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Aafp review questions download pdf free

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UWorld is a great tool for improving your weaknesses. Have a knowledge gap in endocrinology? Select that section and dive straight into endo questions. The hate is for how long it takes to complete the entire Qbank, as Uworld has over 1, questions for family medicine. The best thing to do is make a study plan and stick to it. You can purchase the entire Qbank for different amounts of time. This resource can be overwhelming if you are close to your test date.

One way to incorporate these questions into your studying if you have limited time is to use them to help you with topics that you are still struggling with. Family medicine residents know that these tests are very guideline-heavy with an emphasis on conservative management.

The US Preventive Services Task Force is the quintessential source for all of the most recent recommendations for screening and prevention. There are tons of companies offering questions for these exams, but unless you are way ahead of the game, stick to ITE and UWorld.

Each chapter is focused on a different topic and it will do back-to-back questions about one topic, making it really easy to drive home some topics for example, pediatric fever. This is also a great resource for rotations to drive home important points in question format! If you are struggling with specific topics that you remember learning well from a medical school resource, by all means dust it off First Aid for Step 2, Step Up to Medicine, etc.

Start early, be consistent, and stay calm. The pass rate is extremely high for the family medicine boards, because remember: you are testing with people from all walks of life including doctors who have been in practice for over 30 years. Remember that your training should be preparing you to do well on this exam, and if all else fails on test day: think back to your training!

The Value of In-Training Exams: In-Training Exams are by far the most important study resource because these are the only questions written by the same people who write the test. The Value of ABFM Questions: Again, these questions are the most important resource to prepare you for this exam, and with this app, you can do questions on the go without having to sit down with a whole examination in PDF format.

All it requires is an AAFP membership and login also free. Take advantage of this resource. Parting Wisdom Start early, be consistent, and stay calm. Can I Stop Zooming Now? Previous Post. Next Post. Search the Blog. Fish oil B. Warfarin Coumadin C. Cilostazol Pletal D.

Dipyridamole Persantine E. Clopidogrel Plavix Methicillin-sensitive Staphylococcus aureus C. Pseudomonas aeruginosa D. Klebsiella pneumoniae E. Clostridium difficile E. Clostridium difficile. Sporulating organisms such as Clostridium difficile are not killed by alcohol products.

She does not recall any injury, and the pain is present when she is resting and at night. Her only chronic medical problem is type 2 diabetes mellitus. On examination, she has limited movement of the shoulder and almost complete loss of external rotation. Radiographs of the shoulder are normal, as is her erythrocyte sedimentation rate. Frozen shoulder.

Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory tests and plain films are normal; the diagnosis is clinical SOR C. Frozen shoulder is differentiated from chronic posterior shoulder dislocation and osteoarthritis on the basis of radiologic findings.

Both shoulder dislocation and osteoarthritis have characteristic plain film findings. A patient with a rotator cuff tear will have normal passive range of motion. Impingement syndrome does not affect passive range of motion, but there will be pain with elevation of the shoulder.

Frozen shoulder B. Torn rotator cuff C. Impingement syndrome D. Chronic posterior shoulder dislocation E. Osteoarthritis It delays progression from the catarrhal stage to the paroxysmal stage B.

It reduces the severity of symptoms C. It reduces the duration of illness D. It reduces the risk of transmission to others E. It reduces the need for hospitalization D. It reduces the risk of transmission to others.

Antibiotic treatment for pertussis is effective for eradicating bacterial infection but not for reducing the duration or severity of the disease. The eradication of infection is important for disease control because it reduces infectivity. Antibiotic treatment is thought to be most effective if started early in the course of the illness, characterized as the catarrhal phase. The paroxysmal stage follows the catarrhal phase. The CDC recommends macrolides for primary treatment of pertussis.

The preferred antimicrobial regimen is azithromycin for days or clarithromycin for 7 days. These regimens are as effective as longer therapy with erythromycin and have fewer side effects. Children under 1 month of age should be treated with azithromycin. There is an association between erythromycin and hypertrophic pyloric stenosis in young infants. Fluoroquinolones have been shown to reduce pertussis in vitro but have not been shown to be clinically effective SOR A.

EEG monitoring D. He rates the pain as 6 on a point scale. A chest radiograph shows a thoracic vertebral compression fracture. Which one of the following would be most appropriate at this point?

Complete bed rest for 2 weeks B. Markedly decreased activity until the pain lessens, and follow-up in 1 week C. Referral for vertebroplasty as soon as possible D. Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG.

While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES. Elevated postictal prolactin levels at least two times the upper limit of normal have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable SOR B.

While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.

In addition, patients with epileptic seizures often have normal brain MRIs. Markedly decreased activity until the pain lessens, and follow-up in 1 week. This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks.

Complete bed rest is unnecessary and could lead to complications. He was started on lisinopril Prinivil, Zestril , 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC and a complete metabolic panel, were normal except for a serum creatinine level of 1.

A follow-up renal panel obtained yesterday shows a creatinine level of 3. Which one of the following is the most likely cause of this patient's increased creatinine level? Bilateral renal artery stenosis. The other conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE inhibitor. Bilateral renal artery stenosis B. Coarctation of the aorta C.

Essential hypertension D. Hyperaldosteronism E. Pheochromocytoma They are not severe, but have been interrupting his sleep, and he is becoming exasperated.

What should be the primary focus of treatment in this individual? Drug treatment to prevent recurrent episodes B. Decreasing the intensity of the muscle contractions in the diaphragm C. Finding the underlying pathology causing the hiccups D. Improving the patient's quality of sleep E. Suppressing the current hiccup symptoms His temperature is normal.

Which one of the following medications in combination with fluoxetine could contribute to this patient's symptoms? Dextromethorphan B. Pseudoephedrine C. Phenylephrine D. Guaifenesin E. Diphenhydramine Benadryl C. Finding the underlying pathology causing the hiccups. Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain.

Hiccups that last a matter of hours are usually benign and selflimited, and may be caused by gastric distention. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means e. If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups.

Identifying and treating the underlying disorder should be the focus of management for intractable hiccups. Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin syndrome. SSRIs such as fluoxetine are also associated with serotonin syndrome, and there are many other medications that increase the risk for serotonin syndrome when combined with SSRIs.

The other medications listed here are not associated with serotonin syndrome, however. Pronation and supination of the forearm are painful on examination, as are attempts to flex the elbow.

There is tenderness of the radial head without significant swelling. A radiograph of the elbow shows no fracture, but a positive fat pad sign is noted. Appropriate management would include: check one D. Nondisplaced radial head fractures can be treated by the primary care physician and do not require referral.

Conservative therapy includes placing the elbow in a posterior splint for days, followed by early mobilization and a sling for comfort. Sometimes the joint effusion may be aspirated for pain relief and to increase mobility.

One study compared immediate mobilization with mobilization beginning in 5 days and found no differences at 1 and 3 months, but early mobilization was associated with better function and less pain 1 week after the injury. Radiographs should be repeated in weeks to make sure that alignment is appropriate. Her diabetes has been controlled with diet and glyburide Micronase, DiaBeta. You saw her 2 weeks ago in the office with urinary frequency, urgency, and dysuria.

She improved over the next week, but then developed flank pain, fever to She was hospitalized and intravenous cefazolin Kefzol and gentamicin were started while blood and urine cultures were performed.

This urine culture also grew E. Her temperature has continued to spike to Which one of the following would be most appropriate at this time?

Order CT of the abdomen. Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota's fascia. The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease.

The diagnosis should be considered when a patient has fever and persistence of flank pain. Add vancomycin Vancocin to the regimen B. Order a radionuclide renal scan C. Order intravenous pyelography D. Order a urine culture for tuberculosis E. Order CT of the abdomen Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition.

Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction.

Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT. This can detect perirenal fluid, enlargement of the psoas muscle both are highly suggestive of the diagnosis , and perirenal gas which is diagnostic.

The sensitivity and specificity of CT is significantly greater than that of either ultrasonography or intravenous pyelography. Amiodarone Cordarone B. Lidocaine Xylocaine C.

Adenosine Adenocard D. Vasopressin Pitressin E. Magnesium Which one of the following is the most appropriate treatment plan for this patient? Vasopressin Pitressin. For persistent ventricular fibrillation VF , in addition to electrical defibrillation and CPR, patients should be given a vasopressor, which can be either epinephrine or vasopressin.

Vasopressin may be substituted for the first or second dose of epinephrine. Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor. Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available. Magnesium may terminate or prevent torsades de pointes in patients who have a prolonged QT interval during normal sinus rhythm. Adenosine is used for the treatment of narrow complex, regular tachycardias and is not used in the treatment of ventricular fibrillation.

Based on this patient's reported frequency of asthma symptoms, she should be classified as having intermittent asthma. Low-dose inhaled corticosteroids daily C. A leukotriene receptor antagonist daily D.

Medium-dose inhaled corticosteroids daily E. Examination reveals a hallux valgus and a rigid hammer toe of the second digit. His foot has mild to moderate atrophic skin changes, and the dorsal and posterior tibial pulses are absent. Appropriate treatment includes which one of the following? Surgical correction of the hammer toe B. Custom-made shoes to protect the hammer toe C.

Bunionectomy D. A metatarsal pad B. Custom-made shoes to protect the hammer toe. The treatment of foot problems in the elderly is difficult because of systemic and local infirmities, the most limiting being the poor vascular status of the foot. Conservative, supportive, and palliative therapy replace definitive reconstructive surgical therapy. Surgical correction of a hammer toe and bunionectomy could be disastrous in an elderly patient with a small ulcer and peripheral vascular disease.

The best approach with this patient is to prescribe custom-made shoes and a protective shield with a central aperture of foam rubber placed over the hammer toe. Metatarsal pads are not useful in the treatment of hallux valgus and a rigid hammer toe. Its largest dimension is 0. Excision with a 1-mm margin. The diagnosis of melanoma should be made by simple excision with clear margins. A shave biopsy should be avoided because determining the thickness of the lesion is critical for staging.

Wide excision with or without node dissection is indicated for confirmed melanoma, depending on the findings from the initial excisional biopsy. What should be the first step in management? A shave biopsy B. Excision with a 1-mm margin C. Wide excision with a 1-cm margin D. Wide excision with a 1-cm margin E. Excision with sentinel node dissection When this was no longer effective, she was transferred to an inpatient facility for pain control. However, her pain has worsened over the past 2 days.

Tolerance to morphine. This patient has become tolerant to morphine. The intravenous dose should be a third of the oral dose, so the starting intravenous dose was adequate. Addiction is compulsive narcotic use. Pseudoaddiction is inadequate narcotic dosing that mimics addiction because of unrelieved pain.

Physical dependence is seen with abrupt narcotic withdrawal. Which one of the following is the most likely cause of this patient's increased pain? An inadequate initial morphine dose B.

Addiction to morphine C. Pseudoaddiction to morphine D. Physical dependence on morphine E. Tolerance to morphine During the most recent episode the headaches occurred most days during January and February and lasted about 1 hour. The most likely diagnosis is which one of the following? Migraine headache B. Cluster headache C. Temporal arteritis D. Trigeminal neuralgia B.

Cluster headache. Cluster headache is predominantly a male disorder. The mean age of onset is years. Attacks often occur in cycles and are unilateral. Migraine headaches are more common in women, start at an earlier age second or third decade , and last longer hours. Temporal arteritis occurs in patients above age Trigeminal neuralgia usually occurs in paroxysms lasting seconds. Hospice benefits end if the patient lives beyond the estimated 6-month life expectancy B. Patients in hospice cannot receive chemotherapy, blood transfusions, or radiation treatments D.

Patients must be referred to hospice by their physician E. It should also be suspected in patients with portal vein thrombosis and splenomegaly, with or without thrombocytosis and leukocytosis. Major criteria include an increased red cell mass, a normal O2 saturation,and the presence ofsplenomegaly. Patients with polycythemia vera may present with gout and an elevated uric acid level, but neither is considered a criterion for the diagnosis.

Lindane's efficacy has waned over the years and it is inconsistently ovicidal. Because of its neurotoxicity, lindane carries a black box warning and is specifically recommended only as second-line treatment by the FDA.

Pyrethroid resistance is widespread, but permethrin is still considered to be a first-line treatment because of its favorable safety profile. The efficacy of malathion is attributed to its triple action with isopropyl alcohol and terpineol, likely making this a resistance-breaking formulation.

The probability of simultaneously developing resistance to all three substances is small. Malathion is both ovicidal and pediculicidal. Insulin detemir Levamir daily plus rapid-acting insulin with meals. Basal insulin provides a relatively constant level of insulin for 24 hours, with an onset of action in 1 hour and no peak. NPH gives approximately 12 hours of coverage with a peak around hours.

Regular insulin has an onset of action of about 30 minutes and lasts about hours, with a peak at about hours. New rapid-acting analogue insulins have an onset of action within minutes, peak within minutes, and last only about hours after administration. Rapid insulin alone does not provide any basal insulin, and the patient would therefore not have insulin available during the night.

She has a normal body weight, no other signs of virilization, and regular menses. Which one of the following is the most appropriate treatment for her mild hirsutism?

Spironolactone Aldactone. Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of hirsutism in premenopausal women SOR C.

In addition to having side effects, prednisone is only minimally helpful for reducing hirsutism by suppressing adrenal androgens. Leuprolide, although better than placebo, has many side effects and is expensive. Metformin can be used to treat patients with polycystic ovarian syndrome, but this patient does not meet the criteria for this diagnosis.

Spironolactone Aldactone B. Leuprolide Lupron C. Prednisone D. Metformin Glucophage When evaluating the child to determine whether he is dehydrated, which one of the following would NOT be useful? Skin turgor B. Capillary refill time C. Respiratory rate and pattern D. The serum bicarbonate level The most useful findings for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern SOR C.

Capillary refill time is not affected by fever and should be less than 2 seconds. Skin recoil is normally instantaneous, but recoil time increases linearly with the degree of dehydration. The respiratory pattern should be compared with age-specific normal values, but will be increased and sometimes labored, depending on the degree of dehydration.

Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age in children. In combination with other clinical indicators, a low serum bicarbonate level , colony-forming units of Escherichia coli. She is started on appropriate antibiotic therapy. Evaluation to rule out anatomic abnormalities should include: check one E. Renal ultrasonography and VCUG for this primary episode of infection.

In the first few months of life, the incidence of urinary tract infection UTI in boys is higher than that of girls. However, after that time period, UTIs are much more common in females, with the peak incidence in the 2- to 3-year age range.

The clinical presentation of UTI in children is similar to that of adults, including dysuria, hematuria, frequency, incontinence, suprapubic tenderness, and low-grade fever. Upper tract infection is suggested by high fever, nausea, vomiting, flank pain, and lethargy.

All children who have a culture-documented UTI should undergo evaluation of the anatomy of the urinary tract. This is due to the fact that children who are at most risk for renal parenchymal damage are those with an anatomic defect. In general, studies to evaluate both the upper and lower tract are recommended. Children under the age of 5 years with a UTI, any child with a UTI and a fever, school-aged girls who have had two or more UTIs, and any boy with a UTI should have a voiding cystourethrogram VCUG to evaluate for vesiculoureteral reflux and renal ultrasonography to evaluate the kidneys.

Cystoscopy and retrograde pyelography are rarely indicated in the workup. Renal ultrasonography only if she has recurrent infections B. Renal ultrasonography and cystoscopy only if she has recurrent infections D. Renal ultrasonography for this primary episode of infection E.

Renal ultrasonography and VCUG for this primary episode of infection A 3-year-old male is brought to the emergency department by his parents, who report seeing him swallow a handful of adult ibuprofen tablets 20 minutes ago.

Which one of the following would be the most appropriate initial management of this patient? Oral ipecac B. Oral activated charcoal C. Gastric lavage D. Whole-bowel irrigation E.

Close observation B. Oral activated charcoal. A single dose of activated charcoal is the decontamination treatment of choice for most medication ingestions. It should be used within 1 hour of ingestion of a potentially toxic amount of medication SOR C. Gastric lavage, cathartics, or whole bowel irrigation is best for ingestion of medications that are poorly absorbed by activated charcoal iron, lithium or medications in sustained-release or enteric-coated formulations. Ipecac has no role in home use or in the health care setting SOR C.

A 3-year-old male is brought to your office because of ear pain. On examination you find a round, plastic bead in the lower third of the ear canal close to the tympanic membrane. You restrain the child and are unable to remove the object despite several attempts, first using water irrigation and then fastacting glue on an applicator. Which one of the following is the best option for removal? Referral for removal under anesthesia.

After several unsuccessful attempts to remove an object deep in the ear canal of an uncooperative child, it is best to refer the patient to an otolaryngologist for removal under anesthesia. Additional attempts are very unlikely to succeed, especially with the techniques listed. A loop curette cannot be safely placed behind a foreign body that is close to the tympanic membrane.

A round, hard object cannot be grasped with forceps. Acetone can be used to dissolve Styrofoam foreign bodies, but it would not dissolve a plastic bead. A plastic loop curette through an otoscope B. Referral for removal under anesthesia C. Grasping with forceps D. Applying acetone to dissolve the object A 3-year-old male is brought to your office by his parents because they are concerned about three "spells" he has had in the past month.

In each case, the child started crying when he was prevented by a parent from doing something he wished to do. While crying, he suddenly stopped breathing and his face and lips began to turn blue. After seconds he resumed crying, his color returned to normal, and he showed no evidence of impairment.

A physical examination today is normal and the child is developmentally appropriate for his age. A recent hemoglobin level was in the normal range. Which one of the following should you do now? Reassure the parents that this is a benign condition and will resolve as the child gets older. This child is experiencing simple breath-holding spells, a relatively common and benign condition that usually begins in children between the ages of 6 months and 6 years.

The cause is uncertain but seems to be related to overactivity of the autonomic nervous system in association with emotions such as fear, anger, and frustration. The episodes are selflimited and may be associated with pallor, cyanosis, and loss of conciousness if prolonged. There may be an association with iron deficiency anemia, but this child had a recent normal hemoglobin level. These events are not volitional, so disciplinary methods are neither effective nor warranted.

While children may experience a loss of consciousness and even exhibit some twitching behavior, the episodes are not seizures so neither EEG evaluation nor anticonvulsant therapy is indicated.

No additional laboratory studies are indicated. Parents should be reassured that the episodes are benign and will resolve without treatment. Teach the parents age-appropriate disciplinary procedures to implement when the child behaves in this manner B. Reassure the parents that this is a benign condition and will resolve as the child gets older C.

Order an EEG D. Obtain appropriate laboratory studies to confirm the most likely diagnosis E. Initiate treatment with valproic acid Depakene A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain around his right hip. Today he has a temperature of A radiograph of the hip is normal. A CBC and an erythrocyte sedimentation rate B.

A serum antinuclear antibody level C. Ultrasonography of the hip D. MRI of the hip E. In-office aspiration of the hip A. A CBC and an erythrocyte sedimentation rate. This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate ESR.

Studies have shown that septic arthritis should be considered highly likely in a child who has a fever over If several or all of these conditions exist, aspiration 3 of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner.

MRI may be helpful in cases that are unclear based on standard data, or if other etiologies need to be excluded. A 3-year-old male presents with a 3-day history of fever and refusal to eat. Today his parents noted some sores just inside his lips. No one else in the family is ill, and he has no significant past medical history. He is up-to-date on his immunizations and has no known allergies.

On examination, positive findings include a temperature of He also has cervical lymphadenopathy. The remainder of the physical examination is normal.

The child is alert and has no skin lesions or meningeal signs. Which one of the following would be the most appropriate treatment? Ceftriaxone Rocephin intramuscularly B. Nystatin oral suspension C. Amoxicillin suspension D. Acyclovir Zovirax suspension E. Methotrexate Trexall A 3-year-old male was treated for acute otitis media last month.

His mother brings him in for follow-up because she believes his hearing has not been normal since then. He attends day care and has had several upper respiratory infections. On examination the tympanic membranes are not inflamed, but the membrane is retracted on the right side. An office tympanogram shows a normal peak type A on the left side, but a flat tracing type B on the right side. Which one of the following would be the most appropriate recommendation?

Audiometry B. Observation with follow-up C. Intranasal corticosteroids E. Systemic corticosteroids D. Acyclovir Zovirax suspension.

The history and physical findings in this patient are consistent with gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 HSV After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things.

Although some clinicians might choose to use oral anesthetics for symptomatic care, it is not a specific therapy. Antibiotics are not useful for the treatment of herpetic gingivostomatitis and could confuse the clinical picture should this child develop erythema multiforme, which occurs with HSV-1 infections.

An orally applied corticosteroid is not specific treatment, but some might try it for symptomatic relief. Therefore, the only specific treatment listed is acyclovir suspension, which has been shown to lead to earlier resolution of fever, oral lesions, and difficulties with eating and drinking. It also reduces viral shedding from 5 days to 1 day SOR B. Observation with follow-up. This patient has unilateral serous otitis and is unlikely to have delayed language from decreased hearing on one side.

The patient should be observed for now. Hearing loss of longer than 3 months may indicate a need for tympanostomy tubes. Surgical treatment has been shown to be helpful, but should be reserved for patients with chronic effusion. Audiometry is not needed to make a decision about surgery at this point.

The mother's judgment is likely correct about his current hearing loss, so a hearing test most likely would not add any useful information. Numerous studies have shown that all medical treatments for serous otitis are ineffective, including antihistamine and decongestant therapy, and corticosteroids by any route.

A 3-year-old white female is brought to the emergency department with an acute onset of epistaxis. The child, who has a history of good health, is brought in by her recently-divorced mother, a registered nurse. The mother appears relatively unconcerned about the child's illness, but otherwise is friendly and interacts appropriately with the health care team evaluating the child.

The child's vital signs are normal, but she is bleeding mildly from both nostrils and there are areas of ecchymosis. Laboratory Findings Hemoglobin You suspect that the child's condition is due to: check one C.

Munchausen syndrome by proxy. The patient exhibits signs of a moderate bleeding diathesis. Her prothrombin time PT elevation, without evidence of hepatocellular damage or hepatic dysfunction, is highly suspicious for warfarin ingestion. The normalization of the PT under observation in a hospital setting is consistent with this suspicion. Although accidental poisoning is a possibility, the mother's affect is highly suspicious for Munchausen syndrome by proxy.

The fact that her mother is a healthcare worker and develops a close and appropriate relationship with the health-care team is consistent with this diagnosis. Acetaminophen toxicity of this degree would likely produce transaminase and bilirubin elevations, as well as mental status changes. Antiphospholipid syndrome produces a hypercoagulable state. Henoch-Schonlein purpura presents with purpura, joint pain, abdominal pain, and a normal PT. Traumatic injury would not result in PT elevations.

Acetaminophen overdose B. Antiphospholipid syndrome with lupus anticoagulant C. Munchausen syndrome by proxy D. Traumatic injury child abuse A 4-month-old white male in respiratory distress is brought to the emergency department. He is acyanotic. A chest radiograph shows an enlarged heart and increased pulmonary vascular markings, and an EKG shows combined ventricular hypertrophy. Ventricular septal defect causes overload of both ventricles, since the blood is shunted left to right.

The murmur is harsh and holosystolic, generally heard best at the lower left sternal border. As the volume of the shunting increases, cardiac enlargement and increased pulmonary vascular markings can be seen on a chest radiograph. Of the following, the most likely diagnosis is: check one A. Transposition of the great vessels would cause AV conduction defects and single-sided hypertrophy on the EKG.

The chest radiograph would show a straight shoulder on the left heart border where the aorta was directed to the right. Tetralogy of Fallot causes cyanosis and right ventricular enlargement. The murmur of patent ductus arteriosus is continuous, best heard below the left clavicle. The EKG shows left atrial and ventricular enlargement. A 4-year-old female has had three urinary tract infections in the past 6 months.

She complains of difficulty with urination and on examination is noted to have labial adhesions that have resulted in near closing of the introitus. Which one of the following is the most appropriate management? Application of estrogen cream to the site. The etiology of prepubertal labial adhesions is idiopathic. The adhesions may be partial or complete; in some cases only a small pinhole orifice may be seen that allows urine to exit from the fused labia.

This problem may be asymptomatic, but the patient may also have a pulling sensation, difficulty with voiding, recurrent urinary tract infections, or vaginitis. If there is enough labial fusion to interfere with urination, treatment should be undertaken. The use of topical estrogen cream twice daily at the point of the midline fusion will usually result in resolution of the problem. No treatment at this time B.

Reporting your suspicion of child abuse to the appropriate authorities C. Application of estrogen cream to the site D. Gentle insertion of progressively larger dilators over a period of several days E. Referral to a gynecologist for surgical correction A 4-year-old Hispanic female has been discovered to have a congenital hearing loss.

Her mother is an year-old migrant farm worker who is currently at 8 weeks' gestation with her second pregnancy. The mother has been found to have cervical dysplasia on her current Papanicolaou Pap smear and has also tested positive for Chlamydia. The most likely cause of this child's hearing loss is: check one E. Cytomegalovirus CMV is the most common congenital infection and occurs in up to 2. It is the leading cause of congenital hearing loss.

The virus is transmitted by contact with infected blood, urine, or saliva, or by sexual contact. Risk factors for CMV include low socioeconomic status, birth outside North America, first pregnancy prior to age 15, a history of cervical dysplasia, and a history of sexually transmitted diseases. Infection can be primary or a reactivation of a previous infection. While the greatest risk of infection is during the third trimester, those occurring in the first trimester are the most dangerous to the fetus.

Human parvovirus B19 B. Varicella zoster virus C. Herpes simplex virus D. Toxoplasmosis E. Cytomegalovirus A metabolic panel, including creatinine and total protein, is also normal. Renal ultrasonography B. An antinuclear antibody and complement panel D. Referral to a nephrologist B.

This test correlates well with hour urine protein, which is particularly difficult to collect in a younger patient. Renal ultrasonography is appropriate once renal insufficiency or nephritis is established. A nephrology referral is not necessary until the presence of kidney disease or proteinuria from a cause other than benign postural proteinuria is confirmed.

A 4-year-old male is brought to your office for evaluation of fever, coryza, and cough. On examination, the child appears mildly ill but in no respiratory distress.

His temperature is An HEENT examination is significant only for light yellow rhinorrhea and reddened nasal mucous membranes. Lung auscultation reveals good air flow with a few coarse upper airway sounds.

While performing the examination you note multiple red welts and superficial abrasions scattered on the chest and upper back. When you question the parents, they tell you the marks are where "the sickness is leaving his body," and were produced by rubbing the skin with a coin.

This traditional healing custom is practiced principally by people from which geographic region? Southeast Asia. Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia, Korea, China, and Vietnam. The belief is that one's illness must be drawn out of the body, and the red marks produced by rubbing the skin with a coin are evidence of the body's "release" of the illness.

These marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the illness itself. Sub-Saharan Africa B. Southeast Asia C. The Middle East D. Caribbean islands E.

Andean South America A 4-year-old male presents with a 3-day history of sores on his right leg. The sores began as small red papules but have progressed in size and now are crusting and weeping. Otherwise he is in good health and is up to date with immunizations. On examination he has three lesions on the right anterior lower leg that are 0. There is no regional lymphangitis or lymphadenitis.

Which one of the following is the preferred first-line therapy? Oral erythromycin Erythrocin B. Oral penicillin V C. Topical hexachlorophene pHisoHex D. Topical mupirocin Bactroban D.

Topical mupirocin Bactroban. The lesions described are nonbullous impetigo, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area.

Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs.

Penicillin V and hexachlorophene have both been shown to be no more effective than placebo. Topical antibiotics have been shown to be as effective as erythromycin, which has a common adverse effect of nausea.

A 4-year-old white female is brought to your office by her mother, who reports that the child recently developed a foulsmelling vaginal discharge. After an appropriate history and general examination, you determine that a genital examination is necessary.

Which one of the following positions is most likely to allow for visualization of the child's vagina and cervix without instrumentation? The knee-chest position on an examination table.

The knee-chest position has been found to allow for visualization of the vagina and cervix of a prepubertal child after 2 years of age without instrumentation. The vagina is filled with air when the child is in the knee-chest position, facilitating inspection.

An assistant holds the child's buttocks apart and the child is asked to relax her abdominal muscles and take a few deep breaths. With these preliminary steps, the vaginal orifice opens and the short vaginal canal fills with air. A bright light will help to illuminate the prepubertal child's vagina and cervix.

Inspection of genitalia where examination of the vaginal canal and cervix are not indicated during a general physical examination need not be in the knee-chest position. In the young child usually less than 2 years of age , examination is best done with the child lying supine in the mother's lap.

For the older prepubertal child, examination is best done with the child lying supine with the knees spread apart on the examination table. The other positions listed are not helpful or recommended when examining the genital area of a prepubertal child.

Supine in the mother's lap B. The left lateral decubitus position on an examination table C. Trendelenburg's position on an examination table D. The knee-chest position on an examination table E.

Supine with the knees spread apart on an examination table A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior pharynx.

Herpangina B. Herpes C. Mononucleosis D. Roseola infantum E. Rubella A. Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area SOR C. Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions.

The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate Forschheimer spots , but not the pharynx. A 4-year-old white male is brought to your office in late August. His mother tells you that over the past few days he has developed a rash on his hands and sores in his mouth.

On examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter. The oral lesions are shallow, whitish, 4- to 8mm ulcerations distributed randomly over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx.

Except for a temperature of The most likely diagnosis is check one B. Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus.

In addition to the oral lesions, vesicular lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculoulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx.

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