1 Pediatrics

REFERENCE: NELSON, TEXTBOOK OF PEDIATRICS, 17 TH EDITION Case I. Nos. 1-2 A 3 year old normal child was admitted to a hospital because of simple febrile convulsions 1.

Routine management of the case includes:

A. 2.

careful search for cause of fever* (0.5) B. short term anti-convulsant prophylaxis (0.5) C. Phenobarbital maintenance to prevent recurrence D. Lumbar puncture The anti-convulsant that may be effective in the acute management of prolonged febrile seizures is: A. rectal Diazepam* B. rectal Phenobarbital C. Intravenous Phenobarbital D. Intravenous Phenytoin

Case II. Nos. 3-4 A two-week old baby was noted to have a rapidly increasing head circumference. At birth, head circumference was 40 cms, against a chest circumference of 34 cms. Present physical examination showed a head circumference of 45 cms, wide, bulging anterior fontanel, gaping sutures, dilated scalp veins and a (+) setting sun sign. 3. If the occiput is prominent, the primary consideration is: A. Aqueductal stenosis B. Chiari malformation

C.

p 1489

p1490

Case III. Nos. 5 – 9 A 9 year old child was brought to the OPD clinic because of deterioration in school preformance, frank dementia, myoclonic jerks and cerebellar ataxia. He had no immunization and contracted measles at 10 months of age, varicella at 2 years and mumps at 5 years 5. The most likely diagnosis is: A. progressive rubella panencephalitits B. subacute sclerosing panencephalitis C. post-varicella encephalitis D. adrenoleukodystrophy 6. The seizures are best controlled by: A. Carbamazepine B. Valproate C. Phenytoin D. Lamotrigine

The most important hormone regulating renal calcium excretion is: A. Dihydroxy vitamin D B. Calcitonin C. Parathyroid hormone D. Thyrotoxin

A. B. C. D.

Pulmonary Valve Atresia Tetralogy of Fallot Truncus Arteriosus, type I Transposition of Great Arteries with VSD

A 3 month old boy was noted to be cyanotic on crying when he was 2 months old. This became persistent and more pronounced on exertion. On physical examination, the baby was cyanotic with a grade 2 – 3/6 systolic ejection murmur at the 3rd – 4th ICSLPSB. This baby is suffering from A. B. C. D.

Pulmonary Valve Atresia Tetralogy of Fallot Transposition of Great Arteries, no VSD Tricuspid Valve Atresia

A 4month old baby girl was brought for consultation because of frequent cough and colds accompanied by inability to consume her milk formula, fast breathing during feeding and chest retractions. A murmur was heard accompanied by bounding peripheral pulses and wide pulse pressure. The most likely diagnosis is p 1511 A. Atrial Septal Defect B. Ventricular Septal Defect C. Patent Ductus Arteriosus D. Pulmonic Stenosis

A. B. C. D.

p 844

p 200

A 2 year old female was noted to be oliguric for 24 hours. She was brought to the ER with Creatinine levels of 350 mmol/l. Serum potassium level was 6.5 mmol/l. What possible maneuver can induce a negative potassium balance and decrease serum potassium levels? sodium bicarbonate infusion insulin/glucose infusion calcium gluconate kayexalate

10. A 1 year old baby boy was brought to the ER due to seizure. On PE, the baby was seem to have flexed wrist, fingers extended, thumbs adducted over the palms and the feet extended and adducted. What is the possible cause of the seizures? P 224 A. grand mal seizure B. meningitis C. benign febrile seizures D. hypocalcemia 11.A 3 year old boy has been having diarrhea for 5 days already with stooling of 3 – 5 x per day, voluminous, watery in character. On PE, he was noted to be in moderate dehydration, with serum sodium lever of 160 mmol/l. Patient was hydrated with D5water, however, after 2 hours of hydration. The patient went into a seizure. What is the possible cause of the seizure?

C. D.

A term neonate with an uncomplicated birth history was noted to be cyanotic during the first few days of life. On examination, there was central cyanosis and absence of heart murmur. Chest x-ray showed normal heart size and diminished pulmonary vascular markings. Most likely diagnosis is

A 2 year old boy presented with a history of 5 days fever accompanied by irritability, bilateral conjunctival injection, unilateral cervical lymphadenopathy, rashes in the diaper area and congested buccal mucosa. In order to prevent complication, this boy should be given high dose aspirin and

Administration of this drug may prolong the child’s survival: A. Methisoprinol B. Inosiplex C. Taurine D. Intravenous immunoglobulin

A. B.

14. The best single antibody titer to document cutaneous streptococcal infection in PSGN is: A. Deoxyribonuclease B antigen (DNase) B. ASO titer C. Streptozyme test D. Phadebact test

Dandy-Walker malformation*

D. Hydranencephaly 4. This drug will reduce the rate of CSF production: A. Dexamethasone B. Acetazolamide* C. Prednisone D. Mannitol

A. B. C. D.

13. A 6 year old male was seen in the ER due to Tea colored urine of 2 days duration. This was associated with periorbital edema, abdominal distention and grade 2 pitting edema of the lower extremities. Impression : Acute Glomerulonephritis/PSGN Post streptococcal glomerulonephritis is most common in children aged: P 1740 A. 5 - 10years old B. 2 - 4 years old C. 13-18 years old D. 1-2 years old

Patient developed subdural effusion due to the hyperosmolality There is an excess movement of water into cerebral cells during rehydration causing cerebral edema The patient had late manifestation of hypernatremia Patient had meningitis

12. A 2 year old male was seen in the ER due to fever of 5 days duration. This was associated with vomiting and anorexia. There were no cough, colds associated. CBC revealed leukocytosis with predominance of Segmenters. Urinalysis revealed TNTC pus cells and 5-10/hpf RBC. Impression : UTI. The gold standard for the diagnosis of UTI is:

Digoxin Penicillin Diuretics Intravenous immunoglobulin

A 6 year old child was diagnosed as a case of acute rheumatic fever and received ten days course of aqueous penicillin. In order to prevent the recurrence of group A streptococcal infection, this child should receive A. Benzathine benzylpenicillin 1.2 million units intramuscular once B. Benzathine benzylpenicillin 1.2 million units intramuscular every 21-28 days (1.0) C. Oral penicillin 250 mg twice a day for 10 days D. Oral erythromycin 250 mg twice a day for 10 days A 10 year old boy who presents with difficulty in breathing accompanied by a displaced PMI to the left, apical and systolic thrill and grade 4/6 holosystolic murmur at the apex, is most likely suffering from an insufficient p 1570 A. Aortic valve B. Mitral valve C. Pulmonic valve D. Tricuspid valve Children with small Ventricular Septal Defect are at risk for this complication A. Hypoxic spells B. Heart failure C. Pulmonary Artery Hypertension D. Infective Endocarditis Case 1 Nos. 22 – 24 Lito, a 5 year old child, was seeking enrollment in a nursery school. Both the teacher and the school physician evaluated him for growth and development. Birth history revealed that Lito was born prematurely at 34 weeks with a weight of 1924 grams and a length of 42 cms. Head circumference was 31 cms. The expected anthropometric measurements includes: 22. Weight that has increased at least _________ from birth A. 4x B. 6x C. 8x D. 10x 23. An increased in length of A. 22 inches B. 24 inches C. 26 inches D. 28 inches 24. Ideal head circumference for age is A. 40 cms B. 42 cms C. 44 cms D. 46 cms Case 2. Nos. 25 - 29

A. Urine Culture and sensitivity B. Leukocyte esterase test C. Urinalysis D. Nitrite test

Buboy is a 7 month old infant brought tot the clinic for a well baby visit. His grandmother recalled that his birthweight was 6 lbs but was not aware of the birth length and head circumference. 25. Buboy’s ideal length is A. 24 inches

B. 27 inches C. 31 inches D. 35 inches 26.The expected increase in his head circumference is: A. 2 cms B. 4 cms C. 6 cms D. 8 cms 27.Buboy’s ideal weight at 6 months is A. 11 lbs B. 13 lbs C. 15 lbs D. 17 lbs 28.When Buboy’s is offered an object he is expected to A. use his index finger to get it B. get the object and drop it C. cast the object D. transfer the object form hand to hand 29.The motor milestone expected for age is A. sitting propped up on hands B. crawling C. Pulling up to stand D. Cruising 30.

A 9 year old boy is suffering from greasy foul watery stool of 2 weeks duration accompanied with abdominal cramps and abdominal distention. You are entertaining the possibility of Giardiasis but the stool examinations done thrice were negative. The next best procedure to do is :

40.

A 2 year old girl was brought in for consultation because of watery stool and vomiting of 3 days duration. Modified acid fast staining of the stool revealed a 26 micrometer red oocysts . The most likely diagnosis in this case is : A. giardiasis B. balantidiasis C. cryptosporidiosis D. amebiasis A 4 year old girl with protuberant abdomen has recurrent colicky periumbilical pain. Fecalysis shows a broadly ovoidal ova with thick shell and outer mammilated covering about 40-60 micrometer. Because of high rate of reinfection, chemotheraphy has to be repeated at : A. 1 month interval B. 2 months interval C. 3-6 months interval D. 8-12 months interval

3 year old boy who owns a puppy has a history of pica. He develops fever, cough with wheezing and hepatomegaly. The test that that will most likely helps in making an accurate diagnosis is : A. stool examination B. ELISA C. COPT D. PCR A 24 month old infant with a normal weight came in for diarrhea with severe dehydration. You opted to administer plain LRS. The total amount of fluid that should be administered in 3 hours is approximately A. 800 ml B. 1000 ml C.

1200 ml

D.

1400 ml

37. A 12 month old infant came in for bloody stool, high fever, severe abdominal pain and toxicity for the past 32 hours. Stool exam revealed 60 fecal leukocytes, plenty of bacteria and amoebic cysts. Most likely the cause of the diarrhea is A. Shigella B. Amoeba (Entamoeba histolytica) C. Salmonella D. Enteroinvasive Escherichiae coli 38.

39.

A. B. C. D.

bruises on the back 2 cm skull fracture – parietal area clavicular fracture – medial aspect contusion/abrasions on the upper arm and legs

REFERENCE: APMC Workbook on Child Protection A 2 year old girl was brought to the ER with a history of paracetamol ingestion. Mother claimed that 3 hours PTC, the child ingested an almost full 30 ml bottle of Paracetamol with a concentration of 250 mg./kg. the child weighed 10 kg. 41. This statement is TRUE A. She has ingested a toxic dose of paracetamol B. Children have a lower incidence of toxic plasma levels after ingestion than do adolescents C. Ipecac should be given as an initial GI decontaminant D. Activated charcoal should not be given if NAC is to be administered Initial symptom include: P 2366 - 2367

34. A 6 month old infant with feeding problem was noted to have diffuse papular lesions , chorioretinitis on the right eye and enlarged head circumference . IGM-SAGA test was positive. This patient can best be treated with . p 1164 - 1166 A. pyrimethamine + sulfadiazine + calcium leukoverin B. Metronidazole C. Iodoquinol D. Chloroquine phosphate

36.

800 – 1000 ml

A. B. C. D.

33.An 18 year old male from Samar presented with abdominal distention , hepatomegaly nad some signs of portal hypertension. Fecalysis revealed small egg with short curved spine. The specific drug for this condition is : p 1167 A. diethylcarbamazine B. albendazole C. ivermectin D. praziquantel

35.

D.

A 2 year old child was brought to your clinic with a history of having fallen down the stairs from a height of 6 steps. You would suspect child abuse because of the presence of the following:

42.

32.

600 – 800 ml

Case 1. No. 40

A. abdominal ultrasound B. entero – test or string test C. duodenal biopsy D. polymerase chain reaction 31.

C.

A 3 week old infant came in for non-bilous vomiting occurring immediately after feeding. This was followed by progressive loss of fluids and electrolytes and dehydration. Feeding was alright. Most likely you are dealing with A. Duodenal atresia B. Esophageal atresia C. Hypertrophic pyloric stenosis D. Duodenal stenosis A fairly nourished one year old in some dehydration will be needing approximately this amount of rehydration fluid during the initial replacement therapy A. 200 – 400 ml

oliguria jaundice diaphoresis abdominal pain

A 10 year old child, diagnosed to have Juvenile Rheumatoid Arthritis and maintained on salicylate was brought to the ER with fever, headache and body malaise. You considered the possibility of salicylate toxicity 43. This statement is TRUE: A. Serum salicylate levels should be taken 6 hours after the last salicylate ingestion B. Chronic toxicity usually presents with metabolic acidosis (1.0) C. A salicylate level of 10 – 20 mg/dl will rule out chronic toxicity D. Gastric decontamination should be performed immediately 44. The management of salicylate toxicity would include the administration of A. Potassium B. Calcium C. Acetazolamide D. Mannitol E. Nos. 45 – 49: REFERENCE: Nelson, Textbook of Pediatrics, 16th edition 45. A major criteria in the diagnosis of atopic dermatitis is P 682 A. chronic relapsing course B. elevated serum IgE C. early age of onset D. white dermatographism 46.

A 5 year old with asthma who have daytime symptoms of >2 times a week, nocturnal symptoms of > 2 times monthly. PEFR > or equal to 809. PEFR variability 20 – 30% is diagnosed to have A. intermittent asthma B. mild persistent asthma C. moderate persistent asthma D. severe persistent asthma

47. For controller/maintenance treatment, this patient may need EXCEPT A. inhaled corticosteroid B. cromolyn C. nedocromil D. oral steroids 48. A child who suddenly develops difficulty of breathing, urticarial rashes, abdominal pain 5 minutes after eating crabs need immediate administration of A. intramuscular antihistamine B. intravenous antihistamine C. intramuscular corticosteroid D. epinephrine 1:1000 intramuscular 49. The only effective treatment of B-cell disorder A. Thymic cell transplant B. Bone marrow transplant C. Regular administration of gammaglobulin D. Plasma transfusion

(0.5)

REFERENCE: Nelson, Textbook of Pediatrics, 17th edition Case 1. Nos. 50 - 51 Baby girl OA was born to a 24 year old primigravid at 39 weeks AOG, NSD after an uncomplicated pregnancy. She weighed 2850 grams, AS 9 & 10, On the 12 th hour of life, she was noted to be jittery. There was fair suck. Reflexes were good. Serum calcium was 4 mg/dl. HGT was 70 mg% 50.

51.

The most likely diagnosis is A. Transient idiopathic neonatal hypocalcemia B. Early neonatal hypocalcemia C. Small for age D. Infant of diabetic mother, hypocalcemia secondary The most probable cause of her disorder is A. metabolic imbalance of hypoglycemia B. presence of cytoplasmic antibodies C. functional immaturity of PTG D. prematurity

(0.25)

Case 2. Nos. 52 - 53 B.

400 – 600 ml A 3 month old male was admitted due to frequent vomiting since 2 weeks of age. He had poor suck, weighed 3.5 kgs, dehydrated, hypotensive

52.

53. A. B. C. D.

Differential diagnoses includes all of the following EXCEPT A. septic shock B. adrenocortical insufficiency, etiology to be determined C. failure to thrive D. Acute gastroenteritis Management should include DAT, Prednisone, NaCl supplementation NPO, D5NSS, hydrocortisone succinate, fludrocortisone NPO, D5NSS, hydrocortisone succinate NPO, D5NSS, fludrocortisone and NaCl supplementation

C. iron has no significant effect on the host’s defense mechanism D. the high levels of transferring is still enough to facilitate absorption

66. A newborn was delivered to a mother who is positive for the hepatitis B virus. The following is/are TRUE regarding breastfeeding of the mother in this infant p 159 A. may breastfeed only once maternal infection is fully cured (0.5) B. should stop breastfeeding because hepatitis B is a highly contagious disease C. active and passive immunizations permit breastfeeding with little risk to the infant D. breast feeding is the major route of transfer of infection to the body 67.

Case 3. No. 54 A 9 year old male had a weigh of 120 lbs, height of 4 feet complains of paroxysmal attacks of headache and nape pain. The dark pigmentation on the neck, axilla, nape and his acne bothers him a lot. On consultation, his BP was 120/80 mmHg, CR: 90/min 54.

The patient has A. normal weight, height and BP B. increased weight, normal height and increased BP C. normal weight, increased height and increased BP D. increased weight, increased height and increased BP

55.

If your are present on the delivery of this baby. The Apgar score at 1 minute is A. 0 B. 1 C. 2 D. 3 56. If he was fed on expressed breast milk and no vitamin K given at birth, the anticipatory condition that could probably set in A. Hemorrhage B. Jaundice C. Diarrhea D. Necrotizing enterocolitis

A. B. C. D.

70. The first pubertal sign in boys is p 54 - 56 A. B. C. D. 71.

REFERENCE: Nelson, Textbook of Pediatrics, 17th edition, 57. A 20 year old primigravid mother now on her 31st week age of gestation consulted for painless vaginal bleeding. Stat pelvic ultrasound showed placenta previa totalis and thus emergency caesarean section was done. What immediate problem do you expect in the baby? A. Meconium Aspiration Syndrome 72. B. Respiratory Distress Type I C. Apnea of Prematurity D. Respiratory Distress Type II 58. The pulmonary problems brought about by Respiratory Distress Type I are due to A. low compliance B. high resistance 73. C. high functional residual capacity D. low dead space A post term was delivered thru caesarean section because of non-reassuring fetal heart rate status. Baby was born through thickly meconium stained amniotic fluid, weighed 2400 grams and had poor apgar score. He is at risk for the following problem: A. Respiratory Distress Type II B. Persistent pulmonary hypertension C. Meconium plug D. Meconium ileus

60.

One of the following is responsible for decrease pulmonary venous return at birth A. increase paO2 B. increase paCO2 C. decrease pH D. all of the above

REFERENCE: Nelson, Textbook of Pediatrics, 17 th edition, p 584 61.

Unconjugated hyperbilirubinemia in an otherwise normal 8 day old infant can be attributed to A. breastmilk jaundice B. breastfeeding jaundice C. sepsis neonatorum D. galactosemia

62.

A 3 year old child with malnutrition is being evaluated for admission at the ward. The anthropometric index that reflects recent nutritional experience of the child is p170 A. weight for height B. body mass index C. mid-arm muscle circumference D. triceps skin fold

63.

A 1 ½ year old male consulted the OPD for persistent diarrhea of 2 ½ weeks. Physical examination showed he had dry, scaly eczematous dermatosis at the perioral, cheeks, perianal and acral areas with growth retardation, alopecia and reddish tint of hair. He is likely to have a deficiency of p 2248 A. Iodine B. Magnesium C. zinc D. fluoride

64.

A mother consulted the clinic to manage her 9 year old obese child. Her condition is most often associated with the following features EXCEPT p 176 A. hyperpigmentation in the neck and skin creases B. tall stature C. slightly advanced bone age D. delayed onset of puberty

65. A child with non-edematous protein energy malnutrition is now on the last phase of therapy. Iron therapy for this child is not given in the early phase of treatment because p 173 A. free iron in the early phase may exacerbate oxidant damage B. iron does not promote growth in the early phase of treatment (0.25)

voice change is already completed presence of hair over the chest peak of penile growth ejaculation usually in response to masturbation

69. In the HEADS FIRST acronym for psychosocial history of adolescence, “R” stands for A. Rebelliousness B. Recreation C. Responsibilities D. All of the above

REFERENCE: Routine newborn care

59.

An eleven (11) year old boy will most likely A. groom in favor of the peer group “uniform” B. be able to engage in intimate and empathetic relationship with another person C. be idealistic D. none of the above

68. An adolescent boy was seen at the clinic for a routine check up. On history and physical examination, he was noted to be very self-conscious and his peers were all boys. Genital examination showed scanty long, slightly pigmented pubic hair at the base of the penis and scrotum was slightly enlarged. Based on the above history and PE one of the following is also expected

Case 1. Nos. 55 – 56 A diabetic 33 year old Gravida 1 Para 1 type O+ mother delivered 5 weeks earlier than her expected date of confinement. The baby was delivered in a lying-in and was noted to be limp, cyanotic face and pale body, gasping, pulses weak and no response on suctioning

(0.25) (0.25)

appearance of mustache broadening of the shoulder increase muscle mass testicular enlargement

A 6 year old female was seen at the ER because of fever of 4 days. This was associated with sore throat, decrease in appetite and slight dysphagia. Physical examination revealed hyperemic throat with petechiae on the soft palate. Complete blood count revealed WBC 14,000 with Segmenters of 0.78. Your most likely diagnosis is p 1393 A. Bacterial pharyngitis B. Acute epiglottitis C. Right peritonsillar abscess D. Acute laryngitis The drug of choice for the above case is A. Cloxacillin sodium B. Penicillin C. Ampicillin D. Cephalexin A 9 month old male infant was brought to the ER because of DOB of 1 day. He had intermittent low grade fever for 4 days with nasal discharge and non-productive cough. A day prior to consult, he had fast breathing and decreased appetite. But he remained to be playful. Physical examination revealed RR of 60’s/min, T: 38oC, intercostal and occasional wheezing with inferior displacement of a normalsized liver. The most likely etiology of the disease is A. Parainfluenzae B. Adenovirus C. Influenzae D. RSV

74. A 4 month old male infant was noted to have stridor during sleeping for the past 1 month. The stridor disappears when the infant is carried in an upright position. There was no associated fever and patient was apparently well since birth. The most likely diagnosis is A. Laryngitis B. Laryngeal foreign body C. Laryngomalacia D. Bronchomalacia 75. Signs and symptoms of above condition usually resolve by p1409 A. 6 months B. 12 months C. 18 months D. 24 months 76. A 3 year old healthy child was left alone in the room playing. When the mother went back after a few minutes, she saw her child lying on the floor, awake, aphonic and apneic. She was rushed to the ER. Your most likely diagnosis is complete upper airway obstruction due to foreign body aspiration. The maneuver/s to do on the way to the hospital is/are P 1411 A. Heimlich B. back blows and chest thrusts (0.33) C. blind finger sweep of the oral cavity (0.33) D. A and C 77. An induration of > or = to 5 mm tuberculin skin test reaction is said to be positive if the following condition/s is/are present in a child p 962 A. receiving corticosteroids of < or = to 10 mg per 24 hours for 2 weeks B. clinical or radiographic findings of TB disease C. esposure to laryngotracheobronchitis D. all of the above 78. One of the following viral exanthems is difficult to recognize clinically as symptoms mimic other viral infections as mild illness with lymphadenopathy, slight fever, concurrent with generalized erythematous maculopapular rash starting on the face A. Roseola infantum B. Postnatal rubella C. Measles D. Dengue fever 79.A 2 month old infant was brought to the clinic for immunization. Physical examination were all within normal. Which of the following vaccines may be given? A. DPT

findings

B. C. D.

Hepatitis A Measles vaccine Typhoid vaccine

80.A 3 year old girl was transfused with 3 units of fresh frozen plasma due to dengue hemorrhagic fever. When is the soonest time that MMR can be given after the transfusion? A. > 3 months after B. > 6 months after C. > 9 months after D. > 12 months after 81.A 2 year old child was admitted under your service with a working diagnosis of measles to prevent further complications vitamin A must be given at a dose of p 1029 A. 50,000 IU B. 100,000 IU C. 150,000 IU D. 200,000 IU 82. A 6 year old child and his family spent New Year in Baguio City. A high possibility of exposure to meningococcemia prompted the mother to ask for possible chemoprophylaxis. The drug that can help in such case is p 899 A. penicillin B. rifampicin C. erythromycin D. chloroquine 83. While doing a routine physical examination to a 4 months old infant you found out that his left testes is undescended. As a preventive measure against the possibility of having cancer later in life, you advise the mother to have her child undergo orchiopexy if the testes will not descend before reaching the age of A. B. C. D.

5 -8 months old 9 – 15 months old 2 – 4 years old 5 – 6 years old

93. Infections are a frequent and important cause of morbidity and mortality in the neonatal period because: A. Infectious agents can be transmitted from mother to the fetus or newborn infant by diverse modes. B. Newborn infants are more capable of responding to infection because of less immunologic deficiencies C. Diagnosis and management of neonatal infections are not often complicated by coexisting conditions D. Maternal infections that is the source of transplacental fetal infection is often detected in early pregnancy. 94. This is characteristic of a neonate with early onset of sepsis A. Poor suck, hypothermia, hypoglycemia manifesting at 10 th day of life. B. Increased incidence of seizures and bulging fontanelles C. Multisystem involvement and higher incidence among preterm neonates 1

14 days after onset of the illness 1 day after onset of the illness 3 – 8 days after onset of the illness 30 days after onset of the illness

85.Vaccine associated paralytic poliomyelitis p 1039 A. occurs 7 – 14 days after giving inactivated polio virus vaccine B. occurs 7 – 14 days after giving oral polio virus vaccine C. occurs 15 – 30 days after OPV D. occurs 15 – 30 days after IPV

(0.5)

86.Ninety (90%) of viral meningitis cases in measles, mumps and german measles vaccinated children has been shown to be caused by p 1045 A. Herpes simplex virus B. Enteroviruses C. Cytomegalovirus D. All of the above 87. A 1 ½ year old male infant sought consultation for fever of 2 days with irritability/drooling of the saliva and decrease formula/food intake. Oropharyngeal findings showed vesicles and ulcers on the uvula, soft palate, anterior tonsillar pillars and posterior pharyngeal wall. The most likely diagnosis would be p 1045 A. Aphthous ulcers B. Herpetic gingivostomatitis C. Hand-foot and mouth disease D. Herpangina

95. Vitamin K deficiency is characterized by p 190 A. low platelet count B. normal protime, abnormal PTT C. normal PTT and abnormal PT D. abnormal PT and PTT 96. A prolonged PTT, normal PT and platelet count should make one suspicious of A. Acquired Prothrombin Complex Deficiency B. Disseminated Intravascular Coagulopathy C. Hemophilia D. Idiopathic Thrombocytopenic Purpura 97.

This is not usually administered in chronic Idiopathic thrombocytopenic purpura A. Vincristine sulfate B. Danazol C. Steroids D. Anthracycline

98.

Treatment of choice for severe aplastic anemia is A. Antithymocyte globulin B. Steroids C. Bone Marrow Transplant D. Androgens

99. Severe joint pains, weight loss, organomegalies, anemia are features of A. Acute Lymphocytic Leukemia B. Aplastic anemia C. Fanconi’s anemia D. von Willebrand’s disease 100. Severe hemophilia will present as: A. Hemarthroses B. Petecchial rashes C. Epistaxis D. Ecchymoses ---END---

Subject: Pediatrics Instructions: Choose the BEST answer 1.

88. Genital herpes virus infection occurs in A. B. C. D.

p 1053 any age group especially school age group children via autoinoculation and sexual abuse primary and recurrent disease and can be differentiated clinically a neonate in 90% within the first week of life

(0.5) (0.5)

89. The management of an infant born to a pregnant woman with active genital HSV infection will consist of A. Vaginal delivery for recurrent infection B. Caesarean section within 4-hour of rupture of bag of water (0.33) C. Infant should be treated immediately with acyclovir without need to perform cultures D. If sign/s of HSV infection is/are present on the mother, a serologic determination of her immune status should be performed 90.A 25 year old pregnant woman (+) for Hep Bs Ag delivered a term, AGA male newborn with an Apgar score of 9 (-1 for color) and 10 at 1 and 5 minutes. What measure will you undertake to prevent perinatal infection? P 1329 A. Hepatitis B vaccination at 6 weeks, 10 weeks and 14 weeks of age B. Hepatitis B vaccination at 2 months, 4 months and 6 months of age C. Hepatitis B vaccination within 12 hours of life plus hyperimmune globulin against Hepatitis B D. Hepatitis B vaccination before 1 – 2 month of age 91. Neonatal infants of diabetic mothers are at high risk for hypoglycemia because: A. Hyperinsulinism exists There is impaired gluconeogenesis in response to hypoglycemia Increased metabolic needs disproportionate to substrate stores and calories

B. C.

Ans: 2.

Ans: 3.

Ans: 4.

Ans: 5.

supplied. D. 92. A. B. C. D.

All of the above Intractable neonatal hypoglycemia in infants with macroglossia, large size, visceromegaly, mild microcephaly, omphalocoele, facial nevus flammeus, a characteristic earlobe creases are seen in infants with: Turner syndrome Klinefelter syndrome Down syndrome Beckwith-Wiedemann Syndrome

(1.0)

D. Uncommon maternal obstetric complications

84. If paralysis occurs in a 1 year old infant infected with poliovirus when is it expected to be observed? A. B. C. D.

p 628

Ans: 6.

The parameters used to estimate the gestational age based on physical maturity are description of the following EXCEPT: A. lanugo B. plantar surface C. genitalia D. pupillary dilatation D An infant weighing 1400 gm is born at 32 weeks gestation in a delivery room that has an ambient temperature of 24 degrees centigrade. Within a few minutes of birth, this infant is likely to exhibit all the following EXCEPT: A. Pallor B. Shivering C. a fall in body temperature D. metabolic acidosis B The immediate postnatal changes in a term newborn includes the following EXCEPT A. decrease in pulmonary vascular resistance B. decrease in right to left shunting via ductus arteriosus C. increase in venous return to the left atrium D. increase right to left shunting via foramen ovale D An infant has the following findings at 5 minutes of life; pulse 130 per minute, cyanotic hands and feet, good muscle tone, and a strong cry. This infant’s Apgar score is A. 7 B. 8 C. 9 D. 10 C A newborn infant was noted to have the following physical features at birth: Weight 3.0 kg, absent lanugo, white parchment-like desquamating skin and long nails. The infant’s gestational age is most likely : A. >42 wks B. 37 – 39 wks C. 7 days B Bruise that is fresh (0-48 hours) is red; purple-blue is 48-72 hours; yellow-green 4-7 days; brown > 7 days. A 2 year old male child was seen at the ER due to 2nd degree burns of both hands. What would you do? A. Admit the patient since you cannot clearly tell if the burns are intentional or not B. Treat the burns and send home the patient C. Refer to the surgeon on duty for management of the burns D. Ask for the immunization status of the patient A In cases where the diagnosis is unclear, always admit the patient. The parents should be told why an inflicted injury is suspected. The use of helmets, seat belts, knee and elbow pads are interventions that: A. prevent the occurrence of the injury-producing agent B. will attempt to reduce the likelihood of injury by modifying the transfer of energy to the victim C. will limit the impact of injuries on the victims D. all of the above

A 2 week old baby boy, delivered NSD, TERM, AGA, was admitted due to poor suck and vomiting, upon admission patient was stuporous, dehydrated with sweet smelling urine. The most likely diagnosis: A. Penylketenuria B. Oast house urine disease C. Maple syrup urine disease D. Xanthunuria

Ans: 46.

C Lipid Storage disease associated with the deficiency of the lysosomal enzyme B- hexosaminidase A is: A. Gaucher Disease B. Lesch-Nyhan Disease C. Niemann-Pick Disease D. Tay-Sachs Disease

Ans: 47.

D Jesus, a 7 year old 2nd grader was brought by her mother to their physician because he was always in trouble at school and impossible at home. He cannot sit still at the dinner table or anywhere else, except perhaps in front of the television. Physical examination revealed nothing more than a slight difficulty in performing skillful motor acts and some clumsiness. The most likely diagnosis is: A. Temporal lobe epilepsy B. Conduct disorder C. Attention deficit hyperactivity disease D. Attention deficit hyperactivity disorder

Ans: 48.

D An 18 year old farm worker was brought to the ER with symptoms of abdominal cramps, excessive salivation, vomiting diarrhea and muscle fasciculation. History revealed that he has been applying pesticides on a large area of the banana plantation where he worked. The most common cause of his problem: A. Dioxin poisoning B. Organophosphate poisoning C. Hydrocarbon poisoning D. Heavy metal poisoning

Ans: 49.

B A 20 year old G1P0 woman gave birth to a baby boy with Down Syndrome. Her first pregnancy resulted in abortion. Such chromosomal abnormality is usually due to: A. Translocation B. Nondisjunction C. Mosaicism D. Point mutation

Ans: 50.

A A 12 year old female was brought in for consultation because of poor performance in school especially in mathematics. On physical examination she was found to have short stature, low posterior hairline, webbed neck, widely spaced nipples and sexual infantilism. The most likely diagnosis: A. Klinefelter Syndrome B. Turner Syndrome C. Edward Syndrome D. Adrenogenital Syndrome

Ans: 51.

B Which of the following organisms is the major cause of severe systemic and focal infections in newborns? A. Staphylococcus aureus B. Streptococcus viridans C. Group B streptococcus D. Pseudomonas species

Ans: 52.

C A four year old boy was brought to your clinic because he was exposed to his grandmother who was coughing out blood for two months already. He has good weight gain and appetite, and has no chronic cough nor fever. You administer a Mantoux tuberculin test and the reading after 72 hours is 15mm. What category does this child belong to? A. TB Exposure B. TB Infection C. TB Disease D. TB Inactive

Ans: 53.

B A 5 year old girl developed fever, coryza and conjunctivitis. After 5 days, still with fever, she was noted to have maculo-papular rashes and cervical lymphadenopathy. What is your diagnosis? A. Rubella B. Roseola C. Fifth’s Disease D. Rubeola

Ans: 54.

D A mother with a known herpes simplex type 2 infection gave birth vaginally to a full term healthy looking baby boy with the assistance of a hilot. What is the next immediate step to do after resuscitation? A. Give herpes simplex vaccine intramuscularly within first 12 hours of life B. Send baby to the hospital for admission and intravenous acyclovir treatment C. Advise mother to closely observe baby for appearance of oral lesions D. Start first dose of oral acyclovir and refer to a pediatrician for further management

Ans: 55.

B People of all ages can develop acute rheumatic fever, but it usually occurs in children A. 0 – 1 year old B. 2 – 4 years old C. 5 – 15 years old D. 16 – 19 years old

Ans: 56.

C The diagnosis of acute rheumatic fever is mainly determined by A. blood culture B. clinical signs C. electrocardiogram

Ans: B 38.

Ans: 39.

Ans: 40.

Ans: 41.

Ans: 42.

Ans: 43.

Ans: 44.

The use of seat belts and other safety devices will modify the rate of release of the hazard from its source. A reliable index of long-term glycemic control is provided by measurement of : A. FBS B. Urine sugar C. Glycosylated hemoglobin D. Oral glucose tolerance test C The first and rate – limiting step in steroid synthesis is the conversion of cholesterol to: Aldosterone A. Cortisol B. Pregnenolone C. sex steroids C At what age is onset of puberty considered precocious in girls? A. < 7 years of age B. < 8 years of age C. < 9 years of age D. < 10 years of age B A newborn with congenital Hypothyroidism is diagnosed and treated adequately by two weeks of age. It can be anticipated that with continued treatment he will have: A. Short stature but normal intelligence B. Short stature and slight mental retardation C. Normal growth and development D. Normal stature but a mild degree of mental retardation C A 1 year and 6 months old child has congenital adrenal hyperplasia. He carries a boy’s name, and had been raised as a boy. P.E shows a moderately enlarged phallus but empty scrotal sacs. Chromosome analysis shows an XX pattern. If you were the doctor, you would: A. continue to raise him as a boy B. ask parents how they feel and follow their wishes C. advise the parents that it would be best to raise the child as a girl after surgical correction of the external genitalia D. wait until the child is old enough to decide which sex to assume C The most severe form of mucopolysaccharidoses due to the deficiency of alpha-L- iduronidase is: A. Hurler’s syndrome B. Hunter’s syndrome C. Morquio’s syndrome D. Sanfillippo syndrome A Inborn error of amino acid metabolism associated with mousy or musty odor of the urine is: A. Tyrosinemia B. Hawkinsinuria

Phenylketonuria Oast house urine disease

45.

D Underfeeding is suggested by restlessness, crying, slow weight gain or actual weight l oss. All of the above can cause infant’s failure to take sufficient quantity of food. The most common cause of death from physical abuse is: A. Intra-abdominal injuries B. Burns C. Intentional Head Trauma (IHT) D. Poisoning

C. D. C

D. Ans: 57.

Ans: 58.

Ans: 59.

acute phase reactants

B NOT TRUE regarding mitral stenosis: A. It is usually rheumatic in origin seen in older children and adolescents B. It may cause concentric hypertrophy of the LV C. The heart murmur is diastolic in timing D. It can be managed with balloon valvuloplasty B A 7 year old girl presents with a tender and swollen right knee as well as a more recently appearing swollen left ankle. She also has fever. Which of the following modified Jones criteria does the patient fulfill? A. 1 Major 1 minor B. B.1 Major 2 minors C. C.2 Majors D. D. 2 Minors A The patient is 10 year old who had frequent tonsillitis and he had complained of migratory joint swelling, intermittent high grade fever, palpitations and easy fatigue. PE includes BP 180/20 CR 110/min. Heart dynamic precordium, AB at 6th LICS, AAL, S1 normal, S2 split P2 accentuated, Grade 3/6 diastolic blowing murmur LUSB radiating to apex, Peripheral pulses bounding. The diagnosis is that he has RHD. What is the most likely cardiac pathology? A. mitral insufficiency B. mitral stenosis C. aortic insufficiency D. aortic stenosis

Ans: 60.

C What is the most common cause of asthma attacks in the infancy period? A. Viral infection B. Stressful activity C. Exposure to allergen D. Food hypersensitivity

Ans: 61.

A During the first year of life, the most common scenario in a child with adverse reaction to foods is: A. Rashes after intake of soy-based foods B. Drowsiness after intake of cured meat C. Pruritic erythematous patches after intake of cheese D. Watery, blood-streaked stools after cow’s milk intake

Ans: 62.

Ans:

D A preschooler was brought to the ER for difficulty of breathing. She was noted to be breathless while talking in phrases and prefers to sit when examined. On PE, her RR is >40/minute, wheezing was heard throughout expiration, was tachycardic and PEFR was 55%. What is the classification of severity of this child’s acute asthma attack? A. Mild intermittent B. Mild persistent C. Moderate persistent D. Severe persistent

A 7-year-old boy was brought to the ER due to tightness in the chest. Earlier, he mentioned that he was stung by a bee. Around 30 minutes after the sting, he felt warm and had difficulty swallowing his saliva. He started feel dizzy and was noted to have difficulty of breathing. On PE he was noted to have a BP of 50 palpatory, HR of 50/min regular in rhythm, RR of 50/min, with wheezing all over his lung fields. What is the immediate treatment of choice for this patient? A. Oral corticosteroid B. Inhaled beta-2 agonist C. Intramuscular epinephrine D. Oral antihistamine

Ans: 64.

C Based on the National Prevalence Survey, how many mm induration response to PPD 5 TU test, differentiate the TB infected from the non infected Filipino? A. 5 B. 8 C. 10 D. 15 C A 2 year old boy has recurrent breathing pauses and snoring during sleep, consulted at the ER due to difficulty of breathing. On PE his tonsils are swollen and enlarged. Your most commonly diagnosis is? A. Acute epiglottitis B. Acute tracheitis C. Obstructive sleep apnea D. Diptheria C A 6 month old male infant has mild upper respiratory tract infection and low grade fever gradually develops into respiratory distress characterized by wheezing and dyspnea. The most likely diagnosis is? A. Bronchial asthma B. Acute bronchiolitis C. Acute bronchitis D. Laryngotracheobronchitis (LTB) B NOT included in the management of Acute Laryngotracheobronchitis: A. Give O2 and supportive care B. Start racemic epinephrine by aerosol C. Add inhaled steroids D. Admit and start cephalosporins D

Ans: 66.

Ans: 67.

Ans: 68.

Ans: 69.

Ans: 71.

Ans: 72.

Ans: 73.

Ans:

A 2 year old with class III childhood TB would have the following characteristics EXCEPT: A. (+) history of exposure to an adult with active TB B. (+) mantoux tuberculin test C. abnormal chest radiographs suggestive of PTB D. Started on INH, Rifampicin, PZA and Ethembutol D What is the main stimulus for red blood cell production? A. Anoxia

A A 2 year old child was brought to the emergency room for on and off fever and easy bruisability for 4 weeks already. On PE, you noted palmar pallor, generalized lympadenopathy and hepatomegaly. What is the most likely cause for his signs & symptoms? A. Connective tissue disease B. Chronic infection C. Blood malignancy D. Nutritional anemia C A 5-year-old boy was brought to the OPD for frequent vomiting and abdominal distention. He has had poor appetite for almost one month and would complain of constipation and reddish urine. On PE, BP= 130/90, T= 38.2C. You palpated a mass on the right side of the abdomen which was firm, not movable and non-tender. What is your diagnosis? A. Rhabdomyosarcoma B. Hirschsprung’s disease C. Impacted feces D. Wilms’ tumor D

74.

The most common cause of bacterial meningitis at 2 months of age is: A. Group B Streptococcus B. Mycoplasma pneumoniae C. Psuedomonas aeruginosa D. Listeria monocytogenes

Ans: 75.

A Lumbar puncture is indicated in the following conditions: A. Child with encephalitis with signs of increased intracranial pressure B. Child who present with headache, associated with left-sided hemiparesis, facial asymmetry and ptosis C. Child who presents with fever, generalized seizures and nuchal rigidity D. Child with fever, seizures, purpuric rash and hematoma at all puncture sites

C

63.

Ans: 65.

Ans: 70.

B. Infection C. Hemorrhage D. Immunodeficiency A A 4 year old child with brain tumor underwent radiotherapy and chemotherapy. After 2 years, the child was noted to be stunted (height at p35). What is the likely reason for such a finding? A. Decrease in brain size due to radiotherapy lessened capacity of growth hormones to induce growth B. Damage to hypothalamic axis has decreased amount of growth hormones causing stunting C. Chemotherapy caused hypoperfusion and ischemia of the brain D. Radiation induced hypoplasia of the skull which limited brain development B Laboratory test to confirm the diagnosis of neuroblastoma: A. Urine vanillylmandelic acid (VMA) B. Urine catecholamins C. Serum alpha-fetoproteins (AFP) D. Serum beta- human chorionic gonadotrophin (B-HCG)

Ans: C 76. A 10-year-old boy developed severe headache, photophobia and vomiting. He is febrile. P=180/100 mm Hg. Results of cranial nerve and motor examinations are normal. He has nuchal rigidity and extensor plantar response, (+) Babinski. The most appropriate to obtain this time is: A. CSF analysis B. Electroencephalogram C. CT scan D. Skull x-ray Ans: 77.

C You are evaluating a 5-year-old girl who has fever, vomiting, and nuchal rigidity. CSF examination reveals WBC=1650, 85% segmenters, 15% lymphocytes, glucose=20 mg/dl and protein=250 mg/dl. Gram stain showed Neisseria meningitides. The best choice of parenteral antibiotic for this patient is: A. Penicillin B. Ceftriaxone C. Nafcillin D. Vancomycin

Ans: 78.

B A 7 year old child was admitted for Acute Post Strep Glomerulonephritis. What is the usual presenting symptom of the patient A. Headache B. Dysuria C. Periorbital edema D. Abdominal Pain

Ans: 79.

C Anemia in Post Strep Glomerulonephritis is due to: A. High grade hemoglobin B. Hematuria C. Hemodilution D. decrease production of RBC

Ans: 80.

C Which of the following indicate that the patient is experiencing a severe complication of acute glomerulonephritis? A. Temperature of 38.8 °C B. Blood Pressure of 140/92 /mm Hg C. Severe Sodium of 140 mg/ L D. Weight loss of 2 lbs

Ans: 81.

B A 3 year old boy come in the ER with abdominal pain generalized edema, BP 90/60 mmHg T36.8C HR85/min BUN 217mg/dl Cr).5 mg/dl, Urine Protein is1800mg/24h. Impression is: A. Congestive Heart Failure B. Idiopathic Nephrotic Syndrome C. Systemic Lupus Erythematosus D. Post-streptococcal Glomerulonephritis

Ans: 82.

Ans: 83.

Ans: 84.

Ans: 85.

Ans: 86.

Ans: 87.

Ans: 88.

Ans: 89.

Ans: 90.

Ans: 91.

Ans: 92.

Ans: 93.

B The most common etiologic agent involved in acute hematogenous osteomyelitits in children is A. Group B streptococcus B. Group A streptococcus C. Staphylococcus aureus D. Hemophilus influenza type B C Which of the following statements is TRUE? A. Septic arthritis is a disease most commonly found in adolescent males B. In septic arthritis, the hips and knees are the most commonly affected joints C. In a child with septic arthritis of the hip, redness swelling and warmth are often detectable on PE D. Children with transient synovitis never present with fever B Cardinal features of Ehlers-Danlos syndrome include all of the following EXCEPT: A. hyperextensible doughy skin B. palpable purpura C. joint hypermobility D. vascular fragility and brusing B These are group of bone diseases in which the ossification centers undergo avascular necrosis followed by resorption, fragmentation of dead bones and finally regeneration and replacement of reparative bone tissues. A. Osteochondroma B. Osteochondroses C. Osteopetrosis D. Osteochondritis B The most feared complication of Kawasaki Disease: A. Pericarditis B. Coronary Aneurysm C. Aseptic Meningitis D. Myocarditis B A child who has low grade fever, abdominal pain, arthritis, microscopic hematuria and purpuric rash only in the lower extremity. He most likely has A. Meningococcemia B. Poststreptococcal Glomerulonephritis C. Henoch-Schoenlein purpura D. Wegener’s granulomatosis C In the diagnosis of Marfan syndrome, the most useful information is A. History of consanguinity B. Chromosomal mapping to detect deletions of Chromosome 15 C. Width of aortic root exceeding more than 95th percentile D. Measurement of fibrillin precursors in peripheral leucocytes C A 13 year old girl is seen because of 4 weeks history of body malaise, anorexia, intermittent fever and arthritis of ankles, wrist and knees. She developed shortness of breath and dyspnea on exertion. PE revealed BP 92/58, RR of 24, Pulse 125, crackleson both lung bases, muffled heart sounds accompanied by friction rub. 2 D Echocardiography documents pericardial effusion. The most useful screening laboratory test for this patient is A. Serum Ig levels B. Antinuclear antibody C. Serum complement levels D. Human lymphocyte antigen (HLA)

Ans: 95.

muscle cramps somnolence tachycardia

Ans: 96.

D Normal plasma osmolality is approximately A. 265-275 mOsm/kg H20 B. 285-295 mOsm/kg H20 C. 305-315 mOsm/kg H20 D. 325-335 mOsm/kg H20

Ans: 97.

B Hyponatremia defined as 20% spherocytes B. sex linked recessive C. splenomegaly D. cholelithiasis (Answer: B / Reference: A p 1620 - 1621125 / MPL: 0.6)

6. Which of the micronutrients does not have recognized anti-infective properties? A. Vitamin A B. Vitamin D C. Iron D. Zinc (Recall) - GIT B - 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, Zincdeficiencies. These 3 have roles in the immune system. (Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 44)

98. Which of the following is NOT a feature of aplastic anemia? A. leucopenia B. thrombocytopenia C. hypoferritinemia D. neutropenia (Answer: C / Reference: A p 1288 – 1289; MPL: 0.9) 99. Which of the following is NOT a favorable prognostic factor of acute lymphoblastic leukemia? A. 5 years old C. Hemoglobin: 11 gms B. female D. absence of leukemia (Answer: C / Reference: A p 1694 - 1696 C.

negative

D.

slow

Legend for the references: A Textbook of Pediatrics and Child Health by del Mundo et al 4th Edition B Nelson’s Textbook of Pediatrics by Behrman 17th Edition C Red Book 26th Edition, 2003 Report of the Committee of Infectious Disease (AAP) D Readings on Diarrhea

CNS

nitrogen

growth

END OF EXAMINATION

University of the East RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER FEBRUARY 2005

4. Chronic intake of carotenoids may result in: A. Pseudotumor cerebri B. Yellow skin and sclerae C. Yellow skin D. Cranial nerve palsy (Recall) - GIT C - 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 Atoxicity after chronic intake of >100,000/u/day vitamin A. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 181) 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) - GIT A - 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, 17 th ed, 2004,Chapter 300)

96. Which laboratory tests are helpful in establishing the etiology of anemia? A. hemoglobin, reticulocyte count, bone marrow exam B. serum iron, CBC, platelet count C. CBC, serum iron, reticulocyte count D. CBC, smear review, reticulocyte count, iron studies (Answer: D / Reference: A p 1065 / MPL: 0.6)

100. The most important index for protein malnutrition at present is: A. edema balance B. wasting development (Answer: A / Reference: A p 168 - 169 / MPL: 0.6)

C - 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)

and

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) - GIT C - 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) - GIT D - (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) - GIT A - 90 mmol/l Above 90 is hyperosmolar (Nelson’s Textbook of Pediatrics, 17 th 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: CHOOSE THE BEST ANSWER: A. Hypochloremic alkalosis B. Bilous vomiting 1 A newborn FT was noted to be pale at 4th month of life. Iron is unlikely in this condition because C. Gastric peristaltic wave infants have sufficient stores to meet their iron requirement for: D. Olive-shaped RUQ mass in abdominal palpation A. 2-3 months (Problem Solving) - GIT B. 46 months C - The hallmark of gastric obstruction is non-bilious vomiting.(Nelson’s Textbook of C. 7-8 months th Pediatrics, 17 ed, 2004, Chapter 310) D. 10-12 months (Problem Solving) - GIT 11. A one day old had bilous vomiting. He was noted to be slightly jaundiced. The abdomen was B – It is by 6 months that iron should be supplemented among healthy full terms. not distended but there was occasional visible peristaltic nerves on the abdominal wall. Plain (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 156) abdomen x-ray showed double-bubble sign. The obstruction is on what level? A. Distal esophagus 2 The breastfed baby of a pure vegetarian mother may develop: B. Gastric A. Xerophthalmia C. Duodenal B. Diarrhea & Dementia D. Colonic C. Osteomalacia (Problem Solving) - GIT D. Anemia C - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 1233) (Problem Solving) - GIT When the obstruction is in the duodenum beyond the Ampula of Vater – vomitus is D - Strict Vegan diets contain no eggs, meat or milk products making this deficient in bilous. The Ampulla of Vater is the site where bile exits. Vitamin B 12. (Chap. 446 p. 1612) Nursing Vegan mothers must be given B12 to prevent. Methylmalonic academia and 12. A 2-year old with head trauma underwent a neurosurgical procedure. At the PICU he had anemia in their infants. (166) (A) Xerophthalmia is Vitamin A deficiency and for which Vitamin A rich massive hematemesis. You would consider: A. Curling’s ulcer sources are the vegetables. (B) Diarrhea and dementia are signs of niacin deficiency (Pellagra) B B. H. pylori infection vitamins come from grains and vegetables. (C) Osteomalacia is Vitamin D deficiency (Rickets) C. Cushing’s ulcer (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 446 Table 44-I) D. B and C (Problem Solving) - GIT 3 By 6th month of age micronutrients must be started. Foremost among these is that nutrient C - (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chapter 316.1) that prevents: Gastric hypersecretion is associated with head trauma and severe CNS disorders A. Xerophthalmia (A) Curling’s ulcers are associated with severe burns B. Scurvy (B) The course is too acute for H. pylori infection C. Anemia D. Goiter 13. An 11 year old Tanner stage 2 female developed epigastric pain / 8 hours later there was fever (Problem Solving) - GIT 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 disease B. Ruptured ectopic pregnancy C. Appendicitis D. Mesenteric adenitis (Problem Solving) - GIT C - 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 antiemetics B. Do abdominal x-ray and refer to surgery C. Give antibiotics D. All of the above (Problem Solving) - GIT B - 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 carcinoma B. Colonic carcinoma C. Hepatic carcinoma D. Pancreatic carcinoma (Recall) - GIT C - 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. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 1328) 16. Prolonged antibiotic therapy can result to bleeding with the following laboratory results: A. Normal PT, normal PTT B. Prolonged PT, prolonged PTT C. Prolonged PT, normal PTT D. 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 anemia B. Acute lymphocytic leukemia C. Disseminated intravascular coagulation D. Idiopathic thrombocytopenic purpura (Problem Solving) – Hema/Onco B - 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. ITP B. Hypoprothrombinemia C. TTP D. Von Willebrand Disease (Problem Solving) – Hema/Onco D - 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 iron B. 30 mg elemental iron C. 60 mg elemental iron D. 70 mg elemental iron (Recall) – Hema/Onco C - 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 cases B. Cranial exposure to ionizing radiation is associated with increased incidence of brain tumor C. Supratentorial tumors predominate among children aged 1-10 years D. In general, there is a slight predominance of supratentorial tumor location in children (Recall) – Hema/Onco B - 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 1 st year of life thus Choice C is incorrect. Generally, infratentorial tumors predominate slightly over supratentorial tumors making Choice D incorrect (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 489 21. Neuroblastoma is a condition characterized by the following: A. Malignancy most frequently diagnosed in infancy B. Mixed embryonal neoplasm composed of three elements: blastoma, epithelia and stroma C. Classically presents with leukocoria D. 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 tumor B. Non-Hodgkin’s lymphoma C. Hepatoblastoma D. 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%. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, Chap. 491) 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 acceleration B. Increasing baseline variability C. Early deceleration without baseline variability D. Late deceleration without baseline variability (Problem Solving) - Neonatology D - 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. Hypernatremia B. Hypocalcemia C. Blood in the stool D. Metabolic acidosis (Problem Solving) - Neonatology B - 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. Pallor B. Shivering C. A fall in body temperature D. Increased respiratory rate (Problem Solving) - Neonatology B - 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 margin B. Tremulous movements and ankle clonus C. Redundant skin folds at the nape of the neck D. A transient, longitudinal division of the body into a red half and a pale half (Problem Solving) - Neonatology C - 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 descends B. Eyes descending as the ball hits the ground C. Crying when the ball hits the ground D. 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. permanence appears at approximately 8 months of age. This is also called object constancy. (Nelson Textbook of Pediatrics, 15th ed, Chap. 11))

Object

28. The ability to manipulate small objects with the pincer grasp is usually noted at what age? A. 0 to 2 months B. 3 to 5 months C. 6 to 7 months D. 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, 17 th 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 months B. 15 months C. 14 months D. 24 months (Problem Solving) - Neonatology A - (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 months B. 4 months C. 9 months D. 6 months

(Problem Solving) - Neonatology D - (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 reflex B. Parachute reflex C. Palmar grasp D. Placing reflex (Recall) - Neurology B - 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, 17 th 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 seizure B. First non-febrile seizure C. Meningitis D. Intracranial SOL (Problem Solving) - Neurology B - 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, 17 th 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 meningitis B. TB meningitis C. Cryptococcal meningitis D. Brain abscess of otogenic origin (Problem Solving) - Neurology A - 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. Meningitis B. Degeneration brain disease C. Brain abscess D. Brain tumor (Problem Solving) - Neurology D - 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 meningitidis B. Streptococcus pneumoniae C. Hemophilia influenza D. Listeria monocytogenes (Recall) - Neurology C - 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. (Nelson’s Textbook of Pediatrics, 17th ed, 2004, p. 2043) 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 hemorrhage B. Subarachnoid hemorrhage C. Viral encephalitis D. Subdural effusion (Problem Solving) - Neurology B - 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 growth B. There is blood pooling and reduced phagocytic activity C. They are closer to the skin surface D. They are common sites of trauma (Problem Solving) – Musculoskeletal Disorders B -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 sarcoma B. Osteosarcoma

C. Osteochondroma D. Osterblastoma (Recall) – Musculoskeletal Disorders B - 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 Disease B. Osteoid osteoma C. Osgood-Schlatter disease D. Osteomyelitis (Problem Solving) – Musculoskeletal Disorders C – 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, 17 th 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 synovitis B. Legg-Calve-Perthes disease C. Medial collateral ligament strain D. Slipped capital femoral epiphysis (Problem Solving) – Musculoskeletal Disorders D - 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. (Nelson’s Textbook of Pediatrics, 17th ed., 2004, pp. 2276-2279) 41. This statement is NOT true about infective endocarditis: A. In 90% of cases, the causative agent is recovered from the first 2 blood cultures B. Timing of phlebotomy is important because bacteremia occurs only during the febrile state C. 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) - Cardiovascular B - 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. (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 42. Painless small erythematous or hemorrhagic lesion on the palms and soles are classic lesion in: A. Osler nodic B. Janeway lesions C. Roth spots D. Spincter Hemorrhages (Recall) - Cardiovascular B - 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 (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 43. Neonatal circulation is NOT characterized by: A. In the presence of cardiopulmonary disease PDA may remain patent B. Foramen ovale may persistently be functional C. The wall thickens and muscle mass of the neonatal (L) and (R ) ventricles are almost equal D. 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 wel (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 44. The clinical manifestation of large VSD in neonatal patients does not include: A. Systolic murmur may not be audible B. Dyspnea C. Profuse perspiration D. Recurrent pulmonary infection (Problem Solving) - Cardiovascular A - 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, 17 th ed, 2004) 45. Which of the following cardiac anomaly is NOT present in Tetralogy of Fallot? A. Pulmonary stenosis B. ASD

C. Overriding of the aorta D. Right ventricular hypertrophy (Recall) - Cardiovascular B - 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)

(Problem Solving) - Respiratory A - PEFR variability =