A 1-month-old boy is brought to the clinic for bright red blood in the stool.  He was born at full term via spontaneous vaginal delivery and had an uncomplicated course in the newborn nursery.  The patient has been exclusively breastfeeding since birth and typically has multiple soft, yellow, seedy stools a day.  Over the past week, the stools have been intermittently looser and streaked with blood and mucus.  The patient has also been fussy and spitting up with feeds.  Height and weight have been tracking along the 25th percentile.  Temperature is 37 C (98.6 F), pulse is 120/min, and respirations are 30/min.  Examination shows a well-appearing infant with no pallor.  Heart and lung sounds are normal.  Abdomen is soft and nondistended.  There are no anal fissures.  Stool Hemoccult is positive.

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

The patient returns to the clinic for follow-up 1 week later.  The mother has continued to breastfeed but is avoiding all dairy in her diet.  The patient has had no visible blood in the stool for the past 3 days.  Which of the following is the most likely outcome in this patient?

A 2-week-old girl is brought to the office because she looks “a bit yellow.”  She was born at 40 weeks gestation by normal spontaneous vaginal delivery to a mother whose blood type is AB+.  Apgar scores were 9 (-1 color) and 9 (-1 color) at 1 and 5 minutes, respectively.  Birth weight, length, and head circumference were at the 50th percentile.  She was discharged home on the second day of life and has been breastfeeding every 2-3 hours for 15 minutes on each side.  The infant has 6 wet diapers and 5-6 yellow seedy stools per day.  She has regained her birth weight and has normal vital signs.  Physical examination shows an active, crying infant with moist mucous membranes and jaundice of the face, neck, and chest.  The remainder of the examination is normal.  Total bilirubin is 10 mg/dL and direct bilirubin is 0.6 mg/dL.

Item 1 of 2

Which of the following is the most likely cause of this infant’s hyperbilirubinemia?

Item 2 of 2

Which of the following is the most appropriate next step in management of this patient?

A 3-year-old boy is brought to the emergency department by his parents due to fatigue and refusal to eat.  His family recently arrived in the United States from Syria.  He has had watery diarrhea for the past several days but no fevers or vomiting.  His appetite has been decreased for several weeks.  Today, he has refused to eat but has drunk a few cups of water and juice.  Limited medical records show that tuberculosis skin testing was negative and catch-up vaccines were administered at the time of immigration.  Temperature is 36.1 C (97 F), blood pressure is 100/65 mm Hg, pulse is 100/min, and respirations are 22/min.  Height is 91 cm (36 in) and weight is 12 kg (26 lb 8 oz), corresponding to the 10th and 5th percentiles, respectively.  Physical examination shows a gaunt, tired-appearing boy.  Oral mucous membranes are dry but without ulcers or thrush.  He has bilateral pitting edema of the lower extremities, and his upper extremities have minimal subcutaneous fat.  A soft, vibratory heart murmur is heard on auscultation.  The lungs have no adventitious sounds.  The abdomen is mildly distended but otherwise soft and nontender.  Initial laboratory results are as follows:

Stool occult blood test is negative.  Which of the following is the most appropriate initial step in management of this patient?

A 5-week-old boy is brought to the office by his mother due to vomiting.  The mother explains, “Over the past 4 days, my son has been vomiting forcefully right after drinking his formula.  He used to spit up after feeding, but it has been getting worse, and now, he seems to throw up everything he eats.”  The emesis is the color of milk.  The patient has had fewer wet diapers today and a single stool yesterday.  He was born at 39 weeks gestation after an uncomplicated pregnancy.  Newborn metabolic screening was normal.  Medical history is notable for switching to formula at age 2 weeks due to low breast milk production.  At that time, the patient was at the 25th percentile for length, weight, and head circumference.  Today, he is at the 10th percentile for weight, although length and head circumference remain at the 25th percentile.  Temperature is 36.7 C (98.1 F) and pulse is 169/min.  Physical examination shows an awake, alert, slightly fussy infant.  The anterior fontanelle is open and mildly sunken.  The lips and mucous membranes are slightly dry.  Cardiopulmonary examination shows no abnormalities.  The abdomen is soft and nondistended with active bowel sounds, although waves of peristalsis are visible.  There is no hepatosplenomegaly or tenderness to palpation.  Serum chemistry is pending.

Item 1 of 3

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 3

Which of the following most likely represents the electrolyte profile of this patient?

Item 3 of 3

The diagnosis is confirmed.  Which of the following is the best next step in management of this patient?

A 2-year-old boy is brought to the emergency department by his grandmother due to abdominal pain and lethargy.  The grandmother says that he was playing calmly last night when he suddenly began screaming and holding his abdomen.  The pain resolved after several minutes, but the patient has since had 5 additional episodes of sudden-onset, severe pain.  Today, the grandmother notes that he has no interest in eating or drinking and has been sleeping all morning but intermittently awakens in pain.  The patient has also had several episodes of nonbloody, nonbilious emesis and fewer wet diapers than usual.  He has had no fever, diarrhea, or recent infections.  Temperature is 37 C (98.6 F), blood pressure is 80/46 mm Hg, pulse is 130/min, and respirations are 24/min.  During the examination, the patient sleeps but is arousable.  The abdomen has hypoactive bowel sounds and diffuse, mild tenderness to palpation.  Immediately after the examination, the patient passes blood in his diaper, as shown in the image below:

Item 1 of 3
X-ray of the abdomen reveals dilated loops of bowel and no free air.  Intravenous fluids are started.  Which of the following is the best next step in management of this patient?

Item 2 of 3
The medical team discusses the clinical diagnosis and the recommended procedure with the patient’s grandmother after he passes 2 additional bloody, mucoid stools.  The patient lives with his parents and his grandmother over an hour away from the hospital.  His grandmother drove him to the emergency department but is not his legal guardian.  She states, “His mom should be on the way; she probably just left work.”  However, despite multiple attempts, the medical team is unable to reach either parent by telephone.  Which of the following is the most appropriate next step in management of this patient?

Item 3 of 3
After the appropriate procedure is performed, the intussusception is reduced successfully.  The patient’s parents arrive and are at the bedside.  After approximately an hour of rest, the patient experiences acute-onset, severe abdominal pain and nausea.  Temperature is 37.8 C (100 F), blood pressure is 80/50 mm Hg, pulse is 158/min, and respirations are 28/min.  Examination of the abdomen shows distension and diffuse tenderness.  Which is the best next step in this patient?

A 3-week-old girl is brought to the emergency department due to increasingly forceful and frequent vomiting following feedings over the past 5 days.  She is exclusively breastfed, and the emesis looks like breast milk.  When the patient first started spitting up, her mother gave her 2 doses of acetaminophen spaced 8 hours apart.  The patient was born at 38 weeks gestation to a 39-year-old woman.  The pregnancy was remarkable for an episode of viral gastroenteritis during the third trimester.  The patient’s 3 older brothers had pertussis when she was born, so she received antibiotic prophylaxis during her first week of life.  Physical examination shows an awake, alert, and slightly fussy infant.  Mucous membranes are slightly dry.  The abdomen is soft and nondistended with active bowel sounds.  Laboratory results are as follows:

The results of an abdominal ultrasound are shown in the exhibit.  Which of the following in this patient’s history is a risk factor for her current condition?

A 10-day-old boy is brought to the emergency department by his parents due to poor feeding.  The patient rejects the breast or bottle when his mother tries to feed him.  He sleeps all day and is very difficult to rouse.  The patient was born at 39 weeks gestation via an uncomplicated vaginal delivery.  He received phototherapy for jaundice prior to discharge from the nursery.  The pregnancy was uncomplicated, and prenatal laboratory studies were normal.  Family history is insignificant.  The patient takes no medications.  He is febrile and tachycardic.  Physical examination shows a lethargic infant with mild generalized jaundice.  The lungs are clear to auscultation.  Laboratory results are as follows:

Urinalysis shows positive leukocyte esterase and 15 white blood cells/hpf.  Blood, urine, and cerebrospinal fluid cultures are pending.  Which of the following treatment regimens is most appropriate for this patient?