PEM Source

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PEM Questions

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You are seeing a 16-year-old boy who was walking home from school when he experienced sudden onset of intense dread, racing heartbeat, dizziness, difficulty breathing, tingling in his fingertips, and trembling. His friend called 911 and he was brought in by ambulance. Although many of his symptoms have improved, he remains nervous-appearing and mildly tremulous. He denies any drug intake or intake of other substances, supplements. He does not recall thinking about anything stressful prior to his symptom onset. Vital signs are temp 37.6, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. His physical and neurologic exams are normal.

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You are seeing an 8-year-old boy for prolonged nosebleed last night and this morning. Last night it happened on the right nares, and this morning on the left nares. Dad is a nurse and held pressure until the bleeding stopped, and there is currently no bleeding. Exam shows temp 37.5, HR 90, RR 24, BP 94/56. Exam is negative for lymphadenopathy, hepatosplenomegaly, or pallor. There is a small amount of dried blood in the left nares. His parents did not notice any rash, but on exam with the patient undressed you notice a few petechiae on the ankles and across the lower abdomen. There are no purpura. Laboratory values are: WBC 10.3, diff 40% polys, 45% lymphs, 8% monos; Hgb 13, Hct 39, Platelets 1. Lytes, LFTs, BUN/Cr, are all normal. There are no inpatient beds available, so management will begin in the ED. 

[yop_poll id="334"]

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Which of the following otherwise well-appearing non-toxic patients with a low-grade fever from viral URI should NOT take ibuprofen?

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[yop_poll id="332"]

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A previously-healthy 12-year old girl who was allowed to get a high cartilage ear piercing after much begging now comes in with evidence of infection around the piercing site. There is a small amount of purulent discharge. The piercing has been removed.  The child is afebrile and nontoxic and there are no signs of infection spread such as mastoiditis, brain abscess, meningitis. You plan a trial of outpatient antibiotic therapy with close follow-up. 

[yop_poll id="331"]

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[yop_poll id="330"]

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Ketamine has been in the news lately, contributing to the death of actor Matthew Perry and playing a part in the recent successful prosecution of two paramedics for the death of Elijah McClain. 

[yop_poll id="329"]

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[yop_poll id="328"]

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[yop_poll id="327"]

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[yop_poll id="326"]

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A childless uncle & aunt are picking up a last-minute holiday gift for their nephews and nieces. They desparately want to be thought of as cool by the kids. The children range in age from 2 years to 13 years old. 

[yop_poll id="325"]

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Parents bring in their 18 month old uncircumcised son because of concern regarding a bump on his penis. He has no other symptoms and is afebrile. They first noticed it 3 days ago and it is unchanged. On exam there is a 3-4mm diameter pearl-like white mass under the prepuce (distal foreskin). It is not fluctuant or tender. The child is phimotic, and the foreskin can be retracted to visualize the meatus, but not fully retracted. 

[yop_poll id="324"]

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You are seeing a 10 year old boy with 3 days of submandibular swelling. On exam, he has a 2cm x 3cm tender swelling in his right submandibular area. The parents report that the has had this twice before, each time treated with amoxicillin-clavulanate and resolved. He is afebrile.

[yop_poll id="323"]

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[yop_poll id="322"]

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[yop_poll id="321"]

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You are seeing a 12 year old boy with pain in his lower back and right buttock for 2 weeks. He is an active soccer player. On exam, he has tenderness over his right sacroiliac joint. 

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You are seeing a 15 year old boy who was “jumped” by a group of boys at school today and hit in the head area. He has a 3cm diameter tender ecchymotic area that is swollen and fluctuant on the auricle of his left ear, in the scaphoid fossa, which is the area between the helix and antihelix. 

[yop_poll id="319"]

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You are seeing an 18 month old with 3 days of cough and congestion and 4 hours of tachypnea. On exam, she has diffuse scattered wheezes and mild intercostal retractions. Her vital signs are: temperature of 38.6, HR 160, RR 40, and O2 sat 94% on room air. As part of her fever work-up her urine is dipped, and while there are no signs of UTI, she has glucosuria. Her serum glucose is 160, and her lytes are Na-138, K-4.2, Cl-110, CO2-17. 

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A 20-month old child is brought in by ambulance for lethargy and altered mental status. You find out his grandmother has been administering frequent doses of milk of magnesia to treat constipation. You suspect hypermagnesemia. 

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You are seeing a 3 year old who was running in the house, tripped and fell, hitting his mouth on the coffee table. On exam, his two upper central incisors are pushed up into his gums. None of his teeth, including those two, are loose. There was bleeding initially, but it has stopped spontaneously. He has no apparent pain and is climbing all over the gurney.

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[yop_poll id="314"]

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You are seeing an adolescent who had a syncopal episode at school. It occurred 10 minutes after P.E. class had finished, when she was in the locker room changing out of her gym clothes. 

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Parents bring in their 11 month old baby for a new-onset rash. The baby is unimmunized by parent choice. The baby had fever for the last 3 days to a maximum of 104 F. Although he had fever, he was well-appearing and still eating normally and playful. But since the fever was persistent, they took him to a clinic yesterday and he was diagnosed with a throat infection and started on amoxicillin. He has received 2 doses. Today he awoke with a fine morbilliform blanching pink rash that started on the neck and trunk, then has spread to the face and extremities. It does not seem itchy and it does not involve the mucosa. The only other medication he has had was acetaminophen yesterday at 5pm. On exam, he is nontoxic and interactive. Vital signs: temp 98.9 F, HR 132, RR 28, O2 sat 99% on room air. ENT, chest, and abdomen exams are unremarkable. 

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You are seeing a 3 year old boy with unresolving right-sided ear infection. He was first seen 1 month ago and diagnosed with right AOM and prescribed 10 days of amoxicillin. He returned after completing that course with ongoing pain, was diagnosed with persistent right AOM, and prescribed 10 days of augmentin. He has completed the augmentin and was feeling a little bit better for a few days before his symptoms returned and then became worse. He now also has a fever to 101. During the few days he felt better, he did go to a waterpark. On exam, his external auditory canal is swollen and red. Partial view of his tympanic membrane reveals it to be bright red and bulging. He indicates his entire ear when asked where it hurts, and he has swelling and redness and tenderness to palpation behind his ear as well. 

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You are seeing a 6 year old girl who comes in for right leg pain after a ground level fall at the park. She is currently being worked up by her pediatrician for precocious puberty, including vaginal spotting and breast buds. On exam, her temp is 37.5, HR 90, RR 22, pulse ox 100% on room air. Her face appears asymmetric. Heart and lung exam is normal. Abdomen is soft, and you do not palpate any masses. Her right leg shows no swelling, obvious deformity, or neurovascular compromise, but she is tender to palpation along her anterior tibia. She has a large light brown irregularly shaped macule on her back. 

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You are seeing a 14 month old who has a two irregularly oval yellow-tan lesions on his right upper arm, just under 1cm each. They have been present all his life and have grown slightly. Sometimes they seem to become acutely inflamed, and the boy has flushing and intense itching. 

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A father brings in his 11-year-old son for medial elbow pain. The boy is the star player (and often the starting pitcher) on his little league team, and Dad is the coach. The team is in second place and there are just a few more games until playoffs. At first, the boy had medial elbow pain only at the end of the game, but lately his elbow hurts after the first throws, and he is not pitching as accurately as he had been before. On physical exam, he is tender at the medial epicondyle. On your preliminary read of the xray, there is no fracture, dislocation, and the expected ossification centers are all present. 

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You are seeing a 17-year-old boy with one day of right calf pain and swelling. The day before onset of his symptoms, he was helping with a kitchen remodel and tried to remove a support beam by kicking it multiple times. He continued to help, and it wasn’t until the next morning that he noticed his symptoms. He has no significant PMH. He has taken no medications. He has had no recent travel, illness, or other trauma. On exam, he is afebrile, HR 65, RR 18, BP 140/80, weight 135 kg, BMI 42. His right calf circumference measures 1.5 inches more than his left. His calf is not particularly tender to palpation, and there is no redness or warmth. His leg is not swollen above the knee. He has normal sensation distally and normal color. He is able to walk without a limp but has pain with walking. He has no pitting edema. 

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You are seeing an 18-month-old brought in by ambulance for simple febrile seizure that lasted 2 minutes. You have determined the source of his fever to be viral URI with acute otitis media. He has fully recovered, his temperature has normalized (from 40C) with antipyretic, and he is interactive and playful now. His neurologic exam is normal, and he has no significant past medical history. His parents are asking about whether this will happen again, whether he is at higher risk of epilepsy, and whether he will have any negative neurologic outcome.

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You are seeing a 3-year-old boy with 2 days of fever to a maximum of 102.7 F, an urticarial rash (but no enanthem), and significant arthralgias. The individual urticarial lesions are not transient, but rather present for more than 24 hours. He is not toxic but appears miserable. He was diagnosed with acute otitis media 8 days ago and is on day 8 of a 10-day amoxicillin course. 

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Happy Belated 4th of July!

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You are seeing a 10 month old female with profuse projectile vomiting and one episode of diarrheal stool over the last 2 hours. She is ill-appearing and has signs of significant dehydration. While obtaining vascular access and rehydrating her, you obtain additional history and peruse her chart. She has had three prior similar but more mild episodes, all diagnosed as acute gastroenteritis, starting at age 7 months. This episode began ~90 minutes after the family had dinner. The family had peanut chicken curry over rice and a salad. The baby had rice and small pieces of chicken set aside before being mixed with the peanut curry sauce. The baby has a 3-year-old sister in preschool. She is asymptomatic. 

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You are seeing a 6 year old with 1 ½ weeks of cough, nasal congestion, and malaise. Initially, he seemed to be improving a bit, but now for the last 2 days he has a fever and worsened cough, post-tussive and spontaneous vomiting, as well as a new sore throat and conjunctival injection. His vital signs are: temperature is 38.2, HR 110, RR 32, and pulse ox 96% on room air. On exam he is nontoxic but has some crackles heard bilaterally. Your plan is to treat him with azithromycin for community-acquired pneumonia, pseudoephedrine during the day and diphenhydramine at night for his nasal congestion, and ondansetron for his vomiting. 

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You are seeing a 9 year old African-American child who was hit in the eye with a baseball. On exam there is visible blood layering in the anterior chamber, filling approximately 50% of the anterior chamber. There is no evidence of an open globe injury. 

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You are seeing a 17 year old girl that works in a pet store, where she is sometimes scratched by the animals there. She felt fine that morning, but noted malaise and low-grade fever in the afternoon, and pain in her lower right shin. She presents to the ED with temp 38.5, HR 140, RR 20, BP 95/60. She has a 4cm x 4cm non-well demarcated area of red-purple discoloration on her lower right shin, with mild edema. On close inspection there are a few small bullae in the area of discoloration. On palpation of the area, it is warm, extremely, tender, and has crepitus. 

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You are seeing a 15 year old girl who presents with acute bilateral lower leg weakness / near-paralysis. She is found to be hypokalemic, which led to her weakness and paralysis. She also has a hyperchloremic (non anion gap) metabolic acidosis. She was previously healthy and denies ingestion of any substances. She has not been having diarrhea. Her urine pH is 6.0. 

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Your next patient, actually your next 10 patients, are brought in by their parents because they have been coughing for 2 weeks. Match the characteristic of the cough with the appropriate treatment (you may use letters twice or not at all). (Cannot answer on-line – jot down your answers and then check back for discussion).

  1. Dry cough worse at night and when out in the cold air
  2. Cough that sounds like a seal or dog barking
  3. Cough with an inspiration between each cough (staccato cough)
  4. Wet phlegmy cough accompanied by nasal congestion
  5. Paroxysms of cough with post-tussive vomiting
  1. Albuterol
  2. Amoxicillin
  3. Azithromycin
  4. Dark honey
  5. Dexamethasone

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You are seeing a 17 year old male who had his left upper impacted wisdom tooth extracted 3 days ago. He comes in complaining of unbearable pain despite taking ibuprofen and one oxycodone. He has had no fever. Exam is unrevealing – there is no swelling around the socket, no discharge, no foul odor. 

[yop_poll id="298"]

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You are seeing a 3 year old child with 3 weeks of gradually progressing low back pain, now impacting her ability or willingness to walk. There has been no trauma and no fever noted at home, although temperature is 37.8 in the ED. On exam she has loss of lumbar lordosis and tenderness to palpation of the lumbar spine. She has full passive range of motion without pain of the hips. She was seen by her PCP 3 days ago and CBC was normal, blood cultures negative to date. Today, CBC is still normal and ESR is 47. Plain radiograph shows narrowing of the L3/4 disc space. MRI is not available in your ED.

[yop_poll id="297"]

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You are working locum tenens in Breckenridge, Colorado, and see a 2 year old boy with irritability, vomiting, and poor appetite. He has no fever or diarrhea and no one else in his family is affected. The family landed in the Denver airport the night before and drove to Breckenridge. The patient awoke this morning with these symptoms. 

[yop_poll id="296"]

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You are seeing an 8 year old girl with fever of unclear etiology for 7 days. She is well appearing. Exam reveals 1-2cm tender nodes in her left axilla and left anterior cervical areas. She has a superficial healing scratch on her left forearm, and history reveals that she has been spending time at a cousin’s house with the cousin’s new kitten. She is also noted to have hepatomegaly 2cm below the right subcostal margin, and a palpable spleen tip. She has no petechiae or purpura. The remainder of her exam is noncontributory. 

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You are evaluating a 10 year old patient who had a bone marrow transplant 2 months ago. The patient is presenting with low-grade fever, a maculopapular rash on the nape of the neck, shoulders, palms, and soles as well as nausea, vomiting, and diarrhea. The patient owns a cat but is not involved in caring for it and does not have it sleep with him. 

[yop_poll id="294"]

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[yop_poll id="293"]

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You are seeing a 16 year old basketball player who presents with pain and swelling over his dorsal PIP joint, and inability to extend at the PIP joint. 

[yop_poll id="292"]

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You are caring for a 20 kg child involved in an auto vs. bicycle accident who has several superficial lacerations requiring suturing. You calculated the maximum amount of 1% lidocaine with epinephrine that you can safely infiltrate for laceration repair. 

[yop_poll id="291"]

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You are seeing a 15 year old who sustained significant facial trauma. He complains of decreased vision in his right eye. On exam you note proptosis, periorbital swelling, and relative afferent pupillary defect (aka Marcus-Gunn pupil) on the left. The intraocular pressure is measured at 45.

[yop_poll id="290"]

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[yop_poll id="289"]

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During the recent “tri-demic” of influenza, RSV, and COVID disease, there was also a nationwide shortage of common oral liquid antibiotics used to treat otitis media. Which of the following antibiotics is recommended in the 2013 AAP guidelines as an alternative to amoxicillin to treat acute otitis media?

[yop_poll id="288"]

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COVID is on the rise again, with a more transmissible and immune-evading variant. Nirmatrelvir-ritonavir (brand name Paxlovid) is approved for children 12 years and older AND weighing 40 kg or more in high-risk situations.

[yop_poll id="284"]

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[yop_poll id="286"]

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You are seeing a 5 year old child with known adrenal insufficiency with fluid and pressor-resistant hypotension. You wish to give stress-dose steroids. 

[yop_poll id="285"]

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[yop_poll id="287"]

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A teen living in a state where abortion is newly outlawed ingests something that she has read online is an abortifacient. She presents to the ED with nausea, vomiting, and abdominal pain. Her AST and ALT are elevated, and her acetaminophen level is zero. 

[yop_poll id="283"]

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[yop_poll id="282"]

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[yop_poll id="281"]

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We are currently experiencing a “tridemic” of influenza, RSV, and COVID-19.

[yop_poll id="280"]

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[yop_poll id="278"]

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[yop_poll id="279"]

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A PEM group is performing a quality improvement initiative to improve ED flow in the busy evening shift of their 12-bed PED. They implement a fast-track using three patient care rooms, one nurse, and one physician. They gather data after implementation but find that ED flow is not improved because of the loss of ¼ of their patient care rooms to the new fast track. They then adjust their initiative to using only two rooms and re-gather data. 

[yop_poll id="277"]

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You are seeing a 13 year old girl for menorrhagia. This is her second menses ever, and she has been having to change her pad every 2 hours for 7 days. Her physical exam is unremarkable except for some mild tachycardia and ongoing vaginal bleeding. She has not had any surgeries, but she does recall a nosebleed episode that lasted 15 minutes, and she does endorse easy bruising. She is not taking any medications and has no significant past medical history. There is no known family history of a bleeding disorder, and she has one older brother who is healthy. 

[yop_poll id="276"]

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You are evaluating a 15 year old girl brought in from a foster home for symptoms of psychosis. 

[yop_poll id="275"]

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[yop_poll id="274"]

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You are seeing an 8 year old male with 3 days of progressively worsening redness, tenderness, and swelling of his right index finger proximal lateral nail fold and adjacent skin. The central portion of the swollen area shows a small amount of subcutaneous purulent fluid. He is right-hand dominant, otherwise healthy, and is afebrile. He admits to having a habit of biting his fingernails.

[yop_poll id="273"]

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You are seeing a 6 year old child that was involved in a motor vehicle accident. He was belted in the rear left seat using a regular adult seatbelt. He is alert and crying. His airway is open, there is no evidence of head trauma, trachea is midline, and chest rise is equal with no increased work of breathing. He is tender in the right upper quadrant of his abdomen and has a seatbelt sign across his mid-abdomen. He has no obvious extremity deformities. GCS is 14. His vital signs are HR 160, RR 30, BP 80/40, O2 sat 98% on 5L by face mask non-rebreather.

[yop_poll id="272"]

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A 3 week old female infant presents with a palpable inguinal mass of 2 hours duration. The dad states he noticed it while changing her diaper. He has seen it before while bathing her, but by the end of the bath it had disappeared. She is otherwise well, feeding and growing well, not vomiting, and is afebrile. She appears comfortable. The mass is nontender, and there is no overlying redness or discoloration. 

[yop_poll id="271"]

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[yop_poll id="270"]

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You are seeing an 18 month old girl with chief complaint of itchy scalp and rash at the nape of her neck just below her hairline. On examination, you note nits but do not see any live lice. The parents have not performed any treatments for lice. 

[yop_poll id="269"]

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[yop_poll id="268"]

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You are seeing a 13 year old boy with vague complaints of malaise, nausea, morning headaches, loss of appetite, and intermittent abdominal pain. When he first stands up, he feels dizzy. His exam is notable for tachycardia and hyperpigmentation of his gingiva, lips, knuckles, and palmar creases.

[yop_poll id="267"]

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You are seeing a 6 year old boy who sustained a bee sting. He presents with diffuse urticaria, wheezing and shortness of breath, and crampy abdominal pain, nausea, and vomiting. There is no angioedema. His vital signs are: temperature 37.7 C, HR 140, RR 30, BP 76/36, pulse oximetry 92% on room air. 

[yop_poll id="266"]

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You are seeing a critically ill 4 week old with bilious vomiting, abdominal distension, and shock. You have a high suspicion for volvulus. You have resuscitated the infant and improved hemodynamic stability but you are at an ED with no pediatric surgeon available and no PICU. The nearest children’s hospital with these capabilities is 100 miles away. There is a light rain but the road conditions are good and there is no traffic. 

[yop_poll id="265"]

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It’s summertime, and you are seeing a 15 month old with fever and papulovesicular lesions on the palms, lateral borders of the feet and soles, and buttocks, as well as vesicles in the posterior pharynx. 

[yop_poll id="264"]

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You are seeing a well-appearing 20 day old infant brought in for passing 4 stools instead of 6 today. The baby is full term, eating well, and there were no significant birth complications or maternal infections. Vital signs are rectal temperature 38.0 C, HR 140, RR 36, O2 sat 99% on room air. Physical exam is unremarkable except the right tympanic membrane is redder than the left. 

[yop_poll id="263"]

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You are seeing a 14 year old boy who presents with shortness of breath and chest pain while playing basketball. He has noticed it for the last few weeks, whenever he plays basketball. He has no significant past medical history, and he has not had a syncopal event. On exam, he has a 2/6 harsh systolic murmur best heard at the left lower sternal border. The murmur is louder with the Valsalva maneuver and softer when the patient goes from standing to squatting.

[yop_poll id="262"]

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You are seeing an 8 year old boy with the pictured lesion. He has had it for 2 months; it is slowly growing, and occasionally bleeds when irritated. It is not tender and he has no fever.

[yop_poll id="261"]

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A 14-month old boy presents with altered mental status. He has had 2 days of vomiting and diarrhea, but no fever. He weighs 10 kg. Bedside blood glucose measurement is 38 mg/dL. A 22 gauge peripheral IV is obtained in his right hand.

[yop_poll id="260"]

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A 20 month old boy is brought in by his mother for refusal to bear weight on the right leg. She was at work all day and the child went to the park with his father, but no known trauma occurred. He has had no fever, URI symptoms, or rash. He was born full-term and has no significant past medical history. Physical exam of his right leg is unremarkable. AP and lateral X-rays are as shown. 

[yop_poll id="259"]

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A 10 year boy was out hiking with his family, several feet ahead of everyone else. He heard a rattle, felt a sharp pain in his leg, and may have seen a snake slither away into the underbrush. He is brought to the ED 40 minutes after the event. On exam, his vitals are normal, and he has a bite mark with 2 punctures on his right calf. There is no surrounding swelling or discoloration, and the compartments are soft. He complains of pain, but no paresthesias.

[yop_poll id="258"]

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A 17yo boy presents with fever, myalgias, headaches, swollen cervical lymph nodes, and a maculopapular rash that became vesiculopustular on his face, torso, and extremities including palms and soles. You are working in a small community ED. The triage nurse expresses concern for monkeypox. 

[yop_poll id="257"]

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You are seeing a 3 day old infant with a new onset rash on the chest and abdomen. The baby was born full-term with no complications and went home yesterday. Mom has been exclusively breastfeeding every 1-2 hours, and ate a bag of peanuts several hours before noticing the baby’s rash. The baby has no fever and is eating and urinating well. There is no history of maternal infections.

[yop_poll id="256"]

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You are seeing a 16 month old toddler who is a very picky eater. He mostly eats 32 oz of whole milk per day, and a few finger foods. His parents feel that he looks pale – you check a hemoglobin and find that they are correct! It is 4.8 g/dL. He is active and playful, hemodynamically stable, and has no evidence of bleeding. He has no petechiae, purpura, hepatosplenomegaly, or mass, and the remainder of his blood counts (WBC, platelets) are normal. 

[yop_poll id="255"]

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You are seeing a 4 year old boy who presents with a few weeks of periorbital edema and generalized fatigue. He occasionally complains of abdominal pain. There has been no fever, rash, vomiting, diarrhea, or joint pains. His work-up shows proteinuria and a low serum albumin.

[yop_poll id="254"]

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You are seeing an 8 year old girl who was prescribed an oral cephalosporin antibiotic 1 week ago for rhinitis. She has 3 more days until she finishes the course. Now she has developed an itchy urticarial-like rash, although it is more fixed than urticaria typically are (does not move around nor come and go). She also has some generalized mild arthralgias and a low-grade fever to 100.2 F. 

[yop_poll id="253"]

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[yop_poll id="252"]

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A 6 month old female infant is referred in from PMD for concerns regarding the GU exam. Physical examinations at the 2 and 4 month old visits were normal. There are findings of concern for an STI. 

[yop_poll id="251"]

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You are seeing a 10 month old infant with one day of fever, purpuric rash, and subcutaneous edema of bilateral extremities. He was seen in the ED one week ago for cough and congestion and diagnosed with a viral URI. At that time, COVID, influenza, and RSV were negative. On exam, his temp is 39.1. He has multiple, scattered, annular, sharply demarcated hemorrhagic plaques, mainly on his cheeks and bilateral extremities, lower > upper. He is otherwise well appearing and remainder of the physical exam is unremarkable. CBC including platelet count, CMP, coags, DIC panel, CRP, UA, and CSF were all normal.

[yop_poll id="250"]

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Which of the following physical exam findings on a newborn’s sacrum does NOT mandate an MRI to rule out occult closed spinal dysraphism?

[yop_poll id="249"]

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You are seeing a patient with history of congenital sensorineural hearing loss. 

[yop_poll id="248"]

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You are seeing a 17 year old boy with left flank pain, nausea, and vomiting. There has been no fever, dysuria, hematuria, or urinary frequency. The pain did start after the patient drank a large caffeinated frappuccino and had a brisk diuresis. The patient reports similar pains in the past that self resolved, but never this severe. Urinalysis has 0-2 wbc, 0-2 rbc, no bacteria, and is nitrite negative. Suspecting nephrolithiasis, you obtain a renal US that shows severe left hydronephrosis but no evidence of stone. You then obtain a CT non-contrast that confirms no stone is present. 

[yop_poll id="247"]

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A seven day old neonate is brought in for a fever of 38.5 and lethargy. The baby had a home birth, and the parents have chosen a “lotus birth,” or umbilical nonseverance. The placenta remains attached to the newborn (carried around with the baby, often in a small bag), until it separates on its own, typically in 5-15 days. 

[yop_poll id="246"]

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You are seeing a 1 week old with the pictured oral lesions. 

[yop_poll id="245"]

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You are seeing a 12 year old child that presents with altered mental status, fever, and history of headache and vomiting before the decline in mental status. The patient has a seizure on arrival to the ED, which resolve with lorazepam IV. The CT scan shows evidence of a subdural fluid collection. The lumbar puncture results show a neutrophilic pleocytosis with an elevated protein. Gram stain is negative. 

[yop_poll id="244"]

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Parents bring in a 3 year old child that drank a few sips of household bleach which had been stored by grandparents in an empty coke bottle. 

[yop_poll id="243"]

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You are seeing a 5 year old boy with abdominal pain. His parents say that he has not been eating solids, but has been taking in liquids all day, yet he has not urinated.

[yop_poll id="242"]

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What are pediatric emergency physicians seeing more of when COVID prevalence rises?

[yop_poll id="241"]

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You are seeing a 10 day old ex-full term infant with bilateral watery mucoid eye discharge, mild eyelid edema, and papillary conjunctivitis. You suspect chlamydial conjunctivitis. What is the best management?

[yop_poll id="240"]

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You are told that you will be receiving a 12 month old child in full arrest. CPR is in progress by the paramedics. Your EMS agency does not have pre-hospital providers intubate children. Which of the following is true as you prepare your equipment and medications?

[yop_poll id="239"]

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You are seeing a 19 year old male who has had several ED visits for abdominal pain, nausea and vomiting. He insists that he does not use cannabis at all.

[yop_poll id="238"]

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You are seeing a 7 year old boy who presents with dark coca-cola colored urine and puffy eyes. You suspect glomerulonephritis. Which of the following is NOT consistent with post-streptococcal glomerulonephritis (the most common cause of acute nephritis in children worldwide)?

[yop_poll id="237"]

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You are seeing a 14 year old boy who presents with sudden onset of left scrotal pain and swelling, starting 4 hours prior to presentation. He has had a cold recently, but no fever. He fell off his bike yesterday but did not think he had any injuries beyond a scraped knee. Which of the following aspects of his presentation is not consistent with testicular torsion?

[yop_poll id="236"]

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You are seeing an 8 year old boy brought in by ambulance for a first time unprovoked afebrile seizure. The seizure was generalized tonic-clonic and lasted 3 minutes then self-resolved. The child is now back to baseline. A thorough history and physical exam has revealed no clear etiology for the seizure, and the neurologic exam is normal. The child was well prior to the seizure and has no significant past medical history. Blood glucose in the field was 98. The child is well-appearing and can easily obtain follow-up with his primary physician in a timely fashion. 

[yop_poll id="235"]

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[yop_poll id="234"]

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Last week’s 10 day old patient presented with seizures and jitteriness due to hypocalcemia. In the ED, he has a peripheral 22 gauge IV placed. 

[yop_poll id="233"]

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A 10 day old presents with shaking of bilateral upper extremities and jitteriness. The patient was a term infant born NSVD with no complications. He is afebrile, HR 140, RR 50, and currently not having any abnormal movements. He has been feeding and urinating normally. His blood glucose is 120. Labs, EKG, head CT, and a CXR are performed – the CXR is shown here.

https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c02.html
[yop_poll id="232"]

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You are seeing a 14 year old boy involved in a helmet vs helmet football injury. Which of the following is true regarding his evaluation and management in the ED in regards to his equipment?

[yop_poll id="231"]

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A 16 year old female involved in a motor vehicle accident is brought into your trauma bay; she is obviously gravid and states that she is 8 months pregnant.

[yop_poll id="230"]

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You are evaluating a term neonate for hyperbilirubinemia. The baby was sent home at 36 hours of life with a bilirubin measurement of 7.0, and has returned at 72 hours of life due increased jaundice. 

[yop_poll id="229"]

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You are seeing a 17 year old boy who fell while skateboarding and sustained an axial loading force to his right thumb. He is exquisitely tender at the base of the thumb (carpometacarpal joint), and you note swelling as well. Which of the following injuries is least likely to be encountered based on this mechanism and exam?

[yop_poll id="228"]

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A 16 year old girl arrives to the ED by ambulance and promptly delivers a 34 weeks by dates neonate. The infant is unresponsive, apneic, and you cannot palpate a pulse. After initial steps of drying, warming, and stimulating, the baby is still apneic with a heart rate < 100. You initiate positive pressure ventilation for 15 seconds but still do not hear the heart rate rising. Which of the following is not a part of the MR SOPA ventilation corrective steps recommended to try next?

[yop_poll id="227"]

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You are seeing a 3 year old whose parent noticed a lump in the neck while bathing her. You palpate posterior cervical node(s). 

[yop_poll id="226"]

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You are seeing a toddler with 2 days of cough, congestion, and low-grade fever, who now presents with a worsened barky cough. His vital signs in the ED are temp 38.3 C, HR 110, RR 26, BP 80/40, O2 sat 96% on room air. He has stridor when crying but none at rest. He has no history concerning for foreign body aspiration. He is not happy to be in the ED but is not toxic appearing. He is fully immunized and has no significant past medical history. 

[yop_poll id="225"]

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You are seeing a 9 year old boy who returned from a camping trip in Colorado 6 days ago. He had some vague complaints of paresthesias, myalgias, and general fatigue the night before. On waking this morning, he had significant bilateral lower extremity weakness and ataxia that rapidly worsened. He is afebrile. On exam, he has no patellar or Achilles deep tendon reflexes. 

[yop_poll id="224"]

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You are seeing a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever. 

[yop_poll id="223"]

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[yop_poll id="222"]

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You are seeing a 3 year old girl who was discharged from the hospital a week ago. At that time, she presented with fever, intermittent polyarthralgias, and an evanescent salmon pink rash. She was diagnosed with new onset systemic juvenile idiopathic arthritis, treated with ibuprofen, and initially did well. She now presents with unremitting fever and rash, bruising, petechiae, gum bleeding, hepatosplenomegaly, and lethargy. Labs reveal elevated transaminases, ferritin, LDH, and triglycerides, but a low ESR.

[yop_poll id="221"]

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You are seeing an 18 year old male who presents with palpitations. Electrocardiogram reveals atrial fibrillation with a rapid ventricular response rate at 145.

[yop_poll id="220"]

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Your ED is providing patients who are eligible and interested in receiving the COVID-19 vaccine the opportunity to receive the 1st dose of an mRNA vaccine approved for age 12 years and older during the ED visit. 

[yop_poll id="219"]

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You are seeing a 12 year-old with 2 weeks of nasal congestion, rhinorrhea, sneezing, and sore throat, especially in the mornings. She has had no fever. On exam, her nasal turbinates are pale and boggy. She has a horizontal crease below the bridge of her nose and her lower eyelids are bluish and puffy.

[yop_poll id="218"]

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You are seeing a 16yo girl who has been followed by her primary physician and a rheumatologist for systemic lupus erythematosus since being diagnosed 1 year ago. She is presenting with chest pain.

[yop_poll id="217"]

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You are seeing a 5 year old girl who presents with dysuria and small amounts of blood in her underwear for 3 days. She has no fever, urinary frequency, abdominal pain, or history of trauma or straddle injury. Her mother noted a swelling at her vaginal introitus and shows it to you. She has a red donut-like mass just above the vaginal introitus where you expect to see her urethra.

[yop_poll id="216"]

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[yop_poll id="215"]

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[yop_poll id="214"]

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[yop_poll id="213"]

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You are seeing a 3 year old ex-premature infant who has a ventriculoperitoneal shunt in place. The patient presents with fever to 38.3, cough, and runny nose. There is no headache, vomiting, or altered mental status. The shunt was placed initially while in the NICU, and revised 4 months ago. 

[yop_poll id="212"]

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You are seeing a 15 year old who took a handful of aspirin in a suicide attempt. The salicylate level at 3 hours post-ingestion is 20 mg/dL. Toxicity generally begins at levels of 30 mg/dL and higher. You are certain there were no co-ingestants and the patient’s vital signs, physical exam, metabolic panel, and EKG are normal. 

[yop_poll id="211"]

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You are repairing a large laceration extending from the occipital scalp over the top of the head and onto the forehead of a 5 year old 20 kg child. You have the parent and nurse place the child his head in a sink under tap water to irrigate the wound. You anesthetize the wound with a total of 14 mL of 1% lidocaine. You put on a surgical mask and nonsterile gloves. You use staples on the scalp, transitioning to 5-0 polyglactin irradiated suture for the forehead. 

[yop_poll id="210"]

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[yop_poll id="209"]

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[yop_poll id="208"]

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The pediatric genetics clinic is sending over a patient with respiratory distress. As you prepare for the patient’s arrival, you have a chance to look at the chart. 

[yop_poll id="207"]

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A 6 year old boy presents with 2 days of nontender palpable purpura of bilateral lower extremities, accompanied by arthralgia of the left ankle. Vital signs are temperature 37.6, HR 90, RR 20, BP 105/60. He has no nuchal rigidity. He has no significant past medical history. His CBC shows normal platelet count and PT/PTT are normal. 

[yop_poll id="206"]

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You are seeing an adolescent who slammed her finger in a door and has a subungual hematoma. 

[yop_poll id="205"]

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A 4-year old boy is brought in because of marked edema and pruritis of his penis and foreskin. His family is visiting on vacation and staying at a rental home. He spent most of the prior day playing outside, and he has several papules consistent with bug bites on his arms, legs, and back. He is afebrile and there is no redness or warmth to the edema. He is uncircumcised, and there is no tight constricting band noted. 

[yop_poll id="204"]

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As part of the work-up for abnormal behavior in a 3 year old, the qualitative urine drug screen comes back positive for a substance. 

[yop_poll id="203"]

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You are seeing a 15yo girl with a strong family history of nephrolithiasis who presents with colicky right flank pain, non-bloody non-bilious vomiting twice, and microscopic hematuria. Her UA results do not support a diagnosis of UTI or pyelonephritis. She is not sexually active. She was seen in the ED 6 months prior for RLQ abdominal pain and underwent a CT scan which was negative for appendicitis or any other pathology. She describes the current pain as different from the pain she had 6 months ago. After IV fluids, ketorolac, and morphine therapy her pain is improved.

[yop_poll id="202"]

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[yop_poll id="201"]

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You are seeing a 7 year old patient with his third lifetime episode of angioedema. He has swelling around both eyes and his right upper lip, but none of his tongue or pharynx, and he is maintaining his airway. He has a history of multiple food allergies. Besides lack of urticaria or itching, which of the following findings supports hereditary bradykinin-mediated angioedema over allergic histamine-mediated angioedema as the underlying pathophysiology?

[yop_poll id="200"]

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You are seeing a child who fell on an outstretched hand and sustained a radius fracture. 

[yop_poll id="199"]

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You are seeing a 3 year old who sustained a 2cm laceration to the neck from a jagged edge on a piece of metal play equipment at a local park. 

[yop_poll id="198"]

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You are seeing a previously healthy 9-month old boy brought in for rash. The child had 3 days of fever. He was seen yesterday evening at an urgent care and diagnosed with otitis media and prescribed amoxicillin. He has never taken any antibiotics before. This morning, his fever was gone, but he developed a blanching pink maculopapular rash on the torso that spread to the extremities and face later in the afternoon. He does not seem to be itchy. He has been well appearing and eating normally throughout his illness. 

[yop_poll id="197"]

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You are seeing a 4 month old infant with fever, nasal congestion, and cough for 2 days. The baby is a previously well ex-full term infant with no past medical history, up to date on immunizations. He has been slightly less than usual but still having several wet diapers per day, and is still playful and interactive. On exam, his temperature is 38.4C, HR 135, RR 48, BP 80/40, and O2 sat 93% on room air. He has diffuse mild wheezes and minimal subcostal retractions, but no grunting, nasal flaring, stridor, cardiac murmur, hepatomegaly, or evidence of dehydration. There is no personal or family history of prior wheezing. His parents are able to return to the ED if necessary and can arrange follow-up with their pediatrician. 

[yop_poll id="196"]

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[yop_poll id="195"]

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[yop_poll id="194"]

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A teen who plays on the high school varsity basketball team comes in after jamming her finger during a game. She has a distal phalanx simple dislocation without fracture. 

[yop_poll id="193"]

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You are seeing a 15yo patient with past psychiatric history who takes escitalopram (Lexapro) and quetiapine (Seroquel) for nausea and vomiting. You give the patient a dose of ondansetron (Zofran) and an IV fluid bolus, then discharge him home with a prescription for ondansetron. His parent gives him diphenhydramine (Benadryl) before bed to help him fall asleep. He becomes upset and overdoses on one of the medications in the home. 

[yop_poll id="192"]

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You are seeing a 3 year old child with unrepaired Tetralogy of Fallot who presented with a generalized tonic-clonic seizure, and residual hemiparesis and speech difficulty after waking up from the post-ictal phase. 

[yop_poll id="191"]

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[yop_poll id="190"]

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You are seeing a 3yo girl brought in by ambulance after a new-onset seizure. The patient has no past medical history, but has been having an acute viral gastroenteritis for the last 24 hours, as have several family members. She has had decreased oral intake, vomited 3 times non-bloody non-bilious, and had 3 episodes of watery non-bloody diarrhea. She is afebrile. She went to bed at 9:30pm, sleeping next to her parent, and the parent was awakened by her having a generalized tonic-clonic seizure at 6am. Per EMS, seizure had resolved on their arrival but she was lethargic; point-of-care blood glucose was 40 mg/dL in the field, and she was given 5 mL/kg of D10W IV with patient becoming more alert. In the ED, her urine dip is positive for ketones.

[yop_poll id="189"]

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A 15yo obese patient is brought in after admitting to taking an overdose of “a handful” of metformin as a suicide attempt. No other drugs were available to the patient and co-ingestion is not suspected. 

[yop_poll id="188"]

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You are caring for a 19 year old woman who is breastfeeding her 2 month old infant. She has a superficial 2cm breast abscess located on her inferior breast with minimal overlying cellulitis and no involvement of the nipple. She is nontoxic, afebrile, and not septic appearing. Which of the following ED management choices is most appropriate and most likely to result in rapid improvement?

[yop_poll id="187"]

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You are preparing to repair an upper lip laceration that crosses the vermillion border in a cooperative 15 year old girl who was bitten by the family dog. In order to reduce distension of the tissues which may result in poor vermillion border alignment and poor cosmesis, you decide to use a regional block for anesthesia. 

[yop_poll id="186"]

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You are sedating a 16 year old boy with past medical history of spontaneously resolved VSD as an infant with ketamine for tube thoracostomy to treat a spontaneous pneumothorax. Before the tube thoracostomy procedure can begin, the patient has a sudden episode of oxygen desaturation, lack of end-tidal CO2 waveform, and gurgling noises. It successfully resolves after a couple of minutes of bag-valve-mask ventilation, and the practitioners prepare to begin the procedure again. However, immediately thereafter the patient begins to cough up pink frothy secretions and to desaturate again, although the end-tidal CO2 waveform does not change this time. 

[yop_poll id="185"]

A 16yo patient is brought in directly from a large “pharm” party with altered mental status, respiratory depression, and pinpoint pupils. You suspect opiate overdose and administer naloxone with improvement in spontaneous respirations. To your surprise, however, the qualitative urine drug screen comes back negative for opiates. Which of the following drugs is the patient unlikely to have taken?

[yop_poll id="184"]

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You are seeing a 3 year old child with acute onset draining right ear. The child has no fever and no history of recent swimming or other risk factors for otitis externa. The child has a PMH of frequent otitis media, and pressure equalization (tympanostomy) tubes were placed at age 1 year. There have been no episodes of otitis media since then. As far as the parents know, the tubes are still in place, but they have not had any follow-up with an ENT. On exam, the left ear canal has a PE tube laying in the canal, which you remove; the tympanic membrane is translucent and mobile. The right canal is full of seropurulent drainage. You cannot see the tympanic membrane nor any PE tube. The canal itself is not swollen or red. 

[yop_poll id="183"]

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A toddler, visiting for the holidays, has been roaming his grandmother’s large backyard, nibbling on plants. 

[yop_poll id="182"]

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You are seeing a 2yo who was being carried by a teenager who fell through a glass sliding door. The toddler has a 1.5 inch laceration of the right neck at the level of the thyroid cartilage. 

[yop_poll id="181"]

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You are seeing a 4 year old boy with PMH of two UTIs and frequent episodes of otitis media. He has dysuria, frequency, straining to void, a poor urinary stream, and large volumes of urine when he does void. He is circumcised and his external genitalia exam is normal.

[yop_poll id="180"]

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Which child does not meet the criteria for a low-risk BRUE? (Assume for all patients the events are now resolved and resolved immediately after the period of the event, there is no significant PMH, this is the first and only event, the child appears well in the ED)

[yop_poll id="179"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are managing a 1yo patient with submersion injury who has respiratory distress and falling O2 saturation. You begin bag-valve-mask ventilation as you prepare to intubate the patient, using a 450mL self-inflating bag with oxygen at 10 L/minute, bagging at a rate of 20 breaths/minute. You note that the patient is not improving and there is poor chest rise, so you insert a correctly sized and placed nasopharyngeal airway. The patient is still not improving and has poor chest rise - after repositioning, which is the best intervention? [yop_poll id="178"]
(Click the link to comment and to vote - voting not working through email, sorry!) EMS is bringing you a 10yo patient that has been actively seizing for 20 minutes. They are unable to obtain IV access. [yop_poll id="177"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 4 week old infant with non-bilious forceful vomiting x 3 days. [yop_poll id="176"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 day old infant born term without complications brought to the ED because the parent noted a streak of bright red blood in the diaper. The baby is formula feeding well, not lethargic, has no fever, and has had a few non-bilious spit-up episodes. Physical exam shows mild abdominal distension; no anal fissure seen. [yop_poll id="175"]
(Click the link to comment and to vote - voting not working through email, sorry!) Paramedics are caring for a toddler with respiratory distress in the field. They contact the base hospital and receive instruction to administer nebulized albuterol. [yop_poll id="174"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 month old with a rash for 3 days. It started as fluid-filled vesicles that grew, burst, and released clear-yellow non-purulent fluid. It seems mildly itchy to the parent. The child has had a low-grade fever to 38.2 for one day and appears otherwise well. There is no past medical history and no ill contacts; immunizations are up to date. Bullous Impetigo Open access, Pereira LB - Anais brasileiros de dermatologia (2014 Mar-Apr) [yop_poll id="173"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 day old infant born via midwife-assisted water birth at home, brought in for lethargy and vomiting. Physical exam is significant for lethargy, jaundice, and fever to 38.5. He is exclusively breastfeeding. Labs include pH 7.34, ammonia 80, point of care glucose 80, urine trace ketones. [yop_poll id="172"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="171"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="170"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="169"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy caught a spider, placed it in a jar, and was showing it to his friend when he was bit on the hand. Initially he had minimal pain but now, 1 hour later, has significant hand and arm pain and he has vomited a few times. On physical exam, the wound site is a blanched rounded patch with central punctum, and palpation of extremity reveals muscle rigidity when compared to the other side. [yop_poll id="168"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 3 year old child adopted from another country 6 months ago for abdominal pain. Since then, the child has had chronic nasal congestion and cough as well as failure to thrive which was expected to improve with improved nutrition provided by the adoptive family but has not. The child is afebrile and there are no ill contacts. On exam, there are scant wheezes and O2 sat is 95% on room air. CXR shows hyperinflation. Chart review shows prior visits for respiratory illness, and an episode of rectal prolapse. When asked about the presence of constipation, the parents describe frequent smelly oily stools. [yop_poll id="167"]
[yop_poll id="166"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11yo girl presents with 2 weeks of right knee pain and limp after falling off a bicycle. She has had no fever, rash, other trauma. Vital signs are: temperature 37.5, HR 80, RR 16, BP 110/60. Her exam is normal except for: a 1/6 musical systolic ejection murmur at the LLSB, acanthosis nigricans, and gait with a noticeable limp. Her right knee has no effusion, deformity, erythema, or warmth appreciable. [yop_poll id="165"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo girl is brought in by ambulance after a seizure lasting 1 minute. She has had 2 days of fever, vomiting, and diarrhea. Her temperature is 39.1, HR 202, BP 129/61. Despite antipyretics, calming down, and volume resuscitation, she remained febrile and tachycardic. On exam, a midline neck mass is palpable, and the mother gives a history of several months of sweating and poor weight gain. A lab test confirms her diagnosis. [yop_poll id="164"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 9 year old boy involved in a motor vehicle accident. He has a seatbelt sign on his left neck and you palpate subcutaneous emphysema of his upper chest. [yop_poll id="163"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 12 year old known diabetic who presents in diabetic ketoacidosis. Temperature is 37.5, HR 100, RR 24, BP 96/36, O2 sat 98% on room air. Labs show glucose 550, Na – 132, K – 2.8, pH 7.09. An initial bolus of normal saline 20 mL/kg has been given. [yop_poll id="162"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="161"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 3 week old infant that is positive for RSV has had several prolonged episodes of apnea requiring BVM ventilation. The decision is made to intubate the baby. It is a difficult intubation, although the tube is finally observed to pass through the cords on video laryngoscopy. A 3.5 uncuffed tube has been placed and taped at 12cm at the lip. After several positive pressure breaths on 100% FiO2, the pulse oximetry has fallen to 85% and fails to rise. The ETCO2 waveform is normal and reading 46 mm Hg. Heart rate is 170, BP is 62/30. On auscultation breath sounds are decreased on the left side. Trachea is midline. [yop_poll id="160"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old with history of pseudohypoaldosteronism presents with a K+ level of 9.0 and peaked T waves with mild QRS widening on the electrocardiogram, and blood pressure of 70/40. [yop_poll id="159"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a patient with Trisomy 21 in the ED. [yop_poll id="158"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old boy with complaint of penile pain for 2 days. He is previously healthy, fully immunized, afebrile, and has not had this before. He has been able to urinate although he complains of pain with urination. There is no history of trauma to the area. He is uncircumcised. Exam shows the tip of the foreskin to be swollen and erythematous and tender to the touch. There is no discharge, evidence of trauma, discoloration of the penile shaft or perineum, nor inguinal lymphadenopathy. The testes are descended and nontender. [yop_poll id="157"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="156"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with 2 days of left eye redness and pain, and 1 day of fever. She recently got a new kitten and had been having itchy eyes and nasal congestion for the last 2 weeks. Her temperature is 38.3, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. She is alert, has no nuchal rigidity, and is not toxic appearing. She has left periorbital edema and erythema but her eye can be manually opened. She is PERRL, has no chemosis or proptosis, and has mild conjunctival injection but no discharge. Her extraocular movements are full, but she complains of pain with extraocular movements. Her vision is 20/20 on the right and 20/60 on the left. [yop_poll id="154"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 14 year old boy who hiked in the snow yesterday with inadequate warm clothes and footwear. He has developed swollen violaceous papules and nodules on the toes of both feet. He states that the areas are itchy and sometimes have a burning sensation. Which of the following courses of action would be appropriate?
  1. Advise him to avoid further cold exposure and to use appropriate protective footwear
  2. Perform gentle rewarming in 37 to 39 degree Celsius water
  3. Perform a COVID-19 test
  4. Reassure him that this is a benign Raynaud phenomenon
[yop_poll id="153"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2yo patient with 6 hours of intermittent episodes of apparent abdominal pain happening every 15-20 minutes, and non-bloody non-bilious vomiting. In between episodes, the child appears well and is playful. There is no fever, diarrhea, or concern for toxic ingestion. The child has a history of constipation with hard stools and occasional skipped days with no stooling. There is no other significant past medical history. [yop_poll id="152"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="151"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="150"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="149"]
(Click the link to comment and to vote – voting not working through email, sorry!) A 2yo child presents with a 1.5cm diameter erythematous tender fluctuant swelling in the right preauricular area. There is a small pinhole sized indentation in the center. Which of the following is not appropriate management? [yop_poll id="148"]
(Click the link to comment and to vote – voting not working through email, sorry!) [yop_poll id="147"]
(Click the link to comment and to vote – voting not working through email, sorry!)

Match the child with acute otitis media to appropriate therapy per AAP guidelines (all children well-appearing, non-toxic, no distress or indications of severe otalgia, symptomatic for 1 day, and have not had recent antibiotics in the last 30 days):

Child A) 5mo old with bilateral otitis media, afebrile

Child B) 18mo old with unilateral otitis media, fever to 38.5, penicillin-allergic

Child C) 27mo old with bilateral otitis media and bilateral purulent conjunctivitis and fever to 39.1

Child D) 37mo old with unilateral otitis media, fever to 39.5, penicillin-allergic

  1. Oral analgesic
  2. Amoxicillin 90 mg/kg/day divided BID
  3. Amoxicillin-Clavulanate 90 mg/kg/day divided BID
  4. Cefdinir 14 mg/kg/day
[yop_poll id="146"]
(Click the link to comment and to vote – voting not working through email, sorry!) [yop_poll id="145"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="144"]
(Click the link to comment and to vote - voting not working through email, sorry!) An adolescent is brought in intoxicated with history of drinking large amounts of alcohol at a dorm party. He vomited multiple times at the scene and on arrival to the ED. Initial labs and CXR are normal except for an ETOH level of 390. He is protecting his airway, arousable with deep stimulation, and hemodynamically stable, so the decision is to observe him on a monitor while he slowly sobers up, and then reevaluate him for discharge. However, 2 hours later he is requiring 5L O2 by non-rebreather to maintain an O2 saturation of 97%. He does not show significant respiratory distress or apnea, and a venous blood gas does not reveal CO2 retention or significant acidosis. [yop_poll id="143"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="142"]
(Click the link to comment and to vote - voting not working through email, sorry!)A recent JAMA article summarized China’s experience with 72,314 COVID-19 novel coronavirus cases (Wu & McGoogan, JAMA 2020 Feb 24 [Epub ahead of print]). Which of the following is true? [yop_poll id="141"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8yo boy presents with dribbling urination and pain with urination. When he urinates he sees his foreskin balloon out. On exam, he has phimosis. Per parents, they were previously able to retract his foreskin for hygiene purposes, but now they can’t. The patient is able to urinate and ultrasound shows no significant post-void residual. He is afebrile and urinalysis does not show evidence of UTI. [yop_poll id="140"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 12mo old child with immunizations up to date presents with fever and rash. Which of the following distributions is concerning for measles? [yop_poll id="139"]
(Click the link to comment and to vote - voting not working through email, sorry!) Bullous Myringitis [yop_poll id="138"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo girl presents with LUQ abdominal pain and vomiting x 2 days, and SOB x 1 day. Past medical history includes mild intermittent asthma, treatment for community-acquired pneumonia one month ago, and an MVA 1 year ago – she received head CT that was negative and was admitted and observed overnight at that time. Her CXR is below. Diaphragmatic Hernia [yop_poll id="137"]
(Click the link to comment and to vote - voting not working through email, sorry!) Pediatric patients with sickle cell anemia have a higher susceptibility to becoming infected with which organism? [yop_poll id="136"]
(Click the link to comment and to vote - voting not working through email, sorry!)   [yop_poll id="135"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy comes in with 2 days of fever, chills, myalgias, headache, and a few episodes of non-bloody, non-bilious vomiting. He also has a faint maculopapular rash beginning on his legs. It is influenza season. He has no past medical history. He was bitten 4 days ago by the class pet rat that the teacher bought from a commercial pet store the week before. He went hiking 3 days ago and to Disneyland 2 days ago. He has no drug allergies and takes no medications. [yop_poll id="134"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="133"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="132"]
(Click the link to comment and to vote - voting not working through email, sorry!) At a New Year’s Eve party several glasses of champagne are left lying around the house. The family’s 2yo toddler proceeds to drink some of them. The parents sheepishly bring the somnolent child in to the ED, and the ethanol level is 120 mg/dL. [yop_poll id="131"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="130"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old toddler is brought in for decreased energy and “not acting right.” On exam, the child is noted to be pale, mildly tachypneic, and has a flow murmur. She is afebrile. Her point of care hemoglobin is 3.2 g/dL, and additional history reveals that she is a very picky eater and drinks five 8-oz bottles of milk per day and takes in little else. A full CBC and iron studies are sent to the lab. [yop_poll id="129"]
(Click the link to comment and to vote - voting not working through email, sorry!) EMS has brought in an 8 month old child who had a generalized tonic-clonic seizure at home. The child has a history of 2 prior febrile seizures, starting at age 6 months, and is not on any long-term anticonvulsants. There is no other significant PMH. The child was given IM Ativan 1mg by EMS with resolution after 10 total minutes of seizure. Vital signs are temp 37.9, HR 160, RR 10, BP 72/42, O2 sat 90% room air, weight 7 kg, POC glucose 110. An IV is now in place. What is the MOST appropriate first intervention, assuming all can be instituted within the same amount of time? [yop_poll id="128"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are asked to evaluate a 3 day old male with severe lethargy and hypotonia. He is mildly tachypneic. He is afebrile. As part of your work-up, you evaluate him for inborn errors of metabolism. Which of the following is false about urea cycle disorder as a diagnosis for his findings? [yop_poll id="127"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air. [yop_poll id="126"]
(Click the link to comment and to vote - voting not working through email, sorry!) For which of the following pediatric patients is it most important to have the clinician with the most experience in advanced airway management and endotracheal intubation perform rapid sequence medication-assisted intubation? [yop_poll id="125"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="124"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old boy with abdominal pain. He was seen last night with a few hours of periumbilical abdominal pain. Work-up at that time showed a CBC with WBC 10.2, 55% neutrophils, UA negative, RLQ ultrasound appendix not visualized. He was discharged home with return precautions and instructions to follow-up with his pediatrician. He returns 15 hours later with continued constant right mid-abdomen pain, anorexia, nausea, a few episodes of non-bilious vomiting, and temperature of 37.8. [yop_poll id="123"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2.5 month old baby who underwent a fever work-up yesterday and has been called back due to a positive blood culture growing gram positive cocci in clusters. The baby received the first set of immunizations at age 7 weeks. The baby is afebrile today and has been doing well and eating normally. The only treatments have been acetaminophen, last given 8 hours ago. [yop_poll id="122"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="121"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis?
  1. Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup
  2. Children with bacterial tracheitis do not respond as well to racemic epinephrine and steroids as children with viral croup
  3. Children with bacterial tracheitis may have a “steeple sign” on xray
  4. Children with bacterial tracheitis most commonly have Strep pneumoniae infection
[yop_poll id="120"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 17 year old who was playing basketball for his high school team this evening when he felt a sudden pop and immediate pain in his right Achilles tendon area. He is able to bear weight, but with pain. On exam, there is a palpable gap in his Achilles tendon, and you suspect a ruptured tendon. [yop_poll id="119"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 16 year old boy with sore throat, worse on the left side, dysphagia, low-grade fever, difficulty fully opening jaw (trismus), and muffled voice. You diagnose peritonsillar abscess and plan to perform a needle drainage procedure. [yop_poll id="118"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old left-hand dominant boy is brought in after accidentally sustaining an injury from a paint injection gun while helping his father on a project at home. The injury occurred 2 hours ago. On exam, he has a barely perceptible entrance puncture wound at the tip of his right index finger, no deformity or swelling, and a normal neurovascular exam. Radiographs are negative for fracture and his tetanus is up to date. [yop_poll id="117"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="116"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have diagnosed a 14 year old boy with likely nephrolithiasis, as evidenced by his colicky flank pain, hematuria, and ultrasound showing mild hydronephrosis. [yop_poll id="115"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 12 year old girl with PMH of sickle cell disease complicated only by 2 lifetime hospitalizations for vasoocclusive pain crisis. She presents with fever, cough, and increasing shortness of breath over the last 2 days. Her mother was recently diagnosed with influenza. CXR shows a right upper lobe infiltrate. Vital signs are: temperature 38.8, HR 130, RR 30, BP 110/60, O2 sat 96% on room air. Hemoglobin is 9 g/dL, which is the patient’s baseline. [yop_poll id="114"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="113"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 13yo boy comes in by ambulance after a syncopal episode. He and his friends heard that vaping is dangerous, so they used a hookah to inhale flavored tobacco smoke. His HR is 94, BP 116/60, pulse ox 98% on room air. He complains of dizziness and headache. [yop_poll id="112"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 15 month old who became angry about a toy being taken away, cried, turned blue in the face, passed out, and then developed tonic-clonic activity for 15 seconds. The entire episode lasted 1-2 minutes. The child is playful, drinking from a bottle of juice, and back to baseline in the ED, with a normal physical exam and vital signs. He has never done this before. Which of the following test(s) is/are most indicated?
  1. Bedside glucose
  2. Electrocardiogram
  3. Point of care hemoglobin
  4. Non-contrast CT head
[yop_poll id="111"]
(Click the link to comment and to vote - voting not working through email, sorry!) A full term infant with no birth complications and no known risk factors for hyperbilirubinemia complications, discharged early at 36 hours of life, presents to the ED on day of life #4 with jaundice that just started on the day of presentation. Serum bilirubin is 15, all unconjugated. The baby is exclusively breastfed and having 4 wet diapers per day. [yop_poll id="110"]  
(Click the link to comment and to vote - voting not working through email, sorry!) A 16yo boy presents with chief complaint of a black “hole” in the center of his vision in his right eye 4 days after being hit by a baseball to the eye. He has periorbital ecchymosis but no evidence of orbital fracture. Visual acuity is 20/60 on right, 20/20 on left. He is PERRL, EOMI without pain, and has normal IOP and slit lamp exam. Fundoscopic shows a deep subretinal hemorrhage in his macular area with a small curvilinear yellow line visible. [yop_poll id="109"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8yo boy presents with a 1 month history of progressive periorbital and generalized facial swelling, worse in the morning. Urine dip is positive for proteinuria. You suspect nephrotic syndrome. [yop_poll id="108"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="107"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="106"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 17yo boy with cough x 1 month. You prescribe Tessalon Perles (benzonatate). He has a 2yo sibling at home. [yop_poll id="105"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="104"]
(Click the link to comment and to vote - voting not working through email, sorry!) Perilimbic redness [yop_poll id="103"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 month old with symptoms consistent with varicella. The infant is well-appearing, has no complications, and is 3 days into her illness. Her mother is pregnant. [yop_poll id="102"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a child with suspected methemoglobinemia from overuse of benzocaine teething gel. You plan to treat with methylene blue. Which of the following past medical history conditions makes methylene blue a contraindicated treatment? [yop_poll id="101"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="100"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old boy active in club soccer who comes in complaining of intermittent posterior heel pain, particularly after soccer games. He has pain at the posterior calcaneus, especially when the sides of the heel are squeezed. There is no history of trauma or fall. There are no other abnormal physical exam findings, and radiographs are normal. The patient is not limping and currently does not have pain at rest. [yop_poll id="99"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a pair of 14 year old girls who took “Triple C” at a party. One is altered and the other is hallucinating. In addition, they are tachycardic. [yop_poll id="98"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a child with fever and rash x 1 day. Cognizant that we are in the middle of a measles outbreak, which of the following reassures you that this is unlikely to be measles? [yop_poll id="97"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="96"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="95"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="94"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 14 year old girl is brought in by her parents because of concerns that she is “too thin.” The girl feels that she is not too thin (and, if anything, is a little “chubby”), and that she eats plenty, but says she tries to eat “healthy.” Per her parents, she exercises 2 hours per day. Vital signs in the ED are: temperature 95.8 oral, HR 55, RR 18, BP 88/40. Her BMI is 15, and her weight is 73% of her ideal body weight. Her mental status is normal. Her capillary refill is < 2 seconds. An ECG is performed and is normal. [yop_poll id="93"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19 year old otherwise well-appearing man presents with 2 days of headache, anorexia, tactile fever (but afebrile in the ED), and 1 day of palpable purpura on bilateral lower legs. Which of the following is true? [yop_poll id="92"]
(Click the link to comment and to vote - voting not working through email, sorry!) A toddler is brought in to the ED after it is suspected that he ate his uncle’s brownie containing cannabis. [yop_poll id="91"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 1yo child in status epilepticus (first time seizure). The child received 0.2 mg/kg intranasal midazolam in the field, 0.1 mg/kg IV lorazepam in the ED, then 20 mg/kg fosphenytoin, 60 mg/kg levetiracetam, and 40 mg/kg valproate, with no cessation of seizures. The bedside glucose and i-stat Na and Ca are normal. Which vitamin might you try next? [yop_poll id="90"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following elbow radiography findings can be normal in a 2 year old that fell on an outstretched arm and has decreased use of her elbow? [yop_poll id="89"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following topical antibiotics has the least efficacy against impetigo? (see pictures of impetigo here and a short article here) [yop_poll id="88"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 4 week old brought in for vomiting with every feed. The vomitus is non-bilious, non-projectile, and non-bloody. The baby is making 5 wet diapers per day and weighs 10 lbs, and has gained 30 gm per day since regaining birth weight at 10 days of age. The baby is formula feeding, taking 5 ounces every 2-3 hours. [yop_poll id="87"]
(Click the link to comment and to vote - voting not working through email, sorry!) For which of the following patients is a laryngeal mask airway (LMA) as a temporizing measure after failure of intubation contraindicated? [yop_poll id="86"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="85"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 7 year old boy presents to the ED after falling off his bike and impacting his mouth against the handlebar and the ground. Bystanders reported to the parent that there was a tooth on the ground, and per paramedics the parent is on the way in and may or may not have the tooth. Exam reveals a grossly luxated tooth that is very loose, and two sockets of apparently missing teeth. [yop_poll id="84"]
(Click the link to comment and to vote - voting not working through email, sorry!) About 70% of ear infections improve spontaneously. Which of the following patients is NOT a candidate for the “wait and watch” no-antibiotics option (for all patients assume well appearing otherwise)? [yop_poll id="83"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="82"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10-year old child is brought in for swelling that developed 2 hours ago around the mouth as well as a sensation of difficulty swallowing and breathing. Vital signs are normal and she is not hypoxic nor stridorous, but she does have right sided perioral swelling as well as mucous membrane swelling. There is no discoloration. She has no urticaria, pruritis, nor hypotension. She had dental work on her right lower teeth the day prior, and had local anesthetic injection for that. She took one dose of acetaminophen the day prior and one dose 6 hours ago. Her stepfather gave her diphenhydramine 1 hour ago, but it hasn’t helped. The child denies trauma and says that she felt tingling in the area for 1 hour prior to the onset of swelling. [yop_poll id="81"]
(Click the link to comment and to vote - voting not working through email, sorry!) What is the most common cause of lower GI tract bleeding in young infants after anal fissure? [yop_poll id="80"]
(Click the link to comment and to vote - voting not working through email, sorry!) A child has a large galea aponeurotica laceration that is part of a scalp laceration. The provider sutured the scalp laceration but failed to close the galea. [yop_poll id="79"]
(Click the link to comment and to vote - voting not working through email, sorry!) Regarding common Christmas holiday plants: [yop_poll id="78"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="77"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 1 week old presents with multiple bouts of hematemesis. The baby was born full-term, no complication, has been breast-feeding normally, and is afebrile. The baby is nontoxic, has normal vital signs and perfusion, and has a normal physical examination. Point of care hemoglobin is 15 g/dL. [yop_poll id="76"]
(Click the link to comment and to vote - voting not working through email, sorry!) A new edition of ATLS (10th edition) was recently released. Which of the following is not a recommendation of the 10thedition of ATLS regarding the trauma patient in shock? [yop_poll id="75"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are studying a new rapid flu test’s performance in your ED. Using PCR as a gold standard, you studied 100 kids at the peak of flu season, of whom 60 had influenza and 40 did not. Of the 60 who had influenza by PCR, 54 had a positive rapid flu test, and of the 40 who did not have influenza by PCR, 2 had a positive rapid flu test. [yop_poll id="74"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19 year old man presents 4 hours after leaving his dentist office from wisdom tooth extraction. He has been having bleeding from the socket that will not stop for the last 2 hours. His dentist office is now closed and no one is answering the phone. He has no prior history of excessive bleeding and is not taking any medications. He is hemodynamically stable, and on exam you see a clot in the socket surrounded by a steady ooze of blood, which the patient spits out onto a napkin every minute or so. [yop_poll id="73"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old G1P0 girl at 38 weeks gestation presents in active labor, crowning. OB has been called but is responding from home and won’t be there for 20 minutes. The head delivers, but the baby then has the “turtle sign” with fetal head retracting against the perineum. [yop_poll id="72"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 12 year old boy with a history of ADHD on Adderall comes in for acute onset weakness of his bilateral upper arms, particularly on the right side. He had a viral URI 1 week ago with fever, cough, congestion, sore throat, from which he had recovered. For the past week, he did not take the Adderall because he had been sick and “forgot” to resume. On physical exam, his right arm is flaccid and motionless at his side, and he is unable to use it at all. He is able to lift his left arm partly against gravity, but it is weak. He has a low-grade fever of 38, and mild neck stiffness. His mental status is normal. [yop_poll id="71"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old girl presents with a 2 cm tender lump in her right armpit. It is not fluctuant and there is no overlying redness. On history, she has a kitten, and did sustain scratches to her right hand from the kitten in the last few weeks. She had a small papule on her hand in an area of a scratch 1.5 weeks ago that mom thought was a bug bite. Parents are unsure if she has had any fevers. She is otherwise healthy and well appearing. [yop_poll id="70"]
(Click the link to comment and to vote - voting not working through email, sorry!) An investigator wishes to know whether PED patients seen with bloody diarrhea are prescribed antibiotics in the PED are more likely to develop hemolytic uremic syndrome (HUS). Over a 10-year period, several cases of patients with HUS diagnosed after a PED visit for diarrhea are identified, and for each of these patients, 3 other patients seen in the PED for diarrhea that did not develop HUS matched for age, gender, duration of illness, and stool culture findings are identified. The two groups of subjects are compared regarding whether they received PED antibiotics or not. [yop_poll id="69"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo man was seen in the ED 2 weeks ago with a painless lesion to his penis. He is sexually active with men, has had 2 recent partners, and “sometimes forgets” to use condoms. At that time testing for HIV, RPR, gonorrhea, and chlamydia urine NAT were performed at the time and he was treated empirically with IM bicillin for presumed chancre of syphilis and empiric IM ceftriaxone for gonorrhea. All of the labs were subsequently negative. He now returns with bilateral tender inflamed inguinal adenopathy. His penile lesion resolved after a few days. [yop_poll id="68"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5yo girl comes in for chest pain for 6 hours and is noted to have a heart rate of 250 that is not varying. Review of the electronic medical record reveals a history of WPW. Mom says she has not had an episode of fast heart rate since age 3 weeks when she was first diagnosed. She is not on any medications. She is awake and alert, and her blood pressure is 85/45. SVT WPW 1 [yop_poll id="67"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 16 year old obese teen with no previous history of diabetes who presents with recent viral URI symptoms and increasing altered mental status over the last 8 hours. Her temperature is 37.9, heart rate 140, resp rate 22, and BP 90/35.  Blood glucose is 950, Na 130, K 3.4, and urine negative for ketones. The teen is confused and has a GCS of 13. [yop_poll id="66"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 16 year old football player is brought in with severe right knee pain after being hit from the front. He states that he thought his knee was displaced initially, but now it looks back in place. He has no obvious deformity or effusion on observation, and no ecchymosis. Instability testing is difficult due to the patient’s pain. Radiographs are negative for fracture or dislocation. Dorsalis pedis pulses are palpable and normal bilaterally. [yop_poll id="65"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child has a flat lesion of the entire left forehead and upper eyelid the color of light red wine that has been present since birth. The family has presented to the ED because they are concerned that the child has right sided weakness.   sturge-weber-1 https://mindfulmema.wordpress.com/tag/sturge-weber/ [yop_poll id="64"]  
(Click the link to comment and to vote - voting not working through email, sorry!)   Match the classic serum electrolyte / acid-base findings with the pediatric condition: 1) hypochloremic hypokalemic metabolic alkalosis 2) hyponatremic hyperkalemic metabolic acidosis 3) hyponatremic normokalemic metabolic acidosis 4) hypercalcemic metabolic alkalosis A) DKA B) pyloric stenosis C) milk alkali syndrome D) congenital adrenal hyperplasia [yop_poll id="63"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6yo girl presents with palpable purpura of both legs for 2 days. She has not had any fever and is well appearing. Her labs, including CBC, electrolytes, BUN, Creatinine, and ESR are normal. She does not complain of any pain. Her vital signs are temperature 37.5 C, HR 90, RR 20, BP 90/45. She has no abdominal tenderness, vomiting, respiratory difficulty, joint pain or swelling, and her urination has been normal. Her stool guaiac is negative. [yop_poll id="62"]
(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo boy presents with a round lesion similar to that noted below, but on his penis, noted 1 hour after taking a dose of TMP-SMX that was prescribed to him for “stomach infection.” He had 2 episodes of non-bloody diarrhea 2 days ago and went to a clinic and received the prescription, which he was unable to fill until today. The diarrhea has actually improved. He has no fever. The rash is not painful or itchy. He mentions that he previously had a similar rash in the same place after taking the same drug a few years ago. Fixed drug eruptionWikimedia Commons Donald M. Pillsbury, M.D., and Clarence S. Livingood [yop_poll id="60"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="59"]
(Click the link to comment and to vote - voting not working through email, sorry!) A toddler is accidentally left in the car during summer. Luckily, a bystander sees her and calls 911. The car is broken into, and the patient is brought to the PED. She has a temperature of 105.9. [yop_poll id="58"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old child comes in 20 minutes after falling with avulsion of her left upper lateral incisor. The parents have brought the tooth in a tissue. The entire crown and root are present. There is no active bleeding from the socket. The remainder of her exam is normal; she is able to open her mouth widely without pain and has no bony tenderness over her facial bones or jaw. [yop_poll id="57"]
(Click the link to comment and to vote - voting not working through email, sorry!) 8yo girl with history of asthma presents with increased work of breathing x 1 day. She is alert but anxious appearing, tachypneic, has retractions and flaring, and her O2 sat is 88% on room air. She has poor air movement and few wheezes are heard. She is given two 5mg albuterol nebulized treatments and oral steroids. An initial venous blood gas had a pH of 7.45 and pCO2 of 34. A repeat blood gas shows a pH of 7.33 and pCO2 48, O2 sat on oxygen with 3rdnebulized albuterol is 91%; her mental status is unchanged [yop_poll id="56"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 9 month old baby is brought in with this problem, first noted a few hours prior. Hair tourniquet By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons [yop_poll id="55"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo woman who is 33 weeks pregnant presents with contractions every 2 minutes and thinks her water broke. She has no prenatal care records available, and was only recently diagnosed as pregnant at an outside clinic. On exam, she is 9cm dilated and +1 station. She is screaming with pain. [yop_poll id="54"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="53"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a study to compare a new antiviral to treat herpangina to placebo. During the trial, some of the parents stop giving their children the new drug because it tastes bad, and some (but fewer) parents stop giving their children the placebo because they forget to give it. During the analysis, you compare the outcomes based on the patients’ assignment to their original group. [yop_poll id="52"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old recently moved to the U.S. from Mexico with left sided chest pain for one day, and a fever to 38.2. Lung sounds are clear, the O2 sat is 100% on room air, and the CXR is negative. The ECG shows diffuse 1mm ST elevations and PR depression. The patient is well appearing with normal vital signs and hemodynamics. [yop_poll id="49"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with heavy prolonged menses x 10 days who appears pale to her parents. She had menarche at age 11, and has had heavy irregular menses since then. She actually feels that her menses is slowing down and she is currently using 1-2 pads per day. She has never had any other bleeding. Her HR is 90, and BP 100/50. Her hemoglobin is 9 and her MCV is 65. [yop_poll id="50"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing an 8 month old child with viral URI symptoms and pulling at the left ear. The child has not had any fever, is fully immunized, and is well appearing and playful. The right ear is translucent. The left ear is erythematous, with no bulging, perforation, or air-fluid level. Mobility is normal on pneumatic otoscopy. The child had one previous ear infection diagnosed at age 5 months. [yop_poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old child with cochlear implants placed 8 months ago. The child has fever, headache, vomiting, altered mental status, and meningismus. The implant sites are well healed and show no signs of local infection. [yop_poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) D5 ¼ NS is no longer recommended for maintenance fluids in hospitalized young infants. Why not? [yop_poll id="45"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 4 year old child struck by a car. The child has significant maxillofacial trauma, a large parietal hematoma, and a GCS score of 7. Attempts to intubate with direct and video laryngoscopy have been unsuccessful due to blood obscuring visualization of the airway, and you are only partially able to oxygenate and ventilate the child with bag-mask ventilation, with an O2 sat on 100% FiO2 of 80%. [yop_poll id="44"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo child is brought in after having taken some of Grandma’s “heart medicine.” Because the pills are kept in an unlabeled box and not their original container, the parents don’t know what the medication was. The child has sinus bradycardia with frequent PVC’s on the ECG, a blood glucose of 90; electrolytes on the i-stat are normal except for a slightly elevated potassium level. [yop_poll id="43"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10 month old infant with history of constipation comes in with a 1cm dark red (but not dusky) painless mass extruding from the anus. The patient is afebrile, well appearing and playful, and the remainder of the exam is unremarkable. Rectal_Prolapse_Toddler_1 Wikimedia Commons, user BellaVuk [yop_poll id="42"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a trial comparing two different techniques for draining skin abscesses: standard I&D with packing vs. loop drainage. Your chosen outcome is the proportion of patients that require a second drainage procedure. You expect to enroll 100 patients in each group, and expect an average of 10% to require a second drainage procedure. [yop_poll id="41"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 13 year old girl presents with sudden onset sharp RLQ pain radiating toward her groin, along with nausea and vomiting once, non-bloody, non-bilious. [yop_poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old with ventriculoperitoneal shunt revision 1 month ago, presents with headache and vomiting and increased sleepiness according to mom. The patient is well appearing and nontoxic, tolerating po’s in the ED, and has a normal funduscopic and neurologic exam. He got acetaminophen 2 hours ago and has no headache currently. [yop_poll id="39"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old is brought in because all of his fingernails and toenails are falling off, painlessly. On review of the ED electronic medical record, he was seen 6 weeks ago and diagnosed with a viral infection. What viral infection did he have? [yop_poll id="38"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 3 year old child sustains a cold water submersion injury. He is brought in with a core temperature of 30 degrees C, in ventricular fibrillation, and is successfully defibrillated and intubated. Rewarming is occurring by: removing wet clothes, forced air warming blanket, warmed IV fluids to 40-44C, warmed humidified oxygen at 42-46C. What rate and endpoint of rewarming is best? [yop_poll id="37"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 14 month old is brought in with lethargy and obtundation. The patient is breathing spontaneously and has stable vital signs. The parents admit that they were having a party with alcohol and recreational drugs present, and the toddler had been walking around. [yop_poll id="36"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old uncircumcised boy is brought in because his parents are concerned that they cannot retract his foreskin. On exam he has phimosis, but there are no signs of inflammation or swelling and no palpable scarring or fibrosis. The patient is asymptomatic and has experienced no ballooning, dysuria, incontinence, dribbling, or recurrent balanoposthitis or UTI. [yop_poll id="35"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped. [yop_poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) Teardrop pupil www.jems.com A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above. [yop_poll id="33"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 15 year old girl is brought in by her uncle for a chief complaint of vaginal discharge (he explains that her parents are working and unable to bring her in). She has yellow vaginal discharge and cervical motion tenderness on exam. Her pelvic exam is otherwise unremarkable. She has a linear bruise on her neck, some circular marks on her right dorsal hand, and some linear hyperpigmented marks on her right volar wrist. She shrugs her shoulders when asked how these occurred. Her uncle states that she “does it to herself.” She avoids eye contact, is not very conversant, and her uncle answers most of her questions for her. She shakes her head “no” when asked about depression or suicidality. [yop_poll id="32"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy was scuba diving with his father. Soon after coming to surface, he began to experience symptoms of decompression illness, including joint pains, itchiness, ataxia, paresthesias, and confusion. He has been placed on 100% oxygen by non-rebreather and an IV has been placed and the plan is to transport him to a facility with a hyperbaric chamber. [yop_poll id="30"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 day old male is brought in with bilateral breast enlargement. They seem slightly tender, but there is no redness, fluctuance, or fever. The parents have noted discharge of a milky substance. [yop_poll id="29"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Put these causes of pediatric limp in order of what age they typically present, from youngest to oldest:
  1. Legg-Calve-Perthes disease
  2. Developmental dysplasia of the hip
  3. Slipped capital femoral epiphysis
  4. Nondisplaced hairline oblique fracture of the tibia w/o history of trauma
[yop_poll id="27"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following patients that sustained electrical injury requires further observation in the ED or admission (should not be discharged home now)? A) A toddler that bit on an electrical cord, has an oral commissure burn, but has normal labs and ECG and is tolerating po’s and has no active bleeding B) A 4 year old that put a fork into a European socket and sustained a small burn to the hand, is asymptomatic, has normal CK and ECG and soft compartments C) A teen who was running from law enforcement and was brought in with a retained taser dart, which has been subsequently removed, and who is currently asymptomatic D) A teen who touched a downed power line and sustained electrical shock, labs and ECG are normal and is currently asymptomatic [yop_poll id="26"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are triaging patients from a multi-casualty incident. The following patients are seen: Patient A: Approximately 2 years old, ambulatory, crying, large 8cm parietal hematoma, obvious right humeral deformity Patient B: Approximately 5 years old, unresponsive, apneic after airway positioning and 5 rescue breaths, weak palpable pulse Patient C: Approximately 3 years old, responsive to painful stimuli, breathing at 40 breaths per minute, very weak palpable pulse Patient D: Approximately 7 years old, unresponsive, breathing at 30 breaths per minute, weak palpable pulse [yop_poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child recently brought from a third world country with PMH of an unrepaired hole in the heart and mild cyanosis is brought in to the ED. The patient fed in the AM, then began to cry and became unconsolable, hyperpneic, and deeply cyanotic. On arrival, the patient has a temp of 37.6, HR 180, RR 60, BP unobtainable, O2 sat 40% on room air. [yop_poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED. [yop_poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are evaluating the electrocardiogram of a 2 year old boy. The patient presented for fever and the ECG was inadvertently ordered on him instead of another patient. [yop_poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) You receive word that the clinic is rushing over a patient with a genetic syndrome and respiratory distress. You have a few moments to look in the electronic chart of the patient and set up the resuscitation room. Which of the following syndromes would make you concerned for a potential difficult airway scenario? [yop_poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy presents after taking 3-4 of grandma’s pills about an hour prior. It is unknown what Grandma takes, but she has “chronic pain, a heart condition, high blood pressure, and sugar problems”. He is altered, but arousable to stimuli and answers questions. He says he took the pills because he was “curious.” His vital signs are: Temp 36.6, HR 49, RR 12, BP 80/40, O2 sat 98% on room air. Physical exam is significant only for miosis, bradycardia, and somewhat weak pulses. Bedside glucose is 100. [yop_poll id="18"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is true about erythema multiforme major, Stevens-Johnson syndrome, and toxic epidermal necrolysis? [yop_poll id="17"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
Impetigo http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
Which of the following cervical spine findings would you expect to be less common in a young child as compared to an adolescent or adult? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="11"]  
Jellyfish en.wikipedia.org (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="10"]
A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
A 3 year old comes in after falling 3 feet from the top of a kiddie slide onto cement, hitting his head. His only +PECARN symptom is 2 episodes of vomiting in the 2 hours since the fall. The medical student seeing him states to you that he is PECARN+ and he has discussed CT with the parents. What is the approximate risk of clinically important traumatic brain injury in this patient? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="7"]
A 10yo girl comes home from a family vacation to Florida in June, where she swam in the ocean. She has an itchy rash in the area covered by her bathing suit that started soon after swimming in the ocean and is still present 3 days later. Seabathers   http://www.medicinenet.com (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="6"]
A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]
A 19yo man presents with progressively worsening extremity numbness in a glove and stocking distribution and ataxia x 1 month. He has areflexia, weakness, and a wide-based gait on exam. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="4"]
NEW! Vote your answer and see what others voted for. Correct answer will be in Comments in a few days. A 14yo female soccer player comes to the ED complaining of bilateral knee pain x 1 month, right greater than left. She does not recall a specific traumatic injury or fall, nor of any knee swelling, popping, or locking. The pain is worse after soccer practice or a game, and after getting up from sitting for a prolonged period such as her 2-hour block classes. The pain is described as behind the knee cap. There is no knee effusion, and there is full active range of motion. She has been afebrile throughout the course. [yop_poll id="1"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
A 16yo boy just returned from a vacation to the U.S. Virgin Islands. On the flight, he developed abdominal pain, nausea, vomiting, which he initially attributed to airsickness. He came straight from the airport to the ED, and now he also complains of lingual and circumoral paresthesias, painful paresthesias of his hands and feet, feeling as though his teeth feel “loose”, and generalized weakness. Another classic symptom of this entity is: A. Urticaria and flushing B. Tachycardia C. Profuse watery diarrhea D. Paralysis E. Temperature reversal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
You are conducting a study to compare the efficacy of a new bronchodilator against standard albuterol therapy in patients with acute asthma exacerbations. To reduce the possibility of selection bias in your study, the key element in your study design is: A. Blinding study participants so that they do not know which treatment has been selected for them, and do not change their subjective assessment of improvement in asthma symptoms B. Enrolling sufficient numbers of study participants to ensure an accurate estimate of the difference in treatment effects C. Randomizing study participants to ensure that the two groups studied are equivalent in potential confounding factors D. Only enrolling study participants > 2 years old, to avoid selecting bronchiolitis patients instead of asthma patients Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition? Septal hematoma http://rhinitis.hawkelibrary.com/album09/83_G A. Change antibiotics to amoxicillin-clavulanate B. Attempt removal of foreign body C. Incision and drainage and nasal packing D. Referral to otorhinolaryngologist for polyp removal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here
A 10yo girl is sitting lapbelted in the rear of an SUV that is involved in a rear-end collision at 40mph. She complains of abdominal pain, and has an ecchymosis from the lapbelt going across her lower abdomen. Of the following, which is the LEAST likely injury the patient may have: A. Small bowel injury B. Kidney injury C. Horizontal vertebral body fracture in lower spine D. Spinal cord injury Check back in a few days for my answer and others' comments Also if you're interested in the Peds ID question of the week, go here
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments
You are seeing a 12yo child with right ear pain for 2 days. He has been swimming recently. On examination, he has pain when you pull on the pinna of the ear to straighten the canal, and the canal is swollen and full of purulent discharge. He is afebrile and has no previous history of ear infection. Which of the following is FALSE regarding the management of this patient? A. Systemic antibiotics play no role B. If the patient had a history of pressure equalization tubes, neomycin + polymyxin B + hydrocortisone (cortisporin) drops would be contraindicated C. The patient should be advised not to swim while undergoing treatment D. Pain can be treated with antipyrine + benzocaine (auralgan) drops E. Fluoroquinolone drops are the most commonly used antibiotic therapy
Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C
A 14yo boy presents with fever and chest pain for 2 days. The chest pain is pleuritic and worse with leaning back. On examination, lung sounds are clear bilaterally, heart is regular with no murmurs, but a friction rub is heard. Which of the following is true of this condition? A. Treatment of choice is NSAID therapy B. All patients must be admitted to the hospital on a cardiac monitor C. CXR is always abnormal D. Electrocardiogram most commonly shows ST elevation isolated to leads II, III, and aVF E. Pain is rarely referred to shoulder or back
A 5yo uncircumcised boy comes in because his parents are unable to retract the foreskin of his penis. They have not been able to retract it ever, but now note also that he is having ballooning of the foreskin when he urinates. On exam, the opening of the foreskin is very tight. Appropriate treatment includes: A. Forceful retraction of the foreskin to break any adhesions B. Topical steroid cream and close follow-up C. Topical estrogen cream and close follow-up D. Emergent consultation with a urologist for immediate circumcision E. Reassurance that the condition will resolve by age 10 years
A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is: A. 60 cc/hr B. 75 cc/hr C. 120 cc/hr D. 135 cc/hr E. 150 cc/hr
What is the difference between Enhanced 911 and 911? A. With Enhanced 911, operators are able to give instructions on how to perform CPR in the field B. With Enhanced 911, EMS response times are under 10 minutes C. With Enhanced 911, ALS units are available, whereas with 911 only BLS units are available D. With Enhanced 911, the caller’s location and phone number is automatically transmitted to the operator E. With Enhanced 911, calls are routed by type to specific specialized call centers
A 6yo child is brought in after rescue from a housefire. He is unconscious, and has soot in his nares. You perform rapid sequence intubation. Vital signs are: Temp 37.5, HR 120, BP 68/40, O2 saturation 100%. You note a cherry red color to his skin. What is the antidote most indicated? A. Methylene blue B. 2-PAM C. Hydroxocobalamin D. Sodium bicarbonate E. Naloxone
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis
According to the Belmont report, the 3 main ethical principles for conducting research involving human subjects are: A) Beneficence, nonmaleficence, justice B) Respect for persons, beneficence, justice C) Respect for persons, beneficence, nonmaleficence D) Beneficence, justice, informed consent E) Nonmaleficence, justice, informed consent
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection
A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV
All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed
A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen
Which of the following is true of EMT scopes of practice (EMT-B = EMT-Basic, EMT-I = EMT-Intermediate, EMT-P = Paramedic)?
  1. Only EMT-I and Paramedic level EMT’s can administer oxygen
  2. Training to become an EMT-B is usually 100-150 hours
  3. Training to become a Paramedic is an additional 250 hours of training
  4. IV therapy may be given by EMT-I and EMT-P
A. 1 and 3 B. 2 and 4 C. 1, 2, and 3 D. 4 only E. All of the above
A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
  1. Anterior cord syndrome
  2. Brown-Sequard cord syndrome
  3. Central cord syndrome
  4. Chance fracture
17yo boy with long legs and arms, h/o scoliosis and mild pectus excavatum, hyperextensibility of the thumbs, presents with sudden onset ripping quality chest pain and feeling lightheaded. On exam, patient is anxious appearing, afebrile, HR 105, BP 98/45, RR 14, pulse ox 98% RA, alert, HEENT non-revealing, Lungs BCTA, Cor RRR with mid-systolic click followed by a late systolic murmur at the apex, Abd soft ND NT, Extremities and Skin non-contributory.  Of the following, which diagnostic study is the best choice? A) POC troponin B) Arterial blood gas C) Bedside ultrasound looking for lung sliding D) CT angiogram E) CT abdomen
For aeromedical transport, transport mode transitions from helicopter to fixed wing aircraft when the distance from base station to patient pick-up location exceeds how many miles? A) 70 miles B) 150 miles C) 200 miles D) Distance is not a factor
A child is brought in with a stab wound to the right neck just superior to the cricoid cartilage. What zone of the neck is this? What is the significance of the zones?
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?
In a population of 1,000 people, 100 have a disease. A test is positive in 95 people with the disease and 100 people without the disease. What is the sensitivity, specificity, and positive predictive value of this test?

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