Case #1A mother brings her 12-month-old child, a new patient in the clinic, for a well-child visit. The infant appears to be small for her age. Her weight is below the 5th percentile on standardized growth curves (50th percentile for an 8-month-old), her length is at the 25th percentile, and her head circumference is at the 50th percentile. Her vital signs and her examination otherwise are normal. We diagnosed patient with failure to thrive, most likely “nonorganic” in etiology given normal physical exam. Patient was managed with improved dietary intake, close follow-up, and attention to psychosocial issues.

Case #2J.T is a healthy 16-year-old adolescent male arrives at the office with his parents, who are concerned about his several months’ history of erratic behavior. At times he has a great deal more energy, decreased appetite, and less sleep requirement than usual; at other times he sleeps incessantly and is lethargic. He is doing poorly in school. Last evening he appeared flushed and agitated, he had dilated pupils, and he complained “people were out to get him.” The family notes that he has been skipping school occasionally, and they reluctantly report that he was arrested for burglary 2 weeks previously. You know he is in good health and he previously has been an excellent student. Today he appears normal and on physical exam, patient is well alert and normal vitals. Upon further questioning, patient admitted to try cocaine and we referral him to Emory for further evaluation and better equips to help him.

Case #3B.G. is a 2-year-old boy had been slightly less than the 50th percentile for weight, height, and head circumference, but in the last 6 months he has fallen to slightly less than the 25th percentile for weight. The pregnancy was normal, his development is as expected, and the family reports no psychosocial problems. The mother says that he is now a finicky eater (wants only macaroni and cheese at all meals), but she insists that he eat a variety of foods. The meals are marked by much frustration for everyone. His examination is normal. We encounter this problem a lot in the clinic because most 2 years old are very picky eater so we just reassure the mom.

Case #4: D.L. is a 4-year-old male patient is brought to the clinic by his mother after 5 days of fever (101 F), because of cracking and fissuring lips and bilateral painless conjunctivitis. On examination he manifests a “strawberry tongue,” unilateral cervical adenopathy, and redness and swelling of the palms of the hands. A rapid strep flocculation test and, 2 days later, a throat culture was “negative” (latter meaning no beta-hemolytic streptococcus growth). The fever remains over the next 2 days. Patient was suspected of Kawasaki and send to the Emory ER for treatment.

Case #5A.J. is a 10-year-old boy is brought to the clinic by his parents because of the onset of involuntary and random jerking movements of the extremities, incoordination of purposeful movements and slurred speech, Sydenham chorea. Further history reveals the boy to be atopic

with asthma that he “outgrew,” pneumonia on one occasion treated outside the hospital, and an episode characterized by upper respiratory symptoms during a family vacation 4 years ago that was never treated but was followed by several weeks of mild to moderate changing joint pains and transient “bumps” under skin. The boy has been asymptomatic since and has participated heartily in outdoor play and athletics. The boy is at risk of rheumatic fever, a very rare case in the U.S. because of penicillin availability. We then referral the patient to Emory hospital for an echocardiogram.

Case #6B.E. is a 4-year-old boy is brought to the clinic for inspiratory stridor that began last evening, 3 days after the onset of coryza and evolving tracheobronchial cough. His temperature was 99.8 ° F orally (37.7 ° C). He demonstrates inspiratory stridor at rest after a temporary response to nebulized racemic epinephrine (2.25%). Lateral neck x-rays were read as normal. Patient show classic symptoms of croup but since epinephrine doesn’t work, we added Dexamethasone 0.6 mg/kg IM in a single dose to treat persistent croup. Patient was scheduled to come back in 2 days for a follow up.

Case #7E.A. is a 16-year-old boy is brought to the clinic for the first time by his parents, complaining of increasing fatigability. Auscultation of the heart reveals a grade III/VI systolic ejection murmur and thrills at the right second intercostal space and in the suprasternal notch. S 2 is not split, either in inspiration or in expiration. The murmur is heard neither over the carotid arteries nor in the left axilla. This is the second heart case this week, we referral him to a cardiologist for further evaluation.

Case #8C.A. is a 4-year-old boy is brought to clinic for routine well child examination after his family moved into the area, seeking a new physician for their care. Patient has manifested normal growth and development. He has normal energy output, playing outdoors with his age peers without difficulty. He manifests no cyanosis. On examination I notice a grade IV/VI smooth sounding (i.e., not harsh) systolic murmur, which is loudest at the pulmonic auscultatory area. The second sound has a fixed split, not varying with inspiration. We think the child have a small ASD, although asymptomatic, we have to do further evaluation. We referral him to a nearby cardiologist for further evaluation.

Case #9D.R. is a 7-year-old boy began limping after exercise several months ago. The parents questioned him at first and he denied pain. Later the boy began complaining of pain in the right hip and at times the right thigh and knee. Over the past week, the pain has been disabling. Vital

signs are normal; on examination, the boy is unable to actively abduct and internally rotate as a result of muscle spasm. A CBC count is normal. We then send the patient to the ER to get an Xray and further evaluation because the child is hurting and we don’t want to wait if the situation is serious.

Case#10A.F. is a 4-year-old otherwise healthy boy is brought to the office with an 8-day history of nonspecific malaise and low grade fever as he begins to feel better now manifests a red maculopapular rash on the cheeks that on the day he is brought in appears to be coalescing to produce a diffuse red color now involving the chin and area behind the ears as well as the trunk and buttocks, sparing the circumoral zone. There is no palpable lymphadenopathy and the oral examination is not remarkable for descriptive abnormality. The child showed classic B19 slap face appearance so all we do is reassure the patient parent and tell the child to avoid pregnant family member.

Case #11F.U. is a 10-year-girl, assumed to have viral croup, failed to respond to racemic epinephrine and other standard treatments; she developed fever to 104 ° F (40 ° C) the morning of the visit with the clinic. A lateral x-ray of the neck shows no enlarged epiglottis but a stenotic subglottic lumen. We diagnosed patient with tracheitis and amoxillin was prescribed. Patient was schedule to follow up in 2 days to see if the antibiotic is effective and whether the fever gone down.

Case #12J.K is a 3-week-old male infant come in the clinicfor his first well child visit. On physical examination, he has a harsh, pansystolic loud murmur at the lower left sterna border. There is also a heave over the left precordium. The child has been eating normally and the family has not observed any episodes of cyanosis or dyspnea. There is no cyanosis. This child is normal at and there are no murmurs during newborn examinations. S 2 is normally split (increases with inspiration). Again, we referral the case out to a cardiologist for further evaluation.

Case#13A mother brings to you her 4-year-old child complaining of right-sided earache for 12 hours following three days of coryza, giving way to cough over the past 2 days. The external ear is not tender nor is the tempero-mandibular joint. The eardrum is retracted, fiery red, slightly bulging, and reveals a pus/fluid level. We diagnose the patient with otitis media and amoxicillin was prescribed.

Case#14J.R. is a 16-year-old male student complains of severe sore throat for 3 days and says that he has been unable to ingest solid foods for the past 2 days. He appears moderately ill and in pain, with his head held in a “sniffing”-type position, lips slightly parted, grimacing while swallowing

saliva. His speech is muffled and sounds as though the patient is trying to talk with a hot potato in his mouth. There is no stridor. His temperature is 101 F. His cervical lymph nodes are visibly and palpably enlarged but not tender to palpation; tonsils are present and show an exudates whose color is a mixture of white and yellowish against an erythematous and edematous background. There are palatal petechiae. The rim of the epiglottis is visible above the base of the tongue and appears normal in color and size. Survey for other adenopathy yields nothing of note, and abdominal examination is negative for masses and organomegaly. A rapid streptococcal screen is negative. Therefore, I ordered a stat spot test for infectious mononucleosis, which is positive. We instruct the patient to avoid contact sport.

Case #15A 17-year-old girl is brought to you for the complaint of a sore throat. You note the presence of petechiae of the mucosa overlying the hard palate. Cervical lymph nodes are notably enlarged and palpable but not tender. Infectious mononucleosis and streptococcal pharyngitis each may cause petechiae over the hard palate, though the question regards a nonbacterial cause only. Furthermore, adenopathy due to Bets strep is virtually always tender whereas that due to infectious mono is virtually never tender. In children, herpangina (not mentioned among the choices) causes palatal petechiae and occurs mostly in preschool-age children, generally up to 4 years of age. It may occur, however, as late in childhood as 16 years. In the present case, the existence of impressive lymphadenopathy without tenderness is typical of mononucleosis.

Case#16A 16-year-old is undergoing a routine health maintenance examination. He has had five immunizations of diphtheria, tetanus, and pertussis (DTaP; three in the first year, one at 2 years, and one at 5 years); four shots of Hemophilus influenzae type B (Hib); four shots of inactivated polio vaccine (IPV); two shots of measles, mumps, and rubella (MMR) vaccine; a varicella vaccine; three shots of pneumococcal vaccine (PCV); three doses of hepatitis B vaccine (HBV); and yearly influenza vaccines.

Case #17A young mother comes to you with her 8-month-old formula-fed baby. She is concerned about a rash involving the facial cheeks and the tops of folds of skin over various parts of the body. On occasion, the patches weep and form crusts. The baby does not seem to be bothered greatly by the rash. Both the parents are healthy and without especially apparent inherited diseases, except that the mother has allergic rhinitis in the autumn months and the father had asthma as a child.

Case#18A 17-year-old atopic male sales manager makes an appointment for complaint of a prolonged course of cold. Until the last year, his allergic rhinitis has seldom required antihistamine therapy during his peak season of mid-August until the first cool weather. He noted the onset of coryza 2

1/2 weeks ago during the 4th month of August and that his rhinorrhea has persisted, producing a tenacious discharge, sometimes blood streaked, from the right naris. When he leans forward, he feels a pain in his right facial region and sometimes a sense of shifting fluid in the right cheek anteriorly. On examination, he manifests tenderness of the right nasal rim of the orbit.