Pediatrics

University of the East RAMON 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) - GIT B – 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) - GIT D - 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) - GIT 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) 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 A toxicity 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, 17th ed, 2004,Chapter 300) 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, 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) - 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, 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) - GIT C - 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 not distended 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) - GIT C - (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) - GIT C - (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 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 1st 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. NonHodgkin’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 wellbeing. 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. 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 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, 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 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, 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 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, 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 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, 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 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 5060% 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 well (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, 17th 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) 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 laryngitis B. Acute epiglottitis C. Acute laryngotracheobronchitis D. Acute bacterial tracheitis (Problem Solving) - Respiratory B - 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 mismatch B. Hypoventilation C. Diffusion impairment D. R-L shunt (Problem Solving) - Respiratory C - 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 altitude R-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 (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 48. The common infectious cause/s of bronchiectasis is/are: A. Pertussis B. Klebsiella pneumoniae C. Streptotoccus pneumoniae D. H. influenzae (Recall) - Respiratory

A - 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. (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 49. The pathologic findings of bronchopulmonary dysplasia (BPD) consist of the following: A. Decreased alveolarization B. Decreased alveolar septation C. Minimal airway disease D. All of the above (Recall ) - Respiratory D - 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. (Nelson’s Textbook of Pediatrics, 17th ed, 2004) 50. A patient is considered to have intermittent asthma when the following is/are present: A. PEFR variability =