Case 2
1. You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his
development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally
healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk
slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or
three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination
shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the
following is the most appropriate next step in the management of this patient?
a. Perform a brain-stem auditory evoked potential hearing screen
b. Perform a screening exam for autism
c. Reassure the parents that the boy’s development appears normal
d. Refer the child to a developmental specialist for comprehensive evaluation
e. Refer the child to a specialist for evaluation of his delayed motor development
2. Sammy is healthy male child brought into your office by his mother for a well-child examination. As part of your
evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his
vocabulary, and can remove his own garments. What would you estimate Sammy’s age to be based upon his
developmental milestones?
a. 12 months
b. 15 months
c. 18 months
d. 30 months
e. 36 months
3. Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and
non-productive cough. When he was born he was large for gestational age, and his exam then was notable for
macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals are stable. He has copious nasal
discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right
side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft
and non-tender with active bowel sounds. What is the most likely cause of his mass?
a. Wilms’ tumor
b. Teratoma
c. Renal cell carcinoma
d. Hepatoblastoma
4. An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further
imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as
well. The mother is worried about the prognosis. Which of the following is true about the prognosis of
neuroblastoma in this child?
a. Lymph node involvement is a poor prognostic factor
b. Prognosis of neuroblastoma is predictable
c. Children who are older than 12 months have a better prognosis than younger children
d. Favorable histology does not play a role in prognosis
e. Non-amplification of the n-myc gene is a favorable prognostic factor
5. A 9-month old baby boy comes to the clinic for a well-child visit. The child is at the 50 th percentile for weight,
length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no
concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2
doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which
vaccines should the child receive at today’s visit?
a. Influenza, Hep B, IPV, DTaP
b. Influenza, IPV
c. Influenza, Hep B, IPV
, d. Hep B, DTaP, IPV
e. Hep B, IPV, and MMR
6. A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated
urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is
performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your
suspected diagnosis?
a. Sheets of lymphocytes with interspersed macrophages
b. Small round blue cells with dense nuclei forming small rosettes
c. Hypersegmented neutrophils
d. Stacks of RBCs
e. Enlarged cells with intranuclear inclusion bodies
Case 5
1. A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been
complaining of frequent nosebleeds while at school and bruising easily. She had menarche at the age of 9 and her
periods have always been heavy and irregular. Her mother and grandmother also have heavy periods and easy
bruising. Lab work confirms the most likely diagnosis. What is the pattern of inheritance of the bleeding disorder
in this patient?
a. Autosomal dominant
b. Autosomal recessive
c. X-linked recessive
d. Mitochondrial
2. A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she
and the patient’s grandmother reached menarche at 13 years of age. The patient is concerned she is behind her
friends in terms of development. She is doing well in school and has not had developmental problems in the past.
On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is
present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you
assign this girl?
a. Tanner Stage 1
b. Tanner Stage II
c. Tanner Stage III
d. Tanner Stage IV
e. Tanner Stage V
3. A 16-year-old female presents to the clinic complaining of worsening fatigue. Family history is significant for
hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a
recent piercing but is otherwise normal. Labs reveal HgB 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von
Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?
a. Blood transfusion and iron supplementation
b. Desmopressin
c. Factor VIII concentrate
d. Cryoprecipitate
e. Vitamin K
4. A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in
what order she should expect to see normal pubertal changes in her daughter. Which of the following sequences is
correct?
a. Breast bud -> pubic hair -> menarche -> growth spurt
b. Pubic hair -> breast bud -> growth spurt -> menarche
c. Pubic hair -> menarche -> breast bud -> growth spurt
d. Breast bud -> pubic hair -> growth spurt -> menarche
, e. Pubic hair -> breast bud -> menarche -> growth spurt
5. A 16-year-old male comes to clinic because of concerns about being one of the smallest students in his class. He
says that people think that he looks like he should be in middle school rather than high school. His mother says
that until about four years ago, she did not notice much difference between the patient and his friends. However, in
the past two years, he has become the shortest person in his class. When assessing for pubertal development, what
is the first physical exam finding expected in this patient?
a. Growth of the penis
b. Appearance of pubic hair
c. Testicular enlargement
d. Growth spurt
e. First ejaculations
Case 6
1. John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a
low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he
complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a
temperature of 101.3F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His
participation would be most likely affected by which of the following tests?
a. Chest x-ray
b. CT head/neck
c. EBV serologies
d. Throat culture
e. No further workup
2. A 17-year-old presents for a sports pre-participation physical. She reports that she occasionally gets short of breath
and feels light-headed with exercise, and sometimes she experiences chest pain as well. She lost consciousness
once last season during a playoff basketball game, but attributed it to feeling sick at the time. Her grandfather died
suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?
a. Hypoglycemia
b. Congenital heart block
c. Postural hypotension
d. Prolonged QT syndrome
e. Ventricular septal defect
3. A 16-year-old boy presents to your office requesting clearance o play football. You begin by taking his medical
history. He says that he feels very well, but admits that he recently experienced one episode of syncope that
occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or
chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while
playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?
a. ECG now, and if normal, reassurance
b. Medically clear him to play
c. Stress test
d. ECG and referral to cardiology
e. Observe and follow up in 6 months
4. A 16-year-old previously healthy girl comes to the Pediatrics Urgent Care Clinic having “almost fainted” at soccer
practice. She says that she had not eaten much earlier in the day and it was very hot and muggy outside. She felt
light-headed and sick to her stomach. She denies losing consciousness and did not fall to the ground. She denies
any chest pain. When you examine her, her eyes are sunken, and she is tachycardic. What would be your next step
in her management?
, a. Electrocardiogram (ECG)
b. Measure her blood glucose
c. Echocardiogram
d. Give fluids and recheck her vital signs
e. Stress test
5. Claire is a 16-year-old girl who presents for birth control management. Her review of symptoms is unremarkable
except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the
past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very
brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in.
She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and
physical exam are normal. Which is the next best in management?
a. ECG
b. Reassurance
c. Referral to a cardiologist
d. Fast ultrasound of pericardial window
e. Chest x-ray
Case 7
1. A 2-hour-old infant is evaluated in the nursery for progressively worsening tachypnea. He was born at 32 weeks
gestational age via spontaneous vaginal delivery to a mother with diabetes and negative group B streptococcus
status. His Apgar scores were 8 at one minute and 9 at five minutes. On physical examination he is large for
gestational age. His vital signs are respiratory rate 75, temperature 36.5 C (97.7 F) and heart rate is 130 beats per
minute. His lung exam is remarkable for intercostal and subcostal retractions, grunting and equal breath sounds.
His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and
capillary refill. Which of the following is the most likely cause of the patient’s condition?
a. Transient tachypnea of the newborn (TTN)
b. Pneumothorax
c. Congestive heart failure
d. Respiratory distress syndrome
e. Sepsis
2. A 3-hour-old infant, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5
minutes, respectively, is found to be tachypneic in the newborn nursery. His mother has a history of Type II
Diabetes that was poorly controlled during her pregnancy. She took prenatal vitamins and no other drugs during
her pregnancy. Prenatal labs, including GBS, were negative. The mother’s membranes ruptures 9 hours prior to
delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is large for
gestational age. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He
appears well perfused with normal cardiac exam. He has decreased muscle tone and a weak suck reflex. A
screening test at 3 hours of life reveals blood glucose of 39 mg/dL. What is the most likely diagnosis?
a. Hypoglycemia
b. Transposition of the great arteries
c. Transient tachypnea of the newborn
d. Neonatal sepsis
e. Pneumothorax
3. A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks’ gestational age via planned C-section.
Maternal PMH is unremarkable, and GBS status is negative. Apgars are 7 and 8 at 1 and 5 minutes of life,
respectively. The delivery is uncomplicated, and the infant initially appeared in good condition. However, one hour
following delivery the infant develops increasing respiratory distress. Respiratory rate is assessed as 90
breaths/min. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations
and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of “a radio-opaque line of
1. You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his
development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally
healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk
slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or
three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination
shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the
following is the most appropriate next step in the management of this patient?
a. Perform a brain-stem auditory evoked potential hearing screen
b. Perform a screening exam for autism
c. Reassure the parents that the boy’s development appears normal
d. Refer the child to a developmental specialist for comprehensive evaluation
e. Refer the child to a specialist for evaluation of his delayed motor development
2. Sammy is healthy male child brought into your office by his mother for a well-child examination. As part of your
evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his
vocabulary, and can remove his own garments. What would you estimate Sammy’s age to be based upon his
developmental milestones?
a. 12 months
b. 15 months
c. 18 months
d. 30 months
e. 36 months
3. Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and
non-productive cough. When he was born he was large for gestational age, and his exam then was notable for
macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals are stable. He has copious nasal
discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right
side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft
and non-tender with active bowel sounds. What is the most likely cause of his mass?
a. Wilms’ tumor
b. Teratoma
c. Renal cell carcinoma
d. Hepatoblastoma
4. An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further
imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as
well. The mother is worried about the prognosis. Which of the following is true about the prognosis of
neuroblastoma in this child?
a. Lymph node involvement is a poor prognostic factor
b. Prognosis of neuroblastoma is predictable
c. Children who are older than 12 months have a better prognosis than younger children
d. Favorable histology does not play a role in prognosis
e. Non-amplification of the n-myc gene is a favorable prognostic factor
5. A 9-month old baby boy comes to the clinic for a well-child visit. The child is at the 50 th percentile for weight,
length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no
concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2
doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which
vaccines should the child receive at today’s visit?
a. Influenza, Hep B, IPV, DTaP
b. Influenza, IPV
c. Influenza, Hep B, IPV
, d. Hep B, DTaP, IPV
e. Hep B, IPV, and MMR
6. A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated
urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is
performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your
suspected diagnosis?
a. Sheets of lymphocytes with interspersed macrophages
b. Small round blue cells with dense nuclei forming small rosettes
c. Hypersegmented neutrophils
d. Stacks of RBCs
e. Enlarged cells with intranuclear inclusion bodies
Case 5
1. A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been
complaining of frequent nosebleeds while at school and bruising easily. She had menarche at the age of 9 and her
periods have always been heavy and irregular. Her mother and grandmother also have heavy periods and easy
bruising. Lab work confirms the most likely diagnosis. What is the pattern of inheritance of the bleeding disorder
in this patient?
a. Autosomal dominant
b. Autosomal recessive
c. X-linked recessive
d. Mitochondrial
2. A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she
and the patient’s grandmother reached menarche at 13 years of age. The patient is concerned she is behind her
friends in terms of development. She is doing well in school and has not had developmental problems in the past.
On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is
present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you
assign this girl?
a. Tanner Stage 1
b. Tanner Stage II
c. Tanner Stage III
d. Tanner Stage IV
e. Tanner Stage V
3. A 16-year-old female presents to the clinic complaining of worsening fatigue. Family history is significant for
hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a
recent piercing but is otherwise normal. Labs reveal HgB 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von
Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?
a. Blood transfusion and iron supplementation
b. Desmopressin
c. Factor VIII concentrate
d. Cryoprecipitate
e. Vitamin K
4. A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in
what order she should expect to see normal pubertal changes in her daughter. Which of the following sequences is
correct?
a. Breast bud -> pubic hair -> menarche -> growth spurt
b. Pubic hair -> breast bud -> growth spurt -> menarche
c. Pubic hair -> menarche -> breast bud -> growth spurt
d. Breast bud -> pubic hair -> growth spurt -> menarche
, e. Pubic hair -> breast bud -> menarche -> growth spurt
5. A 16-year-old male comes to clinic because of concerns about being one of the smallest students in his class. He
says that people think that he looks like he should be in middle school rather than high school. His mother says
that until about four years ago, she did not notice much difference between the patient and his friends. However, in
the past two years, he has become the shortest person in his class. When assessing for pubertal development, what
is the first physical exam finding expected in this patient?
a. Growth of the penis
b. Appearance of pubic hair
c. Testicular enlargement
d. Growth spurt
e. First ejaculations
Case 6
1. John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a
low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he
complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a
temperature of 101.3F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His
participation would be most likely affected by which of the following tests?
a. Chest x-ray
b. CT head/neck
c. EBV serologies
d. Throat culture
e. No further workup
2. A 17-year-old presents for a sports pre-participation physical. She reports that she occasionally gets short of breath
and feels light-headed with exercise, and sometimes she experiences chest pain as well. She lost consciousness
once last season during a playoff basketball game, but attributed it to feeling sick at the time. Her grandfather died
suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?
a. Hypoglycemia
b. Congenital heart block
c. Postural hypotension
d. Prolonged QT syndrome
e. Ventricular septal defect
3. A 16-year-old boy presents to your office requesting clearance o play football. You begin by taking his medical
history. He says that he feels very well, but admits that he recently experienced one episode of syncope that
occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or
chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while
playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?
a. ECG now, and if normal, reassurance
b. Medically clear him to play
c. Stress test
d. ECG and referral to cardiology
e. Observe and follow up in 6 months
4. A 16-year-old previously healthy girl comes to the Pediatrics Urgent Care Clinic having “almost fainted” at soccer
practice. She says that she had not eaten much earlier in the day and it was very hot and muggy outside. She felt
light-headed and sick to her stomach. She denies losing consciousness and did not fall to the ground. She denies
any chest pain. When you examine her, her eyes are sunken, and she is tachycardic. What would be your next step
in her management?
, a. Electrocardiogram (ECG)
b. Measure her blood glucose
c. Echocardiogram
d. Give fluids and recheck her vital signs
e. Stress test
5. Claire is a 16-year-old girl who presents for birth control management. Her review of symptoms is unremarkable
except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the
past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very
brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in.
She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and
physical exam are normal. Which is the next best in management?
a. ECG
b. Reassurance
c. Referral to a cardiologist
d. Fast ultrasound of pericardial window
e. Chest x-ray
Case 7
1. A 2-hour-old infant is evaluated in the nursery for progressively worsening tachypnea. He was born at 32 weeks
gestational age via spontaneous vaginal delivery to a mother with diabetes and negative group B streptococcus
status. His Apgar scores were 8 at one minute and 9 at five minutes. On physical examination he is large for
gestational age. His vital signs are respiratory rate 75, temperature 36.5 C (97.7 F) and heart rate is 130 beats per
minute. His lung exam is remarkable for intercostal and subcostal retractions, grunting and equal breath sounds.
His heart exam reveals normal rhythm, normal S1 and S2, no murmurs, and normal peripheral pulses and
capillary refill. Which of the following is the most likely cause of the patient’s condition?
a. Transient tachypnea of the newborn (TTN)
b. Pneumothorax
c. Congestive heart failure
d. Respiratory distress syndrome
e. Sepsis
2. A 3-hour-old infant, born by C-section at 36 weeks to a 30-year-old G1P1 with Apgars of 8 and 9 at 1 and 5
minutes, respectively, is found to be tachypneic in the newborn nursery. His mother has a history of Type II
Diabetes that was poorly controlled during her pregnancy. She took prenatal vitamins and no other drugs during
her pregnancy. Prenatal labs, including GBS, were negative. The mother’s membranes ruptures 9 hours prior to
delivery, she was afebrile, and the amniotic fluid had no meconium. On physical exam, the infant is large for
gestational age. He has good air movement through the lungs bilaterally, without retractions or nasal flaring. He
appears well perfused with normal cardiac exam. He has decreased muscle tone and a weak suck reflex. A
screening test at 3 hours of life reveals blood glucose of 39 mg/dL. What is the most likely diagnosis?
a. Hypoglycemia
b. Transposition of the great arteries
c. Transient tachypnea of the newborn
d. Neonatal sepsis
e. Pneumothorax
3. A male infant weighing 3200 grams is born to a G1P1 female at 39 weeks’ gestational age via planned C-section.
Maternal PMH is unremarkable, and GBS status is negative. Apgars are 7 and 8 at 1 and 5 minutes of life,
respectively. The delivery is uncomplicated, and the infant initially appeared in good condition. However, one hour
following delivery the infant develops increasing respiratory distress. Respiratory rate is assessed as 90
breaths/min. All other vital signs are within normal limits. On exam, the infant is acyanotic with rapid respirations
and robust capillary refill. Chest x-ray shows bilateral lung fields with the appearance of “a radio-opaque line of
