Pediatrics

University of the EastRAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

Aurora Boulevard, Quezon City

DEPARTMENT OF PEDIATRICS

QUESTIONS AND ANSWERS FOR MEDICAL BOARD REVIEW FEBRUARY 2005

CHOOSE THE BEST ANSWER:

1 A newborn FT was noted to be pale at 4th month of life. Iron is unlikely in this condition because infants have sufficient stores to meet their iron requirement for:

A. 2-3 months B. 4-6 months C. 7-8 months D. 10-12 months(Problem Solving) - GITB – It is by 6 months that iron should be supplemented among healthy full terms. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 156)

2 The breastfed baby of a pure vegetarian mother may develop: A. Xerophthalmia B. Diarrhea & Dementia C. Osteomalacia D. Anemia(Problem Solving) - GITD - Strict Vegan diets contain no eggs, meat or milk products making this deficient in Vitamin B 12.

(Chap. 446 p. 1612) Nursing Vegan mothers must be given B12 to prevent. Methylmalonic academia and anemia in

their infants. (166) (A) Xerophthalmia is Vitamin A deficiency and for which Vitamin A rich sources are the vegetables. (B) Diarrhea and dementia are signs of niacin deficiency (Pellagra) B vitamins come from grains

and vegetables. (C) Osteomalacia is Vitamin D deficiency (Rickets) (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 446 Table 44-I)

3 By 6th month of age micronutrients must be started. Foremost among these is that nutrient that prevents:

A. Xerophthalmia B. Scurvy C. Anemia D. Goiter(Problem Solving) - GITC - All nutrient needs of infants must be met by 6 months. But during this time breast milk volume

and iron stores may not be adequate to accommodate the demands of growth – Iron deficiency anemia may ensue.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 164)

4. Chronic intake of carotenoids may result in: A. Pseudotumor cerebri B. Yellow skin and sclerae C. Yellow skin D. Cranial nerve palsy(Recall) - GITC - Carotene (yellow pigment); carotenemia although non-toxic is due to deposition of carotene

pigments in the skin but not the sclerae, (B) Icteresia and jaundice is yellowish discoloration of the sclerae and skin secondary to

deposition of bilirubin due to a pathology in Bilirubin metabolism hemolytic of hepatobiliary disease

(A and D) Pseudotumor cerebri and cranial nerve palsy are CNS manifestations of Vitamin A toxicity after chronic intake of >100,000/u/day vitamin A.


5. A 3-hour old newborn with a prenatal history of maternal hydramnios was noted to have frothing of mouth and nose with circumoral cyanosis. You anticipate that:

A. There is inability to pass the nasogastric tube B. Presence of scaphoid abdomen C. Referral to ENT will be done D. All of the above (Problem Solving) - GITA - In early onset respiratory distress, inability to pass an NGT suggests esophageal atresia with TEF.

This is a surgical problem not seen by ENT (C) maternal polyhydramnios is more associated with TEF rather than diaphragmatic hernia (B) (Nelson’s Textbook of Pediatrics, 17th ed, 2004,Chapter 300)

6. Which of the micronutrients does not have recognized anti-infective properties? A. Vitamin A B. Vi tamin D C. Iron D. Zinc(Recall) - GITB - Deficiency of any essential nutrient may result in failure to thrive and accompanying lack of immune

protection. However, infections are more common in children with Vitamin. A, Iron, Zinc deficiencies. These 3 have roles in the immune system.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 44)

7. A 1-1/2 year old is discovered to have a bottle of alkali solution in his mouth. The bottle was noted to be half empty. No external signs on the child's face were seen. Your advice is to bring the child to the ER. There must be prior administration of:

A. Emetic B. Antiemetic C. Milk D. Laxative(Problem Solving) - GITC - Milk calms the child and dilutes the alkali (A) don’t induce emesis (Nelson’s Textbook of Pediatrics, 17th ed, 2004, (Chapter 308.2)

8. A 3 year old accidentally ingested a coin. A chest x-ray was taken. In contrast to foreign body trachea, the coin in the esophagus as seen on radiograph will show: A. Edge of the coin in AP view B. Edge of coin on lateral view C. Flat surface in AP view D. A and C(Problem Solving) - GITD - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 308.1)

9. The WHO recommends the use of ORS in developing countries to have a sodium concentration of

_____ mmol/L: A. 90 B. 100 C. 110 D. 120(Recall) - GITA - 90 mmol/l Above 90 is hyperosmolar (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 250)

10. A 3-week old with essentially normal birth history had episodes of intermittent vomiting after feeding. If pyloric stenosis is being considered, you expect the following EXCEPT:

A. Hypochloremic alkalosis B. Bilous vomiting C. Gastric peristaltic wave D. Olive-shaped RUQ mass in abdominal palpation(Problem Solving) - GITC - The hallmark of gastric obstruction is non-bilious vomiting. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 310)

11. A one day old had bilous vomiting. He was noted to be slightly jaundiced. The abdomen was notdistended but there was occasional visible peristaltic nerves on the abdominal wall. Plain abdomen x-ray showed double-bubble sign. The obstruction is on what level?

A. Distal esophagus B. Gastric C. Duodenal D. Colonic(Problem Solving) - GITC - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 1233) When the obstruction is in the duodenum beyond the Ampula of Vater – vomitus is bilous. The

Ampulla of Vater is the site where bile exits.

12. A 2-year old with head trauma underwent a neurosurgical procedure. At the PICU he had massive

hematemesis. You would consider: A. Curling’s ulcer B. H. pylori infection C. Cushing’s ulcer D. B and C (Problem Solving) - GITC - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 316.1) Gastric hypersecretion is associated with head trauma and severe CNS disorders (A) Curling’s ulcers are associated with severe burns (B) The course is too acute for H. pylori infection

13. An 11 year old Tanner stage 2 female developed epigastric pain / 8 hours later there was fever nausea and vomiting. She passed 2 soft bowel movements. In the clinic, she limps and abdominal palpation, there was generalized guarding. Most likely, she has:

A. Pelvic inflammatory diseaseB. Ruptured ectopic pregnancyC. AppendicitisD. Mesenteric adenitis

(Problem Solving) - GITC - All choices are differentials of appendicitis (A) PID presents with vaginal discharge (B) Pregnancy is unlikely for Tanner 2

(D) Mesenteric adenitis follows a week of respiratory infection (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 324)

14. A 2 year old previously well child had intermittent crying episodes and projectile vomiting 12 hours

ago. There was gassy abdominal distention and passage of maroon-colored stools. You would:A. Give antiamebics and antiemeticsB. Do abdominal x-ray and refer to surgeryC. Give antibioticsD. All of the above

(Problem Solving) - GITB - The diagnosis is intussusception (A) and (C) are not employed in intussusception (Nelson Textbook of Pediatrics, 17th ed, 2004)

15. The GI malignancy prevented by immunization is:A. Gastric carcinomaB. Colonic carcinomaC. Hepatic carcinomaD. Pancreatic carcinoma

(Recall) - GITC - Hepatitis B directly increases the risk of Hepatocarcinoma in later life. This is prevented by

vaccination. There are no known vaccines for preventing the onset of the other cancers. Gastric cancer from H. pylori gastritis is well documented. So far there are no H. pylori vaccines.


16. Prolonged antibiotic therapy can result to bleeding with the following laboratory results:A. Normal PT, normal PTTB. Prolonged PT, prolonged PTTC. Prolonged PT, normal PTTD. Normal PT, prolonged PTT

(Problem Solving) – Hema/Onco C - Prolonged antibiotic therapy can lead to gut sterilization leading to reduced synthesis of Vitamin

K – dependent clotting factors (Factors II, VII, IX & X, protein C and protein S). This

reduction of clotting factors of the extrinsic limb of coagulation will lead to prolongation of Prothrombin Time with normal PTT.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004)17. The CBC of a 7-yer old male with epistaxis and ecchymoses revealed Hgb 67 g/dl, Hct 18%, WBC 50,000, Neutrophils 5%, Lymphoblast 95%, Platelet Count 20,000. What is you primary consideration?

A. Aplastic anemiaB. Acute lymphocytic leukemiaC. Disseminated intravascular coagulationD. Idiopathic thrombocytopenic purpura

(Problem Solving) – Hema/OncoB - The anemia and thrombocytopenia are due to decreased production of erythroid and megakaryocytic

precursors resulting from blastic proliferation in the bone marrow. Aplastic anemia (Choice a) is associated with pancytopenia. DIC (Choice C) doesn’t produce leukocytosis and blasts

in the peripheral smear. It is associated with the coagulation mechanism, not the hematopoietic cells. ITP (Choice D) is only associated with thrombocytopenia. No leukocytosis and blasts are seen in the peripheral smear.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004)

18. Recurrent gum bleeding was noted in a 7-year old female. CBC and platelet count are normal, Prothrombin time is normal but bleeding time and partial thromboplastin time are prolonged. The most likely diagnosis is:

A. ITPB. Hypoprothrombinemia C. TTPD. Von Willebrand Disease

(Problem Solving) – Hema/OncoD - Von Willebrand disease is a disorder associated with mucocutaneous hemorrhages. The disorder is

due to deficiency of Von Willebrand factor, a glycoprotein that is synthesized in megakaryocytes and endothelial cells. During normal hemostasis VWF adheres to the endothelial matrix after vascular damage. Changes in the conformation of VWF cause platelets to be an adhere to VWF resulting to platelet activation and recruitment of additional platelets. VWF also serves as the carrier protein for plasma factor VIII. Severe deficiency of VWF can cause prolongation of bleeding time and PTT. ITP (Choice A) results only to prolonged BT because the coagulation phase is not affected. Hypoprothrombinemia (Choice B) results to decreased synthesis of Vitamin K – dependent factor causing prolonged PT. ITP (Choice C) is a form of microangiopathic hemolytic anemia with thrombocytopenia.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 469)

19. A 10-kg child with iron deficiency anemia should receive:A. 20 mg elemental ironB. 30 mg elemental ironC. 60 mg elemental ironD. 70 mg elemental iron

(Recall) – Hema/OncoC - The therapeutic dose of elemental iron is 6 mkd. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 447)

20. The following statement is true regarding brain tumors in childhood:A. Hereditary syndromes are associated with increased incidence of brain tumors in 25%

of casesB. Cranial exposure to ionizing radiation is associated with increased incidence of brain

tumorC. Supratentorial tumors predominate among children aged 1-10 yearsD. In general, there is a slight predominance of supratentorial tumor location in children

(Recall) – Hema/OncoB - Cranial exposure to ionizing radiation has been shown to be associated with increased incidence of

brain tumors. This has been observed in pediatric acute lymphocytic leukemia who underwent craniospinal prophylaxis. Hereditary syndrome (Choice A) are associated with increased incidence only in 5% of cases. Supratentorial tumors predominate during the 1st year of life thus Choice C is incorrect. Generally, infratentorial tumors predominate slightly over supratentorial tumors making Choice D incorrect.


21. Neuroblastoma is a condition characterized by the following:A. Malignancy most frequently diagnosed in infancyB. Mixed embryonal neoplasm composed of three elements: blastoma, epithelia and

stromaC. Classically presents with leukocoriaD. Diagnosis does not require a biopsy but is established characteristical clinical findings

(Problem Solving) – Hema/Onco

A - Neuroblastoma is an embryonal cancer of the peripheral sympathetic nervous system. It is the third most common pediatric cancer accounting for about 8% of pediatric cases. It is the most common malignancy in infancy accounting for 28-39% of neonatal malignancies. Mixed

embryonal neoplasm composing of three elements (Choice B) pertains to Wilm’s tumor. Leukoria (Choice C) is the characteristic clinical presentation of retinoblastoma. Diagnosis does not require a biopsy (Choice D) in retinoblastoma since characteristic ophthalmologic findings are sufficient. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 490)22. Among the following tumors, the one with the best over-all survival rate is:

A. Wilm’s tumorB. Non-Hodgkin’s lymphomaC. HepatoblastomaD. Neuroblastoma

(Problem Solving) – Hema/Onco A - Prognosis of neuroblastoma is generally good. Survival in low risk group is 91-100%; average

group 75-98% Stage 4S carries 100% survival with supportive care only because the tumor regresses spontaneously. Wilm’s tumor (Choice A) prognostic factors are tumor size, stage and histology. More than 60% of patients with all stages generally survive. Non-Hodgkin’s lymphoma (Choice B) is considered disseminated disease from the time of diagnosis. Hepatoblastoma (Choice C) if unresected carries survival rate of 60%.


23. Which of the following patterns noted on continuous monitoring of fetal heart rate is most indicative of fetal distress?

A. Baseline variability with periodic accelerationB. Increasing baseline variabilityC. Early deceleration without baseline variabilityD. Late deceleration without baseline variability

(Problem Solving) - NeonatologyD - Baseline variability with or without periodic acceleration of the heart rate is a sign of fetal well-

being. Increasing baseline variability may represent early compromise of fetal oxygenation. The early deceleration pattern is due to pressure of the anterior fontanelle on the cervix and is not a sign of fetal distress. The variable deceleration pattern indicates umbilical cord compression. The late deceleration pattern signifies fetal hypoxemia.

(Behrman, ed. 13, p. 368)

24. A healthy premature infant who weighs 950 g (2 lb, 1 1/2 oz) is fed undiluted breast milk to provide 120 cal/kg per day. Over ensuing weeks the baby is most apt to develop:

A. HypernatremiaB. HypocalcemiaC. Blood in the stoolD. Metabolic acidosis

(Problem Solving) - NeonatologyB - Breast milk has much less calcium and phosphorus than do commercial formulas. (Behrman, ed. 113, pp. 162-163)

25. An infant weighing 1400 g (3 lb) is born at 32 weeks gestation in a delivery room that has an ambient temperature of 24'C. Within a few minutes of birth, this infant is likely to exhibit all the following EXCEPT:

A. PallorB. ShiveringC. A fall in body temperatureD. Increased respiratory rate

(Problem Solving) - NeonatologyB - A room temperature of 24’C provides a cold environment for preterm infants weighing less than

1500 g. Aside from the fact that these infants emerge from a warm intrauterine environment. In order to bring body temperature back to normal they must increase their metabolic rate; ventilation in turn, must increase proportionally to ensure adequate oxygen supply. Infants rarely shiver in response to a need to increase heat production.

(Behrman, ed. 113, p. 363)

26. Initial examination of a full tem infant weighing less than 2500 g (5 lb, 8 oz) shows edema over the dorsum of her hands and feet. Which of the following findings would support a diagnosis of Turner's syndrome?

A. A liver palpable to 2 cm below the costal marginB. Tremulous movements and ankle clonusC. Redundant skin folds at the nape of the neckD. A transient, longitudinal division of the body into a red half and a pale half

(Problem Solving) - NeonatologyC - Turner’s syndrome is a genetic disorder with the 45XO karyotype being most common. At birth

affected infants have low weights, short stature, edema over the dorsum of hands and feet and loose skin folds at the nape of the neck.

(Behrman, ed. 13, pp. 264-266. 1236-1237)

27. Object permanence is not present in a 2 months old, whose response to dropping a ball is: A. Staring descending as the ball descendsB. Eyes descending as the ball hits the groundC. Crying when the ball hits the groundD. Smiling at the game of the hide-and-seek

(Problem Solving) - Neonatology A - Out of sight out of mind is the characteristic response of a 2 month old. Object permanence appears

at approximately 8 months of age. This is also called object constancy. (Nelson Textbook of Pediatrics, 15th ed, Chap. 11))

28. The ability to manipulate small objects with the pincer grasp is usually noted at what age?A. 0 to 2 monthsB. 3 to 5 monthsC. 6 to 7 monthsD. 8 to 9 months

(Recall) - Neonatology D - The pincer grasp, which is noted at age 8 to 9 months, along with increasing mobility, enables an

infant to explore the environment. (Nelson Textbook of Pediatrics, 17th ed, 2004)

29. A developmentally normal child who is able to run, build a tower of two cubes, pretend play with a doll and speak in two-word sentences is what age?

A. 19 monthsB. 15 monthsC. 14 monthsD. 24 months

(Problem Solving) - NeonatologyA - (See Table 11-3, Chapter 11, Nelson Textbook of Pediatrics, 15th ed)

30. A developmentally normal child who is just able to sit without support, transferobjects from hand to hand, and speak in a monosyllabic babble is probably what age?

A. 2 monthsB. 4 monthsC. 9 monthsD. 6 months

(Problem Solving) - NeonatologyD - (Nelson Textbook of Pediatrics, 15th ed, See Table 11-3, Chap 11)

31. This primitive reflex is observed in a normal one year old:A. Tonic neck reflexB. Parachute reflexC. Palmar graspD. Placing reflex

(Recall) - NeurologyB - Among these 4 choices, it is B that persists normally beyond the neonatal period. In fact, the

parachute reflex persists for life. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 1978)

32. Which of the following case scenarios merit an EEG as an initial test as part of the neurodiagnostic evaluation?

A. Febrile seizureB. First non-febrile seizureC. MeningitisD. Intracranial SOL

(Problem Solving) - NeurologyB - While the first febrile seizure is generally a benign one, an EEG is requested if it recurs. The EEG

provides characterization of seizure types which allows for the specific medical or surgical management. A lumbar puncture with CSF analysis would have confirmed meningitis. A brain CT scan would have demonstrated the intracranial SOL.

(Nelson’s Textbook of Pediatrics, 17th ed. ; Behrman, Kliegman & Jenson, 2004, p. 1978)

33. A 2-year old boy was admitted because of low to moderate grade fever of 3 weeks, on and off frontal headache of 1 week, squinting of 1 day, one episode of generalized seizure of 2 minute duration 6

hours prior to admission. No medical consult done. No medications given except paracetamol. Which of the following clinical consideration is NOT COMPATIBLE with this history?

A. Acute meningococcal meningitisB. TB meningitisC. Cryptococcal meningitisD. Brain abscess of otogenic origin

(Problem Solving) - NeurologyA - Except for A, all the rest are compatible of the history, presenting with the clinical manifestations

of at least 2 weeks. (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 965 ; 2040-44)

34. A mother calls to inform you that her previously well 4-year old child has been complaining of headaches for about a month. For the past two weeks he has been keeping his hand in a tilted position, and for the past few days he has been vomiting in the morning. The most likely diagnosis is:

A. MeningitisB. Degeneration brain diseaseC. Brain abscessD. Brain tumor

(Problem Solving) - NeurologyD - Frequently, meningitis or CNS infections will present with fever, headache, and signs of irritability.

Brain abscess, because it behaves like an intracranial SOL, will present as low grade fever, headache, and localizing signs. The hallmark of neurodegenerative disease is

progressive deterioration of neurologic functions with loss of speech, vision, hearing, or locomotion, often associated with seizures, feeding difficulties, and impairment of intellect. Generally, brain tumors present with signs and symptoms relating to increased intracranial pressure (vomiting, lethargy, irritability) and focal neurologic deficits. Within the 1st year of life, supratentorial tumors predominate and include, most commonly, choroids plexus complex tumors and teratomas. From 1-10 years of age, infratentorial tumors predominate, owing to the high incidence of juvenile pilocytic astrocytoma and medulloblastoma. After 10 years of age, supratentorial tumors again predominate, with the diffuse astrocytomas, most common.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 1703, 2029, 2038, 2047)

35. Clinical evidence backs up the use of IV dexamethasone as an adjunctive therapy in acute meningitis caused by _____:

A. Neisseria meningitidisB. Streptococcus pneumoniaeC. Hemophilia influenzaD. Listeria monocytogenes

(Recall) - NeurologyC - Data support the use of IV dexamethasone, 0.15 mg/kg/dose given every 6 hours x 2 days with

bacterial meningitis caused by Hemophilus influenzae type b, but not with other bacterial causes, in terms of less fever, lower CSF protein and lactate levels, and a reduction in permanent auditory nerve damage, as manifested by sensoneural loss.


36. A 12-year old child is admitted because of the sudden onset of coma. The child had been well until about 6 hours prior to admission, when he began to complain of a headache. The headache became more severe, and the child lapsed into coma. Physical examination: T = 38.2'C, flaccid and comatose. CSF: bloody: after centrifugation, the fluid appears xanthochromic, RBC = 3,000, WBC 7/mm3 , protein 400 mg/dl, glucose is 62 mg/dl. The most likely etiology of the coma is:

A. Intraventricular hemorrhageB. Subarachnoid hemorrhageC. Viral encephalitisD. Subdural effusion

(Problem Solving) - NeurologyB - The event is something acute, dramatic, catastrophic so the choices would only be between A and B.

Intracranial bleeding may occur in the subarachnoid space or the bleeding may be primarily located in the parenchyma of the brain. Subarachnoid bleeding characterized by severe headache, nuchal rigidity, and progressive low of consciousness, and intracerebral bleeding is a common event in premature infant (intraventricular hemorrhage). Rupture of an arteriovenous malformation (AV mal) may occur at any age, and causes severe headache, vomiting, nuchal rigidity caused by subarachnoid bleeding, progressive hemiparesis and a focal or generalized seizure.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 2036, 562)

37. The metaphyseal ends of long bones are common sites of osteomyelitis. This condition occurs because:

A. Relative anoxia promotes bacterial growthB. There is blood pooling and reduced phagocytic activityC. They are closer to the skin surfaceD. They are common sites of trauma

(Problem Solving) – Musculoskeletal DisordersB -The unique anatomy and circulation of the ends of long bones results in the predilection for localization

of blood borne bacteria. In the metaphysic, nutrient arteries branch into non-anastomosing capillaries under the physics, which make a sharp loop before entering venous sinusoids

draining into the marrow. Blood flow in this area is sluggish and provides an ideal environment for bacterial seeding.

(Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 2297-2298)

38. It is the most common primary malignant bone tumor in children and adolescents, which shows a "sunburst" pattern on radiographs:

A. Ewing sarcomaB. OsteosarcomaC. OsteochondromaD. Osterblastoma

(Recall) – Musculoskeletal DisordersB - Osteosarcoma is the most common primary malignant bone tumor in children and adolescents,

followed by Ewing sarcoma. In children younger than 10 years of age, Ewing sarcoma is more common than osteosarcoma. Both tumor types occur most frequently in the 2nd decade of life.

(Ref. Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1717)

39. An adolescent male basketball enthusiast consults you with a painful bump below his right knee. He denies fever or trauma. Which of the following is the most likely diagnosis?

A. Legg-Calve Perthes DiseaseB. Osteoid osteomaC. Osgood-Schlatter diseaseD. Osteomyelitis

(Problem Solving) – Musculoskeletal DisordersC – Osgood-Schlatter disease occurs in active children, particularly during late childhood or

adolescence, especially in athletes, and consists of the tearing of cartilage from the tibial tuberosity by the ligamentum patellae. The child presents with pain and swelling

at the site of one or both tibial tubercles. Rest, restriction of activities, and occasionally, a knee immobilizer may be necessary combined with isometric exercise program. Complete resolution of symptoms through physiologic healing (physeal closure) of the tibia tubercle usually requires 12-24 months.

(Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 2272).

40. An overweight adolescent male complains of pain in the medial aspect of his knee. He denies trauma, and he has not had a fever. The most likely diagnosis is:

A. Toxic synovitisB. Legg-Calve-Perthes diseaseC. Medial collateral ligament strainD. Slipped capital femoral epiphysis

(Problem Solving) – Musculoskeletal DisordersD - Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder with an

unknown cause, in which there is a displacement of the femoral head from the femoral neck prior to epiphyseal closure. Common in obese adolescent boys, it presents with pain, limp, or refusal to walk. The pain may be referred to the knee or thigh. Legg-Calve-Perthes Disease, avascular necrosis of the femoral head presents with joint stiffness, hip and pain in the hip, thigh, knee, or groin of several weeks to months. Boys between 1-12 years (average 7 years) are most commonly affected. Toxic synovitis is a transient inflammatory arthritis of the hip associated with fever.


41. This statement is NOT true about infective endocarditis:A. In 90% of cases, the causative agent is recovered from the first 2 blood culturesB. Timing of phlebotomy is important because bacteremia occurs only during the febrile

stateC. Antimicrobial pretreatment of the patients reduces the yield of blood cultures to 50-

60%D. Laboratory should be notified that endocarditis is suspected so that the blood can be

cultures on enriched media for more than 7 days(Problem Solving) - CardiovascularB - Timing of collection is not important because bacteremia can be expected to be relatively constant. (A) It is true that in 90% of cases, the causative agent is recovered from the first 2 blood collection (C ) It is true that pretreatment with antimicrobials of the patients with bacterial endocarditis reduces

the yield of blood culture to 50-60% (D) It is true that the laboratory should be notified that endocarditis is suspected so that if

necessary the blood can be cultured on enriched media for longer than 7 days to detect nutritionally deficient and fastidious bacteria or fungi. And laboratory should be

notified that the patient has received antibiotics so that more sophisticated methods can be used to recover the offending organisms.


42. Painless small erythematous or hemorrhagic lesion on the palms and soles are classic lesion in:

A. Osler nodicB. Janeway lesionsC. Roth spotsD. Spincter Hemorrhages

(Recall) - CardiovascularB - Janeway lesion are painless small erythematous or hemorrhagic lesions on the palms and soles. (A) Osler nodes are tender pea-sized intradermal nodule in the pads of the fingers and toes. These

lesions may represent vasculitis produced by circulating antigen antibody complexes (C ) Sphincter hemorrhages are linear lesions beneath the nodes (D) Roth spots – immune complex phenomena and seen in the eyes


43. Neonatal circulation is NOT characterized by:A. In the presence of cardiopulmonary disease PDA may remain patentB. Foramen ovale may persistently be functionalC. The wall thickens and muscle mass of the neonatal (L) and (R ) ventricles are almost

equalD. The pulmonary vasculature is insensitive to changed pO4 and PC02 levels an acidosis

(Problem Solving) - Cardiovascular D - the pulmonary vasculature is very reactive to changes in pCO2, pO2 and pH by vigorous vascular

constriction (A) in the presence of cardiopulmonary disease resulting to hypoxemia may cause the PDA to remain

open. Normal PDA functionally closes by the 10-15th hour of life (B) Foramen ovale is functionally closed by the 3rd months of life (C ) the wall thickness and muscle mass of the ventricles right and left are almost equal. Without the

placenta, and the closure of the ductus venosus, the left ventricle is now coupled to the high resistance systemic circulation whereas the right ventricle is now coupled with the low resistance pulmonary circulation and the wall is slightly thickened as well


44. The clinical manifestation of large VSD in neonatal patients does not include:A. Systolic murmur may not be audibleB. DyspneaC. Profuse perspirationD. Recurrent pulmonary infection

(Problem Solving) - CardiovascularA - systolic murmur may not be audible this occurs only in small VSD this is due to the fact that the left to

right shunt may be minimal because of the higher right sided pressure (B) Dyspnea happens because of excessive blood flow and pulmonary hypertension (C ) profuse perspiration is a sign of heart failure secondary to high level of left ventricular output heart

rate and stroke volume are increased mediated by an increased level of sympathetic nervous system stimulation and activity thus increasing the circulation of catecholamines

combined with increased work of breathing resulting in the elevation of in total body oxygen consumption often beyond the oxygen transport ability of the circulation

(D recurrent respiratory infection secondary to the presence of “wet” lung syndrome that serves as a niduos infection coupled with the disruption of the mucociliary clearance these will be

responsible for the recurrence of URTI (Nelson’s Textbook of Pediatrics, 17th ed, 2004)

45. Which of the following cardiac anomaly is NOT present in Tetralogy of Fallot?A. Pulmonary stenosisB. ASDC. Overriding of the aortaD. Right ventricular hypertrophy

(Recall) - CardiovascularB - Atrial septal defect is NOT seen in patients with TOF. It is ventricular septal defect (VSD) is the defect

that is part of the defect and the VSD is frequently non restrictive and large frequently located just below the aortic valve.

(A) Pulmonary stenosis leads to the obstruction of the Right ventricular outflow. The pulmonary valve annulus may be of nearly normal size or may be quite small in size. The valve itself is

bicuspid and occasionally is the only site of the stenosis. In cases where the right ventricular outflow tract is completely obstructed, pulmonary blood flow may be supplied by a patent ductus arteriosus (PDA) and by major aortopulmonary collateral arteries arising from the aorta

(C ) Over riding of the aorta is part of the congenital defect (D) Right ventricular hypertrophy is due to the degree of right ventricular outflow obstruction (Nelson’s Textbook of Pediatrics, 17th ed, 2004)

46. A 3-year old boy was admitted to the ER because of difficulty of breathing. History revealed that he developed high grade fever and sore throat 24 hours prior to consult with associated difficulty of swallowing. Physical examination showed a very toxic looking boy, highly febrile, with labored breathing and hyper extended neck and drooling of the saliva. The most plausible diagnosis of the above case is:

A. Acute infectious laryngitisB. Acute epiglottitisC. Acute laryngotracheobronchitisD. Acute bacterial tracheitis

(Problem Solving) - RespiratoryB - Acute epiglotittis

This is a potentially lethal condition characteristically presenting with acute fulminating course of high grade fever, sore throat, dyspnea and rapidly progressing respiratory

obstruction. Drooling of the saliva is frequently present and is due to difficulty of swallowing. Hyperextension of the neck is due to his attempt to maintain the patency of the airway. This fatal disease is frequently caused by H. influenzae.

(A) Acute infectious laryngitis is frequently caused by viral agents and the disease is usually mild and non fatal. The onset of the disease is usually characterized by an upper respiratory tract

infection during which sore throat, cough and hoarseness appear. Respiratory distress is unusual except in the very young infants where the airways are very compliant and small in caliber.

(C) Acute laryngotracheobronchitis “croup” is again frequently caused by viruses. Most of the patients will present with upper respiratory tract infection with a combination of rhinorrhea, pharyngitis,

mild cough and low grade fever for 1-3 days before the appearance of the signs and symptoms of upper airway obstruction. It starts with “barking” cough ,hoarseness and inspiratory stridor which characteristically becoming worse at night and often recurring with decreasing intensity for several days and completely resolves with in a week.

(D) Acute bacterial trachietis this entity is a form of bacterial infection of the upper airway and does not involve the epiglottis. It is capable of causing life threatening airway obstruction. It is

frequently caused by staphylococcus aureus and other organisms like Moraxella catarrhalis, nontypable H. Influenzae and anaerobic organisms have been implicated. It frequently occurs in children younger than 3 years of age.

A patient seen at the pediatric OPD clinic because of prolonged harsh “barky” cough that lingered behind after a bout of viral infection not responsive to treatment i.e. bronchodilators and

mucolytics and disappears when the patient is asleep. (Nelson’s Textbook of Pediatrics, 17th ed, 2004)

47. The mechanism of hypoxia in pulmonary edema is:A. V/Q mismatchB. HypoventilationC. Diffusion impairmentD. R-L shunt

(Problem Solving) - RespiratoryC - diffusion impairment

In pulmonary edema there is fluid that acts as a barrier between the alveolo-capillary membrane which increases the travel time of the O2 from the alveoli to the capillary thus

hindering the diffusion of the gas through the membrane and subsequently lowers theO2 levels in the circulation.

V/Q mismatch as a cause of hypoxemia occurs in two stages: V ventilation when there will be less O2 delivered to the alveoli due to airflow obstruction as it happens in

pneumonia Q (perfusion) hypoxemia occurs despite adequate oxygenation if the circulation is blocked as in pulmonary embolism

Hypoventilation – could cause low O level due to decreased amount of O2 delivered in to the alveoli due to central causes – (CNS depression or infection) or due to low levels

of O2 in the atmosphere due to high altitudeR-L shunt this happens particularly in patient with cardiac shunts where a high percentage of the

cardiac output returns to the general circulation without passing through the lungs. Or this can occur in cases of intrapulmonary shunts as well


48. The common infectious cause/s of bronchiectasis is/are:A. PertussisB. Klebsiella pneumoniaeC. Streptotoccus pneumoniaeD. H. influenzae

(Recall) - RespiratoryA - Pertussis

Infections due to Bordatella pertussis, measles, rubella, togavirus, respiratory syncytial virus and Mycobacterium tuberculosis induce chronic inflammation, progressive bronchial wall

damage and dilatation of the bronchial tree. The common thread in the pathogenesis of bronchiectasis is difficulty clearing secretions and recurrent infections.


49. The pathologic findings of bronchopulmonary dysplasia (BPD) consist of the following:A. Decreased alveolarizationB. Decreased alveolar septationC. Minimal airway diseaseD. All of the above

(Recall ) - RespiratoryD - all of the above

BPD is a result of lung injury in infants requiring mechanical ventilation and supplemental oxygenation. It is apparent that patients with BPD have decreased alveolarization,

alveolar septation and minimal airway disease all of which suggest arrest in lung development. The lung injury occurring in children is due to an interaction of multiple factors. Since RDS is a disease of progressive alveolar collapse, Atelectasis which is affected by insufficient PEEP together with ventilator-induced increased lung volume and regional overdistention promotes injury. Oxygen promotes injury by producing free radical that cannot be metabolized by immature antioxidant systems. Therefore, mechanical ventilation and /or oxygen injure the preterm lung by affecting alveolar and vascular development. Moreover, inflammation as measured by circulating neutrophils and macrophage in the alveolar fluid and pro-inflammatory cytokines contribute to the progression of the lung injury.


50. A patient is considered to have intermittent asthma when the following is/are present:A. PEFR variability = <20%B. PEFR 60-79% of predictedC. FEVI <60%D. PEFR variability = 20-30%

(Problem Solving) - RespiratoryA - PEFR variability =<20%

Peak expiratory flow rate variability is a measure of the stability of the airways and it is considered as a diagnostic tool to predict the success of one’s treatment PEFR variability

=<20% is still within normal limits. Intermittent asthma has normal PEFR and PEFR variability values. Symptoms of these patients are very infrequent

(B) Once PEFR is 60-79% of the predicted, it only means that airway obstruction is present [(N) PEFR = ≥ 80% of the predicted] and signals that the patient belongs to the

moderate persistent category (C ) FEV1 (forced expiratory volume in one second) is a measure of airflow obstruction. And the

value of <60% indicates that the patient belongs to the category of severe persistent asthma.

(D) PEFR variability =20-30% means that airways are still unstable and asthma is not well controlled and the patient belongs to the mild persistent asthma category


51. An 8-year old presents with sneezing, clear rhinorrhea, and nasal itching. P.E. findings show boggy, pale nasal edema with a clear discharge. The most likely diagnosis is:

A. Foreign bodyB. Vasomotor rhinitisC. Neutrophilic rhinitisD. Allergic rhinitis

(Problem Solving) – Immunology/AllergologyD - Allergic rhinitis is often seasonal and associated with allergic conjunctivitis. Eosinophils

predominate in the nasal secretions. (Nelson’s Textbook of Pediatrics, 17thed, 2004, pp. 759-760)

52. The mother of 7-year old girl with acute strep throat calls to report that within 15 minutes after the first dose of oral penicillin you prescribed, she is complaining of itching and has developed hives. Which of the following should you recommend?

A. Give her oral antihistamines and call again if not improved within 30 minutesB. Bring her to your office or the nearest emergency roomC. Substitute erythromycin for penicillinD. Bring her to the nearest emergency room once difficulty of breathing is experienced

(Problem Solving) – Immunology/AllergologyB - The urticarial reaction described in the question may develop into anaphylaxis which requires

emergency treatment. Aside from this, penicillin should be stopped and a substitute non-penicillin appropriate antibiotic chosen.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004,Chap 137, pp. 781-782)

53. A child has abdominal pain, arthritis, microscopic hematuria, and a purpuric rash only on the lower extremities. Which of the following is the most likely diagnosis?

A. MeningococcemiaB. Varicella

C. Henoch-Schonlein vasculitisD. Post streptococcal glomerulonephritis

(Problem Solving) – Immunology/AllergologyC -The purpura on the lower extremities suggests Henoch-Schonlein Vasculitis. Meningococcemia is

generalized. Varicella gives papulo-vesicular lesions which are likewise generalized. Erythema nodosum is the cutaneous lesion usually found on the lower extremities in post-strep infection.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004,pp. 794, 826-828)

54. A 2-day old neonate with vomiting of bilous material since birth was brought to your hospital. X-rays taken showed “double-bubble”.

A. Metabolic problems must be addressed initiallyB. Schedule for emergency laparotomyC. Do upper GI seriesD. Intubate once seen

(Problem Solving) - NeonatologyA - (Nelson’s Textbook of Pediatrics,, 17th ed, 2004, pp. 1233-1234)

55. A 24-hour old neonate is brought to the ER because of inability to pass meconium in 24 hours. He does not have vomiting or distention. Your recommendation would be to:

A. Do suction rectal biopsyB. Request for barium enemaC. Request for abdominal x-rayD. Observe the patient

(Problem Solving) - NeonatologyD - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 1232-1241)

56. A 7-day old 900 gram pre-term has been noted to have abdominal distention with gastric retention. OGT drainage is 10 cc in 24 hours and stool occult blood is positive. Abdominal x-ray showed pneumatosis intestinalis. This patient should:

A. Undergo immediate surgeryB. Have intensive medical therapyC. Peritoneal drainageD. Have a blood culture.

(Problem Solving) - NeonatologyB - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 590-591)

57. A live 30 weeks of gestation baby boy was born via cesarean section to a diabetic mother. Grunting and tachypnea was noted on the 6th hour of life. After receiving therapeutic measures, the patient improved. However on the 4th day of life, lethargy, apnea and poor muscle tone was noted. Transfontanel cranial ultrasonography was done and showed increased echogenecity at the thalamocapsular region with ventricular dilatation. What is the grade of this patient’s germinal matrix hemorrhage?

A. Grade 1B. Grade 2C. Grade 3D. Grade 4

(Problem Solving) - NeonatologyD - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 563)

58. Which of the following chest radiographic findings can be found in mild ventricular septal defect?A. Small heartB. Increased pulmonary vascularityC. Increased size of the aortaD. Left atrial enlargement

(Problem Solving) - NeonatologyB - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 1509)

59. Meconium aspiration in utero is explained by:A. Obstruction of fetal airwaysB. Chemical property of meconiumC. Intrauterine infectionD. Chronic fetal asphyxia

(Problem Solving) - NeonatologyD - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 547, 583-584)

60. A key predictor for death or brain damage after an asphyxial episode:A. HIE Sarnat Stage 2B. Failure to establish spontaneous respiration by 15 minutesC. Onset of seizure within the first 24 hours of lifeD. Establishment of adequate oral feedings by 48 days of life

(Recall) - Neonatology

B - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 567)

61. In a newborn suspected of having choanal atresia, respiratory distress may be relieved by:A. Opening the mouthB. IntubationC. Bag and mask ventilationD. Administering O2

(Problem Solving) - NeonatologyA - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 1387)

62. The most common clinical manifestation of Persistent Pulmonary Hypertension is:A. Respiratory distressB. PallorC. CyanosisD. Apnea

(Recall) - NeonatologyC - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 585)

63. Which of the following statements regarding the diagnosis of intrauterine infection is/are accurate?A. IgM in neonatal serum may be used as a screening toolB. Total IgM has a low rate of both false positive and false negative resultsC. IgM titers may have low specificity and low sensitivityD. IgG rising titers in infancy are not helpful

(Problem Solving) - NeonatologyA - (Nelson Textbook of Pediatrics, 17th ed, 2004)

64. Thyrotoxicosis in the first day of life is most likely to occur in an infant born to a motherA. With untreated hypothyroidismB. With untreated Grave’s diseaseC. With Grave’s disease being treated with antithyroid medicationsD. Receiving iodides as therapy for chronic Thyrotoxicosis

(Problem Solving) - NeonatologyB - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, pp. 1886)

65. A 6-year old male was brought to the OPD because of jaundice of 5 days associated with anorexia of one week. A hepatitis profile done on him revealed the following:

Anti-HAV (IgM) - ReactiveHBsAg - Non-reactiveAnti-HBc - Non-reactiveAnti-HBe - Non-reactiveAnti-HBs - Non-reactiveThe patient Had a recent:A. HAV and HBV infectionB. HAV infection with a post infection of HBVC. HAV infection with HBV immunityD. HAV infection and post infection of HAV

(Problem Solving) – Infectious DiseasesC – (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1324-1329)

66. A 9-month old female was brought to the OPD because of watery diarrhea, yellowish, non-bloody, non-mucoid stools, with no pus nor RBC’s. Her anterior fontanel is slightly sunken. The most likely organism to cause this type of diarrhea is:

A. ETECB. Vibrio choleraC. RotavirusD. Norwalk virus

(Problem Solving) – Infectious DiseasesC – (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1324-1329)

67. Which of the following is TRUE of candidal infection?A. Diaper dermatitis is the most common infection caused by candidaB. With improved survival of very LBW infants, candidemia has become less frequent n

NICU’sC. Fluconazole is the drug of choice for the treatment of systemic candiciasisD. Most cases of candidemia is Immunocompromised patients are due to non-candida

albicans spp.(Problem Solving) – Infectious Diseases A - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1012-1013)

68. Which of the following statements is NOT TRUE of Amebiasis?A. The infective stage is the Entamoeba histolytica cystB. The pathogenic stage is the Entamoeba histolytica trophozoite formC. A carrier of E. histolytica cysts should be treated

D. It is the most common cause of bloody stools(Recall) – Infectious DiseasesD - (Ref. Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1123-1125)

69. Which of the following diseases has the greatest capacity to be a “pandemic?”A. HIVB. InfluenzaC. MeaslesD. Hepatitis B

(Recall) – Infectious DiseasesB - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1072-1074)

70. A newborn was found to have the following anomalies: hydrocephalus, cicatricial scarring over the 6th-7th left intercostals, malformed feet (fusion and maldevelopment of both feet). Which congenital infection shows these findings at birth?

A. HIVB. CMVC. Parovovirus B19D. Varicella-Zoster virus

(Recall) – Infectious DiseasesD - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, p. 1059)

71. Which of the following features is TRUE of all infants born to HIV-infected women?A. They will have low CD4 cell countsB. They will eventually develop AIDSC. They will have antibodies to HIVD. They will be infected with HIV

(Problem Solving) – Infectious DiseasesC - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, p. 1161)

72. One of the following is LEAST associated with ascaris infection in humans:A. Intestinal obstructionB. Loeffler’s syndromeC. Iron deficiency anemiaD. Pancreatitis

(Recall) – Infectious DiseasesC - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1156)

73. Which of the following does NOT RESULT from a vesicoureteral reflux?A. Hypertension B. Chronic failureC. ProteinuriaD. Dilatation of the ureters

(Problem Solving) – Nephro/GUC - Vesicoureteral reflux results from valvular incompetence at the uretero vesicular junction as a

result of a shortened segment of ureter within the bladder wall. It is often associated with other genitourinary anomalies. Vesicoureteral reflux can result in chronic renal failure, dilatation of the ureters, hypertension and urinary tract infections. Proteinuria results from glomerular injury.

(Nelson’s Textbook of Pediatrics, 17th ed, 2004,pp. 1790-1794)

74. The triad of microangiopathic hemolytic anemia, renal failure, and thrombocytopenia is characteristic of which one of the following?

A. Membranous lupus nephritisB. Focal glomerulonephritis secondary to sepsisC. Acute post-streptococcal glomerulonephritisD. Hemolytic-uremic syndrome

(Recall) – Nephro/GUD -The name gives the answer away. (Nelson’s Textbook of Pediatrics, 17th ed, 2004,pp. 1746-1747)

75. A 2-year old male developed an upper respiratory tract infection that was followed in 2 weeks by general edema. His blood pressure is normal. Urinalysis reveals 2-5/hpf and +4 protein. His BUN is 19 mg/dl, creatinine 0.6 mg/dl, cholesterol 402 mg/dl, serum albumin 0.9 g/dl, ASO=200, and C3=92 mg/dl. The most likely diagnosis would be:

A. Poststreptococcal glomerulonephritisB. Membranous glomerulonephritisC. Minimal lesion nephrotic syndromeD. Focal sclerosis

(Problem Solving) – Nephro/GU

C - Hypoalbuminemia, proteinuria, edema and hyperlipidemia constitute the nephrotic syndrome. Hypertension, azotemia, edema or hematuria would suggest nephritis but may also be

encountered in minimal lesion nephrotic syndrome. This patient has nephrotic syndrome, not nephritis.

(Nelson’s Textbook of Pediatrics, 17thed, 2004,pp. 1740-1746 ; 1753-1757)

76. The recommended age to perform corrective surgery in a child with a unilateral undescended testes is:

A. The first 6 months of lifeB. Between 21 and 18 months of ageC. Between 5 and 7 years of ageD. Before puberty

(Recall) – Nephro/GUB - Corrective surgery performed between 12 and 18 months of age represents a safe balance between

anesthetic risk, allowance of time for the testes to descend, and the risks of leaving a testis in the abdomen.

(Nelson’s Textbook of Pediatrics, 17thed, 2004,pp. 1817-1820)

77. Maternal varicella results in severe neonatal varicella when maternal infection takes place during:A. The 1st trimesterB. The 2nd trimesterC. The 3rd trimesterD. The week before and after delivery

(Problem Solving) – Infectious DiseasesD - Birth within 1 week before or after the onset of maternal varicella frequently results in the newborn

developing varicella, which may be severe. The risk to the newborn is dependent on the amount of maternal anti-VZV antibody that the fetus acquired transplacentally before birth. If the internal between maternal chickenpox and parturition is less than 1 week, the newborn will be unlikely to have protective VZV antibody and neonatal chickenpox may be exceptionally severe.

(Nelson’s Textbook of Pediatrics, 17th ed., 2004, p. 1058)

78. A 2-year old has a positive tuberculin test (15 mm induration). Which of the following would be suggestive of “military tuberculosis?”

A. FeverB. HepatosplenomegalyC. Hilar adenopathy on chest x-rayD. Cough

(Problem Solving) – Infectious DiseasesB - “Miliary tuberculosis” suggests lymphohematogenous spread or disseminated form of TB, occurring is

distant sites, including liver, spleen, skin and other organs aside from the lungs. Fever and cough are non-specific manifestations of TB which may be found in other diseases, while hilar adenopathy on chest x-ray, may be found in primary pulmonary TB.

(Nelson’s Textbook of Pediatrics, pp. 962-964)

79. A 3-year old nonimmunized child is seen at the OPD and diagnosed as having measles. There is an 8-month old nonimmunized sibling at home. Appropriate management of this sibling would include:

A. A modifying dose of gammaglobulinB. A preventive dose of gammaglobulinC. Immediate immunization with live attenuated measles vaccineD. Immediate immunization with killed measles vaccine

(Problem Solving) – Infectious DiseasesA - Passive immunization with immune globulin is effective for prevention and attenuation of measles

within 6 days of exposure. Susceptible household and hospital contacts who are <12 months of age or who are pregnant should receive immune globulin (modifying dose, 0.25 ml/kg; maximum 15 ml) IM as soon as possible after exposure, but within 5 days. Immunocompromised persons should receive immune globulin (preventive dose, 0.5 ml/kg ; maximum 15 ml) IM regardless of immunization status.

80. An 8-year old male consulted the OPD because of high grade fever and sore throat. The pertinent P.E. findings were: hyperemic oropharynx, enlarged tonsils with exudates, petecchiae on the soft palate and painful, enlarged cervical lymphadenopathies. This patient is most likely suffering from:

A. Streptococcus pyogenesB. Epstein Barr VirusC. AdenovirusD. Corynebacterium diphtheria

(Recall) – Infectious DiseasesC - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 870-879)

81. An 8-month old boy presents with failure to thrive, thrush, lymphadenopathy, and pneumocystis carinii pneumonia. He most likely has:

A. Severe malnutrition

B. Acute leukemiaC. HIV infectionD. X-linked hypogammaglobulinemia

(Recall) - Infectious DiseasesC - These constellation of manifestation are associated with HIV infection. The clinical manifestations

of HIV infection vary widely among infants, children, and adolescents. In most infants, PE findings at birth are normal. Initial symptoms are subtle, such as lymphadenopathy and

hepatosplenomegaly, or non-specific such as failure to thrive, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush, and may be distinguishable only by their persistence. Whereas systemic and pulmonary findings are common in the United States and Europe, chronic diarrhea, wasting, and severe malnutrition predominate in Africa. Symptoms found more commonly in children than adults with HIV infection include recurrent bacterial infections, chronic parotid swelling, lymphocytic interstitial pneumonitis (LIP), and early onset of progressive neurologic deterioration. The HIV classification system is used to categorize the stage of pediatric disease by using 2 parameters: clinical status, and degree of immunologic impairment (absolute CD4 lymphocyte count or the percentage of CD4 cells).

Category A (Mild Symptoms):Children with at least 2 mild symptoms such as:- lymphadenopathy- parotitis- hepatomegaly- splenomegaly- dermatitis- recurrent or persistent sinusitis or otitis media

Category B (Moderate Symptoms):- lymphocytic interstitial pneumonitis (LIP)- oropharyngeal thrush persisting for <2 months- recurrent or chronic diarrhea- persistent fever >1 month- hepatitis- recurrent herpes simplex stomatitis or HSV esophagitis or pneumonitis- disseminated varicella (i.e., with visceral involvement)- cardiomegaly- nephropathy

Category C (Severe Symptoms):Children with 2 serious infections (i.e., sepsis, meningitis, pneumonia) in a 2 year period- esophageal or lower respiratory tract candidiasis- cryptococcosis- cryptosporidiosis (>1 mo)- encephalopathy- malignancies- disseminated myocobacterial infection- pneumocystis carinii pneumonia (PCP)- cerebral toxoplasmosis (onset after 1 month of age)- severe weight loss

The Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in the pediatric population. The peak incidence of PCP occurs at age 3-6 months with

the highest mortality rate in children <1 year of age. (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1112-1113)

82. In our country, the first dose of live attenuated measles vaccine should be administered:A. at 4 months of ageB. at 6-9 months of ageC. at 12-15 months of ageD at 18-24 months of age

(Recall) - Infectious DiseasesB - The attack rate of measles among the susceptibles in <1 year is 80% (DOH Philippines 2000),

such that even if vaccine efficacy at 6 months is just 50% and at 9 months it is 85%, we give it as early as 6 months, during which time transplacentally acquired maternal antibodies for measles would already be at its nadir.

(DOH Philippines 2000)

83. Neonatal bacterial sepsis is most commonly caused by which one of the following organisms (in the Philippines):

A. Group B streptococciB. Pseudomonas aerugenosaC. Streptococcus pneumoniaeD. E. coli

(Recall) - Infectious Diseases

D - In our country, gram (-) organisms are the most common causes of neonatal bacterial sepsis (2:1) compared with the gram positive organisms. The gram negative enteric bacilli like E. coli

are the more common causative agents. Pseudomonas aerugenosa, a gram negative bacilli, is a common nosocomial pathogen.

(Textbook of Pediatrics and Child Health, Del Mundo, Fe et. al (eds.) 4th ed, 2000, p. 265)

84. The first clinical manifestation of tetanus neonatorum usually is:A. FeverB. VomitingC. SpasmsD. Difficulty sucking and swallowing

(Recall) - Infectious DiseasesD - Neonatal tetanus is generalized in type and starts as progressive difficulty in sucking and

irritability. (Textbook of Pediatrics and Child Health, Del Mundo, Fe, et al (eds.), 4th ed, 2000, p. 469)

85. The usual course of pertussis in an infant is characterized by:A. 4 – 5 days of high grade fever followed by cough and whoopingB. sudden onset of fever, cough, and whoopingC. rhinitis and possibly low grade fever, followed by gradual worsening of cough and

finally whooping D. gradual onset of cough, followed by abrupt onset of fever and whooping(Recall) - Infectious DiseasesC - Pertussis is a 6-week disease, divided into catarrhal (congestion, rhinorrhea, then low grade fever,

lacrimation, conjunctival suffusion), paroxysmal, and convalescent stages. (Nelson’s Textbook of Pediatrics, 17th ed., 2004, p. 909)

86. The findings of sudden onset of fever, petecchial rash, and BP = 70/50 in a 5 year old child is most suggestive of infection with:

A. Neisseria meningitidisB. Hemophilus influenzaeC. Staphylococcus aureusD. Streptococcus pneumoniae

(Problem Solving) - Infectious DiseasessA - These findings are compatible with meningococcemia caused by Neisseria meningitides which can

progress rapidly over hours to septic shock. The other etiologic agents, while they may cause a similar picture these are usually in relation to DIC which would manifest over a longer period of time, not in a matter of hours.


87. Of the following parasitic infections, which is most likely to present with intestinal obstruction?A. Trichuris trichuraB. Necator americanusC. Ascaris lumbricoidesD. Enterobius vermicularis

(Recall) - Infectious DiseasesC - A large mass of Ascaris lumbricoides leads to intestinal obstruction. Rectal prolapse is associated

with Trichuris trichura. Heavily infected children with Necator americanus suffer from intestinal blood loss resulting in iron deficiency, which can lead to anemia as well as protein malnutrition. Pruritus ani is associated with enterobiasis.


88. A 10-month old child has a temperature of 39-40’C for 4 days without other signs. On the 4th day, a maculopapular rash appears, and the temperature returns to normal. The most likely diagnosis is:

A. scrub typhusB. roseolaC. rubeolaD. echoviral infection

(Recall ) - Infectious DiseasesB - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 1069-1072)

89. Which of the following is the chemoprophylactic antimicrobial given to intimate contacts of a 7-year old with meningococcal meningitis?

A. RifampinB. aqueous Pen GC. IsoniazidD. Erythromycin

(Problem Solving) - Infectious DiseasesA - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 898-899)

90. The clinical manifestations in DHF are secondary to the pathogenetic mechanism of:A. direct invasion of the virus to the different organ system

B. hypersensitivity reactionC. immune enhancementD. adherence of the viruses to the endothelial cells

(Recall) - Infectious DiseasesC - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, p. 561)

91. In a case of DHF (Grade 3) who is bleeding profusely, which of the following fluids (all available) would you give?

A. properly typed & X-matched fresh whole bloodB. properly typed & X-matched fresh plasmaC. D5LRSD. D5NSS

(Problem Solving) - Infectious DiseasesA - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, p. 569 - 571)

92. The following CSF analysis results are compatible with which of the following clinical entities?CSF Results: Opening pressure = 300 mm H2O

WBC = 296 (segs: 10% ; lymphos : 90%)Protein = 2 g/LCSF sugar / RBS = 20%

A. Acute meningococcal meningitisB. TB meningitisC. Japanese B encephalitisD. Febrile seizures

(Problem Solving) – Infectious DiseasesB - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 965, 2040-2044)

93. On the 3rd day of treatment for Hemophilus influenzae meningitis, an eight month old child who had been alert is noted to be lethargic. Serum electrolytes reveal the following:

Na = 120 mEq/LCl = 83 mEq/LK = 3.1 mEq/LBUN = 2 mg/dl

The most likely cause of the lethargy and hyponatremia in this patient:A. Acute renal failureB. Congestive heart failureC. Syndrome of inappropriate ADH secretionD. Subdural effusions

(Problem Solving) – Infectious DiseasesC - (Nelson’s Textbook of Pediatrics, 17th Ed, 2004, p. 200)

94. A 28 year old primigravida mother, who had a past history of adequately treated PTB, gave birth to a healthy 3 kg baby. Which of the following preventive measures against TB would you take?

A. Separate the baby from the mother for another monthB. Separate the baby from the mother and give INH for 3 monthsC. Give BCG onlyD. Give BCG now but separate the baby from the mother for a month

(Problem Solving) – Infectious DiseasesC - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 2000 pp. 516-525)

95. A 2-year old boy was admitted because of low to moderate grade fever of 3 weeks, on and off frontal headache of 1 week, squinting of 1 day, one episode of generalized seizure of 2 minute duration 6 hours prior to admission. No medical consult done. No medications given except paracetamol. Which of the following clinical consideration is NOT COMPATIBLE with this history?

A. Acute meningococcal meningitisB. TB meningitisC. Cryptococcal meningitisD. Brain abscess of otogenic origin

(Problem Solving) – Infectious DiseasesA - (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 965, 2040-2044)

For Nos. 96 to 100:Mario is 2 ½ years old, brought to the Well Child Clinic for his regular visit. On physical exam, he had the following anthropometric measurements: Weight - 15 kgs, Height – 90 cms, Head Circumference – 48 cms. On developmental screening, he was able to do the following: could

stand momentarily on one foot, draw a circle and imitate a cross, talk in simple sentences and tell a story. Mother claimed that he is dry by night.

96. Describe the nutritional status of Mario:A. not stunted, not wastedB. mildly stunted, not wasted

C. not stunted, mildly wastedD. Mildly stunted, mildly wasted

(Problem Solving) - NeurodevA - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, pp. 78-80)

97. The head circumference of Mario is:A. normalB. below normalC. above normalD. variation of normal

(Problem Solving) – NeurodevA - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, p. 80)

98. Based on developmental screening, his development is:A. normalB. delayedC. advancedD. deviant

(Problem Solving) - Neurodev C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, pp. 83-112)

99. The approximate developmental age of Mario is:A. 2 years oldB. 2 ½ years oldC. 3 years oldD. 3 ½ years old

(Problem Solving) – NeurodevC - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, pp. 83-112)

100. At 2 years of age, Mario had a height of 85 cms. How tall would he be when he becomes an adult?A. 4 feet 6 inchesB. 5 feetC. 5 feet 6 inchesD. 6 feet

(Recall) - NeurodevC - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4th ed, 2000, pp 78-80)

University of the EastRAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

Aurora Boulevard, Quezon City

DEPARTMENT OF PEDIATRICS

QUESTIONS AND ANSWERS FOR MEDICAL BOARD REVIEWFEBRUARY 2005

Topics No. of Questions

Problem Solving

Recall

GIT 15 11 4Hema/Onco 7 5 2Neonatology 19 16 3Neurology 6 5 1Musculoskeletal 4 3 1Cardiovascular 5 3 2Respiratory 5 3 2Immuno/Allergo 3 3 0Infectious 27 13 14Nephro 4 2 2Neurodev 5 4 1TOTAL 100 68 32

Pediatrics

Documents

Transcript of Pediatrics