NRNP 6541 Pediatric Final Exam 2023-2024: Updated Questions and Accurate Answers, Exams of Nursing

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REAL EXAM

NRNP 6541 PEDIATRIC FINAL EXAM 2023 - 2024

UPDATED QUESTIONS AND ACCURATE ANSWERS

VERIFIED 100 % GRADED A+

A 15-year-old female has a 1-month history of urinary frequency without dysuria and recent onset of an itchy rash beneath both breasts. She has been gaining weight over the past year and regularly complains of fatigue. She is febrile with a weight greater than the 99th percentile and has an erythematous, macular rash beneath both breasts characterized by satellite lesions. UA is significant for 2+ glucosuria, but no pyuria. Which of the following is the most likely diagnosis? A. Diabetes mellitus B. Fanconi syndrome C. Human immunodeficiency virus D. Occult malignancy E. Severe combined immunodeficiency (SCID) A. The obese adolescent in this case has findings of diabetes mellitus. Her cutaneous candidiasis is likely an indication of secondary immunosuppression related to hyperglycemia. In diabetes, hyperglycemia promotes neutrophil dysfunction, and circulatory insufficiency contributes to ineffective neutrophil

chemotaxis during infection. HIV infection is possible and antibody testing might be reasonable, but this scenario is most consistent with hyperglycemia. A mother notes her 6-week-old son's umbilical cord is still attached. His activity and intake are normal; there has been no illness or fever. Delivery was at term without problems. His examination is notable for a cord without evidence of separation and a shallow, 0.5cm ulceration at the occiput without discharge or surrounding erythema. Mother declares that the "sore," caused by a scalp probe, has been slowly healing since birth and was deemed unremarkable at his 2- week checkup. Which of the following is consistent with this child's likely diagnosis? A. Defective humoral response B. Functional leukocyte adherence glycoproteins C. Marked neutrophilia D. Normal wound healing E. Purulent abscess formation C. You suspect leukocyte adhesion deficiency (LAD) as the etiology of this child's problem. LAD is an inheritable disorder of leukocyte chemotaxis and adherence characterized by recurring sinopulmonary, oropharyngeal, and cutaneous infections with delayed wound healing. Neutrophila is common with WBC counts of typically more than 50,000 cells/mm. Severe, life- threatening infection is possible with Staphylococcus species,

Enterobacteriaceae, and Candida species. Good skin and oral hygiene are important; broad-spectrum antimicrobials and surgical debridement are early consideration with infection. A 6-month-old girl is seen after an emergency room visit for decreased intake, emesis, and watery diarrhea for the past 3 days. She was diagnosed yesterday with "stomach flu" and given IV fluids. She is doing better today with improved intake and resolution of her emesis and diarrhea. The father is concerned about her thrush since birth (despite multiple courses of an oral antifungal) and that she has been hospitalized twice for pneumonia over the past 4 months. Her weight has dropped from the 50th percentile on her 4-month visit to the 5th percentile today. She has no findings consistent with dehydration, but she does appear to have some extremity muscle wasting. Her examination is remarkable for buccal mucosal exudates and hyperactive bowel sounds. Vital signs and the remainder of her examination are normal. You suspect severe combined immunodeficiency (SCID). Which of the following is consistent with the diagnosis? A. Autosomal dominant inheritance B. Persistent lymphocytosis C. Defective cellular immunity D. Normal vaccine immune response E. No curative therapy

C. SCID is an autosomal recessive or X-linked disorder of both humoral and cellular immunity. Serum immunoglobulins and T cells are often markedly diminished or absent. Thymic dysgenesis is also seen. Recurring cutaneous, gastrointestinal, or pulmonary infections occur with opportunistic organisms such as cytomegalovirus (CMV) and PCP. Death typically occurs in the first 12 to 24 months of life unless bone marrow transplantation is performed. You are called urgently to examine a term, 2-hour-old newborn who has had temperature instability, difficulty with feeding, and a suspected seizure. He has atypical facies (wide-set eyes, a prominent nose, and a small mandible), a cleft palate, and a holosystolic murmur. Stat laboratory tests and chest radiograph reveal marked hypocalcemia, a boot-shaped heart, and no apparent thymus. Which of the following is the most likely diagnosis? A. Ataxia-telangiectasia B. DiGeorge syndrome C. Hyper-IgE syndrome D. SCID E. Wiskott-Aldrich syndrome B. DiGeorge syndrome is caused by a 22q11 microdeletion. This syndromic immunodeficiency is characterized by decreased T- cell production and recurring infection. Findings include characteristic facies and velocardiofacial defects such as

ventricular septal defect and tetralogy of Fallot. Thymic or parathyroid dysgenesis can occur, accompanied by hypocalcemia and seizures. Developmental and speech delay are common in older patients. A 2-day-old infant has significant nasal and rectal bleeding. He was delivered by a midwife at home; the pregnancy was without complications. His Apgar scores were 9 at 1 minute and 9 at 5 minutes. He has breast-fed well and has not required a health-care professional visit since birth. Which of the following vitamin deficiencies might explain his condition? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D E. Vitamin K E. Newborn infants have a relative vitamin K deficiency, especially if they are breast-fed; most infants are given vitamin K at birth to prevent deficiency-related bleeding complications. A 6-month-old infant has been growing poorly. His parents have changed his formula three times without success. His examination is remarkable for a pale, emaciated child with little subcutaneous fat and anterior fontanelle fullness. His lab test results are notable for a hemolytic anemia and prolonged

bleeding times. Which of the following is the most appropriate next step? A. Gather urine for pH and electrolytes B. Measure serum factor IX levels C. Measure serum immunoglobulins D. Obtain a sweat chloride concentration E. Perform a hemoglobin electrophoresis D. The patient appears to have failure to thrive, with deficiencies of vitamin K (bleeding problems), vitamin A (fontanelle fullness), and vitamin E (hemolytic anemia). Cystic fibrosis (associated with vitamin malabsorption) would explain this condition. An exclusively breast-fed infant with poor routine care is switched at 6 months of age to whole milk and table foods. Screening laboratories at 9 months of age demonstrate the hemoglobin and hematocrit to be 8mg/dL and 25%, respectively, and the lead level to be less than 2mg/dL. A follow-up CBC 2 weeks later shows the hemoglobin to be at 7.8mg/dL, the hematocrit 25%, the mean corpuscular volume (MCV) 62%, and the platelet count to be 750,000/mm. Which of the following would be the next step in the management of this child? A. Order a hemoglobin electrophoresis. B. Obtain a bone marrow aspiration

C. Initiate iron supplementation D. Refer to a pediatric hematologist E. Initiate a soybean-based formula C. The child likely did not get iron (or vitamin D) supplementation in the first 6 months of life while exclusively breast-feeding and was switched to whole milk (low in iron) and to table foods (not supplemented with iron as are baby foods) at too young an age. All of the laboratory data are consistent with iron deficiency anemia; iron supplementation in this child with a resultant brisk erythrocyte response is both diagnostic and therapeutic. Failure of the child to respond to the iron therapy would require further evaluation. A 3-week-old is admitted for FTT, diarrhea, and a sepsis-like picture. He does well on IV fluids; when begun on routine infant formula with iron, his symptoms return. It is Saturday and the state health department laboratory is closed. You should begin feeds with which of the following? A. Amino acid-based formula (Nutramigen or Pregestimil) B. Low-phenylalanine formula (Lofenalac or Phenex-1) C. Low-iron, routine infant formula (Similac with low iron or Enfamil with low iron) D. Low-isoleucine, low-leucine, low-valine infant formula (Ketonex-1 or MSUD 1) E. Soy-based formula (ProSobee or Isomil)

E. This patient appears to have galactosemia; uridyl transferase deficiency is the cause and the condition results in features of jaundice, hepatosplenomegaly, vomiting, hypoglycemia, seizures, lethargy, irritability, poor feeding, and FTT, aminoaciduria, liver failure, mental retardation, and an increase risk of E coli sepsis. Children with galactosemia are managed with a lactose-free formula. The low phenylalanine formulas are for infants with phenylketonuria; low-iron formulas serve no purpose other than causing iron deficiency anemia; the low- isoleucine, low-leucine, low-valine infant formulas are useful for patients with maple syrup urine disease (MSUD); and the amino acid-based formulas are excellent for children with malabsorption syndromes. A healthy, well-developed 6-year-old child arrives as a new patient to your clinic. His immunization card reveals that he received an immunization at birth and some when he was 2 months old, but none since. Which of the following statements about him is correct? A. He should receive the live oral poliovirus vaccine rather than the inactivated (injectable) poliovirus vaccine (IPV) B. The pertussis vaccine is contraindicated at his age and is replaced with the tetanus-diphtheria vaccine. C. He is too old to receive the H influenzae type b vaccine. D. His vaccinations at birth and 2 months are repeated because too much time has elapsed for them to be effective.

E. He is too young for the varicella vaccine. C. The Hib vaccine is generally not recommended for children 5 years of age or older. .Appropriate advice for a mother of a 2-week-old child here for a "well-child" visit includes which of the following? A. By age 1 month the child should be sleeping through the night B. Children should be able to roll over by age 2 months and to sit by age 4 months C. Half-strength fruit juices can be initiated at age 2 months D. Potty training should begin at age 1 year E. Sleep in the supine position is recommended E. Juices (undiluted) are avoided until approximately 6 months of age (in a cup and not in the bottle). At 1 month of age an infant should be able to fix and follow, but not be expected to sleep through the night by age 2 to 3 months. Realistic targets for development include rolling over at 4 months and sitting by 6 months. Potty training starts when the child shows interest, usually no earlier than age 2 years. Parents are told to place healthy children on their backs (or side) for sleep to reduce the incidence of SIDS. During a "well-child" visit, the parents of a healthy 5-month-old offer a great amount of information. Which of the following bits of information is of most concern?

A. A diet that includes baby cereal, five different baby vegetables, and one baby fruits. B. Consuming 32oz of infant formula per day C. Intermittent tugging on the ears D. Limited eye contact with parents E. Rolling from front to back but not back to front D. Children fix and follow on the human face from birth. A 5- month old child who does not engage in eye contact is abnormal. Which of the following statements about "routine" screening tests is accurate? A. All children undergo tuberculosis skin testing at age 12 months B. Lead testing is obtained on all 12- and 14-month-old infants C. Pelvic examinations are part of the examination of a sexually active adolescent D. Screening hematocrit levels are obtained on all infants at age 2 months. E. Universal cholesterol screening begins at age 11 months C. TB and lead testing are performed on at-risk children. Pelvic examinations are performed when girls become sexually active or by age 18 to 21 years. Screening hematocrits are done at age

9 to 12 months, and cholesterol tests are done for children with familial risk factors. A mother brings her 3-year-old son with Down syndrome to the clinic because his gums have been bleeding for 1 week. She reports he has been less energetic than usual. Examination reveals that the child has a temperature of 100F orally, pallor, splenomegaly, gingival bleeding, and bruises on the lower extremities. Which of the following is most likely? A. Aplastic anemia B. Idiopathic thrombocytopenic purpura C. Leukemia D. Leukemoid reaction E. Megaloblastic anemia C. A high susceptibility to leukemia is associated with certain heritable diseases (Klinefelter syndrome, Bloom syndrome, Fanconi syndrome, ataxia telangiectasia, neurofibromatosis) and chromosomal disorders such as Down syndrome. Children with Down syndrome have a 10-to 15-fold increased risk for developing leukemia. Siblings of an ALL patient have a two- to fourfold increased risk for ALL. A few cases of ALL are associated with p53 gene aberrations. Overall, these genetic links account for a small number of total ALL cases. (ALL=acute lymphoblastic leukemia)

A father brings to the clinic his 6-year-old son who currently is undergoing induction chemotherapy for ALL. The school will not allow the child to register until his immunizations are up-to- date. Which of the following is the best course of action? A. Call the school nurse or principal to inform him or her that this child should not receive immunizations while he is taking chemotherapy B. Update all immunizations except for MMR and varicella C. Update all immunizations except for oral polio vaccine D. Update all immunizations E. Call the school nurse or principal to inform him or her that this child will never receive immunizations because of the alteration in his immune system A. Live virus vaccines are contraindicated for the child with ALL (and all members of the household) during chemotherapy and for at least 6 months after completion of treatment. Although the viruses in the vaccine are attenuated, immunosuppression from treatment can be profound and viral disease can result. Immunizations without live virus (diphtheria, tetanus, inactivated poliovirus vaccine, hepatitis A and B) are not absolutely contraindicated in this case, but the immunosuppression with chemotherapy often inhibits antibody responses. A mother brings to the clinic her 4-year-old son who began complaining of right knee pain 2 weeks ago, is limping slightly, is

fatigued, and has had a fever to 100.4F. Which of the following lab tests is most important? A. Antinuclear antibodies B. CBC with differential and platelets C. Epstein-Barr virus titer D. Rheumatoid factor E. Sedimentation rate B. This child has symptoms of JRA and leukemia. The CBC with differential and platelets is the best initial screening test. The leukocyte and platelet counts are normal to increased in JRA, and no blast cells are present. Frequently, blast cells are found on the peripheral smear with ALL. The child in the question ultimately may require a bone marrow aspiration. Two weeks after a viral syndrome, a 2-year-old develops bruising and generalized petechiae that is more prominent over the legs. He has neither hepatosplenomegaly nor lymph node enlargement. Lab testing reveals a normal hemoglobin, hematocrit, and white blood cell count and differential. The platelet count is 15,000/mm. Which of the following is the most likely diagnosis? A. Acute lymphoblastic leukemia B. Aplastic anemia C. Immune thrombocytopenic purpura

D. Thrombotic thrombocytopenic purpura E. von Willebrand disease C. Immune (or idiopathic) thrombocytopenic purpura (ITP) is common in children. In most cases, a preceding viral infection can be documented. The platelet count frequently is less than 20,000/mm, but other laboratory test results are normal, including the bone marrow aspiration (which may show an increase in megakaryocytes). Treatment consists of observation or possibly intravenous immunoglobulin (IVIG), anti-RhD, immunosuppressives, or steroids. The history is explored for other possible causes of thrombocytopenia, including recent MMR vaccination, drug ingestion, and human immunodeficiency virus. A mother recently feels a mass in the abdomen of her 4-year- old son during a bath, and brings him to your clinic for evaluation. He has no history of emesis, abnormal stooling, or abdominal pain. Physical examination reveals a resting blood pressure of 130/88, heart rate of 82, pallor, and a firm left-sided abdominal mass that doesn't cross the midline. Which of the following is the most likely explanation for these findings? A. Constipation B. Intussusception C. Neuroblastoma D. Wilms tumor

E. Volvulus D. The scenario presented is typical for Wilms tumor. Beyond abdominal imaging, checking a UA for hematuria, metabolic panel for renal or hepatic dysfunction, and CBC for anemia should be considered in the workup of Wilms tumor. A 1-week-old infant presents with a right midquadrant abdominal mass and decreased urinary output. There has been no temperature lability, irritability, or abnormal stooling or urine appearance. Which of the following is the most likely diagnosis? A. Intussusception B. Hydronephrosis C. Neuroblastoma D. Sepsis E. Wilms tumor B. Urinary tract obstruction is often silent. In the newborn, a palpable abdominal mass is commonly a hydronephrotic or multicystic dysplastic kidney. A father presents his otherwise healthy 15-month-old daughter to the emergency center with cough, post-tussive emesis, and subjective fever over the past 3 days. He also thinks her abdomen has been hurting her. Diarrhea started yesterday, with "regular" stooling prior to this illness. She has been drinking well and recently had a wet diaper. Physical examination reveals

a temperature of 98.9F, congested nares, shoddy neck lymphadenopathy, and a mildly distended and apparently tender abdomen without obvious guarding. Which of the following is the most likely etiology for her abdominal pain? A. Constipation B. Lymphoma C. Neuroblastoma D. Appendicitis E. Mesenteric lymphadenitis E. Upper respiratory tract infection symptoms, neck lymphadenopathy, and diarrhea are consistent with viremia; viral-mediated mesenteric lymph node enlargement can occur and cause nonspecific abdominal pain. This otherwise healthy child with classic viremia lacks history or findings consistent with an intra-abdominal tumor, enteritis, or intestinal dysmotility. An abdominal CAT scan may show diffuse, mildly enlarged lymph nodes in mesenteric lymphadenitis, but imaging is rarely warranted unless an etiology for abdominal pain remains elusive. Other nonmalignancy-related causes of abdominal pain include enteritis caused by bacteria (salmonella, E coli, Yersinia sp, and typical or atypical mycobacteria) or viruses (mononucleosis, coxsachie, and adenovirus). During a routine preventative health visit for a 3-year-old boy, you incidentally note an irregular abdominal mass involving

both lower quadrants. His mother denies having noted this previously and declares her son to be generally healthy. There has been neither GI distress nor apparent abdominal pain. Beyond the abdominal mass and pallorous conjunctivae, his vital signs and physical exam are normal. Which of the following tests would be most helpful in determining the etiology of his abdominal mass? A. Abdominal radiograph B. Chest radiograph C. Urinary catecholamines D. Complete blood count E. Urine myoglobin C. The boy's history and examination are consistent with neuroblastoma. Given the vast majority of neuroblastoma patients have elevated urinary catecholamines, a 24-hour quantitative assessment of these metabolites should be confirmatory. A 2-year-old girl has a rash. She was well until 2 weeks prior when she had fever and URI symptoms that resolved without treatment. On examination, she has petechiae on her upper and lower extremities and trunk. Her platelet count is 25,000/mm. Her WBC count is 9000/mm and hemoglobin level is 11mg/dL. Which of the following is the best next step in management?

A. Obtain a review of the peripheral blood smear B. Administer IV immunoglobulin C. Send a blood culture and begin empiric antimicrobial therapy D. Order a platelet transfusion E. Arrange for bone marrow biopsy A. This child has the classic ITP features of isolated thrombocytopenia in a well-appearing child. An examination and peripheral blood smear are necessary. If no lymphadenopathy or organomegaly is found and the peripheral blood smear is normal, initial management includes close observation and a protective environment. A 14-year-old adolescent female has a rash on her arms and legs. She was diagnosed with a urinary tract infection 4 days ago, which is being treated with trimethoprim- sulfamethoxadole. She denies fever, vomiting, diarrhea, headache, and dysuria. On examination she has multiple upper- and lower- extremity petechiae. Her WBC count is 7000/mm and hemoglobin level 13mg/dL; her platelet count is 35,000/mm. Which of the following is the best next step in management? A. Send blood for antinuclear antibody (ANA) B. Send a repeat urinalysis C. Discontinue the trimethoprim-sulfamethoxazole D. Obtain HIV testing

E. Administer IV immunoglobulin C. The thrombocytopenia may be the result of the trimethoprim-sulfamethoxazole; the medicine is discontinued and her platelet count is monitored. If thrombocytopenia continues, she may have ITP and is followed for chronic ITP. Chronic ITP occurs in older children (female predominance); it may be seen with autoimmune disease such as SLE or with chronic infections including HIV. A 7-year-old boy has a rash on his lower extremities and pain in his right knee. He has had a low-grade fever and abdominal pain, and has felt tired. He is nontoxic appearing, but he has palpable petechiae on his lower extremities and buttocks. His right knee is mildly edematous and he can bear weight on his right leg, but complains of pain. His prothrombin time (PT), PTT, and platelet counts are normal. Which of the following is the best next step in management? A. Begin a course of systemic corticosteroids B. Begin empiric antimicrobial therapy for sepsis C. Obtain a UA and provide supportive care D. Perform aspiration of the synovial fluid in his right knee E. Administer IV immunoglobulin C. This child has signs and symptoms of HSP, a vasculitis of the small vessels with renal, GI, joint and dermatologic involvement. Initial therapy consists of hydration and pain

control. With renal involvement, UA reveals red blood (cell) counts (RBCs), WBCs, casts, or protein. GI complications include hemorrhage, obstruction, and intussusception; abdominal pain requires careful evaluation. A 3-year-old boy has pallor, lethargy, and decreased urine output. He was well until the preceding week, when he had fever, vomiting, and bloody diarrhea (now resolved). On examination, he is lethargic and has hepatosplenomegaly and scattered petechiae. UA reveals hematuria and proteinuria. Which of the following statements about his condition is accurate? A. A CBC is likely to reveal thrombocytosis B. Initial therapy includes systemic corticosteroids C. Empiric antimicrobial therapy for sepsis should be initiated D. An emergent oncology consultation for probable leukemia should be arranged E. Peripheral blood smear is likely to reveal helmet cells and burr cells E. This child has features of HUS, which frequently follows a bout of gastroenteritis; it has been associated with E coli 0157:H7, Shigella, and Salmonella. Patients have pallor, lethargy, and decreased urine output; some have hepatosplenomegaly, petechiae, and edema. Lab findings include hemolytic anemia and thrombocytopenia; peripheral blood smear demonstrates helmet cells, burr cells and

fragmented RBCs. Acute renal failure is manifested by hematuria, proteinuria, and an elevated serum creatinine level. Management is supportive with careful monitoring of renal and hematologic parameters; dialysis may be required. Recommended treatment for RSV in a 7 month old (outpatient) Use of saline drops and suctioning of the nares. Indications of when to use antipyretics. Signs of respiratory distress or dehydration. Guidelines for feeding an infant with signs of mild respiratory distress which includes smaller more frequent feedings; monitoring of the respiratory rate; and guarding against vomiting. The parents should be educated that the child may have the symptoms over the course of 2-3 weeks Epiglottitis s/s Acute and rapid onset of high fever, chills, and toxicity. Severe sore throat and drooling saliva. Will not eat or drink, muffled (hot potato) voice, and anxiety. Sitting posture with hyperextended neck with open-mouth breathing. Stridor, tachycardia, and tachypnea Epiglottitis prevention Haemophilus influenzae type B (Hib) vaccine Steeple sign a radiologic sign found on radiograph where the subglottic tracheal narrowing produces a shape of a church steeple which supports a diagnosis of croup

Foreign body aspiration antibiotic? Depends on the nature of the material aspirated, plus the location and degree of obstruction. Bronchial or laryngeal foreign body aspiration, a bronchoscopy must be performed for removal of the foreign body Antibiotics for bronchiolitis? Use of saline drops and suctioning of the nares. There is no evidence to support the routine use of antibiotics Antibiotics for croup? Nebulized epinephrine, corticosteroids (dexamethasone oral or IM), blow by oxygen or heliox in severe croup. Racemic epinephrine with the use of corticosteroids to limit rebound swelling Antibiotics for epiglottitis? Establish an airway preferably by nasotracheal intubation. Administer IV antibiotics such as rocephin to cover H.influenzae. Administer oxygen and respiratory support. Antibiotics should be continued for 10 days. Rifampin prophylaxis 20 mg/kg in a single dose (maximum of 600 mg) for 4 days for infants and children, 600 mg once a day for adults for 4 days. Should be provided for household contacts who are at risk (Younger than 4 years old who is non-immunized or incompletely immunized, children less than 12 months who have not received primary series of Hib, and immunocompromised children.

Asthma treatment The pharmacological management of asthma in children is based on the severity of asthma and the child's age. After initial control, decrease treatment to the least amount of medication needed to maintain control. Systemic corticosteroids may be needed at any time and stepped up if there is a major flare-up of symptoms. Step 1 Asthma management for children 0-4 years old Step 1: SABA (Short acting beta2-agonist) PRN: With viral respiratory symptoms short acting beta 2-agonist should be used every 4-6 hours up to 24 hours (longer with a physician consult). Consider short course of oral systemic corticosteroids if severe exacerbation. Frequent use of SABA may indicate the need to step up treatment Step 2 Asthma management for children 0-4 years old Step 2: Consider consultation with asthma specialist. Low dose of inhaled corticosteroids. Step 3 asthma mgmt for children 0-4 yrs Step 3: Medium-dose of inhaled corticosteroids Steps 4-6 asthma mgmt for children 0-4 yrs Step 4: Medium-dose ICS and Long acting beta2-agonist or montelukast.

Step 5: High dose ICS and Long acting beta 2-agonist or montelukast. Step 6: High dose of ICS and LABA or montelukast and oral corticosteroids Steps 1-3 asthma mgmt for children 5-11 yrs Step 1: SABA (Short acting beta 2-agonist) PRN: Increasing the use of short-acting beta 2-agonist or use greater than 2 days a week for symptom relief generally indicates inadequate control and the need to step up treatment. Step 2: Consider consultation with asthma specialist. Low dose of inhaled corticosteroids. Step 3: Low dose of inhaled corticosteroid and LABA. Or medium dose of inhaled corticosteroids. Steps 4-6 asthma mgmt for children 5-11 yrs Step 4: Medium-dose ICS and LABA or medium dose of inhaled corticosteroid and leukotriene receptor antagonist or theophylline..

Step 5: High dose ICS and LABA or high dose of inhaled corticosteroid and leukotriene receptor antagonist or theophylline.. Step 6: High dose of ICS and LABA and oral corticosteroids or high dose of inhaled corticosteroids and leukotriene receptor antagonist or theophylline and oral corticosteroids. Theophylline levels must be monitored. Differentials for patient with sore throat Strep pharyngitis Peritonsillar abscess Viral pharyngitis Infectious mononucleosis Epiglottitis small-for-gestational-age infants: which type of chromosomal analysis should be included? Trisomy 18 Holt-Olram Trisomy 13 Turner Syndrome Trisomy 21