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ABFM Family Medicine study materials
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ABFM Family Medicine practice questions

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Question 1Adult Medicine

A 58-year-old man with no symptoms has a fasting plasma glucose of 118 mg/dL on two occasions. Which is the most appropriate next step?

  1. Repeat fasting glucose in one year
  2. Order an oral glucose tolerance test to confirm diabetes
  3. Diagnose prediabetes and recommend intensive lifestyle intervention Correct answer.
  4. Diagnose diabetes mellitus and start metformin

Explanation

A fasting plasma glucose of 100-125 mg/dL defines prediabetes, and two values in this range establish the diagnosis. The recommended management is referral to a structured lifestyle program with 7% weight loss and 150 minutes of weekly activity. Metformin is generally reserved for prediabetes in selected high-risk patients, not as the default first step.

Question 2Adult Medicine

Which medication is the preferred initial pharmacologic therapy for most adults with newly diagnosed type 2 diabetes and no contraindications?

  1. Insulin glargine
  2. Pioglitazone
  3. Metformin Correct answer.
  4. Glipizide

Explanation

Metformin remains the preferred first-line agent because of its efficacy, weight neutrality, low hypoglycemia risk, and low cost. It is typically started at 500 mg daily and titrated to a maximally tolerated dose. Other agents are added or substituted based on comorbidities such as heart failure, CKD, or ASCVD.

Question 3Adult Medicine

A 45-year-old woman has a blood pressure of 152/96 mmHg at two separate visits. She has no diabetes, CKD, or ASCVD. Which is the most appropriate initial management?

  1. Start a thiazide diuretic plus a beta-blocker
  2. Start an ACE inhibitor and recheck in 1 month
  3. Start lifestyle modification plus a single antihypertensive agent Correct answer.
  4. Lifestyle modification alone with recheck in 6 months

Explanation

Stage 2 hypertension (≥140/90 mmHg) warrants initiating pharmacologic therapy along with lifestyle modification at the time of diagnosis. A single agent from the first-line classes-thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers-is appropriate for most patients. Monotherapy is preferred over two-drug combinations unless BP is more than 20/10 mmHg above goal.

Question 4Adult Medicine

Which lipid target is the primary goal when initiating statin therapy in a 62-year-old man with established coronary artery disease?

  1. Triglycerides less than 150 mg/dL
  2. LDL-C reduction of at least 50% from baseline and LDL-C less than 70 mg/dL Correct answer.
  3. Non-HDL cholesterol less than 160 mg/dL
  4. LDL-C less than 100 mg/dL

Explanation

Patients with clinical ASCVD are managed with high-intensity statin therapy, targeting at least a 50% reduction in LDL-C and an absolute LDL-C below 70 mg/dL. If goals are not met, ezetimibe or a PCSK9 inhibitor may be added. Triglyceride and non-HDL goals are secondary considerations.

Question 5Adult Medicine

A 34-year-old woman reports 3 days of dysuria and urinary frequency without fever or flank pain. She is otherwise healthy and has had no recent antibiotics. Which is the most appropriate management?

  1. Pelvic examination with STI testing before any treatment
  2. Imaging with renal ultrasound
  3. Urine culture and await results before treating
  4. Empiric antibiotics for uncomplicated cystitis Correct answer.

Explanation

Classic symptoms of uncomplicated cystitis in a healthy, nonpregnant woman justify empiric antibiotics targeting E. coli, such as nitrofurantoin, TMP-SMX (if local resistance is under 20%), or fosfomycin. Cultures are reserved for atypical presentations, recurrence, or treatment failure. STI testing is considered when symptoms suggest urethritis or vaginitis.

Question 6Adult Medicine

Which finding most strongly suggests a diagnosis of community-acquired pneumonia rather than acute bronchitis in an otherwise healthy adult?

  1. Productive cough lasting 5 days
  2. Low-grade fever of 100.4°F
  3. Rhonchi on auscultation
  4. Focal crackles and an infiltrate on chest radiograph Correct answer.

Explanation

Acute bronchitis is a clinical diagnosis without focal consolidation on chest imaging. The presence of a new infiltrate on chest radiograph, often with focal crackles, establishes pneumonia. Antibiotics are not indicated for uncomplicated acute bronchitis.

Question 7Adult Medicine

A 68-year-old man with COPD has had three exacerbations in the past year requiring oral corticosteroids. He uses a long-acting bronchodilator daily. What is the most appropriate addition to reduce future exacerbations?

  1. Inhaled corticosteroid combined with a LABA Correct answer.
  2. Daily azithromycin
  3. Oral prednisone taper with each exacerbation
  4. Nebulized ipratropium as needed only

Explanation

For patients with COPD and repeated exacerbations despite long-acting bronchodilator use, adding an inhaled corticosteroid to a LABA reduces exacerbation frequency. Corticosteroids are especially beneficial when blood eosinophils are elevated. Chronic azithromycin is a later option and carries QT and hearing risk.

Question 8Adult Medicine

A 55-year-old woman presents with sudden palpitations. ECG shows irregularly irregular rhythm without P waves and a ventricular rate of 148 bpm. She is hemodynamically stable. Which is the next step?

  1. Start anticoagulation and observe
  2. Intravenous amiodarone
  3. Synchronized cardioversion
  4. Rate control with a beta-blocker or calcium channel blocker Correct answer.

Explanation

For stable atrial fibrillation with rapid ventricular response, the initial step is rate control. Beta-blockers and nondihydropyridine calcium channel blockers are first-line. Cardioversion is reserved for hemodynamic instability or when a rhythm-control strategy is chosen after appropriate evaluation.

Question 9Adult Medicine

Which finding on physical exam is most characteristic of heart failure with reduced ejection fraction?

  1. Sustained elevation of the jugular venous pressure at 45 degrees Correct answer.
  2. Widened pulse pressure
  3. Pulsus paradoxus
  4. Pleural rub

Explanation

Elevated jugular venous pressure reflects elevated right-sided filling pressures and is a useful marker of volume overload in heart failure. A pleural rub suggests pleuritis, and pulsus paradoxus suggests tamponade or pericardial constriction.

Question 10Adult Medicine

A 50-year-old man is diagnosed with heart failure with reduced ejection fraction (LVEF 30%). Which medication improves mortality in this condition?

  1. Sacubitril-valsartan Correct answer.
  2. Digoxin
  3. Amlodipine
  4. Ranolazine

Explanation

Sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, reduces mortality and hospitalization in HFrEF. It is a cornerstone of guideline-directed medical therapy alongside beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. Digoxin reduces hospitalizations but not mortality.

Question 11Adult Medicine

Which finding is most suggestive of an acute exacerbation of asthma requiring hospitalization?

  1. Sinus tachycardia at 100 bpm with mild anxiety
  2. A cough responding to albuterol within 10 minutes
  3. Occasional end-expiratory wheeze with normal peak flow
  4. SpO2 of 92% with a peak expiratory flow at 40% of predicted after beta-agonist treatment Correct answer.

Explanation

A peak expiratory flow that remains at or below 40% of predicted and hypoxemia after initial bronchodilator therapy indicate severe asthma exacerbation and warrant hospitalization. In contrast, a rapid and complete response to albuterol suggests a mild exacerbation suitable for outpatient management.

Question 12Adult Medicine

A 30-year-old woman reports 3 weeks of symmetric small-joint hand pain and morning stiffness lasting more than 1 hour. Which test is most useful in confirming the diagnosis of rheumatoid arthritis?

  1. Antinuclear antibody
  2. Anti-CCP antibody Correct answer.
  3. Rheumatoid factor alone
  4. Serum uric acid

Explanation

Anti-CCP antibodies have high specificity for rheumatoid arthritis and help confirm the diagnosis in a patient with compatible clinical findings. Rheumatoid factor is sensitive but less specific and can be positive in other conditions. ANA is used for lupus, and uric acid evaluates gout.

Question 13Adult Medicine

A 68-year-old woman with osteoporosis has a T-score of -2.8 at the femoral neck. She is unable to tolerate bisphosphonates. Which medication is appropriate for her osteoporosis?

  1. Teriparatide Correct answer.
  2. Calcium and vitamin D alone
  3. Raloxifene
  4. Estrogen therapy

Explanation

Teriparatide is an anabolic agent approved for osteoporosis and is particularly appropriate when bisphosphonates are not tolerated or fail. It is also used for severe osteoporosis or high fracture risk. Calcium and vitamin D are adjuncts but do not adequately treat established osteoporosis.

Question 14Adult Medicine

A 70-year-old man has a serum creatinine of 2.0 mg/dL and an estimated GFR of 42 mL/min/1.73 m². Which medication requires dose adjustment because of his chronic kidney disease?

  1. Amoxicillin
  2. Metformin Correct answer.
  3. Simvastatin
  4. Aspirin

Explanation

Metformin is renally cleared and should be restricted or stopped in chronic kidney disease, especially when eGFR falls below 45 mL/min/1.73 m². This is because of the increased risk of lactic acidosis. The other agents generally do not require renal dose adjustment for this degree of CKD.

Question 15Adult Medicine

A 26-year-old man is found to have a fasting serum calcium of 11.2 mg/dL and an elevated PTH. What is the most likely diagnosis?

  1. Hypoparathyroidism
  2. Primary hyperparathyroidism Correct answer.
  3. Bisphosphonate therapy
  4. Vitamin D deficiency

Explanation

Elevated calcium with inappropriately elevated PTH indicates primary hyperparathyroidism. It is most often due to a parathyroid adenoma. Low PTH would suggest nonparathyroid causes of hypercalcemia.

Question 16Adult Medicine

A 60-year-old man with a history of gout presents with an acutely swollen, tender first metatarsophalangeal joint. Which treatment is most appropriate during the acute attack?

  1. Probenecid
  2. Prednisone only if there is no response to indomethacin
  3. Naproxen unless contraindicated Correct answer.
  4. Initiation of allopurinol at high dose

Explanation

NSAIDs such as naproxen are first-line therapy for an acute gout flare unless contraindicated by renal disease, gastrointestinal bleeding risk, or heart failure. Colchicine and corticosteroids are alternatives. Urate-lowering therapy is not started during an acute attack unless already established.

Question 17Adult Medicine

A 28-year-old woman has recurrent major depression after two prior episodes. She currently is in remission on sertraline. Which is the most appropriate recommendation?

  1. Discontinue sertraline after 6 months of remission
  2. Switch to a monoamine oxidase inhibitor
  3. Increase the sertraline dose and add a second antidepressant
  4. Continue sertraline for at least 2 years given recurrent episodes Correct answer.

Explanation

Patients with recurrent major depression (two or more episodes) should generally continue antidepressant therapy for at least 2 years. Prolonged maintenance reduces the risk of relapse. A single first episode is typically treated for 6-12 months after remission.

Question 18Adult Medicine

A 72-year-old man is brought in by family with 6 months of progressive memory loss. Which finding most suggests a reversible cause of his cognitive decline?

  1. Stepwise decline with focal deficits
  2. Nocturnal confusion with sundowning
  3. New-onset depression with hypothyroidism Correct answer.
  4. Paratonia

Explanation

Depression and hypothyroidism are potentially reversible contributors to cognitive decline. A targeted workup for reversible causes includes TSH, B12, and screening for depression. The other findings are more consistent with neurodegenerative disease.

Question 19Adult Medicine

Which feature most strongly distinguishes an acute migraine with aura from a transient ischemic attack?

  1. Slowly spreading visual symptoms with gradual onset Correct answer.
  2. Age older than 50 at onset
  3. Presence of accompanying weakness
  4. Sudden max</br>imal deficit at onset

Explanation

Migraine aura typically has a gradual, spreading onset with positive visual symptoms that develop over 5-20 minutes and resolve within an hour. TIA classically has sudden maximal onset. New focal neurologic symptoms in older patients or weakness warrant urgent evaluation.

Question 20Adult Medicine

A 45-year-old woman with a seizure disorder stopped taking her medication 3 days ago. She now has continuous tonic-clonic activity for 5 minutes. What is the first-line medication?

  1. Oral valproic acid
  2. Intramuscular phenytoin
  3. Intravenous fosphenytoin
  4. Intravenous lorazepam Correct answer.

Explanation

First-line therapy for status epilepticus includes a benzodiazepine such as intravenous lorazepam. Fosphenytoin or levetiracetam is used as a second-line agent after the benzodiazepine.

Question 21Adult Medicine

A 65-year-old man has a serum PSA of 6.0 ng/mL and a history of recurrent prostatitis. What is the most appropriate next step?

  1. Immediate prostate biopsy
  2. Empiric antibiotics followed by repeat PSA in 6-8 weeks Correct answer.
  3. MRI of the pelvis before repeat PSA
  4. Reassurance that PSA is normal for his age

Explanation

An elevated PSA can be caused by prostatitis. Empiric antibiotics with repeat PSA after 6-8 weeks help evaluate whether inflammation is responsible. If PSA remains elevated, imaging and biopsy are considered.

Question 22Adult Medicine

A 55-year-old woman has iron deficiency anemia. She has no gastrointestinal symptoms. What is the next step?

  1. Endoscopy and colonoscopy Correct answer.
  2. Barium swallow
  3. Start iron replacement and recheck in 3 months without further workup
  4. Upper endoscopy alone

Explanation

Iron deficiency anemia in a postmenopausal woman requires evaluation for occult gastrointestinal blood loss. Both upper and lower endoscopy are recommended to identify sources of bleeding. In premenopausal women with heavy menses, treatment without endoscopy may be reasonable.

Question 23Adult Medicine

A 40-year-old man reports intermittent burning epigastric pain that awakens him at night for 6 weeks. He takes naproxen daily for back pain. What is the most appropriate initial management?

  1. H. pylori stool antigen testing alone
  2. Immediate upper endoscopy
  3. Start a H2 blocker and continue naproxen
  4. Discontinue naproxen and start a proton pump inhibitor Correct answer.

Explanation

NSAID-induced ulcer disease is best managed by stopping the NSAID and adding acid-suppressive therapy with a proton pump inhibitor. H. pylori testing is also appropriate. Endoscopy is reserved for alarm symptoms or failure of therapy.

Question 24Adult Medicine

Which combination of symptoms most suggests a diagnosis of acute pancreatitis?

  1. Periumbilical pain that migrates to the right lower quadrant
  2. Right lower quadrant pain with rebound tenderness
  3. Left lower quadrant pain with fever and rise in white blood cell count
  4. Epigastric pain radiating to the back with nausea and vomiting Correct answer.

Explanation

Acute pancreatitis classically presents with severe epigastric pain radiating to the back along with nausea and vomiting, often after a fatty meal or alcohol. The other patterns reflect appendicitis or diverticulitis.

Question 25Adult Medicine

A 63-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 3. He has had no prior stroke. What is the most appropriate management to reduce the risk of stroke?

  1. Clopidogrel
  2. Aspirin alone
  3. Warfarin or direct oral anticoagulant Correct answer.
  4. No anticoagulation if rhythm is controlled

Explanation

A CHA2DS2-VASc score of 2 or higher in men warrants long-term anticoagulation. Direct oral anticoagulants are preferred over warfarin in most patients without mechanical valves or moderate-severe mitral stenosis. Aspirin is not an adequate substitute.

Question 26Child and Adolescent Medicine

At what age do most typically developing infants sit steadily without support?

  1. 6 to 8 months Correct answer.
  2. 10 to 12 months
  3. 14 to 16 months
  4. 2 to 3 months

Explanation

Independent sitting is a gross motor milestone usually achieved between 6 and 8 months, after head and trunk control are established. It precedes pulling to stand and cruising, which appear in the second half of the first year.

Question 27Child and Adolescent Medicine

A term newborn delivered vaginally is noted to be jaundiced at 18 hours of life. He is feeding well and the examination is otherwise unremarkable. Which is the most likely explanation?

  1. Physiologic jaundice of the newborn
  2. Breastfeeding-associated dehydration
  3. Breast milk jaundice
  4. Hemolytic disease Correct answer.

Explanation

Any jaundice appearing within the first 24 hours of life is considered pathologic and warrants evaluation for hemolysis, sepsis, or other causes. Physiologic jaundice does not appear before 24 hours.

Question 28Child and Adolescent Medicine

Which vaccine is routinely recommended for all newborns before hospital discharge in the United States?

  1. DTaP
  2. Hepatitis B Correct answer.
  3. Varicella
  4. MMR

Explanation

The hepatitis B vaccine birth dose is recommended for all medically stable newborns weighing at least 2,000 grams before discharge. It prevents perinatal transmission from mothers with unknown or positive HBsAg status.

Question 29Child and Adolescent Medicine

A 2-month-old is exclusively breastfed. At what age should iron supplementation at 1 mg/kg/day be started?

  1. At 4 months Correct answer.
  2. At birth
  3. At 2 months
  4. At 2 weeks

Explanation

Exclusively breastfed infants should receive 1 mg/kg/day of oral iron beginning at 4 months and continuing until iron-containing complementary foods are established. Maternal iron stores generally suffice before that age.

Question 30Child and Adolescent Medicine

A 6-week-old formula-fed infant has daily episodes of inconsolable crying lasting 2 to 3 hours each evening. He feeds well, gains weight appropriately, and the examination is normal. The episodes have occurred for 3 weeks. What is the most likely diagnosis?

  1. Intussusception
  2. Pyloric stenosis
  3. Infant colic Correct answer.
  4. Cow's milk protein allergy

Explanation

Infant colic is defined by crying for more than 3 hours per day on more than 3 days per week for more than 3 weeks in a thriving infant under 3 to 4 months of age. A normal examination and appropriate growth support this diagnosis.

Question 31Child and Adolescent Medicine

The American Academy of Pediatrics recommends universal screening for autism spectrum disorder at which ages?

  1. 9 and 12 months
  2. 18 and 24 months Correct answer.
  3. 36 and 48 months
  4. 24 and 36 months

Explanation

Standardized autism screening is recommended at the 18-month and 24-month well-child visits, in addition to ongoing developmental surveillance at every visit. Earlier detection allows earlier intervention.

Question 32Child and Adolescent Medicine

A 15-year-old has crampy lower abdominal pain for the first 2 days of each menstrual period that improves with rest. Pelvic examination is normal. What is the most appropriate initial treatment?

  1. Acetaminophen as needed
  2. Narcotic analgesics
  3. Ibuprofen scheduled with menses Correct answer.
  4. Combined oral contraceptive pills

Explanation

Primary dysmenorrhea is mediated by prostaglandins, so scheduled nonsteroidal anti-inflammatory drugs started at or just before the onset of menses are first-line therapy. Hormonal contraception is an option when NSAIDs fail.

Question 33Child and Adolescent Medicine

What is the first-line treatment for head lice infestation in a 7-year-old?

  1. Lindane shampoo
  2. Petroleum jelly overnight
  3. Oral ivermectin
  4. Permethrin 1% lotion Correct answer.

Explanation

Topical permethrin 1% is the recommended first-line pediculicide for children 2 months and older, applied to damp hair and repeated in 9 to 10 days. Treatment of close contacts and combing of nits improve cure rates.

Question 34Child and Adolescent Medicine

An 8-year-old has a 2-day history of sore throat and fever to 38.9 C with tonsillar exudates and tender anterior cervical adenopathy, but no cough or rhinorrhea. Which is the most appropriate next step?

  1. Obtain a Monospot test
  2. Start amoxicillin empirically
  3. Rapid strep antigen test Correct answer.
  4. Recommend supportive care only

Explanation

When group A streptococcal pharyngitis is likely, guidelines recommend confirming with a rapid antigen detection test or culture before treating. This avoids unnecessary antibiotics while ensuring treatment that prevents acute rheumatic fever.

Question 35Child and Adolescent Medicine

A 2-year-old has bilateral acute otitis media with a temperature of 39.2 C and moderate otalgia. There are no drug allergies. Which is the most appropriate initial antibiotic?

  1. Amoxicillin-clavulanate 90 mg/kg/day
  2. Azithromycin
  3. Ceftriaxone injection
  4. Amoxicillin 80 to 90 mg/kg/day Correct answer.

Explanation

High-dose amoxicillin at 80 to 90 mg/kg/day is first-line for acute otitis media because it covers most Streptococcus pneumoniae, including many penicillin-nonsusceptible strains. Amoxicillin-clavulanate is reserved for recent antibiotic use, purulent conjunctivitis, or treatment failure.

Question 36Child and Adolescent Medicine

A 5-month-old with respiratory syncytial virus bronchiolitis has a respiratory rate of 50, mild retractions, and an oxygen saturation of 94% on room air. Which management is supported by current evidence?

  1. Prophylactic azithromycin
  2. Nebulized albuterol every 4 hours
  3. Oral dexamethasone for 3 days
  4. Supportive care and hydration Correct answer.

Explanation

Bronchiolitis is managed with supportive care: nasal suctioning, maintenance of hydration, and supplemental oxygen when saturation falls below the treatment threshold. Bronchodilators, corticosteroids, and antibiotics have not been shown to alter the course.

Question 37Child and Adolescent Medicine

A 2-year-old has a barking cough and inspiratory stridor at rest. Which is the most appropriate initial treatment?

  1. Dexamethasone plus nebulized epinephrine Correct answer.
  2. Nebulized racemic epinephrine without corticosteroid
  3. Oral amoxicillin
  4. Nebulized albuterol alone

Explanation

Stridor at rest marks moderate croup; a single dose of dexamethasone reduces airway edema while nebulized epinephrine provides rapid relief of obstruction. Children with stridor at rest should be observed for recurrence after epinephrine.

Question 38Child and Adolescent Medicine

An 18-month-old has a first generalized tonic-clonic seizure lasting 3 minutes during a febrile illness and returns to baseline within 30 minutes. Which management is most appropriate?

  1. Reassurance and parental education Correct answer.
  2. Daily phenobarbital prophylaxis
  3. Head CT in the emergency department
  4. Routine electroencephalography

Explanation

A simple febrile seizure is brief, generalized, and occurs once in 24 hours in a child with a normal postictal examination. Routine EEG, neuroimaging, and antiseizure medication are not indicated; counseling the family is the mainstay.

Question 39Child and Adolescent Medicine

Which finding is required to establish a diagnosis of attention-deficit/hyperactivity disorder in a school-aged child?

  1. A coexisting learning disability
  2. Symptoms in two or more settings Correct answer.
  3. Onset of symptoms after age 12
  4. An abnormal continuous performance test

Explanation

ADHD is a clinical diagnosis requiring developmentally inappropriate symptoms present in at least two settings, such as home and school, before age 12. No laboratory or neuropsychological test is required.

Question 40Child and Adolescent Medicine

Which medication has US Food and Drug Administration approval and the strongest evidence for treating major depressive disorder in adolescents?

  1. Escitalopram
  2. Fluoxetine Correct answer.
  3. Bupropion
  4. Sertraline

Explanation

Fluoxetine is the only agent approved by the US Food and Drug Administration for major depressive disorder in adolescents and is supported by randomized trial data. It is typically paired with cognitive behavioral therapy, and patients should be monitored for suicidality after initiation.

Question 41Child and Adolescent Medicine

A 15-year-old has moderate inflammatory acne with papules and pustules on the face. Which initial regimen is most appropriate?

  1. Topical clindamycin as long-term monotherapy
  2. Benzoyl peroxide plus a retinoid Correct answer.
  3. Oral tetracycline alone
  4. Oral isotretinoin

Explanation

Moderate inflammatory acne is treated with a topical retinoid plus benzoyl peroxide, with a topical antibiotic added for inflammation. Antibiotics are never used as monotherapy because of resistance.

Question 42Child and Adolescent Medicine

A 2-year-old has a capillary blood lead level of 15 mcg/dL. What is the most appropriate next step?

  1. Reassure the family; no further action
  2. Confirm with a venous sample Correct answer.
  3. Begin chelation therapy
  4. Repeat capillary testing in 12 months

Explanation

An elevated capillary result must be confirmed with a venous blood lead level because capillary specimens are prone to contamination. Chelation is considered only at much higher levels, generally 45 mcg/dL or above.

Question 43Child and Adolescent Medicine

A 3-month-old with a temperature of 38.6 C has no identified source of fever and requires a urine specimen. Which collection method is preferred?

  1. Clean-catch midstream after fluid intake
  2. Urine bag collection
  3. Catheterization or suprapubic aspiration Correct answer.
  4. First-voided diaper specimen

Explanation

In a young infant who cannot void on command, catheterization or suprapubic aspiration provides the uncontaminated specimen needed for culture. Bag and diaper specimens have unacceptably high contamination rates.

Question 44Child and Adolescent Medicine

When should pulse oximetry screening for critical congenital heart disease be performed in a healthy term newborn?

  1. At 24 hours of life Correct answer.
  2. Immediately after delivery
  3. At 6 hours of life
  4. At the 2-week visit

Explanation

Screening is performed at 24 hours of life or before discharge, measuring oxygen saturation in the right hand and one foot. Earlier testing produces false positives from normal transition, and later testing risks missing ductal-dependent lesions after discharge.

Question 45Child and Adolescent Medicine

A 9-year-old has 3 weeks of polyuria, polydipsia, and 4 kg of weight loss and presents with Kussmaul respirations, a glucose of 480 mg/dL, pH 7.15, and bicarbonate of 9 mEq/L. What is the most likely diagnosis?

  1. Diabetic ketoacidosis Correct answer.
  2. Type 2 diabetes mellitus without ketosis
  3. Viral gastroenteritis with dehydration
  4. Diabetes insipidus

Explanation

Hyperglycemia with a primary metabolic acidosis and low bicarbonate in a child with weeks of polyuria and weight loss defines diabetic ketoacidosis, the typical presentation of new-onset type 1 diabetes. Management requires fluid resuscitation and an insulin infusion with close monitoring for cerebral edema.

Question 46Child and Adolescent Medicine

A 3-year-old has had fever for 6 days with bilateral nonexudative conjunctivitis, cracked lips, a strawberry tongue, a polymorphous rash, and unilateral cervical lymphadenopathy. Which is the most appropriate management?

  1. Oral amoxicillin and antipyretics
  2. Oral corticosteroids alone
  3. Observation and repeat examination in 48 hours
  4. IVIG plus aspirin Correct answer.

Explanation

These findings meet the criteria for Kawasaki disease, and treatment with intravenous immunoglobulin plus aspirin reduces the risk of coronary artery aneurysms and should be started promptly with echocardiography. Delay in therapy increases cardiac complications.

Question 47Child and Adolescent Medicine

A 15-year-old with anorexia nervosa has a heart rate of 42 beats/min, orthostatic hypotension, and a temperature of 35.6 C. Which is the most appropriate disposition?

  1. Inpatient admission for medical stabilization Correct answer.
  2. Electrocardiogram in the office and discharge home
  3. Intensive outpatient program starting next week
  4. Outpatient nutrition counseling

Explanation

Bradycardia, orthostatic hypotension, and hypothermia are markers of medical instability in eating disorders and are indications for inpatient stabilization with monitored refeeding. Outpatient care is appropriate only for medically stable patients.

Question 48Child and Adolescent Medicine

A 21-day-old presents with a rectal temperature of 38.3 C and appears well. Which is the most appropriate management?

  1. Observation in the office for 2 hours then discharge
  2. Antipyretics and recheck in 24 hours
  3. Urine culture alone with outpatient follow-up
  4. Sepsis evaluation with empiric IV antibiotics Correct answer.

Explanation

Febrile infants 21 days old or younger require a full sepsis evaluation including blood, urine, and cerebrospinal fluid studies with empiric intravenous antibiotics while awaiting results. Clinical appearance alone is not sufficiently reliable at this age.

Question 49Child and Adolescent Medicine

A 12-year-old with obesity has 3 weeks of hip and knee pain and walks with an antalgic gait; passive internal rotation of the hip is limited. Which is the most appropriate next step?

  1. Reassurance with return precautions as needed
  2. Oral NSAIDs and crutches with follow-up in 6 weeks
  3. Urgent radiographs and orthopedic referral Correct answer.
  4. Physical therapy for a muscle strain

Explanation

The combination of obesity, age, knee-referred pain, antalgic gait, and limited internal rotation suggests slipped capital femoral epiphysis, which requires prompt radiographic confirmation and orthopedic pinning. Delay increases the risk of further slip and avascular necrosis.

Question 50Child and Adolescent Medicine

A 10-day-old presents with a cluster of vesicles on the scalp and mild lethargy. Which is the most appropriate management?

  1. Reassurance that this is transient neonatal pustular melanosis
  2. Admission for IV acyclovir and full sepsis evaluation Correct answer.
  3. Oral acyclovir as an outpatient with follow-up in 24 hours
  4. Topical acyclovir and observation at home

Explanation

Vesicles in a neonate suggest herpes simplex virus infection, which can disseminate or involve the central nervous system. Empiric intravenous acyclovir with surface cultures, blood and cerebrospinal fluid PCR, and full sepsis evaluation is required.