Free SMLE Pediatrics questions

An 11-month-old girl in day care has 3 days of rhinorrhoea and cough followed by 1 day of fever to 38.8 °C, irritability, and pulling at her right ear. Otoscopy shows a bulging, opaque, erythematous right tympanic membrane with absent mobility on pneumatic otoscopy. Middle ear fluid from tympanocentesis is sent for bacterial culture and a respiratory virus panel. Which virus is most likely to be recovered from the fluid?

A 3-year-old girl has 6 months of bulky, pale, foul smelling stools. Her weight has fallen from the 50th to below the 3rd percentile. Symptoms began several months after wheat cereals were introduced. Examination shows a distended abdomen, wasted buttocks, and irritability. Total IgA is normal with a tissue transglutaminase IgA antibody level more than 10 times the upper limit of normal. Which is the most appropriate management?

A 10-year-old boy attends a pediatric cardiology clinic after completing 4 weeks of intravenous antibiotics for culture-positive infective endocarditis caused by viridans group streptococci, which followed a dental extraction performed 3 weeks before his illness. He was born with an unrepaired congenital cardiac defect detected at 6 months of age. Which unoperated congenital lesion is most commonly associated with infective endocarditis?

A 5-year-old boy of consanguineous parents has had four admissions for pneumonia, chronic bulky greasy foul-smelling stools since infancy, and weight below the 3rd percentile despite a good appetite. He has bilateral nasal polyps, digital clubbing, and coarse crackles at both lung bases. Sweat chloride is 92 mmol/L on two occasions and sputum culture grows Pseudomonas aeruginosa. Which is the most common long-term pulmonary complication of his underlying disease?

A 5 month old girl with weight faltering, greasy stools and recurrent chest infections has a sweat chloride of 78 mmol/L, repeated on a separate day at 82 mmol/L. Her parents are first cousins and her 4 year old brother is well. They want definitive confirmation of the diagnosis and counselling about the recurrence risk in a future pregnancy. Which is the most appropriate confirmatory test?

A 2-year-old girl has a soft, painless swelling in the left posterior triangle of the neck, present since early infancy and now 10 by 10 cm. It is compressible and brightly transilluminates; she is afebrile with no stridor, dysphagia, or facial nerve weakness. Ultrasound shows a multiloculated cystic lesion with thin septations, and aspiration yields clear straw-colored lymphatic fluid. What is the most appropriate initial treatment?

A 12 year old boy with type 1 diabetes stopped his insulin during 2 days of vomiting and polyuria. He is drowsy with deep sighing respirations, heart rate 134 beats/min, blood pressure 92/56 mm Hg and capillary refill 4 seconds. Capillary glucose is 29 mmol/L, venous pH 7.09, bicarbonate 7 mmol/L, potassium 4.1 mmol/L and urine ketones 4+. Which of the following is the most appropriate initial step in management?

A 9-year-old boy is brought to the emergency department with three days of polyuria, polydipsia and 3 kg weight loss, and one day of vomiting and abdominal pain. He is drowsy but rousable, his respiratory rate is 38 breaths/min with deep unlaboured breathing, heart rate is 132 beats/min, blood pressure is 96/58 mm Hg, and his breath smells fruity. A bedside capillary glucose reads 28 mmol/L (504 mg/dL) and a bedside blood beta-hydroxybutyrate is 5.4 mmol/L. Which of the following is the most appropriate investigation to confirm the diagnosis?

A 6-month-old uncircumcised boy has a 2-day fever up to 39.2 °C and irritability. He is alert and drinking well from a bottle, with moist mucous membranes and no vomiting. A catheter urine sample shows positive nitrites and leucocyte esterase with 60 white cells per high power field, and culture has been sent. What is the most appropriate antibiotic therapy?

A 5-week-old boy born to consanguineous parents has jaundice since the second week of life that has deepened as breastfeeding was established. He vomits after most feeds and has gained 200 g since birth. Temperature is 38.4 °C. Examination shows hepatomegaly and bilateral lens opacities. Direct bilirubin is 118 µmol/L, and urine is positive for reducing substances with a negative glucose oxidase dipstick. Which is the most likely diagnosis?

A 9-year-old boy is much shorter than his classmates. Both parents are of average height. Height is 120 cm, below the 3rd percentile, and weight is 25 kg. He is chubby with mid-facial hypoplasia and normal body proportions. Thyroid stimulating hormone is 3.2 U/L, insulin-like growth factor 1 is 18 ng/mL (normal 67 to 405), and bone age is 6 years. Which of the following is the most likely diagnosis?

A term newborn develops jaundice at 12 hours. At 36 hours total bilirubin is 285 µmol/L, direct fraction 12 µmol/L, hemoglobin 118 g/L, reticulocytes 9 percent, and mean corpuscular hemoglobin concentration 375 g/L. The direct antiglobulin test is negative and the blood film shows dense round red cells without central pallor. His father had a splenectomy as a teenager for anemia. What is the most likely cause of the hyperbilirubinemia?

A 10-year-old boy with an unrepaired perimembranous ventricular septal defect has 8 days of fever up to 39.2 °C and malaise. He underwent a dental extraction 2 weeks earlier without antibiotic cover. Examination reveals a harsh pansystolic murmur louder than previously documented, splinter hemorrhages, and a spleen tip palpable 2 cm below the costal margin. Which of the following is the most important investigation to establish the diagnosis?

A 9-month-old boy born at term is brought because of pallor and increasing irritability. He remains exclusively breastfed, and no iron-fortified cereal, pureed meat, or legumes have been introduced. Examination shows pale conjunctivae and palmar creases. Hemoglobin is 8.0 g/dL, mean corpuscular volume 60 fL, red cell distribution width 18 %, reticulocyte count 1 %, and platelets 520 × 10⁹/L. What is the most likely cause of his anemia?

A 12 year old girl with systemic lupus erythematosus and biopsy proven class IV lupus nephritis has completed 6 months of induction with corticosteroids and mycophenolate mofetil. Her arthritis and rash have resolved, and the urine protein to creatinine ratio has fallen from 320 to 80 mg/mmol. Her rheumatologist plans serial testing to detect impending renal flares. Which test is most useful for monitoring her response to therapy?

A 4-year-old boy has 10 days of puffy eyes progressing to swollen legs. Blood pressure is 96/58 mm Hg and there is pitting pedal edema with mild ascites and no rash or joint swelling. Urine dipstick shows protein 4 plus with no blood, serum albumin is 17 g/L, total cholesterol 340 mg/dL, and complement C3 is normal. What is the most effective treatment to reduce his urinary protein loss?

A 10-year-old girl has a painless anterior neck swelling enlarging over 4 months. There is a firm, mobile 2 cm nodule in the right thyroid lobe and no cervical lymphadenopathy. Serum TSH is 2.1 mIU/L with a normal free T4. Ultrasound shows a solitary solid hypoechoic nodule with irregular margins and microcalcifications. Ultrasound-guided fine-needle aspiration is non-diagnostic, with insufficient follicular cells. What is the most appropriate next step in management?

A 5-year-old unvaccinated girl has fever of 37.9 °C and a pink maculopapular rash that started on the face and spread to the trunk within 24 hours. She has tender enlarged occipital, posterior auricular and posterior cervical lymph nodes, and mild pain in both wrists. There are no Koplik spots, no conjunctivitis and no cough. Which schedule of vaccine doses in Saudi Arabia would have prevented this infection?

A 13 year old girl with a photosensitive malar rash, painless oral ulcers, polyarthritis of the hands and knees, and 2+ proteinuria is being evaluated for systemic lupus erythematosus. Hemoglobin is 98 g/L, white cell count 2.9 × 10⁹/L, and serum creatinine 62 µmol/L. Her antinuclear antibody is positive at 1:1280 in a homogeneous pattern and C3 is low. Which antibody is the most specific for systemic lupus erythematosus?

An 18-month-old boy is brought to the emergency department after a single generalized tonic-clonic seizure lasting 3 minutes during a febrile illness. He has had no previous seizure and his development is normal. Temperature is 39.2 °C. He is now fully alert and playful, with no neck stiffness, no rash and no focal neurologic deficit, and a bulging erythematous right tympanic membrane. What is the most appropriate management?

A 3-year-old boy was admitted 5 days ago with fever of 39.6 °C, vomiting, and loin tenderness. Urine culture grew more than 100000 colony-forming units per mL of Escherichia coli and his fever resolved on intravenous antibiotics. This was his first documented urinary tract infection, serum creatinine has remained normal, blood pressure is 96/58 mm Hg, and there is no antenatal hydronephrosis. Which is the most appropriate next investigation?

A 4 year old girl was diagnosed 2 months ago with oligoarticular juvenile idiopathic arthritis affecting the right knee and left ankle. Her antinuclear antibody is positive at a titre of 1:320, rheumatoid factor is negative, and she has no eye redness, pain, photophobia or visual complaints. Her mother asks how frequently she needs slit lamp examination. Which is the most appropriate screening interval for chronic anterior uveitis?

A 6-year-old unvaccinated boy has 2 days of fever, followed by an intensely itchy rash that began on the scalp and face and spread to the chest and upper trunk. The lesions are at different stages simultaneously: red macules, papules, clear vesicles on an erythematous base and honey-coloured crusts. Several shallow ulcers are present on the soft palate. Which serological test is most likely to be positive?