PPS COMPILED SAMPLEX [PART 1 OF 5] - 652 items total with Rationale Flashcards
“Patient with recurrent pneumonia, abscesses, osteomyelitis
a. Chediak Higashi Syndrome
b. Chronic Granulomatous Disease
c. Leucocyte Adhesion Deficiency
d. None of the above”
B
“Chediak Higashi - defective granulation of neutrophils; hemophagocytic lymphohistiocytosis
Chronic Granulomatous Disease - unable to kill catalase-positive microorganism; recurrent pneumonia, lymphadenitis, hepatic subcutaneous, or other abscesses, osteomyelitis at multiple sites, FHx of recurrent infections
Leucocyte adhesion Deficiency - delayed separation of umbilical cord, omphalitis
Nelson 21st Ch156 Disorders of phagocyte function pg1133”
“Adverse drug reactions in children than in adults
a. Aspirin - Reye syndrome
b. Cefaclor - serum sickness
c. Valproic acid - hepatotoxic in infants
d. All of the above”
D
“B complement defect can be detected by measuring:
a. lgG
b. lgM
c. lgA
d. Complement”
C
“Nelson 20th, ch 122 eval of immunodeficiency pg 999-1000
A simple screening test for B cell defects is the measurement of serum IgA. If the IgA level is normal, selective IgA deficiency, which is the most common B cell defect, is excluded, as are most of the permanent types of hypogammaglobulinemia, as IgA is usually very low or absent in those conditions. Ig IgA is low, IgG and IgM should be measured.
Nelson 21st p1097
One useful test for B-cell function is to determine the presence and titer of isohemagglutinins, or natural antibodies to type A and B red blood cell polysaccharide antigens. This test measures predominantly IgM antibodies. Isohemagglutinins may be absent normally in the first 2 yr of life and are always absent if the patient is blood type AB.
Nelson 21st p1097
One useful test for B-cell function is to determine the presence and titer of isohemagglutinins, or natural antibodies to type A and B red blood cell polysaccharide antigens. This test measures predominantly IgM antibodies. Isohemagglutinins may be absent normally in the first 2 yr of life and are always absent if the patient is blood type AB.”
"A patient eats nuts. Developed anaphylactic shock. What will you give? A. Diphenhydramine B. Cetririzine C. Epinephrine IM D. None of the above"
C
“Nelson 21st Ch 174 Anaphylaxis pg 1231
Epinephrine is the most important medication and there should be no delay in its administration. Epinephrine should be given by the IM route to the lateral thigh (1:1000 dilution, 0.01 mg/kg; max 0.5mg). For children >12yo, many recommend the 0.5mg IM dose. The IM dose can be repeated at intervals of 5-15 min if symptoms persist or worsen. If there is no response to multiple doses of epinephrine, IV epinephrine using the 1:10,000 dilution may be needed.”
“10 yr old with asthma born to a then 16yr old mother, underweight. Grandmother has asthma. What is the predictor for asthma morbidity & mortality
a. Underweight
b. Age of mother
c. Age of patient
d. Family history of asthma”
B
“Nelson 21st p1206. Table 169.16. Risk factors for asthma morbidity and mortality
BIOLOGIC
Previous severe asthma exacerbation (intensive care unit admission, intubation for asthma)
Sudden asphyxia episodes (respiratory failure, arrest)
Two or more hospitalizations for asthma in past year
Three or more emergency department visits for asthma in past year
Increasing and large diurnal variation in peak flows
Use of >2 canisters of short-acting β-agonists per month
Poor response to systemic corticosteroid therapy
Male gender
Low birthweight
Nonwhite (especially black) ethnicity
Sensitivity to Alternaria
ENVIRONMENTAL Allergen exposure Environmental tobacco smoke exposure Air pollution exposure Urban environment
ECONOMIC AND PSYCHOSOCIAL Poverty Crowding Mother <20 yr old Mother with less than high school education Inadequate medical care: Inaccessible Unaffordable No regular medical care (only emergency) Lack of written Asthma Action Plan No care sought for chronic asthma symptoms Delay in care of asthma exacerbations Inadequate hospital care for asthma exacerbation Psychopathology in the parent or child Poor perception of asthma symptoms or severity Alcohol or substance abuse"
“Discharge criteria for asthma
a. 02 saturation >92%
b. 40% PEF
c. both of the above
d. none of the above”
A
“Nelson 21st p1208.
The patient may be discharged home if there is sustained improvement in symptoms, normal physical findings, PEF >70% of predicted or personal best, and oxygen saturation >92% while the patient is breathing room air for 4 hr. Discharge medications include administration of an inhaled β-agonist up to every 3-4 hr plus a 3-7 day course of an OCS. Optimizing controller therapy before discharge is also recommended.”
“A patient presented with nasal congestion, sneezing. PE showed edematous boggy and bluish mucus membranes. Associated with postnasal drip, conjunctival suffusion. This could be due to what?
a. Allergic Rhinitis
b. Bronchial asthma
c. Bronchiolitis
d. None of the above “
A
“Nelson 21st p1180
Typical complaints include intermittent nasal congestion, itching, sneezing, clear rhinorrhea, and conjunctival irritation…Conjunctival edema, itching, tearing, and hyperemia are frequent findings. A nasal exam performed with a source of light and a speculum may reveal clear nasal secretions; edematous, boggy, and bluish mucus membranes with little or no erythema; and swollen turbinates that may block the nasal airway.”
“Asthma therapy stepped down after:
a. 2 months
b. 3 months
c. 4 months
d. 5 months “
B
”
Nelson 21st p1200
Asthma therapy can be stepped down after good asthma control has been achieved and maintained for at least 3 mo.”
“A patient with bronchial asthma came in respiratory distress. Can talk in phrases. Classification?
a. Mild
b. Moderate
c. Severe
d. Critical”
B
“Nelson 21st p1190. Table 169.4”
"A patient with asthma attacks during cold season. What will you give? A. Cetirizine B. Montelukast C. SABA D. prednisone"
C
“Nelson 21st p1199. Table 169.11”
"Treatment for all ages with persistent bronchial asthma A. Daily ICS B. SABA C. Daily ICS + LABA D. Montelukast"
A
“Nelson 21st p1199. Table 169.11.
Nelson 21st p1198
The preferred treatment for all patients with persistent asthma is ICS therapy, as monotherapy or in combination with adjunctive therapy. The type(s) and amount(s) of daily controller medications to be used are determined by the asthma severity and control rating. “
"lpratropium Br acts on which receptor? A. M1 B. M2 C. M3 D. B2"
B
“NCBI Muscarinic receptor antagonists, from folklore to pharmacology; finding drugs that actually work in asthma and COPD
doi: 10.1111/j.1476-5381.2010.01190.x
Blocking M2 receptors with muscarinic antagonists including atropine and ipratropium or using selective M2 receptor antagonists such as gallamine, significantly potentiates vagally induced bronchoconstriction”
“True of allergic rhinitis except
A. Associated with at least two fold increase in risk for asthma
B. Risk increases in children introduced to foods or formula early in infancy
C. Increased likelihood in rural and underdeveloped regions
D. All of the above are true”
C
“Nelson 21st p1179
Childhood AR is associated with a 3 fold increase in risk for astham at an older age
*no mention of association between AR and introduction to food/formula; no mention of regions where AR is more prevalent”
"What is the most common inciting agent of outdoor anaphylaxis in children? A. Insect bites B. Exposure to pollens C. Food allergy D. Intake of medicines"
C
“Nelson 21st p1228
The most common causes of anaphylaxis in children are different for hospital and community settings. Anaphylaxis occurring in the hospital results primarily from allergic reactions to medications and latex. Food allergy is the most common cause of anaphylaxis occurring outside the hospital.”
"Which of the following signs/ symptoms is a major feature of atopic dermatitis in infants? A. Chronic scaling of the scalp B. Post-auricular fissures C. Hyper-linear palms D. Facial lichenification"
A
“Nelson 21st p1210. Table 170.1 Clinical features of atopic dermatitis
MAJOR FEATURES
- Pruritus
- Facial and extensor eczema in infants and children
- Flexural eczema in adolescents
- Chronic or relapsing dermatitis
- Personal or family history of atopic disease
ASSOCIATED FEATURES
- Xerosis
- Cutaneous infections (Staphylococcus aureus, group A streptococcus, herpes simplex, coxsackievirus, vaccinia, molluscum, warts)
- Nonspecific dermatitis of the hands or feet
- Ichthyosis, palmar hyperlinearity, keratosis pilaris
- Nipple eczema
- White dermatographism and delayed blanch response
- Anterior subcapsular cataracts, keratoconus
- Elevated serum IgE levels
- Positive results of immediate-type allergy skin tests
- Early age at onset
- Dennie lines (Dennie-Morgan infraorbital folds)
- Facial erythema or pallor
- Course influenced by environmental and/or emotional factors”
"Case of immunodeficiency with no tonsils and lymph nodes that are palpable. Had multiple infections. Males are more affected than females. what is the cause? A. X- linked agammaglobulinemia B. X-linked lymphoproliferative C. Complement deficiency D. Chronic mucocutaneous candidiasis"
A
“What immunoglobulin is tested for B cell deficiency?
a. lgM
b. lgG
c. lgA
d. lgE”
C
”"”Nelson 20th, ch 122 eval of immunodeficiency pg 999-1000
A simple screening test for B cell defects is the measurement of serum IgA. If the IgA level is normal, selective IgA deficiency, which is the most common B cell defect, is excluded, as are most of the permanent types of hypogammaglobulinemia, as IgA is usually very low or absent in those conditions. Ig IgA is low, IgG and IgM should be measured.
Nelson 21st p1097
One useful test for B-cell function is to determine the presence and titer of isohemagglutinins, or natural antibodies to type A and B red blood cell polysaccharide antigens. This test measures predominantly IgM antibodies. Isohemagglutinins may be absent normally in the first 2 yr of life and are always absent if the patient is blood type AB.
Nelson 21st p1097
One useful test for B-cell function is to determine the presence and titer of isohemagglutinins, or natural antibodies to type A and B red blood cell polysaccharide antigens. This test measures predominantly IgM antibodies. Isohemagglutinins may be absent normally in the first 2 yr of life and are always absent if the patient is blood type AB.”””
“What is not a major criteria for the diagnosis of atopic dermatitis?
a. Pruritus
b. Family history of allergic diseases
c. Rashes found at the extensor surfaces
d. Xerosis”
D
”"”Nelson 21st p1210. Table 170.1 Clinical features of atopic dermatitis
MAJOR FEATURES
- Pruritus
- Facial and extensor eczema in infants and children
- Flexural eczema in adolescents
- Chronic or relapsing dermatitis
- Personal or family history of atopic disease
ASSOCIATED FEATURES
- Xerosis
- Cutaneous infections (Staphylococcus aureus, group A streptococcus, herpes simplex, coxsackievirus, vaccinia, molluscum, warts)
- Nonspecific dermatitis of the hands or feet
- Ichthyosis, palmar hyperlinearity, keratosis pilaris
- Nipple eczema
- White dermatographism and delayed blanch response
- Anterior subcapsular cataracts, keratoconus
- Elevated serum IgE levels
- Positive results of immediate-type allergy skin tests
- Early age at onset
- Dennie lines (Dennie-Morgan infraorbital folds)
- Facial erythema or pallor
- Course influenced by environmental and/or emotional factors”””
“What is true regarding asthma?
a. Chronic inflammatory and airway hyperresponsiveness
b. Chronic immunologic response
c. Use of bronchodilator to decrease hyperresponsiveness
d. All of the above are true”
D
“Which has no role in the prevention of asthma?
a. Blockage of the histamine pathway
b. Blockage of Phospholipase A
c. Blockage of leukotrienes
d. None”
B
B - MOA of nifedipine
“Child puts tongue to palate and scratches it. What is this manifestation of allergic rhinitis?
a. Allergic salute
b. Allergic shiners
c. Nasal crease
d. Allergic cluck”
D
“Nelson 21st p1180
Children with AR often perform the allergic salute, an upward rubbing of the nose with an open palm or extended index finger. This maneuver relieves itching and briefly unblocks the nasal airway. It also gives rise to the nasal crease, a horizontal skin fold over the bridge of the nose.
Signs on physical examination include abnormalities of facial development, dental malocclusion, the allergic gape (continuous open-mouth breathing), chapped lips, allergic shiners (dark circles under the eyes), and the transverse nasal crease.”
“10-month-old underweight infant presents with pearly string node, whitish plaques on the pharynx and buccal mucosa without previous antibiotic treatment. She was given nystatin for 4 days and provided temporarily relief and noted recurrence of the plaques after. What else will you ask in the history with regards to the cause of the diagnosis?
a. Hygiene
b. T cell defect
c. B cell defect
d. Complement defect”
B
“Nelson 21st p1112
Defects in cellular immunity, historically referred to T-cell defects, comprise a large number of distinct immune deficiencies. The manifestations usually include prolonged viral infections, opportunistic fungal or mycobacterial infections, and a predisposition to autoimmunity.”
“Test for T-cell deficiency
a. Candida test
b. ANC
c. ESR
d. CRP”
A
“Murmur with thrill
a. 1/6
b. 2/6
c. 3/6
d. 4/6”
D
“Nelson 21st p2353
The intensity of systolic murmurs is graded from I to VI:
I, barely audible;
II, medium intensity;
III, loud but no thrill;
IV, loud with a thrill;
V, very loud but still requiring positioning of the stethoscope at least partly on the chest; and
VI, so loud that the murmur can be heard with the stethoscope off the chest.
In patients who have undergone prior heart surgery, a murmur of grade IV or greater may be heard in the absence of a thrill.”
“PMI will move to 5th LICS at
a. 1 year old
b. 2 years old
c. 3 years old
d. 4 vears old”
D
“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. Something about corticosteroids din and the arthritis na mali
B. Corticosteroids are not necessary because there is no carditis
C. Fulfilled Jones criteria of 1 major and at least 3 minor
D. The difference between RHO and ARF is ECH findings”
B
"Nelson 21st p1448 Antiinflammatory agents (e.g., salicylates, corticosteroids) should be withheld if arthralgia or atypical arthritis is the only clinical manifestation of presumed acute RF.
Nelson 21st p1449
Patients with carditis and more than minimal cardiomegaly and/or congestive heart failure should receive corticosteroids. The usual dose of prednisone is 2 mg/kg/day in 4 divided doses for 2-3 wk, followed by half the dose for 2-3 wk and then tapering of the dose by 5 mg/24 hr every 2-3 days. When prednisone is being tapered, aspirin should be started at 50 mg/kg/day in 4 divided doses for 6 wk to prevent rebound of inflammation.”
"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. None of the above"
C
“Nelson 21st p2448
Approximately 65% of sudden deaths are a result of heart-related problems in patients with either normal or congenitally (corrected, palliated, or unoperated) abnormal hearts. 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”
"Most prognosticating diagnostics in Kawasaki A. 2D Echo B. ESR C. CRP D. ECG"
A
“Nelson 21st p1316
The vast majority of patients with KD return to normal health; timely treatment reduces the risk of coronary aneurysms to <5%. Acute KD recurs in 1–3% of cases. The prognosis for patients with CCA depends on the severity of coronary disease; therefore, recommendations for follow-up and management are stratified according to coronary artery status.”
“Preterm infant, seen at the local health center. Noted with continuous murmur, bounding pulses. What is the most probable lesion?
a) VSD
b) ASD
c) PDA
d) TOF”
C
Nelsons 21st C2382 A small PDA is associated with normal peripheral pulses, and a large PDA results in bounding peripheral arterial pulses and a wide pulse pressure, caused by runoff of blood into the pulmonary artery during diastole. The classic continuous murmur is described as “machinery-like” in quality.
“Initial management of hypercyanotic spell includes the following, except:
a) knee chest position
b) oxygen support
c) sedation
d) intubation”
D
“Nelsons 21st p2397
Depending on the frequency and severity of hypercyanotic attacks, 1 or more of the following procedures should be instituted in sequence: (1) placement of the infant on the abdomen in the knee-chest position while making certain that the infant’s clothing is not constrictive, (2) administration of oxygen (although increasing inspired oxygen will not reverse cyanosis caused by intracardiac shunting), and (3) injection of morphine subcutaneously in a dose not in excess of 0.2 mg/kg. Calming and holding the infant in a knee-chest position may abort progression of an early spell. Premature attempts to obtain blood samples may cause further agitation and may be counterproductive.”
"2 hour old neonate, who was born vigorous and without complications, developed progressive cyanosis. Chest PE is normal. What is the most probable lesion? a. ASD b. VSD c. TOF D. TGA"
D
“VSD (Nelsons 21st p2379)
Characteristically, a loud, harsh, or blowing holosystolic murmur is present and heard best over the lower left sternal border, and it is frequently accompanied by a thrill.
ASD (Nelsons 21st p2375)
In most patients with an ASD, the characteristic finding is that the second heart sound (S2) is widely split and fixed in its splitting during all phases of respiration.
TOF (Nelsons 21st p2397)
The systolic murmur is usually loud and harsh; it may be transmitted widely, especially to the lungs, but is most intense at the left sternal border. The murmur is generally ejection in quality at the upper sternal border, but it may sound more holosystolic toward the lower sternal border. It may be preceded by a click. The murmur is caused by turbulence through the RVOT. It tends to become louder, longer, and harsher as the severity of pulmonary stenosis increases from mild to moderate; however, it can actually become less prominent with severe obstruction, especially during a hypercyanotic spell, because of shunting of blood away from the RV outflow through the aortic valve.
TGA (Nelsons p2407-2408)
Physical findings, other than cyanosis, may be remarkably nonspecific. The precordial impulse may be normal, or a parasternal heave may be present. The second heart sound (S2) is usually single and loud, although it may be split. Murmurs may be absent, or a soft systolic ejection murmur may be noted at the mid-left sternal border.”
“What is the length of prophylaxis for rheumatic fever with carditis? Patient has mild mitral regurgitation.
a) 5 years after last episode
b) 10 years after last episode
c) 18 years after last episode
d) for life”
D
“Nelson 21st p1450. Table 210.5. Duration of prophylaxis for people who have had acute rheumatic fever: AHA recommendations
Rheumatic fever without carditis - 5 yr or until 21 yr of age, whichever is longer
Rheumatic fever with carditis but without residual heart disease (no valvular disease) - 10 yr or until 21 yr of age, whichever is longer
Rheumatic fever with carditis and residual heart disease (persistent valvular disease) - 10 yr or until 40 yr of age, whichever is longer, stometimes lifelong prophylaxis “
"The 1st heart sound is best heard at the: a. Right sternal border b Left sternal C. Midclavicular d. Apex"
D
“The first heart sound is best heard at the apex, whereas the second heart sound should be evaluated at the upper left and right sternal borders. S1 is caused by closure of the AV valves. S2 is caused by closure of the semilunar valves.
Nelson 21st Ch 449, p 2352”
“Infant with blue lower extremities and pink right upper extremity?
a. Shunt through the PDA with COA
b. VSD
c. TOF
d. TAPVR”
A
“Decreased and muffled heart sounds, unusually quiet precordium, dyspneic patient. Diagnosis?
a. Pericardial effusion
b. Heart failure
c. Myocarditis
d. Endocarditis”
A
"A neonate presented with fever and cyanosis on the 3rd DOL. On PE, cyanotic, tachycardic, cardiomegaly by CXR A. Sepsis B. TOF C. Viral myocarditis D. cardiac fibroelastosis"
C
“A Patient came in with 3/6 holosystolic murmur but otherwise asymptomatic. CXR: no cardiomegaly
a. ASD
b. VSD
c. TOF
d. TGA”
B
“VSD (Nelsons 21st p2379)
Characteristically, a loud, harsh, or blowing holosystolic murmur is present and heard best over the lower left sternal border, and it is frequently accompanied by a thrill.
ASD (Nelsons 21st p2375)
In most patients with an ASD, the characteristic finding is that the second heart sound (S2) is widely split and fixed in its splitting during all phases of respiration.
TOF (Nelsons 21st p2397)
The systolic murmur is usually loud and harsh; it may be transmitted widely, especially to the lungs, but is most intense at the left sternal border. The murmur is generally ejection in quality at the upper sternal border, but it may sound more holosystolic toward the lower sternal border. It may be preceded by a click. The murmur is caused by turbulence through the RVOT. It tends to become louder, longer, and harsher as the severity of pulmonary stenosis increases from mild to moderate; however, it can actually become less prominent with severe obstruction, especially during a hypercyanotic spell, because of shunting of blood away from the RV outflow through the aortic valve.
TGA (Nelsons p2407-2408)
Physical findings, other than cyanosis, may be remarkably nonspecific. The precordial impulse may be normal, or a parasternal heave may be present. The second heart sound (S2) is usually single and loud, although it may be split. Murmurs may be absent, or a soft systolic ejection murmur may be noted at the mid-left sternal border.”
"A 3-month old male was brought to the OPD because of skin lesions. Two weeks PTC, diffuse scaling & crusting were noted on the scalp. His mother applied virgin coconut oil twice daily but no improvement was noted. Three days PTC, greasy, scaly & erythematous papules appeared on the face, neck, axillae & diaper areas. The lesions did not seem to be pruritic because he continued to have good suck & slept well. What is the most probable diagnosis? A. Psoriasis B. Atopic dermatitis C. Candidosis D. Seborrheic dermatitis"
D
“Nelson 21st p3495
Seborrheic dermatitis is a chronic inflammatory disease most common in infancy and adolescence that parallels the distribution, size, and activity of the sebaceous glands.
The disorder may begin in the 1st month of life, and typically resolves by 1 yr. Diffuse or focal scaling and crusting of the scalp, sometimes called cradle cap, may be the initial, and at times, the only manifestation. A greasy, scaly, erythematous papular dermatitis, which is usually nonpruritic in infants, may involve the face, neck, retroauricular areas, axillae, umbilicus, and diaper area. “
“An 11-year old female was seen at the OPD because of multiple comedones on the central area of her face. Which of the following interventions has proven benefit ?
A. Avoid all forms of nuts & oily foods.
B. Repetitive cleansing of the face with preparations containing hexachlorophene
C. Apply topical retinoids for 6 -8 weeks
D. Engage in physical activities to improve circulation”
C
“Nelson 21st p3577
With the exception of isotretinoin therapy, no evidence shows that early treatment alters the course of acne
Little evidence shows that the ingestion of particular foods can trigger acne flares
No evidence shows that preparations containing alcohol or hexachlorophene decrease acne, because surface bacteria are not involved in the pathogenesis.
All topical preparations must be used for 6-8 wk before their effectiveness can be assessed. Retinoids may be used alone for mild acne, but combination therapy is frequently more effective. A popular and effective combination is use of benzoyl peroxide gel in the morning and a retinoid at night”
“Lab finding consistent with Cushing’s disease
a. High urinary cortisol
b. Hypoglycemia
c. Hypotension
d. None of the above”
A
“Nelson 21st p2984 Cushing syndrome
Urinary excretion of free cortisol is increased. This is best measured in a 24 hour urine sample and is expressed as a ratio of micrograms of cortisol excreted per gram of creatinine.
Hypertension and hyperglycemia usually occur; hyperglycemia may progress to frank diabetes.”
“To determine bone age maturation, which is not examined on xray?
a. Hand
b. Wrist
c. Knee
d. Ankle”
D
“AAP Vol 140 Issue 6 (December 2017)
Bone age is an interpretation of skeletal maturity, typically based on radiographs from the left hand and wrist or knee…”
“Hormone that has no role in bone maturation in adolescents?
a. Thyroid hormone
b. GH
c. Adrenal
d. Estrogen”
C
“Labo ng choice ng adrenal hindi ko gets kung anong adrenal
Nelson 21st p2876
The biologic effects of growth hormone include increases in linear growth, bone thickness, soft tissue growth, protein synthesis, fatty acid release from adipose tissue, insulin resistance, and blood glucose
Nelson 21st p2912
Thyroid hormones increase oxygen consumption, stimulate protein synthesis, influence growth and differentiation, and affect carbohydrate, lipid, and vitamin metabolism.
Nelson 21st p2957
Glucocorticoids have multiple effects on carbohydrate, lipid, and protein metabolism. They also regulate immune, circulatory, and renal function. They influence growth, development, bone metabolism, and CNS activity.
In stress situations, glucocorticoid secretion can increase up to 10-fold. This increase is believed to enhance survival through inmproved cardiac contractility, cardiac output, sensitivity to the pressor effect of catecholamines and other pressor hormones, work capacity of the skeletal muscles, and capacity to mobilize energy stores.
Nelson 21st p2958
The most significant effect on long-term glucocorticoid excess on calcium and bone metabolism is osteoporosis. Glucocorticoids inhibit osteoblastic activity by decreasing the number and activity of osteoblasts. Glucocorticoids also decrease osteoclastic activity but to a lesser extent, leading to low bone turnover and overall negative balance. The tendency of glucocorticoids to lower serum calcium and phosphate causes secondary hypoparathyroidism. These actions decrease bone accretion and results in a net loss of bone material.
Nelson 21st p2993
Maturation and closure of the epiphyses is estrogen-dependent, as demonstrated by a very tall 28 year old, completely masculinized male with continued growth as a result of incomplete closure of epiphyses, who had complete estrogen insensitivity caused by an estrogen-receptor defect.
“
“2-week-old neonate with vomiting, Na 124, K 6, Cl 100, HC03 15
a. Congenital adrenal hyperplasia
b. Congenital hypothyroidism
c. ACTH insensitivity syndrome
d. None of the above”
A
“Nelson 21st p2973 Congenital adrenal hyperplasia
The signs and symptoms of of cortisol and aldosterone deficiency, and the pathophysiology underlying them, are essentially those described in Chapter 593. These include progressive weight loss, anorexia, vomiting, dehydration, weakness, hypotension, hypoglycemia, hyponatremia, and hyperkalemia. These problems typically first develop in affected infants at approximately 10-14 days of age. Without treatment, shock, cardiac arrythmias, and death may occur within days or weeks.
Nelson 21st p2917 Congenital hypothyroidism
Because symptom are usually, not present at birth, the clinical depends on neonatal screening tests for the diagnosis of congenital hypothyroidism. The anterior and posterior fontanels are open widely, and the presence of this sign at birth may be a clue to early recognition of contenital hypothyroidism. Prolonged jaundice may be present due to delayed maturation of hepatic glucoronide conjugation. Affected infants cry little, sleep much, have poor appetitets, and are generally sluggish.
Feeding difficulties, especially sluggishness, lack of interest, and choking spells during nursing, can be present during the first month of life. Respiratory difficulties, partly causes by macroglossia, include apneic episodes, noisy respiration, and nasal obstruction. There may be constipation unresponsive to treatment. The abdomen is large, and umbilical hernia may be present. The temperature may be subnormal (<35C) and the skin may be cold and mottled, particularly on the extremities. Edema of the genitals and extremities may be present. The pulse is slow and heart murmurs, cardiomegaly, and asymtomatic pericardial effusion are common. Macrocytic anemia is often present. Because symptoms appear gradually and may be nonspecific, the clinical diagnosis of neonatal hypothyroidism is often delayed.
“
"Case of DKA given insulin. What is the most common adverse event to anticipate? A. Hyponatremia, dilutional B. Hypoglycemia C. Hypertension D. Bleeding"
B
“Nelson 21st p3030
Insulin must be given to promote movement of glucose into cells, to subdue hepatic glucose production, and to halt the movement of fatty acids from the periphery to the liver. An initial insulin bolus does not speed recovery and may increase the risk of hypokalemia and hypoglycemia. Therefore, insulin infusion is typically begun without an insulin bolus at a rate of 0.1 units/kg/hr. This approximates maximal insulin output in normal subjects during an oral glucose tolerance test.”
“Anterior pituitary does not secrete this hormone
a) Antidiuretic hormone
b) Prolactin
c) growth hormone
d) TSH”
A
“Nelson 21st p2876
Five cell types in the anterior pituitary produce 6 peptide hormones:
1. Somatotrope - growth hormone (GH)
2. Lactotropes - prolactin (PRL)
3. Thyrotropes - thyroid stimulating hormone (TSH)
4. Corticotropes - proopiomelanocortin (precursor of adrenocorticotropic hormone, ACTH)
5. Gonadotropes - luteinizing hormone (LH) and follicle stimulating hormone (FSH)
Nelson 21st p2880 Argenine vasopresin (antidiuretic hormone, ADH) and oxytocin are the 2 hormones produced by neurosecretion in the hypothalamic nuclei and released from the posterior pituitary. "
“A child was diagnosed with hyperthyroidism. What drug will you start?
a. Levothyroxine
b. PTU
c. Methimazole
d. Propranolol”
C
“Nelson 21st p2932
Methimazole is the first line ATD for children with Graves disease and functions by blocking the organification of iodide necessary to synthesize thyroid hormone. Methimazole has a long serum half-life (6-8 hr) that allows once- or twice-daily dosing.
Propylthiouracil is a similar ATD that is effective in hyperthyroidism, but its use is not recommended in children due to its potential to cause liver failure.”
“Most common cause of congenital hypothyroidism
a. Autoimmune thyroiditis
b. Iodine deficiency
c. Thyroid dysgenesis
d. Iodine excess”
C
“Nelson 21st p2194
Thyroid dysgenesis is the most common cause of permanent congenital hypothyroidism, accounting for 80-85% of cases. “
“HbA1C reflects blood glucose from
a. 1-2 months
b. 2-3 months
c. 3-4 months
d. 4-5 months”
B
“Nelson 21st p3036
Because a blood sample at any given time contains a mixture of red blood cells of varying ages, exposed for varying times to varying blood glucose concentrations, an HbA1c measurement reflects the average blood glucose concentration from the preceding 2-3 mo.”
“A 13- year-old female without breastbud and menarche is concerned. Which will support delayed puberty?
A. No menarche by 16 years old
B. No breast development by 13 years old
C. Both of the above
D. None of the above”
B
“Nelson 21st p2907
Delayed puberty is a failure of development of any pubertal feature by 13 yr of age in females and 14 yr of age in males
Delay or absence of puberty is caused by
- Constitutional delay: a variant of normal
- Hypogonadotropic hypogonadism: low gonadotropin levels as a result of a defect of the hypothalamus/pituitary gland
- Hypergonadotropic hypogonadism: high gonadotropic levels as a result of a lack of negative feedback because of a gonadal problem. Females may have isolated absence of adrenarche with normal breast development “””
"A patient with generalized obesity, short stature, with fracture of the lower extremities. A. Addison's disease B. Cushing syndrome C. Congenital hypothyroidism D. None of the above"
B
“Nelson 21st p2984 Cushing syndrome
The face is rounded, with prominent cheeks and a flushed appearance (moon facies). Generalized obesity is common in younger children. In children with adrenal tumors, signs of abnormal masculinization occur frequently; accordingly there may be hirsutism on the face and trunk, pubic hair, acne, deepening of the voice, and enlargement of the clitoris in girls. Growth is impaired, with length falling below the 3rd percentile, except when significatn virilization produces normal or even accelerated growth. Hypertension is common and may occasionally lead to heart failure. An increased susceptibility to infection may also lead to sepsis.
In older children, in addition to obesity, short stature is a common presenting feature. Gradual onset of obesity and deceleration or cessation of growth may be the only early manifestations. Older children most ofen have severe obesityof the face and trunk compared to the extremities. Purplish striae on the hips, abdomen, and thighs are common. Pubertal development may be delayed, or amenorrhea may occur in girls pas menarche. Weakness, headache, and emotional lability may be prominent. Hypertension and hyperglycemia may occur; hyperglycemia may progress to frank diabetes. Osteoporosis is common and may cause pathologic fractures. “
"Adolescent female engaged in ballet still with amenorrhea, eating problem, and low bone density. A. Anorexia nervosa B. Bulimia nervosa C. Female athlete triad D. None of the above"
C
“Nelson p3706
In females with eating disorders and those who exercise to the point of excessive weight loss with amenorrhea or oligomenorrhea, exercise can be detrimental to bone mineral acquisition, resulting in reduced bone mineral content, or osteopenia.
Specifically, bone mineralization is negatively affected by amenorrhea (absence of menstruation for ≥3 consecutive months). This may be influenced by abnormal eating patterns, or disordered eating. When occurring together, disordered eating, amenorrhea, and osteoporosis
form the female athlete triad.”
“Thiocyanite from Kamote causes thyroid enlargement due to
a. Deiodinase deficiency
b. Competitive binding with iodine
c. Destruction of thyroid follicles
d. None of the above”
B
“Nelson 21st p2927 Table 583.1. Goitrogens and their mechanism
Cassava, lima beans, sweet potato - contain cyanogenic glucosides that are metabolized to thiocyanates that compete with iodine for uptake by the thyroid “
"Child with anterior neck mass treated with thyroid meds but no response to treatment and has normal thyroid function tests. what to do next? A. Observe B. Repeat thyroid function tests C. FNAB D. Increase medication dose"
C
“10-year-old female came to the OPD. PE shows purplish striae at abdomen, hips and thigh. Hypertension is also noted. What is your consideration?
a. Cushing Syndrome
b. Pheochromocytoma
c. Metabolic syndrome
d. None of the above”
A
“Nelson 21st p2984 Cushing syndrome
The face is rounded, with prominent cheeks and a flushed appearance (moon facies). Generalized obesity is common in younger children. In children with adrenal tumors, signs of abnormal masculinization occur frequently; accordingly there may be hirsutism on the face and trunk, pubic hair, acne, deepening of the voice, and enlargement of the clitoris in girls. Growth is impaired, with length falling below the 3rd percentile, except when significatn virilization produces normal or even accelerated growth. Hypertension is common and may occasionally lead to heart failure. An increased susceptibility to infection may also lead to sepsis.
In older children, in addition to obesity, short stature is a common presenting feature. Gradual onset of obesity and deceleration or cessation of growth may be the only early manifestations. Older children most ofen have severe obesityof the face and trunk compared to the extremities. Purplish striae on the hips, abdomen, and thighs are common. Pubertal development may be delayed, or amenorrhea may occur in girls pas menarche. Weakness, headache, and emotional lability may be prominent. Hypertension and hyperglycemia may occur; hyperglycemia may progress to frank diabetes. Osteoporosis is common and may cause pathologic fractures.
Nelson 21st p2986 Phaeochromocytoma
Phaeochromocytomas detected by surveillance of patients who are known carriers of mutations in tumor-suppression genes may be asymptomatic. Otherwise, patients are detected owing to hypertension, which results from excessive secretion of metanephrines, epinephrine, and norepinephrine. Between attacks of hypertension, the patient may be free of symptoms. During attacks, the patient complains of headache, palpitations, abdominal pain and dizziness; pallor, vomiting, and sweating also occur. Seizures and other manifestations of hypertensive encephalopathy may occur.
Nelsons 21st p351
The metabolic syndrome consists of central obesity. hypertension, glucose intolerance, and hyperlipidemia “
“Which of the following is compatible with brain death?
a. Trauma victim, no brainstem function, Temp 33C
b. Hypoxic baby, isoelectric on EEG
c. Drowning victim, no brainstem function
d. All of the above”
C
“Nelson 21st p563-565
Brain death is determined by clinical assessment. Although ancillary tests such as EEG and cerebral blood flow studies are sometimes used to assist in making the diagnosis, repeated clinical examinations is the standard for diagnosis.
The 3 components for determining brain death are demonstration of coexisting irreversible coma with a known cause, absence of brainstem reflexes, and apnea.
Before determiniation of brain death can be made, it is of utmost importance that the cause of the coma be determined to rule out a reversible condition.
Contributing factors that can interfere with the neurologic examination must be corrected:
- Temp >35C
- SBP or MAP in acceptable range
- Sedative/analgesic drug effect excluded as a contributing factor
- Metabolic intoxication excluded as a contributing factor
- Neuromuscular blockade excluded as a contributing factor “
“Which is a poor prognostic factor for drowning
a. Arrived at ER GCS 10
b. Submersion for more than 5 minutes
c. No return of cardiac activity for 25 minutes
d. HR 0 on arrival at ER”
C
“Nelson 21st p612
Poor outcome is highly likely in patients with deep coma, apnea, absence of pupillary responses, and hyperglycemia in the ED, with submersion durations >10min and with failure of response to CPR given for 25min”
“Case of a 2 month old infant with diarrhea, sunken eyeballs, oliguria, present with distress. What is the cause of tachypnea?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory alkalosis
d. Respiratory acidosis”
A
“Child with diarrhea. Sunken eyeballs. What is the ABG?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory alkalosis
d. Respiratory acidosis”
A
“What fluids will you use for resuscitation?
a. 20 ml/kg 0.9 NSS
b. 10 ml/kg 0.9 NSS
c. 10 ml/kg DSLR
d. 20 ml/kg D5NSS”
A
“In drowning, which causes apnea
a. Water in pharynx
b. Myocardial hypoxia
c. Muscle spasm
d. Hypoxic ischemic injury of CNS”
D
“Nelson 21st p609
After experimental submersion, a conscious animal initially panics, trying to surface. During this stage, small amounts of water enter the hypopharynx, triggering laryngospasm. There is a progressive decrease in arterial blood oxyhemoglobin saturation (SaO2), and the animal soon loses consciousness from hypoxia. Profound hypoxia and medullary depression lead to terminal apnea. At the same time, the cardiovascular response leads to progressively decreasing cardiac output and oxygen delivery to other organs”
