March 2017 Flashcards
A 5 yo male came in with cough of 5 days, low grade fever. He sought consult due to persistence. Rr 28 other vitals normal. What is your management? A. Supportive and symptomatic management B. Amoxicillin 50mkd C. Nebulization with B agonist D. Fluticasone
A
Mother has Hepa A. Baby is 15 months old, immunocompetent. How would you give the prophylaxis? A. Hepatitis vaccine immediately B. Hepa IG 5 7 days after exposure C. Hepa vaccine 5 7 days after exposure D. Immunoglobulin immediately after
A
What is the first serologic marker to be detected in Hepa B infection? A. HbV surface antigen B. Anti HbsAg IgM C. Anti HbcAg IgM D. Anti HbeAg IgG
A
Patient was diagnosed with Hepa B 2 months ago. What serologic marker is the best to detect infection. A. Anti Hbc IgM B. HbsAg C. Anti Hbe IgG D. Anti Hbs IgM
A
5yo male, cough, 5 days. Symptoms persisted with fever, more productive cough. Rr 32, crackles, cxr diffuse infiltrates, wbc 20000 neut 30 ly 70. Management? A. Symptomatic and supportive B. Nebulization with b agonist C. Amoxicillin 50mkd D. Clarithromycin 15mkd
D
Atypical pneumonia
Most common site of Tb arteritis. A. Jejunum B. Descending colon C. Rectum D. Anus
Ileocecal region, followed by colon and jejunum
B
Patient had sudden bilateral ascending paralysis with dysphagia after viral infection. What vaccine should not be given? A. Influenza B. MMR C. Varicella D. NOTA
A
Case of a 5yo male. 10 days cough, persistent. Given ampicillin 7 days. No effect. Pe rr 40s, cracles, retractions, occasional wheezes. Management? A. Supportive B. Nebulization with b agonisy C. Cefuroxime 50mkd D. Clindamycin 40mkd
C
Vitamin A: A. Water soluble B. Fat soluble C. No role with growth and development D. NOTA
B
Metabolite affected in nerve conduction A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypomagnesemia
D
Nelson 21st p404
Magnesium is a necessary cofactor for hundreds of enzymes. It is important for membrane stabilization and nerve conduction. Adenosine triphosphate and guanosine triphosphate need associated magnesium when they are used by ATPases, cyclases, and kinases
Breastmilk compared with formula milk?
A. Higher osmolarity
B. Higher protein
C. Lower osmolarity
B
Without the addition of a thickener, the mean osmolality was similar for raw human milk (281 ±2.23mOsm/kg), pasteurized human milk (285 ± 1.28mOsm/kg), and an infant formula (287 ±15.43mOsm/kg) after 1 hour at 37± 2°C
Breastmilk has MORE components compared to formula milk, EXCEPT for iron, vitamin D, vitamin K
Preterm nutrition should be: A. Higher in protein B. Lower in protein C. Same as term D. Lowered in calories during the 3rd week
A
Mental retardation. Deficient nutrient? A. Biotin B. Niacin C. Zinc D. NOTA
C
5 day old has white cheesy lesions on the buccal mucosa. Most significant cause of lesion? A. Contaminated fomites (bottle nipples) B. Maternal flora (vaginal flora) C. Systemic antibiotics D. NOTA
B
Oral candidiasis
Which one has a defect on amino acid metabolism A. Maple syrup urine disease B. Congenital hypothyroidism C. Galactosemia D. G6PD deficiency
A
MSUD - branched chain alpha ketoacid dehydrogenase deficiency, increased valine, leucine, isoleucine
Congenital hypothyroidism - deficiency in thyroid hormone
Galactosemia - GALT/GALK/GALE deficiency, carbohydrate metabolism anomaly
G6PD deficiency - deficiency in antioxidants
A case of 6yo with cough. After 3-4 days became productive. On PE, noted with coarse crackles, occasional wheeze rr 38. Labs: wbc 20000 neutrophilic predominance A. Acute bronchitis B. Nonsevere pneumonia C. Acute brochiolitis D. Severe pneumonia
C
Acute bronciolitis:
The child first presents with nonspecific upper respiratory infectious symptoms, such as rhinitis. Three to 4 days later, a frequent, dry, hacking cough develops, which may or may not be productive. After several days, the sputum can become purulent, indicating leukocyte migration but not necessarily bacterial infection
Findings on physical examination vary with the age of the patient and stage of the disease. Early findings include no or low-grade fever and upper respiratory signs such as nasopharyngitis, conjunctivitis, and
rhinitis. Auscultation of the chest may be unremarkable at this early phase. As the syndrome progresses and cough worsens, breath sounds become coarse, with coarse and fine crackles and scattered high-pitched
wheezing.
(Nelson 21st p. 2220)
Corticosteroids are given in miliary TB for?
A. Prevent strictures
B. Prevent microalveolar block
C. Resorption of pleural fluid
D. Reduce size of mediastinal lymph nodes
B
Corticosteroids for TB
- TB meningitis - reduces vasculitis, inflammation, and intracranial pressure
- TB pericarditis - recommended as adjuctive treatment during first 11 weeks of anti-Koch
- TB pleural effusion - there is insufficient data to support routine use, but may contribute to more rapid resolution of symptoms
- Endobronchial TB - to reduce size of enlarged mediastinal lymph nodes (which may cause respiratory difficulty or a severe collapse-consolidation lesion in the middle to lower lobes)
- Miliary TB - dramatic improvement with corticosteroids to prevent alveolocapillary block
(TBIC 2017 p 157)
First consult, case of rheumatic fever with the ff: fever, polyarthritis, elevated esr, normal cardiac borders, no murmurs, prolonged P R interval. ASO positive. Which is true?
A. Severity of joint & heart involvement tend to be directly related
B. Corticosteroids are not necessary because there is no carditis
C. Fulfilled Jones criteria of 1 major and at least 3 minor criteria
D. ECG findings cannot differentiate RF with carditis and RHD in activity
C
A. Severity of joint & heart involvement tend to be INVERSELY related
B. Corticosteroids are not necessary because there is no carditis - still indicated to give corticosteroids
C. Fulfilled Jones criteria of 1 major and at least 3 minor
> Jones criteria for initial episode: 2 major OR 1 major + 2 minor + evidence of strep infection
> Jones criteria for recurrence:
2 major + evidence of strep infection
1 major + 1 minor + evidence of strep infection
3 minor + evidence of strep infection
D. ECG findings can differentiate RF with carditis and RHD in activity (signs of chamber enlargement in RHD)
Which is the most important factor in the recurrence of febrile seizures? A. Age more than 18 months B. Seizure lasting less than 5 minutes C. Family history of seizures D. Long duration of fever
C
Risk factors for recurrence of febrile seizure
- Age younger than 18 months
- Fever duration of less than 1 hour before seizure onset
- First degree relative with a history of febrile seizures
- Temperature of less than 40 C
(AAFP CPG 2019)
Risk factors for recurrence of febrile seizure MAJOR 1. Age <1 year 2. Duration of fever <24hr 3. Fever 38-39C
MINOR
- Family history of febrile seizures
- Family history of epilepsy
- Complex febrile seizure
- Daycare
- Male gender
- Lower serum sodium at the time of presentation
0 risk factors: 12% recurrence risk
1 risk factor: 25-50% recurrence risk
2 risk factors: 50-59% recurrence risk
3 or more risk factors: 73-100% recurrence risk
(Nelson 21st p3093)
Patient lost consciousness after drinking from a metal polish container. Etiology? A. Lead B. Mercury C. Cyanide D. Arsenic
C
Lead - Paint chips, Dust, Soil Occupational exposure Glazed ceramics Herbal remedies, some home remedies Stored battery casings Lead-based gasoline, moonshine alcohol Guns and bullets Lead plumbing (water) Foods and toys in lead-containing packaging Home renovations
Mercury - primarily through food, especially fish
Cyanide - silver jewelry cleaner
Arsenic - from contaminated food or water, especially contaminated drinking water
(Nelsons 21st, Algorithms of Common Poisonings)
Chorioamionitis greatest risk factor with this etiology: A. E. Coli B. Listeria C. Group B streptococcus D. Group A nonhemolytic streptococcus
C
Patient with painless purging of rice water stools with fishy odor? Drug of choice? A. Doxycycline B. Pen G C. Ciprofloxaxin D. TMP SMX
A (Technically tetracycline according to Nelsons)
Cholera presents with rice-water stools with fishy odor.
Treatment:
WHO (severe dehydration): Doxycycline or tetracycline in adults; Tetracycline in children; Erythromycin as second line
PAHO (moderate to severe dehydration): Doxycycline in adults; Erythromcyin or azithromycin in children; Ciprofloxacin/azithromycin as second line in adults, ciprofloxacin/doxycycline as second line in children
(Nelsons 21st p1518)
What is a major risk factor for poor prognosis in meningococcemia? A. Hypertension B. Petichiae more than 24 hrs C. Seizure D. None of the above
C
Risk factors for poor prognosis in meningococcemia on presentation
- Hypothermia or extreme hyperpyrexia
- Hypotension or shock
- Purpura fulminans
- Seizures
- Leukopenia
- Thrombocytopenia/DIC
- Acidosis
- High circulating levels of endotoxin and TNF alpha
Major risk factors indicating rapid fulminant progression and poor prognosis
- Presence of petechiae for <12 hours before admission
- Absence of meningitis
- Low to normal ESR
(Nelsons 21st p1476)
What is the least helpful in the diagnosis of meningococcal infection? A. Isolation from petichiae and purpura B. Isolation from nasopharynx C. Titers from csf studies D. Blood culture
B
A confirmed diagnosis of meningococcal disease is established by
isolation of N. meningitidis from a normally sterile body fluid such as
blood, CSF, or synovial fluid. Isolation of the
organism from the nasopharynx is not diagnostic of invasive disease
because the organism is a common commensal.
(Nelsons 21st p1474)
Adolescent with vitiligo, orthostatic hypotension. Labs: hypoNa, hyperK, hypogly and metabolic acidosis. Diagnosis?
A. Primary hypoparathyroidism
B. Addison’s disease
C. McCune-Albright syndrome
D. Autoimmune thyroiditis
B
Female athlete with sudden LOC. What part of history will you be most worried of? Event happened after: A. Quarrel with boyfriend B. Stress after difficult exam C. Playing with volleyball D. All of the above
C
Sudden death:
Competitive high school sports (basketball, football) are high-risk environmental factors. Common identifiable causes of death in competitive athletes includes hypertrophic cardiomyopathy, with or without obstruction to left ventricular outflow, other cardiomyopathies, and anomalous coronary arteries; most are sudden unexplained deaths
(Nelson 21st p2448)
Highest risk of conversion from tuberculous infection to active disease? A. Neonate B. Infant C. Toddler D. None
A
Neonates have the weakest immune reponse, thus would need further workup
Case of mother with chlamydia. What will you do with newborn? A. Oral erythromycin for 14 days B. Observe until symptoms arise C. Erythromycin eye ointment at birth D. No intervention needed
A
The recommended treatment regimens for C. trachomatis conjunctivitis or pneumonia in infants are erythromycin (base or ethylsuccinate, 50 mg/kg/day divided 4 times a day PO for 14 days) and azithromycin suspension (20 mg/kg/day once daily PO for 3 days).
The rationale for using oral therapy for conjunctivitis is that 50% or more of these infants have concomitant nasopharyngeal infection or disease at other sites, and
studies demonstrate that topical therapy with sulfonamide drops and erythromycin ointment is not effective.
(Nelson 21st p1617)
Double bubble sign with recurrent vomiting A. Duodenal atresia B. Pyloric stenosis C. Intussussception D. Volvulus
A
Duodenal atresia - double bubble sign (gas-filled stomach and proximal duodenum), bilious vomiting
Pyloric stenosis - string sign, shoulder sign, double tract sign, nonbilious vomiting, 2x2cm olive-shaped firm movable mass
Intussussception - painful paroxysms, sausage shaped mass, currant jelly stool, target sign
Volvulus - vomiting, abdominal distension, target sign, coffee bean sign
Which is most ethical?
A. Pediatrician informing parents of the need to refer to a sub specialist
B. Physician charging exuberant amount for a difficult case
C.
INCOMPLETE QUESTION, answer is A
When will you talk to a parent/guardian re withholding/withdrawal of life support? A. Vegetative state of SSPE B. When going home C. DIC in meningococcemia D. None of the above
A
Case of SSPE. Most important part of history? A. History of rubeola B. History of trauma C. Depression D. Nine of the above
A
What is not an example of informed consent?
A. Parents who were explained thoroughly of the case
B. Consent given freely
C. Paternalistic attitude of physicians
D. None of the above
C
Case of stridor with cough, hoarseness and dysphagia. Most important part of diagnosis? A. History and PE B. Chest and neck radiograph C. Blood cultures D. Direct laryngoscopy
A
Diagnosis is laryngotracheobronchitis. Croup is a clinical diagnosis and does not require radiographs. Direct laryngoscopy is more useful in epiglottitis
Best screening test for SLE A. ANA B. Anti Smith C. Anti Ro D. Anti DsDna
A
ANA is positive in 95-99% of SLE patients, however with poor specificity for SLE.
Autoantibodies associated with SLE
1. Anti DSDNA - specific for diagnosis of SLE, correlates with disease activity, especially nephritis
- Anti Smith - specific for diagnosis of SLE
- Anti-RNP - increased risk for Raynaud phenomenon, interstitial lung disease, and pulmonary hypertension
- Anti Ro, Anti La - Associated with sicca syndrome, may suggest diagnosis of Sjogren syndrome. Associated with cutaneous and pulmonary manifestations of SLE. Increased risk of congenital lupus in offspring
- Anti phospholipid - Increased risk for venous and arterial thrombotic events
- Anti histone - Associated with drug-induced lupus
(Nelson 21st p1277)
3 yr old male. What anthropometric measurement to take if this were his first check up ever? A. BP B. Head circumference C. Abdominal girth D. MUAC
A
The 2017 AAP guideline recommends that children 3 yr or older should have their BP measured during annual preventive visits, unless the childhas risk factors such as obesity, chronic kidney disease (CKD), or diabetes, in whom it should be checked at every healthcare encounter
(Nelson 21st p2490)
Patient with rashes and arthritis in the extremities. What is least likely? A. JIA B. Ankylosing spondylitis C. Lyme disease D. SLE
B
Lyme disease - erythema migrans, arthralgia, myalgia, other constitutional symptoms (Nelson 21st p1606)
Spondyloarthritis - arthritis of the axial skeleton and hips, enthesitis, symptomatic eye inflammation, GI inflammation, rash is not as prominent (Nelson 21st p1269)
JIA - Peripheral arthritis, evanescent rash, lymph node enlargement, hepatomegaly/splenomegaly, serositis (Nelson 21st p1259)
SLE may present with arthritis and rash
Adverse effect of pyrazinamide A. Arthralgia B. Leukopenia C. Cataract D. None of the above
A
Adverse effect of anti-TB drugs
1. Isoniazid - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis in G6PD patients. Inhibits drug-metabolizing enzymes (DME) leading to increased risk of phenytoin, ethosuximide, and carbamazepine toxicity
- Rifampicin - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thrombocytopenia in patients given intermittent high dose therapy), orange discoloration of body fluids. Induces drug-metabolizing enzymes
- Pyrazinamide - Nausea, vomiting, most common cause of hepatotoxicity in regimens also containing H and R, hypersensitivity reactions, polyarthralgia
- Ethambutol - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision)
(TBIC 2016 p141-142)
Most common cause of peritonitis in nephrotic syndrome A. Staphylococcus aureus B. Streptococcus pyogenes C. Hemophilus influenza type B D. Streptococcus pneumonia
D
Primary peritonitis is a well-described infectious complication of NS. It usually occurs within the first 2 years of diagnosis, especially during relapse periods; its incidence is about 1.4–3.7% of children with NS, with a mortality rate of 9%. Streptococcus pneumoniae is the most common organism causing bacterial peritonitis and sepsis in these patients
Conti, G., Carucci, N.S., Comito, V. et al. Acute abdominal pain and nephrotic syndrome: pediatric case reports and review of the literature. Ann Pediatr Surg 17, 61 (2021). https://doi.org/10.1186/s43159-021-00130-7
Skin to skin contact benefits except: A. Maternal flora B. Warmth C. Facilitates breastfeeding D. Prevents anemia
D
Which is true of cord clamping A. 2 cm above base B. Milking C. Before 30 seconds of life D. None of the above
A
Properly timed cord clamping at 30-60 seconds of life or when pulsations cease, about 2cm above the base
Most sensitive test for iron deficiency anemia A. Hemoglobin B. Serum iron stores C. Serum ferritin D. TIBC
C
Indicators of iron deficiency anemia
1. Low Hemoglobin - when used alone, has low specificity and sensitivity
- Low MCV - reliable but late indicator of iron deficiency; low values can also be a result of thalassemias and other causes of microcytosis. False negative results in liver disease
- Low serum ferritin (<12 less than 5 yrs, <15 in greater than 5yrs) - most useful laboratory measure of iron stores. Low ferritin is diagnostic of iron deficiency anemia in a patient with anemia. Ferritin is an acute phase reactant that increases in many acute or chronic inflammatory conditions independent of iron status. In all age groups with infection, ferritin <30-100
- Low Reticulocyte hemoglobin content - sensitive indicator that alls within days of onset of iron deficient erythropoiesis and is unaffected by inflammation. Not widely available
- High Serum transferrin receptor - upregulated in iron deficiency
- Low transferrin - limited by diurnal variation in serum iron and inflammatory conditions, aging, and nutrition
- High Erythrocyte zinc protoporphyrin - useful screening test
- Low Hepcidin - extremely elevated in anemia of inflammation and suppressed in IDA but limited availability
(Nelson 21st p2523)
True of caput except A. Crosses midline B. Subperiosteal bleeding C. With edema D. Resorption at 3-4 days
B
- Caput succedaneum - caused by scalp pressure from the uterus, cervix, or pelvis; circular boggy area of edema with indistinct borders, crossing suture lines, with overlying ecchymosis
- Cephalhematoma - well-circumscribed fluid filled mass that does not cross suture lines. Not present at delivery, develops over first few hours of life
- Subgaleal hemorrhage - not restricted by boundaries of sutures, larger, more diffuse
(Nelson 21st p869)
White pearly papules with erythematous base. A. Milia B. Erythema toxicum C. Neonatal sebaceous hyperplasia D. Cutis marmorata
B
Neonatal Skin Lesions
1. Sebaceous hyperplasia - minute profuse yellow-white papules in forehead, nose, upper lip, cheeks
- Milia - superficial epidermal inclusion cysts with laminated keratinized materia, firm pearly opalescent white cyst 1-2mm diamter on face and gingivae and in the middle of palate (Epstein pearls)
- Cutis marmorata - evanescent lacy reticulated red and blue cutaneous vascular pattern over most of the body surface when infant is cold
- Harlequin color change - autonomic vascular regulation instability, longitudinal half pale, half red
- Nevus simplex (salmon patch) - small pale pink ill defined vascular macule on glabella eyelids, upper lip, nuchal area
- Dermal melanocytosis (mongolian spots) - blue or slate gray macular lesions with variably defined margins most common on sacral area
- Erythema toxicum - benign self limited evanescent eruption; firm yellow-white 1-2mm papules or pustules with surrounding erythematous flare; eosinophilic infiltrates
- Neonatal pustular melanosis - transient benign self-limited dermatosis; evanescent superficial pustules, ruptured pustules with colarette of fine scale, hyperpigmented macules; polymorphonuclear infiltrates
(Nelson 21st 3453-3455)
Most characteristic of shaken baby A. Retinal hemorrhages B. Clavicular fracture C. Limb fracture D. None of the above
A
Abusive head trauma / shaken baby syndrome - poor neck muscle tone and relatively large heads of infants make them vulnerable to acceleration-deceleration forces from shaking.
Features of AHT (sensitive especially when occurring together)
- Subdural hematoma
- Retinal hemorrhages - multiple, involve >1 layer of retina and extend to periphery; traumatic retinoschisis
- Diffuse actional injury
(Nelson 21st p104)
Lacy reticulated skin changes of a neonate exposed to cold surroundings. A. Harlequin color change B. Erythema toxicum C. Neonatal sebaceous hyperplasia D. Cutis marmorata
D
Neonatal Skin Lesions
1. Sebaceous hyperplasia - minute profuse yellow-white papules in forehead, nose, upper lip, cheeks
- Milia - superficial epidermal inclusion cysts with laminated keratinized materia, firm pearly opalescent white cyst 1-2mm diamter on face and gingivae and in the middle of palate (Epstein pearls)
- Cutis marmorata - evanescent lacy reticulated red and blue cutaneous vascular pattern over most of the body surface when infant is cold
- Harlequin color change - autonomic vascular regulation instability, longitudinal half pale, half red
- Nevus simplex (salmon patch) - small pale pink ill defined vascular macule on glabella eyelids, upper lip, nuchal area
- Dermal melanocytosis (mongolian spots) - blue or slate gray macular lesions with variably defined margins most common on sacral area
- Erythema toxicum - benign self limited evanescent eruption; firm yellow-white 1-2mm papules or pustules with surrounding erythematous flare; eosinophilic infiltrates
- Neonatal pustular melanosis - transient benign self-limited dermatosis; evanescent superficial pustules, ruptured pustules with colarette of fine scale, hyperpigmented macules; polymorphonuclear infiltrates
(Nelson 21st 3453-3455)
