UWORLD

14 y/o boy w father sudden cardiac arrest. PR shows carotid pulse with dual upstone and strong apical impulse and faint midsystolic murmur heard at the cardia apex along the left sternal border. Which maneuvers most likely to increase murmur intensity in patients?

Valsalva Strain phase
*HCM → midsystolic or cresendo-decresendo systolic murmur heard at the left sternal border or cardiac apex. Valsalva and standing increase the intensity.

12 y/o 2 wks itchy red eyes, intermittent, mild, clear eye drainage w/o pain or photobhobia. Rubbing eyes leads to burning sensation. Light crusting of both eyes, history of eczema uses topical emollients for. Has younger sister with fever, cough, rhinorrhea and pharyngiitis for 2 days. Exam show diffuse conjunctival injections and mild eyelid edema. Best next step?

Topical antihistamine
Diffuse conjunctival injections just means readiness of the eye. This is allergic conjunctivitis. (Watery discharge, eyelid edema, ocular pruritus.

12-year-old girl with confusion and rapid breathing; three days ago had rhinorrhea, cough, and fever; now has increased urination, abdominal pain, and fatigue progressing to somnolence. Vitals: 36.7 °C (98 °F), 110/70 mm Hg, pulse 138/min, respirations 36/min, pulse oximetry 99%. Exam shows tachypnea, subcostal retractions, and dry mucous membranes. Labs: Sodium 129 mEq/L, Potassium 4.8 mEq/L, Bicarbonate 9 mEq/L, Glucose 450 mg/dL. Question: Which of the following is most likely decreased in this patient?

Total body potassium
Excess serum glucose exceeds threshold for reabsorption by the kidneys causing glucosuria and osmotic diuresis causing a net loss of potassium. Levels may be normal because acidemia

5-month-old girl with poor weight gain; drinks 5–6 oz every 4 hours, increasing caloric density did not help; no diarrhea but spits up after feeding; newborn screening normal; labs: Sodium 140 mEq/L, Potassium 3 mEq/L, Chloride 119 mEq/L, Bicarbonate 11 mEq/L, urine pH 7.8, Glucose in UA negative—evaluating failure to thrive.

Renal tubular acidosis Type 1 because there is low serum bicarbonate, a high urine pH and no glucose in the urine. A type 2 would have glucosuria and Urine pH below 5/5 due to severely low serum bicarb.

2-hour-old boy with minimal right arm movement; born at 37 weeks gestation by vacuum-assisted delivery after a 3-minute shoulder dystocia; arm held in adduction and internal rotation with the elbow extended, forearm pronated, and wrist & fingers flexed; Moro and biceps reflexes absent on the right—next step in management?

→ Management involves observation and physical therapy because 80% have spontaneous recovery within 3 months. IT may just be nerve compression and not sever rupture or avulsion. If no improvements by 3-9 months then surgical intervention is indicated.

2-month-old girl, routine newborn examination, born at 39 weeks gestation to a 26-year-old primigravida, fed formula every 3-4 hours and sleeps 5-6 hours overnight; there are 4 skin creases along the inner left thigh and 1 on the right; when the patient is supine with the knees flexed, the left knee appears to be inferior to the right knee; Barlow and Ortolani maneuvers are negative; Which of the following is the most appropriate next step in management of this patient?

Ultrasonography of the hips-- due to developmental dysplasia of the hip

Below 4 months need ultrasonography and above 4 month need x-ray because the femoral head and acetabulum are ossitfied.