly overweight male, presents with pain in his left hip. There
is no history of trauma or fever. What is in your differential diagnosis? How would
you evaluate this patient?

87

Cardiology

___________

_______________

Heart Murmur
151. On routine physical exam a five-year-old girl is found to have a heart murmur. How
would you distinguish between and innocent and a pathologic murmur? What
information and anticipatory guidance should you give the parents of a child that has
an innocent murmur?
152. You are examining an otherwise healthy one-month-old child and detect a systolic
murmur along the left sternal border that radiates to the back. What would you tell
these parents and how would you manage the patient?
Chronic Illness and Disability
153. A newborn has hypotonia, downward slanting palpebral fissures, a single palmar
crease, and an III/VI holosystolic murmur at the mid left sternal border. What would
you tell the parents? What are the short-term implications? What medical conditions
are these children at risk for?

88

Neurology/ CNS Problems

______ ______________

154. A previously healthy fourteen-month-old presents to the Emergency Department

following a 2-3 minutes of generalized, symmetric tonic-clonic movements. There is
no prior history of seizures. Discuss your approach for the following scenarios:
a. The child was sleepy initially but is now awake, alert and easily consoled by her
parents. Her temperature is 104F. Her examination is normal
b. The child remains somnolent and appears to have nuchal rigidity
155. A nine-year-old boy is complaining of headaches for the past two weeks. His mother
brings him to the pediatrician for evaluation. Discuss your differential diagnosis and
key elements of the history and physical exam
156. A fourteen-year-old girl presents to the ER with a right-sided headache, which she
describes as the worst headache Ive ever had. She reports seeing flashing lights
prior to the onset of the headache. Discuss your initial assessment and treatment of
this patient.

89

Dermatology __________________________

_____ _____________

Rashes
157. A four-year-old girl presents to your clinic with a diffuse pruritic rash. She has
numerous evanescent raised erythematous lesions with serpiginous borders and
blanched centers. What other information would you like to know about this patient?
What other physical findings would concern you? What is the appropriate diagnosis
and treatment of this condition?
158. A four-year-old presents with a dry, erythematous, itchy rash in the antecubital and
popliteal fossae. What are the most likely diagnosis and appropriate therapy?
Therapeutics
159. A two-year-old presents with a recurrent pruritic rash on his arms and legs. He has
patches of erythema with obvious excoriations on the extensor surfaces of his arms,
legs, and also in the antecubital fossae. How would you treat this condition? What
preventive measures may be helpful to prevent further flare-ups?
Rashes
160. An eighteen-month-old presents with many golden-yellow crusted-weeping lesions
around the nose which seem to be spreading according to the childs parents. Discuss
the likely diagnosis and management considerations.
161. A fifteen-year-old boy is concerned that his acne is worsening. He has multiple open
and closed comedones scattered over his face. How would you counsel and treat this
patient?
Therapeutics
162. The mother of two young children asks which sunscreen and insect repellent to use on
a camping trip. What advice would you give her? When and how often should she
apply the products?

90

Gastroenterology

__________

____ Page 1 of 2

Abdominal Pain
163. A ten-month-old presents with bouts of irritability during which he draws up his legs
and appears to be in pain. He had a viral illness the previous week. His stools are
hematest negative and he is very lethargic. There is abdominal distention and diffuse
tenderness. What is your differential diagnosis? What is the most likely diagnosis?
How would you evaluate this patient?
164. A fourteen-year-old male present with six hours of severe abdominal pain that is now
more right sided. He has vomited twice and has no appetite. He has had no diarrhea.
There is localized pain in the right lower quadrant. What other history and physical
findings would be important in this boy? How would you evaluate this patient? How
would your approach differ if the patient were a girl?
165. An eight-year-old female present with abdominal pain, purpuric lesions on the
buttocks and lower extremities, and knee and ankle pain. She has also noted her urine
to be darker than usual. What is the most likely diagnosis? How would you evaluate
this patient? What treatment options are available?
166. The mother of a fourteen-month-old baby feels an abdominal mass while giving her
son a bath. On physical examination you palpate a mass in the left upper abdomen.
What is your differential diagnosis? How would you evaluate this child?
167. The parents of a three week-old male are concerned because their child squirms and
grunts while having a bowel movement. The stools are soft and the child is thriving.
How would you counsel these parents?
168. A seven-year-old girl complains of a periumbilical abdominal pain several times a
week, often keeping her home from school. It is not associated with vomiting,
diarrhea, or fever. She is growing and developing normally and her physical
examination is normal. How would you further evaluate this child?
Diarrhea
169. A six-year-old boy present with pallor and irritability following a week of abdominal
pain and blood tinged diarrheal stools. What would you be most concerned about?
How would you evaluate and manage this patient?
Heptomegaly
170. A four-year-old child presents with nausea, vomiting, fever, and fatigue. On physical
exam he has scleral icterus and a tender liver edge palpable 3 cm below the costal
margin. Discuss your plan for evaluating and treating this patient. What prophylactic
measures are necessary?

91

Gastroenterology

_____ _____ Page 2 of 2

Constipation
171. A six-year-old presents with chronic abdominal pain of six weeks duration and
episodic fecal soiling of his underwear. He has been gaining and growing well. How
would you evaluate this patient? What advice and treatment plans would you offer to
this family?
Child Advocacy
172. A child is seen in the pediatric clinic for vomiting. On further questioning you find
that the family is homeless and living in a car. Describe how you would approach
helping the family. Discuss how you would treat the childs acute and ongoing
medical needs.

92

Lethargy/ Fever/ Sepsis_

___________

_______________

173. A four-month-old baby presents to the Emergency Department with a fever of 104F
and petechiae. How would you evaluate and manage this patient?
174. A four-year-old boy present with brief loss of consciousness and vomiting after
falling off a six-foot high slide. How would you evaluate him and what are your
concerns?
175. What is the differential diagnosis of lethargy in a 9 month old?
176. A mother rushes a two-month-old girl to the Emergency Department after finding her
cyanotic in her crib. Her examination is now normal and she is acting appropriately.
How would you evaluate this infant and counsel her mother?
177. A two-year-old boy is brought to the Emergency Department in a coma after his
mother found him limp and unresponsive in his room. What questions would you
want to ask the mother to help learn why this patient might be unresponsive?
178. During the winter, the parents of a seven year-old bring their son to your office
because of headaches, fatigue, and nausea. Other family members have had similar
complaints. What would you be concerned about?

93

Poisoning____________

______________________________

179. An eighteen-month-old boy is found in the garage holding a jar of paint thinner. The
parents smell the chemical on his breath and on his clothing. He is acting normally.
What would you instruct the parents to do?
180. You receive a phone call from the mother of a 12 kg two year-old child who was
found eating her mothers prenatal vitamins that contain iron. Each tablet contains 60
mg of elemental iron. She thinks he may have swallowed 16 tablets. What amount of
elemental iron ingestion is potentially toxic for a child? What additional information
do you need from the mother? What advice would you give the mother?
181. After a fight with her boyfriend, an 80 kg. sixteen year-old takes thirty 500 mg
acetaminophen tablets. She presents to the emergency department six hours later
when she is feeling nauseated. What is the appropriate evaluation and management of
this adolescent?
182. A three-year-old is brought to the Emergency Department because of weakness,
diarrhea and drooling. He had been playing unsupervised in the garage. He is found
to have pinpoint pupils and bradycardia. What is the most likely cause of these
symptoms and how should the patient be treated?
183. A three-year-old child is seen in the clinic because of irritability, decreased appetite
and intermittent abdominal pain. He has developmental delay and a history of iron
deficiency anemia. How would you evaluate and manage this child?
184. The parents of a twelve-month-old girl bring her for a routine health care supervision
visit. What anticipatory guidance would you give them to minimize the likelihood of
an accidental poisoning occurring in the house?
185. A two-year-old girl is brought to the Emergency Department after ingesting an
unknown quantity and type of her grandmothers pills. What resources are available
to help identify and treat the ingestion?
186. A two year-old child is found in the bathroom with an open bottle of liquid drain
cleaner. She has a small area of bleeding on her lips. What is the most serious
toxicity of this ingestion/exposure.

94

Child Abuse

__________

_______________

187. A four-year-old male presents to the clinic because of a sore throat for two days.
During the physical examination looped shaped marks on his back and arms are seen.
How would you evaluate and manage this patient? What would you tell the parents?
188. An eighteen-month-old infant presents with scald burns to the buttocks and legs. The
parents report the child turned on the hot water tap while playing in the bathtub.
How would you differentiate an accidental burn from an inflicted burn?
189. A two-year-old presents to the Emergency Department after breaking her arm during a
fall. The child was seen six months ago with a broken leg. What are your concerns?
How would you evaluate this child?
190. A two-month-old boy presents with lethargy and is poorly responsive. On physical
examination there is no evidence of trauma but you discover bilateral retinal
hemorrhages. What are your ethical and legal obligations? To whom would you
report your findings? What would you say to the boys parents?
191. A nine-month-old boy has a history of poor weight gain for several months. His
weight has fallen from the 50% to the 10% over the past four months. During a
hospitalization for poor weight gain he had a normal physical examination, normal
laboratory values, and demonstrated excellent weight gain on an age-appropriate diet.
Now one month following discharge from the hospital he has lost weight. What
would you do for this child? Discuss the medical, legal and social implications of
your actions.
192. A seven-year-old female patient present with vaginal discharge. In addition to poor
hygiene, what else is in the differential diagnosis?
193. An eight-year-old male with dysuria and a urethral discharge grows N. gonorrhea
from a urethral culture. What medical, legal, and social issues should you address?

95

Medical Genetics and Dysmorphology ______ ______________

194. A three-year-old girl presents for evaluation of recurrent pneumonia (five times in two
years) and chronic diarrhea. She is at the fifth percentile for height and weight. What
are your differential diagnoses? How would you evaluate this patient?
195. A newborn infant has prominent epicanthal folds, small ears, hypotonia, short, broad
hands and feet, brachycephaly and a heart murmur. The mother notes that the baby
looks different than her two previous children. How would you evaluate this infant
and counsel the mother?
196. The parents of a two-year-old boy with developmental delay report a history of mental
retardation in several male members of their family. What are your differential
diagnoses and what diagnostic screening would you recommend?
197. A sixteen-year old girl presents to your clinic with primary amenorrhea. She has been
doing well at school but is not athletic and her height is less than the 5% for age. On
physical examination she has redundant neck skin, broadly spaced nipples, and is
Tanner stage I. How would you evaluate and counsel her?
198. The mother of a newborn tells you she has taken seizure medications throughout her
pregnancy and wants to know what effect this may have on her baby. How would you
counsel the mother?
199. You are asked to evaluate a baby in the nursery who is small for gestational age and
microcephalic. How would you evaluate the infant? What questions would be
important to ask the mother?
200. The pregnant mother of one of your patients calls to say that a prenatal ultrasound
revealed that her fetus might have spina bifida. She had not taken multivitamins prior
to conception. She wants to know the implications of the disease. How would you
counsel her? Should any special precautions be taken at the time of delivery and in
neonatal period?

96

Hematology/ Oncology

___________

_______________

Splenomegaly
201. A four-year-old boy presents with fevers and malaise for a week. He appears pale,
has diffuse petechiae, palpable axillary lymph nodes, and his liver and spleen are both
enlarged. What is your differential diagnosis? How would you evaluate this patient?
202. A two-year-old boy with sickle cell disease presents with the sudden onset of pallor
and has an enlarged spleen on examination. What would you be most concerned
about?
Chronic Illness and Disability
203. A fifteen-year-old boy with sickle cell disease is concerned because he has not yet
developed facial hair and is considerably shorter than his peers. How would you
counsel him?
Bleeding
204. A previously healthy two-year-old present with persistent nosebleeds over the past
two days and petechiae on her extremities. What is your differential diagnosis? How
would you evaluate this patient?
205. On a routine health supervision visit a one-year-old boy is found to have an Hgb of
8.8, Hct of 27%, an MCV of 68, and an RDW of 17. What is your differential
diagnosis? How would you manage this patient?
Genetics
206. A mother of a two-year-old child with sickle cell disease is pregnant and wants to
know the likelihood that the current fetus will have sickle cell disease. How would
you counsel her?

97

Nephrology_______________________________________ ___________

Hematuria/ Proteinuria
207. A ten-year-old boy complains of dark urine and a headache. Discuss your
diagnostic approach to this patient.
208. A three-year-old boy is brought to the pediatrician because of puffy eyes, swollen
legs, an enlarged scrotum, and a sudden weight gain. What is your differential
diagnosis and how would you evaluate this patient?

98

Issues Unique to the Newborn

_______________

_______________

209. A six-hour-old infant born at term is persistently tachypneic with respiratory rates in
the 80s. What additional information would be helpful in evaluating this infant?
Discuss the diagnostic considerations and initial approach to the evaluation of this
child.
210. An eight hour-old neonate is noted to have a distended abdomen and has not passed a
meconium stool. How would you evaluate and treat this patient?
211. A twenty-four-hour-old infant has not passed meconium. Discuss the possible
explanation and your concerns.
212. A full-term infant appears yellow at 48 hour of age. She weighs 3700 g. The total
bilirubin is 13 mg/dl and the indirect is 12.7. What components of the history,
physical examination and laboratory data would be helpful in evaluating this child?
213. An otherwise thriving 21-day-old infant appears yellow. What additional history and
evaluation would be important in assessing this infant?
214. A full term newborn weighs 2000 grams. What factors might have contributed to this
infants small size? How do you assess the maturity of this infant? What should you
monitor in the nursery?
215. A term newborn weights 4800 grams. His mother is an insulin dependent diabetic
who had good control during her pregnancy. What immediate complications might
this infant experience in the nursery?
Prevention
216. The parents of a newborn are concerned about Sudden Infant Death Syndrome and
have purchased a baby alarm. What advice would you give them to help prevent
SIDS in their infant?
Chronic Illness and Disability
217. During routine screening at fourteen-weeks gestation the mother of one of your
patients is found to be HIV antibody positive. What interventions can be done to
minimize perinatal transmission? After delivery, how would you confirm or exclude
HIV infection in the infant?

99

Ethics/ Professional Conduct and Attitudes

_______ ____________

218. In a crowded elevator a fellow medical student begins discussing a fascinating patient
that he has seen earlier in the day. How would you respond?
219. While on attending rounds with the Pediatric Clerkship Director (who assigns the
final grade for the rotation) you are asked if one of your patients has been febrile
during the past 24 hours. You cannot remember if the patient has been afebrile or not.
What should you tell the attending?
220. During a routine health care supervision visit of a sixteen-year-old girl, the mother
pulls you aside to tell you that she is very concerned about her daughters behavior
and demands to know if the daughter is using drugs or having sex. What are you
ethical and legal obligations? What would you tell the mother?
221. A previously healthy sixteen-year-old girl presents for a routine health care
supervision visit with her mother. When you ask the mother to leave the room she
refuses. How would you approach this situation?
222. Brothers aged 10 and 16 present for a routine health care supervision visit with their
mother. How would you interview these parents? How would your interview
strategy or questions differ?
223. You and two other students are alone waiting for attending rounds to begin. One of
the students makes a racist remark about a patient he had seen earlier in the day.
What should your response be?
224. The clerkship director has scheduled a mandatory meeting with all the students on the
rotation to discuss the final examination. Just before the meeting, a sixteen-year-old
girl with cystic fibrosis whom you have been following on the ward, says that she
needs to speak with you right away and begins to cry. What should you do?

100