A 2 yo F attended a birthday party at a local petting zoo yesterday and presents to ED with diffuse abdominal pain, fever of 39.0C and 8 episodes of bloody diarrhea with mucous. What is the most likely causative agent

16 yo F admitted with lower abdominal pain, intractable vomiting, and fever for 2 days. Admits with questioning to sexual activity with 1 male partner. Pelvic exam is significant for erythema and friability of cervical mucosa and exquisite cervical motion tenderness with no adnexal masses. You obtain specimens for testing and start empiric treatment any of the following regimens EXCEPT:

A 4 yo M presents with 3-day history of fever to 40C, diarrhea, abdominal pain, and listlessness. His mother reports they returned last week from Pakistan, where the family spent 1 month visiting relatives in both urban and rural areas. The child received no prophylactic vaccinations or medications prior to the trip. On physical exam, you see a fatigued-appearing boy with a temp 39.5C, diffuse, moderate abdominal tenderness, a spleen tip palpable 2 cm below the left costal margin. A CBC shows a peripheral white blood cell count of 14,000, Hgb 12 mg/dL, and plt count of 350,000. Of the following, the most likely pathogen causing the patient's symptoms is

A 6 mo old term male is brought to the ED for evaluation of 2-day history of fever to 39.8C, irritability, decreased activity, and emesis. His mother states everyone in the house has been sick with runny nose and nasal congestion for the past week and the patient does attend day care. He has only had his 2-month immunizations. On exam, he has a temp of 40C, appears ill, and is extremely irritable. His anterior fontanelle is full and he has a stiff neck. Studies obtained on his CSF show: Glu 5 Prot 170 WBC 550 RBC 2 gram stain positive for many WBCs and gram-positive cocci. Of the following, the most appropriate empiric antibiotic regimen for the treatment of this patient is

You are caring for a 6 yo M with CAP at a tertiary care children’s hospital. He was admitted after the failure of outpatient high-dose amoxicillin. He has no chronic illness or drug allergies and is fully immunized. Since admission, he has received ceftriaxone daily. On HD 3, because of persistent fevers and respiratory distress, a blood culture was obtained and IV vancomycin was added.

Now, on HD 5, he remains febrile and in significant respiratory distress. He has a fever of 39.5°C, HR 130, RR 36, and SpO2 92%, requiring an increase from 1 to 3 L/min of oxygen by simple nasal cannula. He is in moderate respiratory distress with tachypnea, retractions, intermittent nasal flaring, and absent breath sounds in the right base with egophony and dullness to percussion. A repeat CXR is obtained. Subsequent chest ultrasonography shows a large pleural effusion on the right that does not appear septated or loculated.

Of the following, the BEST next step for this patient is

High fevers, lethargy, and listlessness develop in a 9-month old child who attends a child care center. She experiences a 5-minute generalized tonic-clonic seizure. CSF analysis reveals

10000 WBCs with 90% neutrophils and 10% lymphocytes

Protein 130

Glucose 5

CSF culture yields growth of Neisseria meningitidis. Which of the following statements is true

An 8-year-old previously healthy boy was admitted 1 day ago with dehydration following 4 days of nonbloody diarrhea that progressed to bloody diarrhea and worsening crampy abdominal pain on defecation over the last 48 hours. The abdominal pain has been increasing despite the use of diphenoxylate over the last 3 days. Since admission, he has been on IV fluids and is receiving scheduled morphine for abdominal pain with partial relief. On this morning’s physical examination, he has decreased bowel sounds and a moderately distended and diffusely tender abdomen. He has a temperature of 40°C, pulse rate of 160 beats/min, blood pressure of 84/56 mm Hg, and respiratory rate of 18 breaths/min. He had a white blood cell count of 22,000/µL (22 × 109/L) at admission. An immediate abdominal radiograph is obtained.

After stopping opioid analgesia, the next BEST next step in management is to

An 8-month-old ex-28 week preemie developed cough and congestion several days ago. Her parents noted increased work of breathing and brought her to the ED. She had a RR50 with a SpO2 85% on room air. Her tachypnea improved with suctioning but she remained hypoxemic, so oxygen was started and she was admitted. Her rapid viral screen was positive for respiratory syncytial virus.

During her 8-week NICU stay she was given oxygen by nasal cannula for 1 week and then was a stable feeder and grower. Since that time, she has not had any respiratory or cardiac issues and began receiving monthly palivizumab at the beginning of the RSV 1 month ago.

During the current hospitalization, she received supplemental oxygen and suctioning and was weaned to room air within 48 hours. No episodes of apnea were noted. The family is concerned about her discharge, particularly they are concerned about her prematurity and having a sibling at home with upper respiratory symptoms.

Of the following, the MOST appropriate recommendation at discharge is

A 11 yo F has a 2-day history of fever and muscle aches. Her parents report that yesterday she had multiple episodes of NBNB emesis, and is now having multiple episodes of nonbloody diarrhea. She has a fever 39°C, HR 125 RR 22 and BP 108/68 mm Hg. She is alert but listless. Dry lips on exam with 2+ distal pulses and a cap refill ~3 seconds. Her abdomen is nondistended and soft with hyperactive bowel sounds and without tenderness or guarding. She feels nauseated and does not want to drink, and urine output is decreased. On further questioning, the parents report that the patient and family returned 10 days ago from a country experiencing a Lassa fever outbreak. She remained in the main city with healthy family members and did not visit areas where the virus outbreak was occurring. Her parents did travel to different parts of the country. They are afebrile and have no concerns at this time.

A 3-week-old, previously healthy full-term male newborn is brought to your office for evaluation of a rash on the bottom of his feet that began a few days ago. The mother has no other concerns. On physical examination, the newborn is afebrile with normal vital signs. The anterior fontanel is soft, open, and flat. There is minimal clear rhinorrhea. The liver and spleen are palpable 2 cm and 1 cm below the right and left costal margins, respectively. There are numerous copper-colored, circular lesions, each less than 0.5 cm in diameter on the plantar surfaces of both feet. The remainder of the physical examination is unremarkable.

A 13-month-old girl is hospitalized with fever and pancytopenia. She has a history of an orthotopic liver transplant for biliary atresia. She currently is on tacrolimus and prednisone for rejection prophylaxis and trimethoprim-sulfamethoxazole for pneumocystis prophylaxis. Vital signs show a temperature of 38.8°C, respiratory rate of 44 breaths/min, heart rate of 130 beats/min, blood pressure of 121/67 mm Hg, and weight of 9.85 kg. On physical examination, she is irritable, mottled and has several erythematous macules over her face. Her abdomen is distended and you note hepatosplenomegaly. Laboratory data shows:

White blood cells, 1,110/µL (1.1 x 109/L) Hemoglobin, 7.5 g/dL (75 g/L) Platelets, 42 x 103/µL (42 x 109/L) Differential, 1% segmented neutrophils, 18% bands, 78% lymphocytes, 2% monocytes, 1% eosinophils Aspartate aminotransferase, 90 U/L Alanine aminotransferase, 61 U/L Human herpesvirus 6 polymerase chain reaction, 261,000 copies/mL Tacrolimus level 11.5 ng/mL

Of the following, the MOST likely cause of this child’s pancytopenia is

A term male newborn is born to a 35-year-old woman known to have hepatitis C. The mother is anxious to know if her newborn has acquired the infection.

Of the following, the test that would BEST identify early infection in the newborn is

A 5-year-old girl, visiting the United States from India, is brought to the emergency department with a complaint of fever, abdominal pain, back pain, and lethargy. On physical examination, her temperature is 39.5°C, heart rate is 135 beats/min, respiratory rate is 30 breaths/min, and blood pressure is 95/65 mm Hg. She is thin and ill appearing. Her conjunctivae are pale and mucous membranes are tacky. Capillary refill is 2 seconds. There is an II/VI vibratory systolic ejection murmur. Lungs are clear to auscultation. Her abdomen is diffusely tender to palpation, and the liver and spleen are palpated 4 cm and 5 cm, respectively, below the costal margins. Examination of the spine and paraspinal muscles is normal.

A complete blood cell count shows:

White blood cell count, 4,000/µL (4.0 × 109/L) with 40% neutrophils, 40% lymphocytes, and 20% monocytes Hemoglobin, 8 g/dL (80 g/L) Platelet count, 120 × 103/µL (120 × 109/L)

A review of the peripheral smear by pathology is requested ).

Of the following, the MOST likely etiology of this child’s illness is

A 2 yo boy presents to ED with fever, vomiting, and behavioral changes. He has had increased agitation and repeated episodes of facial twitching. Vital signs show a T39.5°C, RR 38, HR 131, BP 124/76 , weight of 12.8 kg. On physical examination, he is irritable, has nuchal rigidity, and several insect bites are noted over his legs. Laboratory data shows:

WBC 20,200/µL (20.2 x 109/L) Hgb 11.3 Platelets, 341 Differential (S62, L26, M12)

CSF WBC 145 (S23, L45, M32) CSF red blood cells, 2/µL CSF glucose, 49 mg/dL (2.7 mmol/L) CSF protein, 15 mg/dL CSF West Nile immunoglobulin M, 1:64

The resident working with you asks about the epidemiology of West Nile virus.

Of the following, the BEST response to your resident’s question is

An 8-year-old, previously healthy, fully immunized boy presents to your ED with bilateral facial swelling that developed over the last 24 hours. Throughout the past week, the patient had a subjective fever, myalgias, and a mild cough. On physical examination, his T 37.5°C, HR 100, and RR18. The boy’s voice is hoarse. There is bilateral, tender, firm, nonerythematous swelling of the pre-auricular area that extends to the angle of the mandible. His teeth and gingiva are normal, with mild erythema of the buccal mucosa. His posterior oropharynx is erythematous with enlarged tonsils without exudates. He has clear rhinorrhea, erythema of the nasal mucosa, and mildly hyperemic and retracted tympanic membranes. There is shotty bilateral cervical lymphadenopathy. The remainder of the physical examination is unremarkable.

Of the following, the MOST likely etiology of the patient’s illness is

In the winter, a previously healthy 2.5-year-old boy with suspected pneumonia is referred for direct admission by his PCP. The pediatrician noted that the boy has been ill for 1 to 2 days with upper airway congestion, a worsening cough, high fevers, myalgias, poor oral intake, and scant urine output. The boy appeared to be in moderate respiratory distress with diffuse bilateral crackles, tachypnea, and increased work of breathing. In the office, the boy had a T38.7°C, HR 115, RR 42, and SpO2 90% on room air.

The boy has no significant medical, surgical, or family history. He did not receive a seasonal influenza vaccination, but the rest of his immunizations are up-to-date. He attends day care and lives with his parents and older brother.

You review the patient’s CXR, and accept the patient as a direct admission.

Of the following, the BEST next diagnostic step is to order a

You receive a transfer from an outside ED. The patient is a previously healthy 7 yo boy who fell and scraped his lower left leg on the pavement yesterday. Redness and swelling of the leg developed this morning, approximately 18 hours after the injury, and worsened throughout the day, prompting the mother to bring him to the ED. The boy was transferred as a direct admission because of concern for left leg osteomyelitis.

The mother reports that the pain, redness, and swelling of the left leg has increased since they left the ED. The patient reports pain of 10 on a 10-point scale, extending from the left distal aspect of the thigh to the lower part of the calf. He is now refusing to walk because of the pain.

Vital signs are T 38.4°C, HR 110, RR 20 BP110/65 mm Hg.

On examination, the patient appears anxious and in pain. He has erythema, warmth, and edema of the left proximal aspect of the lower leg in an area that extends 15 cm in diameter, which surrounds a 1-cm superficial laceration. There is crepitus surrounding the laceration, but no fluctuance or drainage. He complains of exquisite pain to light touch in an area that extends beyond the area of erythema, from the distal aspect of the left thigh to the ankle. He refuses to move his left knee because of pain, but there is full range of motion to passive movement and no evidence of knee effusion on a patellar ballottement test. The remaining findings of his examination are normal, including strong distal pulses (including left dorsalis pedis) with brisk capillary refill.

Broad-spectrum antibiotics are ordered.

Of the following, the BEST next step in management is to

A 7-yo previously healthy boy with a history of mild persistent asthma is referred to the hospitalist service for direct admission by his pediatrician for a 10-day history of daily fevers. The family reports that fevers have occurred 1 or 2 times each day and range from 38.5°C to 39°C. Associated symptoms include anorexia, abdominal pain, myalgias, and headache. The boy has experienced a 2-lb weight loss since the illness began. The family lives on an organic farm and sells raw dairy products. The boy has no history of recent travel or sick contacts. He appears tired but nontoxic. He has mild diffuse abdominal tenderness without guarding or rebound. The spleen tip is palpable.

Laboratory data are shown:

Laboratory Test Result CRP 22.5 mg/L (241 nmol/L) WBC 6,200/µL (6.2 x 109/L) S 22% L68% M 8% Eos 2% Hgb 10.1 g/dL Plt 160 AST 110 ALT 135. Of the following, the MOST likely diagnosis in this patient is

You are admitting a 17 yo M adolescent with history of ADHD, anxiety, and depression. He has a 5-day history of daily fever to 38.3°C, diffuse nonpruritic rash, malaise, and myalgias. His medications include methylphenidate hydrochloride and fluoxetine. His immunizations are up-to-date, and he reports no weight loss or recent travel. He has no allergies or pets. He had been sexually active 2 months prior to admission. He reports condom use and no prior STIs. He is alert, nontoxic, well nourished, and normally developed. His has T38.7°C, HR85, RR 16, and BP 115/75 mm Hg. He has a diffuse polymorphic maculopapular rash that includes the palms and soles. Bilateral mildly tender cervical and inguinal adenopathy is palpable. Perineal examination reveals nontender, flat gray papules around the anus. Heart, lung, abdominal, and joint examination findings are unremarkable.

Of the following, the drug of choice for treatment of this patient is