1. Breastmilk has low levels of vitamin D. Vitamin D supplementation required:
a. 200 – 400 IU
b. 500 – 700 IU
c. 800 – 1000 IU
d. 1100 – 1500 IU
A Most cases of nutritional rickets can be prevented by universal administration of a daily multivitamin
containing 200–400 IU of vitamin D to children who are breast-fed. (Chapter 48, Nelson’s 18th edition)
2. Antiviral agent not available in the treatment
a. Dengue virus
b. Hepatitis B virus
c. Herpes virus
d. Respiratory Syncitial Virus
A No currently available medical therapy is reliably successful in the majority of persons infected with HBV.
Treatment of the acute infection is largely supportive. Interferon-α-2b (IFN-α2b) and lamivudine (synthetic
nucleoside analog) are the current therapies approved for treatment of chronic hepatitis B in adults >18 yr of
age with compensated liver disease and HBV replication. (Chapter 355, Nelson’s 18th edition)
Three antiviral drugs—acyclovir, valacyclovir, and famciclovir—are available in the United States for the
management of HSV infections. (Chapter 249, Nelson’s 18th edition)
Ribavirin is an antiviral delivered through an oxygen hood, face mask, or endotracheal tube using the small
particle aerosol generator (SPAG-2) for 12–20 hr/day for 3–5 days. Early trials showed a modest beneficial
effect on the course of RSV pneumonia with some reduction in the duration of mechanical ventilation and days
of hospitalization. Subsequent studies failed to document a clear beneficial effect of ribavirin.(Chapter 257,
Nelson’s 18th edition)
3. Virus shedding in measles infection starts at:
a. Incubation period
b. Prodromal period
c. Exanthematous period
d. Recovery period
B The portal of entry of measles virus is through the respiratory tract or conjunctivae following contact with
large droplets or small droplet aerosols in which the virus is suspended. Patients are infectious from 3 days
before the rash up to 4–6 days after its onset. (Chapter 243, Nelson’s 18th edition)
4. Patient with a GIT infection which later became aseptic meningitis with paralysis:
a. Parvovirus
b. Poliovirus
c. Herpes virus
d. Herpes zoster
B Poliomyelitis should be considered in any unimmunized or incompletely immunized child with paralytic
disease.. The CSF, while often normal during the minor illness, with CNS involvement demonstrates a
pleocytosis of 20–300 cells/mm3. The cells in the CSF may be polymorphonuclear early during the course of the
disease but shift to mononuclear cells soon afterward. By the 2nd week of major illness, the CSF cell count falls
to near-normal values. In contrast, the CSF protein is normal or only slightly elevated at the outset of CNS
disease but usually rises to 50–100 mg/dL by the 2nd week of illness. In polioencephalitis, the CSF may remain
normal or show minor changes. Serologic testing demonstrates seroconversion or a 4-fold or greater increase
in antibody titers, when measured during the acute phase of illness and 3–6 wk later. (Chapter 246, Nelson’s
18th edition)
5. Deep-seated fungal infection
a. Aspergillus
b. Candida
c. Epidermophyton
d. Trichophyton
A Aspergillosis of the bone is extremely rare and follows direct extension of infection from surgical
inoculation, traumatic injury, or hematogenous seeding. Involvement of the vertebrae is most common.
Osteomyelitis of the rib is rare and classically occurs in children with chronic granulomatous disease as an
extension from a pulmonary focus. Surgical drainage is often required. In patients with CGD, A. nidulans is
seen more frequently as a cause of osteomyelitis and has a poorer outcome than A. fumigatus. Treatment
requires prompt systemic antifungal therapy combined with surgery and immunotherapy. Although definitive
studies are not available, therapy with amphotericin B plus flucytosine has been used successfully, in spite of
the poor bony penetration of amphotericin B. Itraconazole achieves good bone concentrations and has also
been used successfully. Voriconazole is an alternate therapy. (Chapter 234, Nelson’s 18th edition)
6. 2 year old patient who weighs 10 kg was diagnosed to have Iron Deficiency Anemia. What is the total dose
of elemental iron to be given daily
a. 10-20 mg
b. 20-30 mg
c. 50-60 mg
d. 60-70 mg
C A daily total dose of 4–6 mg/kg of elemental iron in 3 divided doses provides an optimal amount of iron for
the stimulated bone marrow to use. (Chapter 455, Nelson’s 18th edition)
7. True about Fever of Unknown Origin
a. The cause could not be identified after 2 weeks of OPD evaluation
b. Most cases result from atypical presentation of common diseases
B The term fever of unknown origin (FUO) is best reserved for children with a fever documented by a health
care provider and for which the cause could not be identified after 3 wk of evaluation as an outpatient or after
1 wk of evaluation in hospital. (Chapter 175, Nelson’s 18th edition)
8. 10 year old patient who had high grade fever of 2 days, associated with vomiting, diarrhea, sore throat,
and myalgia. 1 day PTA noted to have strawberry tongue. At the ER, the patient was noted to have
hypotension and delirium. Diagnosis?
a. Stevens-Johnson syndrome
b. Toxic shock syndrome
c. Scarlet fever
d. Toxic epidermal necrolysis
B TSS is an acute multisystem disease characterized by high fever, hypotension, vomiting, diarrhea,
myalgias, nonfocal neurologic abnormalities, conjunctival hyperemia, strawberry tongue, and an
erythematous rash with subsequent desquamation on the hands and feet.
TABLE 180-3 -- Diagnostic Criteria of Staphylococcal Toxic Shock Syndrome
MAJOR CRITERIA (ALL REQUIRED)
Acute fever; temperature >38.8°C
Hypotension (orthostatic, shock; below age-appropriate norms)
Rash (erythroderma with late desquamation)
MINOR CRITERIA (ANY 3)
Mucous membrane inflammation
Vomiting, diarrhea
Liver abnormalities
Renal abnormalities
Muscle abnormalities
Central nervous system abnormalities
Thrombocytopenia
EXCLUSIONARY CRITERIA
Absence of another explanation
Negative blood cultures (except occasionally for S. aureus)
9. Late-onset group B streptococcal infection
a. Bacteremia
b. Pneumonia
c. Sepsis
d. Cellulitis
A The most common manifestations of early-onset GBS disease are sepsis (50%), pneumonia (30%), and
meningitis (15%)… Late-onset neonatal GBS disease occurs on or after 7 days of life and most commonly
manifests as bacteremia (45–60%) and meningitis (25–35%). Focal infections involving bone and joints, skin
and soft tissue, the urinary tract, or lungs have been reported in approximately 20% of patients with late-onset
disease. Cellulitis and adenitis are often localized to the submandibular or parotid regions. (Chapter 183,
Nelson’s 18th edition)
TABLE 183-1 -- Characteristics of Early- and Late-Onset GBS Disease
EARLY-ONSET DISEASE
LATE-ONSET DISEASE
Age at onset
0–6 days
7–90 days
Increased risk after obstetric
complications
Yes
No
Common clinical manifestations
Sepsis, pneumonia,
meningitis
Bacteremia, meningitis, other focal
infections
Common serotypes
Ia, III, V, II Ib
III predominates
Case fatality rate
4.7%
2.8%
10. Poor prognostic indicators of meningococcemia
a. Hypertension
b. Leukocytosis and thrombocytosis
c. Presence of petechiae >24 hours
d. Seizures
D Poor prognostic factors on presentation include hypothermia or extreme hyperpyrexia, hypotension or
shock, purpura fulminans, seizures, leukopenia, thrombocytopenia (including DIC), acidosis, and high
circulating levels of endotoxin and TNF-α. The presence of petechiae for <12 hr before admission, absence of
meningitis, and low or normal erythrocyte sedimentation rate indicate rapid, fulminant progression and
poorer prognosis. (Chapter 190, Nelson’s 18th edition)
11. Favorable prognosis of tetanus
a. Absence of fever
b. Age > 5 years
c. Cephalic tetanus
d. Hypoxia
A The most important factor that influences outcome is the quality of supportive care. Mortality is highest in
the very young and the very old. A favorable prognosis is associated with a long incubation period, absence of
fever, and localized disease. An unfavorable prognosis is associated with <7 days between the injury and the
onset of trismus and <3 days between trismus and the onset of generalized tetanic spasms. Sequelae of
hypoxic brain injury, especially in infants, include cerebral palsy, diminished mental abilities, and behavioral
difficulties. Most fatalities occur within the 1st wk of illness. Reported case fatality rates for generalized
tetanus are 5–35%, and for neonatal tetanus extend from <10% with intensive care treatment to >75%
without it. Cephalic tetanus has an especially poor prognosis because of breathing and feeding difficulties.
(Chapter 208, Nelson’s 18th edition)
12. Paul is a 15 year old male who does well in school. When he came home from summer vacation, he was
noted to have become a loner, with complaints of occasional cough and wheezing. He also started
chewing breath mints. What is the explanation for the change in behavior?
a. Marijuana
b. Tobacco
c. Methadone
d. Cocaine
A/B?
Point for Marijuana: An “amotivational” syndrome has been described in long-term marijuana users who lose
interest in age-appropriate behavior, yet proof of the causative relationship remains equivocal.
Points for Tobacco: Adolescents see the positive aspects of smoking as helping with boredom, dealing with
stress, staying thin, and appearing more mature and ignore negative aspects such as making their teeth
yellow, playing sports being harder, being harder to quit, and having bad breath… Adverse health effects of
smoking may occur during adolescence. These adverse effects include an increased prevalence of chronic
cough, sputum production, and wheezing. (Chapter 113, Nelson’s 18th edition)
13. Amber-colored crust
a. S. aureus
b. S. pyogenes
c. H. influenza
d. L. monocytogenes
B
Group A streptococcus (GAS), also known as Streptococcus pyogenes…. Impetigo (or pyoderma) has
traditionally been classified into 2 clinical forms: bullous and nonbullous (see Chapter 664 ). Nonbullous impetigo is
the more common form and is a superficial infection of the skin that appears 1st as a discrete papulovesicular
lesion surrounded by a localized area of redness. The vesicles rapidly become purulent and covered with a thick,
confluent, amber-colored crust that gives the appearance of having been stuck on the skin. The lesions may occur
anywhere but are more common on the face and extremities. If untreated, nonbullous impetigo is a mild but
chronic illness, often spreading to other parts of the body, but occasionally is self-limited. Regional lymphadenitis is
common. Nonbullous impetigo is generally not accompanied by fever or other systemic signs or symptoms.
Impetiginized excoriations around the nares are seen with active GAS infections of the nasopharynx. However,
impetigo is not usually associated with an overt streptococcal infection of the upper respiratory tract. (Chapter
182, Nelson’s 18th edition)
14. A 3 year old female watched her lola cook “kuchinta.” While waiting for her lola to come back, the patient
became thirsty and drank from the bottle labeled lime water. When her lola came, she was noted to be
crying and had erythematous lips. At the ER, burn marks were noted on her lips and in her mouth. What
will you do?
a. Gastric lavage
b. Induce emesis
c. Activated charcoal
d. Endoscopy to look for esophageal burns
D
Ingestion of caustic substances results in esophagitis, necrosis, perforation, and stricture formation (see
Chapter 58 ). Most cases (70%) are accidental ingestions of liquid alkali substances that produce severe, deep
liquefaction necrosis; drain decloggers are most common, and because they are tasteless, more is ingested. Acidic
agents (20% of cases) are bitter, so less may be consumed; they produce coagulation necrosis and a somewhat
protective thick eschar. They can produce severe gastritis, and volatile acids can result in respiratory symptoms.
Caustic ingestions produce signs and symptoms such as vomiting, drooling, refusal to drink, oral burns, dysphagia,
abdominal pain, and stridor. Twenty percent of patients develop esophageal strictures. Absence of oropharyngeal
lesions does not exclude the possibility of significant esophagogastric injury, which can lead to perforation or
stricture. The absence of symptoms is usually associated with no or minimal lesions; in contrast, hematemesis,
respiratory distress, or presence of at least three symptoms predict severe lesions. An upper endoscopy is
recommended as the most efficient means of rapid identification of tissue damage and must be undertaken in all
symptomatic children. Dilution by water or milk is recommended as acute treatment, but neutralization, induced
emesis, and gastric lavage are contraindicated. Treatment depends on the severity and extent of damage. Stricture
risk is increased by circumferential ulcerations, white plaques, and sloughing of the mucosa. They may require
treatment with dilation, and in some severe cases, surgical resection and colon or small bowel interposition are
needed. Silicone stents (self-expanding) placed endoscopically after a dilatation procedure can be an alternate and
conservative approach to the management of strictures. Rare late cases of superimposed esophageal carcinoma
are reported. (Chapter 324.2, Nelson’s 18th edition)
15. A diabetic mother who is being treated with Metformin recently gave birth. She wants to breastfeed.
What will you advise her?
a. May continue taking Metformin since it is safe
b. Stop Metformin. Shift her to insulin therapy
c. Take Metformin after breastfeeding.
A
Sars: according to the internet journal articles I’ve read on this topic, Metformin is considered safe during
the breastfeeding period. The table is from madam joy: Table 94-7, Chapter 94, Nelson’s 18th edition.
CONTRAINDICATED
AVOID OR GIVE WITH CAUTION
PROBABLY SAFE
Amphetamines
Alcohol
Acetaminophen
Antineoplastic agents Amiodarone
Acyclovir
Bromocriptine
Anthroquinones (laxatives)
Aldomet
Chloramphenicol
Aspirin (salicylates)
Anesthetics
Clozapine
Atropine
Antibiotics (not chloramphenicol)
Cocaine
β-adrenergic blocking agents
Antiepileptics
Cyclophosphamide
Birth control pills
Antihistamines[*]
Diethylstilbestrol
Bromides
Antithyroid (not methimazole)
Doxorubicin
Calciferol
Bishydroxycoumarin
Ergots
Cascara
Chlorpromazine[*]
Gold salts
Ciprofloxacin
Codeine[*]
CONTRAINDICATED
AVOID OR GIVE WITH CAUTION
PROBABLY SAFE
Heroin
Danthron
Cyclosporine
Immunosuppressants Dihydrotachysterol
Depo-Provera
lodides
Domperidone
Digoxin
Lithium
Estrogens
Dilantin (phenytoin)
Methimazole
Metoclopramide
Diuretics
Methylamphetamine
Metronidazole
Fluoxetine
Phencyclidine (PCP)
Meperidine
Furosemide
Radiopharmaceuticals Phenobarbital[*]
Haloperidol[*]
Thiouracil
Primidone
Hydralazine
Psychotropic drugs
Indomethacin, other nonsteroidal antiinflammatory drugs
Reserpine
Salicylazosulfapyridine (sulfasalazine) Low molecular weight heparius
Metformin
Methadone[*]
Morphine
Muscle relaxants
Paroxetine
Prednisone
Propranolol
Propylthiouracil
Sedatives[*]
Sertraline
Theophylline
Vitamins
Warfarin
16. A patient diagnosed with CKD secondary to CGN who is on dialysis presented with bone dystrophy. What
treatment will you give?
a. Growth hormone
b. Vitamin D
c. Phosphates
d. Calcium
B
The cornerstone of therapy for renal osteodystrophy is vitamin D administration. (Chapter 535.2, Nelson’s
18th edition)
17. No object permanence at this age should be considered a red flag
a. 2 mo
b. 6 mo
c. 12 mo
d. 18 mo
C
(Chapter 8, Nelson’s 18th edition, PPS Preventive Pediatric Handbook 2012)
COGNITIVE
Stares momentarily at spot where object
2 Lack of object permanence (out of sight, out of mind) [e.g.,
disappeared
yarn ball dropped]
Stares at own hand
4 Self-discovery, cause and effect
Bangs 2 cubes
8 Active comparison of objects
Uncovers toy (after seeing it hidden)
8 Object permanence
Egocentric symbolic play (e.g., pretends to
12 Beginning symbolic thought
drink from cup)
Uses stick to reach toy
17 Able to link actions to solve problems
Pretend play with doll (e.g., gives doll bottle)
17 Symbolic thought
18. What is the amount of toothpaste recommended for a 3 year old?
a. Smear
b. Pea size
c. ½ pea size
d. ¼ pea size
C
PPS preventive pediatric handbook : 6 months – 2 years SMEAR, 2-6 years – ½ PEA, >6 years old – PEA SIZE
19. A mother recently gave birth. On history, it was reported that she drank alcohol and used illicit drugs
during her pregnancy. At birth the patient presented with seizures, hypotension, tremors and irritability.
What is the cause of the patient’s symptoms?
a. Cocaine
b. Alcohol
c. Opiates
d. Amphetamines
C(?) (Chapter 106, Nelson’s 18th edition)
Heroin addiction
Tremors and hyperirritability are the most prominent symptoms. The tremors may
be fine or jittery and indistinguishable from those of hypoglycemia, but they are more often coarse, “flapping,”
and bilateral; the limbs are frequently rigid, hyperreflexic, and resistant to flexion and extension. Irritability and
hyperactivity are generally marked and may lead to skin abrasions. Other signs include wakefulness, hyperacusis,
hypertonicity, tachypnea, diarrhea, vomiting, high-pitched cry, fist sucking, poor feeding with weight loss
(disorganized sucking), and fever. Sneezing, yawning, hiccups, myoclonic jerks, convulsions, abnormal sleep cycles,
nasal stuffiness, apnea, flushing alternating rapidly with pallor, and lacrimation are less common. The Neonatal
Intensive Care Unit Neurobehavioral Scale (NNNS) is a useful way to evaluate opiate or other drug exposed
neonates ( Table 106-1 ). The risk of sudden infant death syndrome is increased. The diagnosis is generally
established by the history and clinical findings. Examining the urine for opiates may reveal only low levels during
withdrawal, but quinine, which is often mixed with heroin, may be present in higher concentrations.
Methadone addiction is associated with severe withdrawal symptoms. The mothers have a high incidence
of polysubstance abuse, including alcohol, barbiturates, and tranquilizers, and they are often heavy smokers. The
incidence of congenital anomalies is not increased. The clinical manifestations are similar except that the former
group has a higher incidence of seizures (10–20%) and the late onset (2–6 wk of age) of withdrawal.
Alcohol withdrawal Hypoglycemia and a metabolic acidosis may be present. Infants in whom withdrawal
symptoms develop often become agitated and hyperactive, with marked tremors lasting 72 hr, followed by about
48 hr of lethargy before return to normal activity. Seizures may develop.
Cocaine abuse … premature labor, abruptio placentae, and fetal asphyxia. Infants may have intrauterine
growth restriction and neurobehavioral deficits characterized by impaired state regulation, impaired auditory
information processing, developmental delay, and learning disabilities.
20. A patient was noted to have jaundice. On laboratory work up, it was found that the patient has
hemoglobin “kell” and that the bilirubin was at 18 mg/dl. What can you give to the patient?
a. Phenobarbital
b. IVIg
c. Metalloporphyrins
d. Exchange transfusion
?
Sarsi: I dunno the answer to this one. I just remembered that exchange transfusion or any other
procedures were not included in the choices. If I remember correctly the choices were mostly drugs. I tried looking
for drugs for use in hyperbiriubinemia involving the kell antigen. There’s none. So here’s what I got from Nelson’s
regarding eryhtroblastosis fetalis.
The main goals of therapy are to (1) prevent intrauterine or extrauterine death from severe anemia and hypoxia,
and (2) avoid neurotoxicity from hyperbilirubinemia.
Treatment of a Liveborn Infant. The birth should be attended by a physician skilled in neonatal resuscitation.
Fresh, low-titer, group O, leukoreduced, and irradiated Rh-negative blood cross matched against maternal serum
should be immediately available. If clinical signs of severe hemolytic anemia (pallor, hepatosplenomegaly, edema,
petechiae, ascites) are evident at birth, immediate resuscitation and supportive therapy, temperature stabilization,
and monitoring before proceeding with exchange transfusion may save some severely affected infants. Such
therapy should include correction of acidosis with 1–2 mEq/kg of sodium bicarbonate; a small transfusion of
compatible packed RBCs to correct anemia; volume expansion for hypotension, especially in those with hydrops;
and provision of assisted ventilation for respiratory failure.
Exchange transfusion (Chapter 103.2, Nelson’s 18th edition)
Comments from madam joy: If I remember it right, these are the choices kaya lang di ko sure yung order. THOUGH
DI KO DIN SURE ANG SAGOT. From Nelson’s 19th ed [Treatment of hyperbilirubinemia], these are some of the
discussions.
Intravenous Immunoglobulin
The administration of intravenous immunoglobulin is an adjunctive treatment for hyperbilirubinemia due to
isoimmune hemolytic disease. Its use is recommended when serum bilirubin is approaching exchange levels despite
maximal interventions including phototherapy. Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr)
has been shown to reduce the need for exchange transfusion in both ABO and Rh hemolytic disease, presumably
by reducing hemolysis.
Metalloporphyrins
A potentially important alternative therapy is the use of metalloporphyrins for hyperbilirubinemia. The
metalloporphyrin Sn-mesoporphyrin (SnMP) offers promise as a drug candidate. The proposed mechanism of
action is competitive enzymatic inhibition of the rate-limiting conversion of heme-protein to biliverdin (an
intermediate metabolite in the production of unconjugated bilirubin) by heme-oxygenase. A single intramuscular
dose on the 1st day of life may reduce the need for subsequent phototherapy. Such therapy may be beneficial
when jaundice is anticipated, particularly in patients with ABO incompatibility or G6PD deficiency or when blood
products are objected to, as with Jehovah's Witness patients. Complications from metalloporphyrins include
transient erythema if the infant is receiving phototherapy. Administration of SnMP may reduce bilirubin levels and
decrease both the need for phototherapy and the duration of hospital stay; however, it remains unclear whether
treatment with metalloporphyrins for unconjugated hyperbilirubinemia will alter the risk of kernicterus or longterm neurodevelopment impairment. Data on efficacy, toxicity, and long-term benefit are currently being
evaluated.
Exchange Transfusion
Double-volume exchange transfusion is performed if intensive phototherapy has failed to reduce bilirubin levels to
a safe range and if the risk of kernicterus exceeds the risk of the procedure. Potential complications from exchange
transfusion are not trivial and include metabolic acidosis, electrolyte abnormalities, hypoglycemia, hypocalcemia,
thrombocytopenia, volume overload, arrhythmias, NEC, infection, graft versus host disease, and death. This widely
accepted treatment is repeated if necessary to keep indirect bilirubin levels in a safe range (see Fig. 96-12 and
Table 96-7)
21. A patient was noted to have jaundice at the 36th hour of life. Mother was O+, infant was A+. (-) coombs’
test
a. ABO incompatibility
b. Physiologic jaundice
c. Pathologic jaundice
A/B?
ABO incompatibility is the most common cause of hemolytic disease of the newborn. Maternal antibody may be
formed against B cells if the mother is type A or against A cells if the mother is type B. Usually, the mother is type O
and the infant is type A or B. Although ABO incompatibility occurs in 20-25% of pregnancies, hemolytic disease
develops in only 10% of the offspring in such pregnancies, and the infants are generally type A1, which is more
antigenic than A2. Most cases are mild, with jaundice being the only clinical manifestation. The infant is not
generally affected at birth. Jaundice usually appears during the 1st 24 hr. A presumptive diagnosis is based on
the presence of ABO incompatibility, a weakly to moderately positive direct Coombs test result.
Hyperbilirubinemia is often the only other laboratory abnormality. In 10-20% of affected infants, the unconjugated
serum bilirubin level may reach 20 mg/dL or more unless phototherapy is administered.
Physiologic: Jaundice becomes visible on the 2nd or 3rd day, usually peaking between the 2nd and 4th days at 5-6
mg/dL and decreasing to <2 mg/dL between the 5th and 7th days of life. Jaundice associated with these changes is
designated physiologic and is believed to be the result of increased bilirubin production from the breakdown of
fetal red blood cells combined with transient limitation in the conjugation of bilirubin by the immature neonatal
liver. Risk factors for elevated indirect bilirubin include maternal age, race (Chinese, Japanese, Korean, and Native
American), maternal diabetes, prematurity, drugs (vitamin K3, novobiocin), altitude, polycythemia, male sex,
trisomy 21, cutaneous bruising, blood extravasation (cephalohematoma), oxytocin induction, breast-feeding,
weight loss (dehydration or caloric deprivation), delayed bowel movement, and a family history of or a sibling who
had physiologic jaundice (see Table 96-2). In infants without these variables, indirect bilirubin levels rarely rise
above 12 mg/dL, whereas infants with several risk factors are more likely to have higher bilirubin levels. A
combination of breast-feeding, variant-glucuronosyl transferase activity (1A1), and alterations of the organic
anion transporter 2 gene increases the risk in Asian children. Predicting which neonates are at risk for exaggerated
physiologic jaundice can be based on hour-specific bilirubin levels in the first 24-72 hr of life (Fig. 96-8). (Chapter
103, Nelson’s 18th edition)
22. Late onset sepsis
a. Pneumonia?
b. Bacteremia
c. Sepsis
d. Shock
Nads and Sarsi: What is this question about?! If it is a repeat of the question in number, check out that one instead
:P
23. Newborn immune to encapsulated organisms except for coliform bacteria because this does not pass the
placental barrier
a. IgM
b. Complement
c. Phagocyte
d. IgG
A
IMMUNOGLOBULINS.IgG is actively transported across the placenta, with concentrations in a full-term infant
comparable to or higher than those in the mother… Other classes of immunoglobulins are not transferred across
the placenta, although a fetus can synthesize IgA and IgM in response to intrauterine infection.
The presence of passively transferred specific IgG antibody in adequate concentration provides neonates
protection against infections to which protection is mediated by that antibody (tetanus, encapsulated bacteria
such as GBS). Specific bactericidal and opsonic antibodies against enteric gram-negative bacteria are
predominantly in the IgM class. Newborn infants usually lack antibody-mediated protection against Escherichia
coli and other Enterobacteriaceae.
COMPLEMENT. The complement system mediates bactericidal activity against certain organisms such as E. coli
and functions as an opsonin with antibody in the phagocytosis of bacteria such as GBS. No transplacental passage
of complement from the maternal circulation takes place. A fetus begins to synthesize complement components as
early as the 1st trimester. Full-term newborn infants have slightly diminished classical pathway complement
activity and moderately diminished alternative pathway activity. Considerable variability, however, is seen in both
the concentration and activity of complement components. Premature infants have lower levels of complement
components and less complement activity than full-term newborns do. These deficiencies contribute to diminished
complement-derived chemotactic activity and to a diminished ability to opsonize certain organisms in the absence
of antibody. Opsonization of Staphylococcus aureus is normal in neonatal sera, but various degrees of impairment
have been noted with GBS and E. coli.
MONOCYTE-MACROPHAGE SYSTEM. The monocyte-macrophage system consists of circulating monocytes and
tissue macrophages, particularly in the liver, spleen, and lung. Activated macrophages are involved in antigen
presentation, phagocytosis, and immune modulation. The number of circulating monocytes in neonatal blood is
normal, but the mass or function of macrophages in the reticuloendothelial system is diminished, particularly in
preterm infants. In both term and preterm infants, chemotaxis of monocytes is impaired; this impairment affects
the inflammatory response in tissues and the results of delayed hypersensitivity skin tests. Monocytes from
neonates ingest and kill microorganisms as well as monocytes from adults. (Chapter 109.3, Nelson’s 18th edition)
24. 2 months for vaccination. He has a sibling who is on chemotherapy due to leukemia. What will you give?
a. OPV, Tdap
b. OPV, DTap
c. IPV, DTP, or DTaP
d. IPV, TDaP
Comments from madam joy: I THINK IT’S C.
Comment #2: Nads and Sarsi agree, but we do not know how to fully explain except that the vaccines that should
be given to the 2 month old patient must not include live vaccines as the vaccinated kid can shed it and thereby
produce infection in the immunocompromised sibling. :s
Madam joy lifted this from Chapter 165, Nelson’s 19th edition: VACCINES IN SPECIAL CIRCUMSTANCES
SPECIFIC IMMUNODEFICIENCY
CONTRAINDICATED
RISK-SPECIFIC
EFFECTIVENESS AND
VACCINES*
RECOMMENDE COMMENTS
D VACCINES*
Malignant neoplasm,
Live viral and bacterial,
Pneumococcal
Effectiveness of any
transplantation, immunosuppressive depending on immune
vaccine depends on degree
or radiation therapy
status[‡][§]
of immune suppression
‡
Live bacterial vaccines: BCG and oral Ty21a Salmonella typhi vaccine.
25. External genitalia is visible in UTZ at:
a. 8 weeks
b. 12 weeks
c. 16 weeks
d. 20 weeks
B
By 12 wk, the gender of the external genitals becomes clearly distinguishable. (Chapter 6.1, Nelson’s 18th
edition)
Table 6-5 -- MILESTONES OF PRENATAL DEVELOPMENT (19TH ED)
WK DEVELOPMENTAL EVENTS
1 Fertilization and implantation; beginning of embryonic period
2 Endoderm and ectoderm appear (bilaminar embryo)
3 First missed menstrual period; mesoderm appears (trilaminar embryo); somites begin to form
Neural folds fuse; folding of embryo into human-like shape; arm and leg buds appear; crown-rump length 4-5
4
mm
5 Lens placodes, primitive mouth, digital rays on hands
6 Primitive nose, philtrum, primary palate
7 Eyelids begin; crown-rump length 2 cm
8 Ovaries and testes distinguishable
9 Fetal period begins; crown-rump length 5 cm; weight 8 g
12 External genitals distinguishable
20 Usual lower limit of viability; weight 460 g; length 19 cm
25 Third trimester begins; weight 900 g; length 24 cm
28 Eyes open; fetus turns head down; weight 1,000-1,300 g
38 Term
26. Stranger anxiety during consult
a. Talk to the infant
b. nakalimutan ko
c. do not look directly to her eyes
d. calm baby first
C
In the office setting, certain procedures may lessen the child's stranger anxiety. Avoid direct eye contact
initially. Perform as much of the examination as feasible with the child on the parent's lap. (Chapter 9, Nelson’s
18th edition)
27. Loss of asymmetric tonic reflex means
a. can inspect objects or hands at midline
b. release objects voluntarily
A
Early reflexes that limited voluntary movement recede. Disappearance of the asymmetric tonic neck reflex
means that infants can begin to examine objects in the midline and manipulate them with both hands (see Chapter
591 ). Waning of the early grasp reflex allows infants both to hold objects and to let them go voluntarily. A novel
object may elicit purposeful, although inefficient, reaching. (Chapter 8, Nelson’s 18th edition)
28. Object permanence
a. 6 months
b. 9 months
c. 12 months
d. 16 months
B
A major milestone is the achievement at about 9 mo of object permanence (constancy), the
understanding that objects continue to exist, even when not seen. (Chapter 8, Nelson’s 18th edition)
29. HC at 18 months old increased by
a. 4
b. 6
c. 8
d. 12
D
By the 1st birthday, birth weight has tripled, length has increased by 50%, and head circumference has
increased by 10 cm… The growth rate slows further in the 2nd yr of life (see Table 14-1 ) and appetite declines.
Toddlers have relatively short legs and long torsos, with exaggerated lumbar lordosis and protruding abdomens.
Brain growth, with continuing myelinization, results in an increase in head circumference of 2 cm over the year.
(Chapter 8 and 9, Nelson’s 18th edition)
30. Homosexuality is related to:
a. genetic predisposition
b. abnormal parenting
c. traumatic experience
d. sexual abuse
A
The clustering of homosexuality within some families has long been recognized. Compared with dizygotic
twins, the greater concordance of homosexuality in monozygotic twins highlights the role of genetic constitution…
Well-designed studies have not found differences in the familial and social backgrounds of homosexual and
heterosexual men and women, nor any evidence that homosexuality is related to abnormal parenting, sexual
abuse, or other traumatic events. (Chapter 13.3, Nelson’s 18th edition)
31. Most commonly measured developmental delay
a. socio-emotional
b. learning disabilities
c. speech language impairment
d. autism
B?
Sarsi: I can’t find anything that says “most commonly measured developmental delay” but here’s what I
found… Dyslexia is the most common and most comprehensively studied of the learning disabilities, affecting at
least 80% of children identified as manifesting learning disabilities. (Chapter 32, Nelson’s 18th edition)
32. Handedness is seen at
a. 12
b. 24
c. 36
d. 48
C
Handedness is usually established by the 3rd yr. Frustration may result from attempts to change children's
hand preference. Variations in fine motor development reflect both individual proclivities and different
opportunities for learning. Children who are seldom allowed to use crayons, for example, develop a mature pencil
grasp later. (Chapter 10, Nelson’s 18th edition)
33. 3 years old who drops down 2 percentiles or more down
a. acute malnutrition
b. chronic malnutrition
c. nakalimutan ko
d. failure to thrive
D
The diagnosis of failure to thrive (see Chapter 37 ), usually a diagnosis of children under 3 yr of age, is
considered if a child's weight is below the 5th percentile, if it drops down more than two major percentile lines, or
if weight for height is less than the 5th percentile. Weight for height below the 5th percentile remains the single
best growth chart indicator of acute undernutrition. A BMI less than the 5th percentile also indicates that a child is
underweight. Brief periods of weight loss or poor weight gain are usually rapidly corrected and do not permanently
affect size. Children who have been chronically malnourished may be short as well as thin, so that their weight-forheight curves may appear relatively normal. Chronic, severe undernutrition in infancy may depress head growth,
an ominous predictor of later cognitive disability. (Chapter 14, Nelson’s 18th edition)
34. True about OSA
a. tonsilloadeniodal hypertrophy is pathognomonic
b. PSG is the gold standard
c. nasal dilator and steroids can relieve obstruction
B
The most common risk factor for childhood OSA is adenotonsillar hypertrophy…. There are no physical
examination findings that are pathognomonic for OSA, and most healthy children with OSA appear normal;
however, certain physical examination findings may suggest OSA.... Because no combination of clinical history and
physical findings can accurately predict which children with snoring have OSA, the gold standard for diagnosing
OSA is an overnight polysomnogram. (Chapter 18, Nelson’s 18th edition)
35. Hepatitis B vaccine for preterm 1.8kg born to HBsAg+ mother
a. 0,1,6
b. 0, 2, 4
c. 0, 2, 4, 6
d. 0, 2, 6, 12
C
Preterm infants generally can be vaccinated at the same chronologic age as full-term infants according to
the recommended childhood immunization schedule. An exception is the birth dose of HepB vaccine. Infants
weighing ≥2 kg and who are stable may receive a birth dose. However, HepB vaccination should be deferred in
infants weighing <2 kg at birth until 30 days of age, if born to an HBsAg-negative mother. All preterm, low birth
weight infants born to HBsAg-positive mothers should receive HepB IG and HepB vaccine within 12 hr of birth.
However, such infants should receive an additional 3 doses of vaccine starting at 30 days of age.(Chapter 170,
Nelson’s 18th edition and Prev Ped)
36. DPT vaccination for 8 years old if completely immunized
a. DPT
b. Tdap
c. Td
B?
Sars: This is one weird question. I’ll just assume that the kid is not completely immunized and go ahead to
say that for this age group, you can give Tdap. “Children and adolescents 7-18 years of age who are not fully
immunized with DPT vaccine should be given a single dose of Tdap. The remaining doses are given as Td.” (PPS
Preventive Pediatrics Handbook 2012)
37. Viral Shedding for Congenital Rubella Syndrome
a. no need to isolate
b. isolate for 1 month
c. isolate for 1 year
C
Children with CRS may excrete the virus in respiratory secretions up to 1 yr of age and should be
maintained in contact precautions until then unless repeated cultures of urine and pharyngeal secretions are
negative. (Chapter 244, Nelson’s 18th edition)
38. interval for varicella vaccine between 12 months and 12 years
a. 1 month
b. 2 months
c. 3 months
d. 6 months
C
The 1st dose of the vaccine is administered from age 12 to 15 month. The 2nd dose is administered at 4-6
years or at an earlier age provided the interval between the 1st and 2nd dose is at least 3 months. (PPS Preventive
Pediatrics Handbook 2012)
39. Varicella Ig is given to
a. newborns born to mother with varicella infection
b. exposed to playmate for 5 minutes
c. nakalimutan ko
d. born to mother with varicella infection within 5 days of delivery
C
High-titer anti-VZV immune globulin as postexposure prophylaxis is recommended for
immunocompromised children, pregnant women, and newborns exposed to maternal varicella… Newborns whose
mothers develop varicella 5 days before to 2 days after delivery should receive 1 vial of VariZIG. VariZIG is also
indicated for pregnant women, premature infants <28 wk of gestation (<1,000 g) who were exposed to varicella,
and premature infants >28 wk of gestation who are exposed to varicella and whose mother has no evidence of
varicella immunity… Close contact between a susceptible high-risk patient and a patient with herpes zoster is also
an indication for VariZIG prophylaxis. Passive antibody administration or treatment does not reduce the risk for
herpes zoster or alter the clinical course of varicella or herpes zoster when given after the onset of symptoms.
(Chapter 250, Nelson’s 18th edition)
40. For a patient with disseminated intravascular coagulopathy
a. vitamin k, ffp, plt concentrate
b. ffp, activated c protein
c. activated c protein, low molecular weight heparin
d. low molecular weight heparin, ffp
A
The first 2 steps in the treatment of DIC are the most critical: (1) treat the trigger that caused DIC and (2)
restore normal homeostasis by correcting the shock, acidosis, and hypoxia that usually complicate DIC. If the
underlying problem can be controlled, bleeding quickly ceases, and there is improvement of the abnormal
laboratory findings. Blood components are used for replacement therapy in patients with hemorrhage. This may
consist of platelet infusions (for thrombocytopenia), cryoprecipitate (for hypofibrinogenemia), and/or fresh frozen
plasma (for replacement of other coagulation factors and natural inhibitors). (Chapter 483, Nelson’s 18th edition)
Table 68-11 (Chapter 68, Nelson’s 18th edition)
System
Disorder
Goals
Hematologic Coagulopathy (DIC) Prevent/treat:bleeding
Therapies
Vitamin K
Fresh frozen plasma
Platelets
Thrombosis
Prevent/treat:abnormal clotting Heparinization
Activated protein C
41. decreased perfusion is characterized by
a. dec HR, dec peripheral pulses, dec bp
b. dec HR, dec peripheral pulses, inc BP
c. inc HR, dec peripheral pulses, dec BP
d. inc HR, dec peripheral pulses, inc BP
C
(Chapter 68, Nelson’s 18th edition)
TABLE 68-7 -- Signs of Decreased Perfusion
ORGAN SYSTEM
↓PERFUSION
↓↓PERFUSION
↓↓↓PERFUSION
Central nervous
system
—
Restless, apathetic, anxious
Agitated/confused, stuporous, coma
Respiration
—
↑Ventilation
↑↑Ventilation
Metabolism
—
Compensated metabolic
acidemia
Uncompensated metabolic acidemia
ORGAN SYSTEM
Gut
Kidney
↓PERFUSION
↓↓PERFUSION
↓↓↓PERFUSION
—
↓Motility
Ileus
↓Urine volume
Oliguria (<0.5 mL/kg/hr)
Oliguria/anuria
Delayed capillary
refill
Cool extremities
Mottled, cyanotic, cold extremities
↑Heart rate
↑↑Heart rate
↑↑Heart rate, ↓blood pressure,
central pulses only
↑Urinary specific
gravity
Skin
Cardiovascular
system
↓Peripheral pulses
42. teenage female presented with a mass at the back of the knee. Mass described to be firm, non-tender,
and most prominent when extended. No history of infection. Diagnosis?
a. popliteal cyst
b. Osgood schlatter
c. malignancy
d. rickets
A
The usual presentation is that of a mass behind the knee that may be fairly large when first noted. There
are usually no symptoms of internal derangement of the knee. Physical examination reveals a firm mass in the
popliteal fossa, often medially located and usually distal to the popliteal crease. The mass is most prominent when
the knee is extended and the patient is lying in prone position. (Chapter 676.2, Nelson’s 18th edition)
43. school-aged patient presents with difficulty reading books due to droopy eyelids. Mother also noted that
recently, the patient also has some difficulty swallowing. What would be the best test to determine her
diagnosis?
a. EMG
b. Muscle biopsy
c. Nakalimutan ko
d. Antibody titer to Ach
A
Myasthenia gravis is 1 of the few neuromuscular diseases in which electromyography (EMG) is more
specifically diagnostic than a muscle biopsy. A decremental response is seen in response to repetitive nerve
stimulation; the muscle potentials diminish rapidly in amplitude until the muscle becomes refractory to further
stimulation… Anti-ACh antibodies should be assayed in the plasma but are inconsistently demonstrated. (Chapter
611.1, Nelson’s 18th edition)
44. A father refused a diagnostic procedure due to a cultural belief. You would:
a. Respect the father’s decision
b. Report the father to the Child Protection Network
c. Talk to the grandparents and ask them to help make a decision
d. Do the procedure anyway
45. Consent is least like to be obtained from:
a. Guardian who is not related to the patient
b. Elder sibling who is >21 years old
c. grandparents
d. nakalimutan ko na.
46. A patient was diagnosed to have SIADH. What would you do?
a.
b.
c.
d.
Fluid restriction
Vasopressin
Fluid administration
Diuretics
47. A patient who has a brain tumor now presents with hyponatremia, polyuria, and hypovolemia. Upon
workup, he was noted to have urine Na >150 mg/dl. What is the diagnosis?
a. Cerebral Salt Wasting
48. What is the best diagnostic clue to hypopituitarism?
a. Microphallus
b. Nakalimutan ko na yun ibang choices
49. A 6 month old patient presents with generalized hypotonia. What would be the best laboratory workup to
aid in making a diagnosis?
a. EMG
b. Muscle biopsy
c. Enzyme levels
50. A patient you diagnosed with pneumonia still has not improved even after 3 days of antibiotics. What
would you not do?
a. Change the initial antibiotics
b. Consider another diagnosis
c. Start a macrolide
d. Refer to a specialist
51. A patient presents with anemia, frontal bossing, maxillary hyperplasia and splenomegaly. What is your
diagnosis?
a. Spherocytosis
b. Aplastic anemia
c. Thalassemia
d. Fanconi Anemia
52. Which of the following will present with decreased pulmonary vascular markings on CXR?
a. Pulmonary atresia
b. TGA
c. Nakalimutan ko na yun ibang choices
53. In a patient who presents with hematuria secondary to ureteral bleeding, you would expect?
a. Normal RBC morphology
b. As
54. A patient presents with high grade fever refractory to antibiotics. If you suspect pyelonephritis, what
laboratory/diagnostic will aid you best?
a. DMSA scan
b.
55. A 4 year old patient presents at your ER with focal seizures, anisocoria and increased intracranial
pressure. BP was taken and revealed values of 130/90. What would you include in your laboratory work
up?
a. Cranial CT scan
b. Lumbar puncture
c. EEG
56. A patient with CKD is admitted to the ER. Among the laboratory results that returned was K = 6.7 mg/dl.
What medication will you give to shift the potassium to the intracellular space?
a. Salbutamol
b. Kayexalate
c. I forgot
57. A 1 year old patient is suspected to have asthma. What is the best way to diagnose this patient?
a. Spirometry
b. History and PE
c. PEFR
58. A patient presents with diarrhea with dehydration. What fluids should you NOT use?
a. Plain NSS
b. Plain LR
c. 0.45 NSS
d. Maintenance
59. Characteristics of tension pneumothorax:
a. Decreased breath sounds ipsilaterally, trachea deviated ipsilaterally, hyperresonant affected side
b. Decreased breath sounds ipsilaterally, trachea deviated ipsilaterally, hyperresonant affected side
c. Decreased breath sounds more ipsilaterally than contralaterally, trachea deviated contralaterally,
distended neck veins, normal heart tones
d. Decreased breath sounds ipsilaterally, trachea deviated contralaterally, hyporesonant affected
side
e. Decreased breath sounds more ipsilaterally than contralaterally, trachea deviated contralaterally,
flat neck veins, normal heart tones
B
In complicated, or tension, pneumothorax, continuing leak causes increasing positive pressure in the
pleural space, with further compression of lung, shift of mediastinal structures toward the contralateral side,
decreased venous return, and decreased cardiac output... Usually, there is respiratory distress, retractions, and
markedly decreased breath sounds over the involved lung. The percussion note over the involved area is
tympanitic. The larynx, trachea, and heart may be shifted toward the unaffected side. (Chapter 410, Nelson’s 18th
edition)
60. Atelectasis will present as:
a. Mediastinal shift to ipsilateral side
b. Forgot the other choices
A
Symptoms vary with the cause and extent of the atelectasis. A small area is likely to be asymptomatic.
When a large area of previously normal lung becomes atelectatic, especially when it does so suddenly, dyspnea
accompanied by rapid shallow respirations, tachycardia, cough, and often cyanosis occurs. If the obstruction is
removed, the symptoms disappear rapidly. Although it was once believed that atelectasis alone can cause fever,
studies have shown no association between atelectasis and fever. Physical findings include limitation of chest
excursion, decreased breath sound intensity, and coarse crackles. Breath sounds are decreased or absent over
extensive atelectatic areas. Massive pulmonary atelectasis usually presents with dyspnea, cyanosis, and
tachycardia. An affected child is extremely anxious and, if old enough, complains of chest pain. The chest appears
flat on the affected side, where decreased respiratory excursion, dullness to percussion, and feeble or absent
breath sounds are also noted. Postoperatively atelectasis usually presents within 24 hr after operation but may not
occur for several days. Massive pulmonary atelectasis is generally diagnosed by chest radiograph. Typical findings
include elevation of the diaphragm, narrowing of the intercostal spaces, and displacement of the mediastinal
structures and heart toward the affected side. (Chapter 407, Nelson’s 18th edition)
61. Paralytic shellfish poisoning is due to what toxin?
a. Okaic acid
b. Saxitoxin
c. Shiga toxin
d. Verotoxin
Filter-feeding mollusks, such as the black mussel and sea scallop, may become contaminated during
dinoflagellate blooms or “red tides.” The dinoflagellate Ptychodiscus brevis often is responsible for these red tides
and contains several potent neurotoxins... Saxitoxin is the most potent of the neurotoxins responsible for paralytic
shellfish poisoning. This toxin prevents conduction by inhibiting the sodium-potassium pump. (Chapter 710.3,
Nelson’s 18th edition)
62. A 2 year old patient was noted to initially have high grade fever and irritability. After the fever lysed, the
patient was seen to have coughing episodes. A few days later, the cough worsened such that the patient
was seen to have coughing bouts followed by cyanosis. What medications will you give the patient?
a. Clarithromycin 15 mg/kg
b. Amoxicillin
c. Clindamycin
A
(Table 194-2 Chapter 194, Nelson’s 18th edition)
TABLE 194-2 -- Recommended Antimicrobial Treatment and Postexposure Prophylaxis for Pertussis, by Age
Group
PRIMARY AGENTS
ALTERNATE AGENT[*]
AGE GRP
Azithromycin
Erythromycin
Clarithromycin
TMP-SMZ
<1 mo
Recommended agent. 10
mg/kg/day in a single dose
for 5 days (only limited
safety data available)
Not preferred.
Erythromycin is
associated with
infantile hypertrophic
pyloric stenosis.
Not recommended
(safety data
unavailable)
Contraindicated for
infants aged <2 mo
(risk for kernicterus)
15 mg/kg/day in 2
divided doses for 7
days
Contraindicated at age
<2 mo For infants aged
≥2 mo.
Use if azithromycin is
unavailable; 40–50
mg/kg/day in 4 divided
doses for 14 days.
1–5 mo
10 mg/kg/day in a single
dose for 5 days
40–50 mg/kg/day in 4
divided doses for 14
days.
TMP 8 mg/kg/day, SMZ
40 mg/kg/day in 2
divided doses for 14
days
Infants
(aged ≥6
mo) and
children
10 mg/kg in a single dose
on day 1 then 5 mg/kg/day
(maximum 500 mg) on
days 2–5
40–50 mg/kg/day
(maximum 2 g/day) in 4
divided doses for 14
days.
Adults
500 mg in a single dose on 2 g/day in 4 divided
day 1 then 250 mg/day on doses for 14 days.
15 mg/kg/day in 2
divided doses
(maximum 1 g/day)
for 7 days
TMP 8 mg/kg/day, SMZ
40 mg/kg/day in 2
divided doses for 14
days
1 g/day in 2 divided
doses for 7 days
TMP 320 mg/day, SMZ
1,600 mg/day in 2
ALTERNATE AGENT[*]
PRIMARY AGENTS
AGE GRP
Azithromycin
Erythromycin
Clarithromycin
days 2–5
TMP-SMZ
divided doses for 14
days
From Centers for Disease Control and Prevention: Recommended antimicrobial agents for treatment and
postexposure prophylaxis of pertussis. 2005 CDC Guidelines. MMWR 2005;54:1–16.
63. Koplik spots appear when?
a. At the start of the fever
b. Prior to appearance of rash
c. Upon disappearance of rash
d. Upon disappearance of fever
B
The enanthem, Koplik spots, is the pathognomonic sign of measles and appears 1 to 4 days prior to the
onset of the rash ( Fig. 243-3 ). They first appear as discrete red lesions with bluish white spots in the center on the
inner aspects of the cheeks at the level of the premolars. They may spread to involve the lips, hard palate, and
gingiva. They also may occur in conjunctival folds and in the vaginal mucosa. Koplik spots have been reported in
50–70% of measles cases but probably occur in the great majority. (Chapter 243, Nelson’s 18th edition)
B
64. Oysters, nuts, liver, margarine, legumes, and corn oil all contain this trace element:
a. Iodide
b. copper
c. Molybdenum
d. Zinc
(Table 51-1, Nelson’s 18th edition)
EFFECTS OF DEFICIENCY
EFFECTS OF EXCESS
DIETARY
SOURCES
ELEMENT
PHYSIOLOGY
Chromium
Potentiates the action Impaired glucose tolerance,
of insulin
peripheral neuropathy and
encephalopathy
Unknown
Meat, brewer's
yeast
Copper
Absorbed via specific
intestinal transporter;
circulates bound to
ceruloplasmin;
enzyme cofactor
(superoxide
dismutase,
cytochrome oxidase,
and enzymes involved
in iron metabolism
and connective tissue
formation)
Microytic anemia,
osteoporosis, neutropenia,
neurologic symptoms,
depigmentation of hair and
skin
Acute: nausea, emesis,
abdominal pain, coma,
and hepatic necrosis;
chronic toxicity (liver and
brain injury) occurs in
Wilson disease and
another genetic disorder
(see Chapters 354.2 and
354.3 ) and secondary to
excess intake (see
Chapter 354.4 )
Oysters, nuts,
liver,
margarine,
legumes, corn
oil
Fluoride
Incorporated into
bone
Dental caries (see Chapter
309 )
Chronic: dental fluorosis Toothpaste,
water (see Chapter 304 ) fluoridated
water
Iodine
Component of thyroid Hypothyroidism (see Chapters Hypothyroidism and
Saltwater fish,
hormone (see Chapter 567 and 569.2 )
goiter (see Chapters 566 iodized salt
565 )
and 568 ); maternal
ELEMENT
PHYSIOLOGY
EFFECTS OF DEFICIENCY
EFFECTS OF EXCESS
DIETARY
SOURCES
excess may cause
congenital
hypothyroidism and
goiter (see Chapter
569.1 )
Iron
Component of
hemoglobin,
myoglobin,
cytochromes, and
other enzymes
Anemia (see Chapter 455 ),
Acute (see Chapter 58 ):
decreased alertness, impaired nausea, vomiting,
learning
diarrhea, abdominal
pain, and hypotension;
chronic excess usually
secondary to hereditary
disorders (see Chapter
462.9 and 354.5 );
causes organ
dysfunction
Deficiency may
also result from
blood loss
(hookworm
infestation,
menorrhagia)
Manganese
Enzyme cofactor
Hypercholesterolemia, weight Neurologic
loss, decreased clotting
manifestations,
proteins
cholestatic jaundice
Nuts, grains, tea
Molybdenum Enzyme cofactor
Tachycardia, tachypnea, night Hyperuricemia and
(xanthine oxidase and blindness, irritability, coma
increased risk of gout
others)
Legumes,
grains, liver
Selenium
Enzyme cofactor
(prevents oxidative
damage)
Cardiomyopathy (Keshan
disease), myopathy
Nausea, diarrhea,
Meat, seafood,
neurologic
whole grains,
manifestations, nail and garlic
hair changes, garlic odor
Zinc
Enzyme cofactor;
constituent of zinc
finger proteins, which
regulate gene
transcription
Decreased growth, dermatitis
of extremities and around
orifices, impaired immunity,
poor wound healing,
hypogonadism, diarrhea;
supplements beneficial in
diarrhea and improve
neurodevelopmental
outcomes
Abdominal pain,
diarrhea, vomiting; may
worsen copper
deficiency
Meat, shellfish,
whole grains,
legumes,
cheese
65. Patient presented with anal pruritus at night. Diagnosis?
a. Enterobius
A
The cause of enterobiasis, or pinworm infection, is Enterobius vermicularis. Pinworm infection is innocuous
and rarely causes serious medical problems. The most common complaints include itching and restless sleep
secondary to nocturnal perianal or perineal pruritus. The precise cause and incidence of pruritus are unknown.
They may be related to the intensity of infection, psychologic profile of the infected individual and his or her family,
or allergic reactions to the parasite. Eosinophilia is not observed in most cases because tissue invasion does not
occur. Aberrant migration to ectopic sites occasionally may lead to appendicitis, chronic salpingitis, pelvic
inflammatory disease, peritonitis, hepatitis, and ulcerative lesions in the large or small bowel. (Chapter 291,
Nelson’s 18th edition)
66. Patient presented with nonbilious vomiting, abdominal pain, and epigastric mass. Diagnosis?
a. Pyloric stenosis
b. Duodenal atresia
c. Intussusceptions
A
Nonbilious vomiting is the initial symptom ofpyloric stenosis. The vomiting may or may not be projectile
initially but is usually progressive, occurring immediately after a feeding. Emesis may follow each feeding, or it
may be intermittent. The vomiting usually starts after 3 wk of age, but symptoms may develop as early as the 1st
wk of life and as late as the 5th mo. After vomiting, the infant is hungry and wants to feed again…. Jaundice
associated with a decreased level of glucuronyl transferase is seen in ≈5% of affected infants. The indirect
hyperbilirubinemia usually resolves promptly after relief of the obstruction. The diagnosis has traditionally been
established by palpating the pyloric mass. The mass is firm, movable, ≈2 cm in length, olive shaped, hard, best
palpated from the left side, and located above and to the right of the umbilicus in the mid epigastrium beneath the
liver edge. In healthy infants, feeding can be an aid to the diagnosis. After feeding, there may be a visible gastric
peristaltic wave that progresses across the abdomen. After the infant vomits, the abdominal musculature is more
relaxed and the “olive” easier to palpate. The diagnosis can be established clinically 60–80% of the time by an
experienced examiner. (Chapter 326, Nelson’s 18th edition)
C
67. Initial steps in managing upper airway obstruction:
a. Inspect for presence of a foreign body
b. Do finger sweep and suctioning
c. Open airway by head tilt-chin lift maneuver
d. Suction nose and mouth
Interventions included in initial management of respiratory distress or failure for airway:
1)Support an open airway (allow child to assume position of comfort) or, if necessary, open the airway with
head tilt-chin lift or jaw thrust without head tilt if cervical spine injury is suspected.
2)Clear the airway if indicated (eg. Suction nose and mouth, remove visualized foreign body).
3)Consider an oropharyngeal airway or nasopharyngeal airway to improve airway patency. (Part 5, PALS 2011)
68. A 4 month old infant with a right cheek mass was brought to the clinic. At birth, the mass started as a pale
area, eventually developing a fine telangiectatic pattern, and is now gradually enlarging. The mass is
bright red and sharply demarcated. What is the diagnosis?
a. Sturge – Weber syndrome
b. Hemangioma
c. NF
d. forgot
B
Hemangiomas are proliferative hamartomas of vascular endothelium that may be present at birth or,
more commonly, become apparent in the 1st 2 mo of life, predictably enlarge, and then spontaneously involute.
Hemangiomas are the most common tumor of infancy, occurring in 1–2% of newborns and 10% of white infants in
the 1st yr of life... Superficial hemangiomas are bright red, protuberant, compressible, sharply demarcated lesions
that may occur on any area of the body. Although sometimes present at birth, they more often appear in the 1st 2
mo and are heralded by an erythematous or blue mark or an area of pallor, which subsequently develops a fine
telangiectatic pattern before the phase of expansion. (Chapter 649, Nelson’s 18th edition)
69. Individual with cafe au lait spots increasing in size since birth, axillary freckling, and iris Lisch nodules.
Neurologic complications include cognitive abnormalities and seizures. What is the diagnosis?
a. Sturge-Weber syndrome
b. Tuberous sclerosis
c. Neurofibromatosis
d. Forgot
C
NF-1 is the most prevalent type, with an incidence of 1/4,000, and is diagnosed when any two of the
following seven signs are present: (1) six or more café au-lait macules over 5 mm in greatest diameter in
prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals. (2) Axillary or inguinal
freckling consisting of multiple hyperpigmented areas 2–3 mm in diameter. (3) Two or more iris Lisch nodules. (4)
Two or more neurofibromas or one plexiform neurofibroma. (5) A distinctive osseous lesion such as sphenoid
dysplasia (which may cause pulsating exophthalmos) or cortical thinning of long bones with or without
pseudoarthrosis. (6) Optic gliomas are present in ≈15% of patients with NF-1.
Children with NF-1 are susceptible to neurologic complications. Cognitive abnormalities are common and occur in
40–60% of NF-1 children. Complex partial and generalized tonic-clonic seizures are a frequent complication.
(Chapter 596.1, Nelson’s 18th edition)
70. Question on Revised Trauma Score (Table 71-3, Nelson’s 18th edition)
REVISED TRAUMA
GLASGOW COMA SCALE SYSTOLIC BLOOD PRESSURE
SCORE
SCORE
(MM HG)
RESPIRATORY RATE
(BREATHS/MIN)
4
13–15
>89
10–20
3
9–12
76–89
>29
2
6–8
50–75
6–9
1
4–5
1–49
1–5
0
3
0
0
* A score of 0–4 is given for each variable, then added (range, 1–12). A score ≤11 indicates potentially important
trauma.
71. Which is the most appropriate pairing for management of organ system dysfunction in shock?
a. Hematologic – coagulopathy: heparinization
b. GI – prevent / treat gastrointestinal bleeding: early enteral feeds
c. Respiratory – prevent barotrauma; PEEP
d. Endocrine – prevent / treat adrenal insufficiency; stress dose steroids
D
(Table 68-11, Nelson’s 18th edition)
SYSTEM
DISORDERS
GOALS
THERAPIES
Respiratory
Oxygen
Acute respiratory
distress syndrome
Prevent/treat:hypoxia and
respiratory acidosis
Respiratory muscle Prevent barotrauma
fatigue
Early endotracheal intubation and
mechanical ventilation
Central apnea
PEEP
Decrease work of breathing
Permissive hypercapnia
High-frequency ventilation
ECMO
Renal
Prerenal failure
Prevent/treat:
hypo/hypervolemia,
hyperkalemia, metabolic
acidosis, hyper/hponatremia,
and hypertension
Establish normal urine output
and BP for age
Hematologic
Coagulopathy (DIC) Prevent/treat:bleeding
Judicious fluid resuscitation
Monitoring of serum electrolytes
Low dose dopamine
Furosemide (Lasix)
Dialysis, ultrafiltration, hemofiltration
Vitamin K
Fresh frozen plasma
Platelets
Thrombosis
Prevent/treat:abnormal clotting
Heparinization
Activated protein C
Gastrointestinal Stress ulcers
Ileus
Prevent/treat:gastric bleeding
H2-blocking agents or proton pump
inhibitors
Avoid aspiration, abdominal
distention
Nasogastric tube
Avoid mucosal atrophy
Early enteral feedings
Prevent/treat:adrenal crisis
Stress dose steroids in patients
previously given steroids
Bacterial
translocation
Endocrine
Adrenal
insufficiency
primary or
secondary
to chronic steroid
therapy
Physiologic dose for presumed
primary insufficiency in sepsis
Metabolic
Metabolic acidosis
Correct etiology
Treatment of hypovolemia (fluids),
poor cardiac function
(fluids, inotropic agents)
Normalize pH
Improvement of renal acid excretion
Low-dose (0.5–2 mEq/kg) sodium
bicarbonate if the patient is not
responding and pH < 7.1 and
ventilation (CO2 elimination) is
adequate
73. Patient came in your clinic with pallor which was noted for more than a year. On PE, you noticed he has
hyperpigmentation of the skin, hypoplastic thumb and short stature. Laboratory work-up showed Hb 88,
Hct 0.24, wbc 2.1, platelet 36. Your initial impression is?
a. ALL
b. Fanconi Anemia
c. Thalassemia
d. Lymphoma
B
The most common anomaly is hyperpigmentation of the trunk, neck, and intertriginous areas, as well as
café-au-lait spots and vitiligo, alone or in combination ( Fig. 468-1 and Table 468-2 ). Most patients have short
stature. Growth failure may be associated with abnormal growth hormone secretion, or with hypothyroidism.
Absent radii and hypoplastic, supernumerary, bifid, or absent thumbs are common. Anomalies of the feet,
congenital hip dislocation, and leg abnormalities are seen. Males may have an underdeveloped penis;
undescended, atrophic, or absent testes; and hypospadias or phimosis. Females can have malformations of the
vagina, uterus, and ovary. Many patients have a Fanconi “facies,” including microcephaly, small eyes, epicanthal
folds, and abnormal shape, size, or positioning of the ears (see Fig. 468-1 ). Approximately 10% of patients are
mentally retarded. Ectopic, pelvic, or horseshoe kidneys are detected by imaging, as well as duplicated,
hypoplastic, dysplastic, or absent organs… Marrow failure usually ensues in the 1st decade of life.
Thrombocytopenia often appears initially, with subsequent onset of granulocytopenia and then macrocytic
anemia. Severe aplasia develops in most cases, but its full expression is variable and evolves over a period of mo to
yr. The marrow becomes progressively hypocellular and fatty, similar to severe acquired aplastic anemia. (Chapter
468, Nelson’s 18th edition)
74. For how long can breast milk be stored in a 2-door refrigerator?
a. 8hrs
b. 2 days
c. 3 weeks
d. 4 days
C (?) Recommended breastmilk storage period (PPS Prev Ped):
Room temp (<25C)
4 hours
Room temp (>25C)
1 hour
Refrigerator (4C)
8 days
Freezer compartment of 1-door ref
2 weeks
Freezer compartment of 2-door ref
3 months
Deep freezer with constant temp (-20C)
6 months
75. A 2 year old female came in to your clinic with-----. Family history showed male siblings with unusual
facies, and heart disease. On CXR you notice absent thymus, infiltrates both lung fields, cardiomegaly.
Initial consideration is?
a. DiGeorge
b. Duncan
c. Ataxia Telangectasia
d. Hyper IgM syndrome
A
DiGeorge syndrome occurs in both males and females. Microdeletions of specific DNA sequences from
chromosome 22q11.2, the DiGeorge chromosomal region (DGCR), are found in a majority of cases. Several
candidate genes have been identified in this region. A T-box transcription family member, TBX1, has been
implicated as an etiology for most of the major signs of DGS. There appears to be an excess of 22q11.2 deletions of
maternal origin. Polymerase chain reaction (PCR)–based genotyping using microsatellite DNA markers located
within the commonly deleted region permits rapid detection of such microdeletions. Conotruncal heart defects and
22q deletions are observed in DiGeorge syndrome, velocardiofacial syndrome (VCFS), and conotruncal anomaly
face syndrome (CTAFS). The CATCH 22 syndrome (cardiac, abnormal facies, thymic hypoplasia, cleft palate,
hypocalcemia) includes the broad clinical spectrum of conditions with 22q11.2 deletions. Other deletions
associated with DiGeorge and velocardiofacial syndromes have been identified on chromosome 10p13 (Chapter
124, Nelson’s 18th edition).
76. An infant came in for fever, cough and colds. On history you noted that its is the 6 th time they sought
consult with the same problem and was admitted for 4 times within a year. On PE you noticed nasal
congestion, non palpable lymph nodes, rales on both lung fields. What is yo impression?
a. IgA deficiency
b. Agammaglobinemia
c. Wiskott Aldrich
d. Severe combined immunodeficiency
B
Patients with X-linked agammaglobulinemia (XLA), or Bruton agammaglobulinemia, have a profound
defect in B-lymphocyte development resulting in severe hypogammaglobulinemia, an absence of circulating B
cells, small to absent tonsils, and no palpable lymph nodes… Most boys afflicted with XLA remain well during the
1st 6–9 mo of life by virtue of maternally transmitted IgG antibodies. Thereafter, they acquire infections with
extracellular pyogenic organisms, such as Streptococcus pneumoniae and Haemophilus influenzae, unless they are
given prophylactic antibiotics or immunoglobulin therapy. Infections include sinusitis, otitis media, pneumonia, or,
less often, sepsis or meningitis. (Chapter 123, Nelson’s 18th edition)
77. A 3 year old male came in for recurrent ear infection. Her mother also complained of recurrent rashes
which her previous doctor diagnosed as atopic dermatitis. On PE there were ear discharge on both ear,
matted lymph nodes, nasal discharge and petechiae. What is your diagnosis?
a. Chediak Higashi
b. Duncan
c. Hyper IgM syndrome
d. Wiskott Aldrich
D
Wiskott-Aldrich syndrome, an X-linked recessive syndrome, is characterized by atopic dermatitis,
thrombocytopenic purpura with normal-appearing megakaryocytes but small defective platelets, and undue
susceptibility to infection… Patients often have prolonged bleeding from the circumcision site or bloody diarrhea
during infancy. The thrombocytopenia is not initially due to antiplatelet antibodies. Atopic dermatitis and
recurrent infections usually develop during the 1st year of life. Streptococcus pneumoniae and other bacteria
having polysaccharide capsules cause otitis media, pneumonia, meningitis, and sepsis. Later, infections with
agents such as P. carinii (jiroveci) and the herpesviruses become more frequent. Survival beyond the teens is rare;
infections, bleeding, and EBV-associated malignancies are major causes of death. (Chapter 125, Nelson’s 18th
edition)
78. A girl with micturition will resolve on what age?
a. 3
b. 4
c. 5
d. 6
B
Bowel and bladder control emerge during this period, with “readiness” for toileting having large
individual and cultural variation. Girls tend to train faster and earlier than boys. Bed-wetting is normal up to age 4
yr in girls and age 5 yr in boys (see Chapters 22.3 and 543 ). Many children master toileting with ease, particularly
once they are able to verbalize their bodily needs. For others, toilet training can involve a protracted power
struggle. Refusal to defecate in the toilet or potty is relatively common and can lead to constipation and parental
frustration. Defusing the issue with a temporary cessation of training (and a return to diapers) often allows toilet
mastery to proceed. (Chapter 10, Nelson’s 18th edition)
79. A defect of complement function should be considered in any patient with
a. Pneumococcal
b. Aspergilosis
c. Neisseria
d. Burkholderia
C (Table 133-1, Nelson’s 18th edition)
TABLE 133-1 -- Genetic Deficiencies of Plasma Complement Components and Associated Clinical Findings
INFECTION[*]
AUTOIMMUNE DISEASE[*]
DEFICIENT
COMPONENT
Very Common
Common
Very
Common Common
Occasional
Pneumococcal
B/M, other
pyogenic
SLE
DV/DLE
Pneumococcal
B/M, DGI
SLE
Occasional
CLASSICAL PATHWAY
C1q
C1rs
Other pyogenic
GN
GN
INFECTION[*]
DEFICIENT
COMPONENT
Very Common
AUTOIMMUNE DISEASE[*]
Common
Occasional
Very
Common Common
C4
Other pyogenic
SLE
C2
Other pyogenic,
pneumococcal B/M,
meningococcal M
SLE, GN,
DV/DLE,
other AD
Pneumococcal B/M,
meningococcal M
GN,
DV/DLE
Occasional
GN, other
AD
C3
Other pyogenic
C5
Meningococcal M DGI
Other pyogenic
SLE, GN
C6
Meningococcal M DGI
Other pyogenic
SLE, GN,
other AD
C7
Meningococcal M
DGI, other
pyogenic
C8
Meningococcal M DGI
Other pyogenic
SLE, GN
MBL
Other pyogenic,
fungal, HIV
SLE
MASP-2
Pneumococcal
pneumonia
SLE
C9
SLE, other
AD
SLE, other
AD
Meningococcal M
LECTIN PATHWAY
ALTERNATIVE PATHWAY
Factor D
DGI,
meningococcal M,
other pyogenic
CONTROL PROTEINS
C1 INH
Hereditary
angioedema[†]
Factor I
Other pyogenic,
meningococcal M
SLE
Pneumococcal B/M
Factor H
Meningococcal B/M Other pyogenic
GN, HUS
Properdin
Meningococcal M
DV/DLE
C4-binding
protein
Pneumococcal
B/M, other
pyogenic
SLE
Other AD
B/M, Bacteremia or meningitis; DGI, disseminated gonococcal infection; DV/DLE, dermal vasculitis or typical
discoid lupus erythematosus; GN, glomerulonephritis in various forms, often membranoproliferative; HIV, human
immunodeficiency virus; HUS, hemolytic-uremic syndrome; M, meningitis; MASP, MBL-associated serine protease;
MBL, mannose-binding lectin; other AD, autoimmune disease (almost all possible diagnoses have been reported);
INFECTION[*]
DEFICIENT
COMPONENT
Very Common
AUTOIMMUNE DISEASE[*]
Common
Occasional
Very
Common Common
Occasional
other pyogenic, serious deep or systemic infection due to, or typically caused by, a pyogenic bacterium (abscess,
osteomyelitis, pneumonia, bacteremia other than pneumococcal, meningitis other than meningococcal or
pneumococcal, cellulitis, myopericarditis, and peritonitis); SLE, typical systemic lupus erythematosus or an SLE-like
syndrome without characteristic serologic findings.
80. What is on the top of food pyramid that should be given in limited amount?
Top tier: margarine, butter, red meat, sugar, potato, white rice, noodles
2nd tier: yoghurt, cheese, milk
3rd tier: eggs, chicken, fish
4th tier: nuts, taho, beans
5th tier: breastfeeding
6th tier: vegetables (leafy and non-leafy) and fruits (varied)
7th tier: vegetable oil, whole grain, brown rice, bread and cereals
8th tier: potable water
Lowest tier: at least 30 minutes to 1 hour of daily physical activity/exercise, weight control, exercise and sports
81. A mother came in your clinic with the concern that her son’s pre-school classmate had Hepatitis A 2
weeks ago. What is your action?
a. Observe/reassure
b. Give Hepa A vaccine
c. Give Hepa A immunoglobulin
d. Give Hepa A vaccine and Immunoglobulin
D
postexposure prophylxis
≤2 wk since exposure
Ig 0.02 mL/kg and HAV vaccine if >1 yr and future exposure likely
>2 wk since exposure
No prophylaxis. Consider HAV vaccine if >1 yr and future exposure likely
82. A NB on his 7th day of life presented with jaundice down to the thigh but good suck and activity. His TB
18mg/dL, blood type of mother is O and baby is B. Your impression?
a. Breastfeeding jaundice
b. ABO incompatibility
c. Hemolytic anemia
d. Kernicterus
Guru Jensan: My answer is breastmilk jaundice; masyado na late for ABO incompatibility; mukha namang
hindi C/D.
Significant elevation in unconjugated bilirubin (breast-milk jaundice) develops in an estimated 2% of breast-fed
term infants after the 7th day of life, with maximal concentrations as high as 10–30 mg/dL reached during the
2nd–3rd week. If breast-feeding is continued, the bilirubin gradually decreases but may persist for 3–10 wk at
lower levels. If nursing is discontinued, the serum bilirubin level falls rapidly, reaching normal levels within a few
days. With resumption of breast- feeding, bilirubin levels seldom return to previously high levels. Phototherapy
may be of benefit ( Chapter 102.4 ). Although uncommon, kernicterus can occur in patients with breast-milk
jaundice. The etiology of breast-milk jaundice is not entirely clear, but may be attributed to the presence of
glucuronidase in some breast milk.
This syndrome should be distinguished from an early-onset, accentuated unconjugated hyperbilirubinemia
known as breast-feeding jaundice which occurs in the 1st week of life, in breast-fed infants who normally have
higher bilirubin levels than formula-fed infants ( Fig. 102-9 ). Hyperbilirubinemia (>12 mg/dL) develops in 13% of
breast-fed infants in the 1st wk of life and may be due to decreased milk intake with dehydration and/or reduced
caloric intake. Giving supplements of glucose water to breast-fed infants is associated with higher bilirubin levels,
in part because of reduced intake of the higher caloric density of breast milk. Frequent breast-feeding (>10/24 hr),
rooming-in with night feeding, discouraging 5% dextrose or water supplementation, and ongoing lactation support
may reduce the incidence of early breast-feeding jaundice.
83. In the patient in the above number, what is your plan of action?
a. Hold breastfeeding
b. Phototherapy
c. Exchange transfusion
d. Partial exchange transfusion
Guru Jensan: My answer is B – dahil dapat i-promote ang breastfeeding ^_^ Hindi naman siya kernic level.
For medium risk infant, 18mg/dL is borderline for phototherapy at 7th DOL.
84. An adolescent male came in you clinic with penile discharge. You consider gonorrhea but you must screen
him for
a. Syphillis
b. Mycoplasma
c. Trachomanoiasis
d. Chlamydia
D
C. trachomatis and N. gonorrhoeae are the most common pathogens. Ureaplasma urealyticum and
Mycoplasma genitalium are considered potential pathogens in nongonococcal urethritis, when Chlamydia cannot
be confirmed. There are classic descriptions of discharges, associating pathogens with color and consistency:
yellow-green purulent discharge for gonococci and white mucopurulent discharge for chlamydia; co-infection and
other factors can alter the appearance of discharges. Co-infection with gonococcal and chlamydial urethritis is
reported in >25% of men with urethritis. Consequently, laboratory evaluation is key to determining the involved
pathogens. . (Chapter 119, Nelson’s 18th edition)
85. A pregnant mother who is diagnosed with Tuberculosis came in your clinic and asks an advice on what to
do upon baby’s delivery.
a. Isolate upon delivery
b. Do TST
c. Treat with triple therapy
d. Do CXR
Guru Jensan: The question is a bit vague, ganito talaga siya sa actual exam… It’s not mentioned whether
latent TB infection or active disease, or whether adequately treated for 2 weeks or not… So, assuming na PTB III si
mommy and treated naman, my answer would be B, pero at birth, baby is given isoniazid for 3 months then do the
TST. Separation is only done if mommy has current TB disease and not yet treated and considered infectious. Kindly
check chapter 12 of TB guidelines. ^_^
86. SAMPLEX regarding Probiotic
a. A
Probiotics are living microorganisms or components of microbial cells that have a beneficial effect on the
host. They are mainly lactic acid–producing bacilli, mostly Lactobacilli and Bifidobacteria, and also the yeast
Saccharomyces boulardii.
A probiotic agent must fulfill the following criteria: be of human source, nonpathogenic, and safe; resist
gastric, bile, and pancreatic digestion; and adhere to and colonize the enterocytes. Moreover, it should produce
antimicrobial substances, have favorable immunomodulation properties, and have the ability to influence
metabolic activities.
Prebiotics include materials that enhance the proliferation and development of probiotic microorganisms;
they include substances such as fructo- and galacto-oligosaccharides, inulin, germinated barley foodstuff, and
psyllium. Prebiotics should pass harmlessly through the upper digestive tract and be a substrate for selective
probiotic agents in the large bowel.
The combined approach utilizing prebiotics and probiotics to induce synergistic effects so as to produce a more
favorable host intestinal environment is termed synbiotics. (Chapter 337.2, Nelson’s 18th edition)
87. A 4 yo male with fever and on UA pus cell was TNTC. What will you do?
a. Repeat urinalysis
b. Increase OFI
c. Do culture and sensitivity
d. Do UTZ
C
A UTI may be suspected based on symptoms or findings on urinalysis, or both, but a urine culture is
necessary for confirmation and appropriate therapy. (Chapter 538, Nelson’s 18th edition, CPG for UTI)
88. The ff can manifest hand, foot, and mouth disease, except:
a. Enterovirus
b. Echovirus
c. Coxsackie virus
d. Parvovirus
D
Hand-foot-and-mouth disease, 1 of the more distinctive rash syndromes, is most frequently caused by
coxsackievirus A16 and can also be caused by enterovirus 71; coxsackie A viruses 5, 7, 9, and 10; and coxsackie B
viruses 2 and 5. Echovirus is part of the genus Enterovirus. Parvovirus causes erythema infectiosum. (Chapter 247,
Nelson’s 18th edition)
89. NB admitted at NICU with IV antibiotic for 2 weeks. Antibiotic was shifted and after 1 week presented
with fever and skin rashes(?). What is most probable cause?
a. Pseudomonas
b. Candida
c. Staphylococcal pyogenes
d. Mycoplasma
90. Question is unrecalled but it was Something about a patient was given antibiotic for 2 weeks then
presented with profuse diarrhea
a. ETEC
b. –
c. –
d. Clostridium difficile
D
Clostridium difficile–associated diarrhea, also known as pseudomembranous colitis or antibioticassociated diarrhea or, is the major cause of health care–associated diarrhea. Normal gut flora appears to be
protective. Administration of antibiotics that impair growth of normal flora but not C. difficile is the most common
risk factor, but any process that disrupts the normal bowel flora (weaning, chemotherapy) or bowel motility (bowel
stasis, bowel surgery) predisposes to C. difficile–associated diarrhea. Clinical symptoms vary widely. Asymptomatic
colonization is common in infants and young children. Illness varies from a mild self-limited diarrhea without
pseudomembranes, to explosive watery diarrhea with occult blood, to the classic picture of pseudomembranous
colitis with bloody diarrhea accompanied by fever, cramps, abdominal pain, nausea, and vomiting. Disease may
develop during and as long as several weeks after antibiotic therapy. Severe and extensive colitis occurs in children
undergoing chemotherapy or those with Hirschsprung disease or inflammatory bowel disease; it has been reported
in a few children with cystic fibrosis. C. difficile disease occasionally involves the small gut; in some hosts,
bacteremia and abscess formation have been reported. (Chapter 209, Nelson’s 18th edition)
91. A patient came in the ER with rashes after intake of medicine 12 hours ago. On history she was treated
with URTI and was given cefaclor. There was no history of allergy or asthma. On PE, there were
erythematous vesicles on the mouth and vaginal area. There are areas of denudation on the face, trunk,
and extremities. (Something like this ang question)
a. Serum sickness
b. Anaphylaxis
c. TEN
d. Steven Johnson
(Steven Johnson syndrome ang answer ko. Yung PE ng rash na nag-occur at 2 mucosal site and naging hint ko
dun)
92. A mother came in your clinic with the complaint that her 3 months old baby had vomiting; nonbilous and
no projectile, every feeding. After vomiting, the infant is hungry and wants to feed again. Your initial
consideration (another question of PS)
a. Overfeeding
b. Milk intolerance
c. Duodenal atresia
d. Pyloric stenosis
D
Nonbilious vomiting is the initial symptom ofpyloric stenosis. The vomiting may or may not be projectile
initially but is usually progressive, occurring immediately after a feeding. Emesis may follow each feeding, or it
may be intermittent. The vomiting usually starts after 3 wk of age, but symptoms may develop as early as the 1st
wk of life and as late as the 5th mo. After vomiting, the infant is hungry and wants to feed again…. Jaundice
associated with a decreased level of glucuronyl transferase is seen in ≈5% of affected infants. The indirect
hyperbilirubinemia usually resolves promptly after relief of the obstruction. The diagnosis has traditionally been
established by palpating the pyloric mass. The mass is firm, movable, ≈2 cm in length, olive shaped, hard, best
palpated from the left side, and located above and to the right of the umbilicus in the mid epigastrium beneath the
liver edge. In healthy infants, feeding can be an aid to the diagnosis. After feeding, there may be a visible gastric
peristaltic wave that progresses across the abdomen. After the infant vomits, the abdominal musculature is more
relaxed and the “olive” easier to palpate. The diagnosis can be established clinically 60–80% of the time by an
experienced examiner. (Chapter 326, Nelson’s 18th edition)
93. What is the deficient enzyme in Galactosemia?
a. Galactokinase
b. UDP-galactose-4-epimerase
c. galactose-1-phosphate uridyl transferase
d. –
C
Galactosemia denotes the elevated level of galactose in the blood and is found in 3 distinct inborn errors of
galactose metabolism defective in 1 of the following enzymes: galactose-1-phosphate uridyl transferase,
galactokinase, and uridine diphosphate galactose-4-epimerase. The term galactosemia, although adequate for the
deficiencies in any of these disorders, generally designates the transferase deficiency.(Chapter 87.2, Nelson’s 18th
edition )
94. Something about a adolescent female na may syndrome for work-up and look for… Sarsi: from what I
remember of this question, the description was that of a patient with Turner syndrome and amenorrhea.
In this patient, you have to also work up for the probability of
a. Primary amenorrhea
b. Gonadoblastoma
c. Infantile ovary
d. –
B
Turner syndrome, a condition characterized by the complete or partial absence of the second sex
chromosome, is defined by a combination of phenotypic features ( Table 81-9 ). Half of the patients with Turner
syndrome have a 45,X chromosome complement. The other half exhibits mosaicism and varied structural
abnormalities of the X or Y chromosome. Parental age is not a factor in the 45,X abnormality; its variants occur in
approximately 1 in 5,000 female live births. In 75% of patients, the lost chromosome is of paternal origin. 45,X is
one of the chromosome abnormalities most frequently associated with spontaneous abortion. It has been
estimated that 95–99% of 45,X conceptions are miscarried.
TABLE 81-9 -- Disorders Associated with Turner Syndrome
Short stature
Congenital lymphedema
Horseshoe kidney
Patella dislocation
Increased carrying angle of elbow
Madelung deformity (chondrodysplasia of distal radial epiphysis)
Congenital hip dislocation
Scoliosis
Widespread nipples
Shield chest
Redundant nuchal skin (in utero cystic hygroma)
Low posterior hairline
Coarctation of aorta
Bicuspid aortic valve
Cardiac conduction abnormalities
Hypoplastic left heart syndrome?
Gonadal dysgenesis (infertility, primary amenorrhea)
Gonadoblastoma (if Y chromosome material present)
Learning disabilities (nonverbal perceptual motor and visuospatial skills) [in 70%]
Developmental delay (in 10%)
Social awkwardness
Hypothyroidism (acquired in 15–30%)
Type 2 diabetes mellitus (insulin resistance)
Strabismus
Cataract
Red-green colorblindness (as in males)
Recurrent otitis media
Sensorineural hearing loss
Inflammatory bowel disease
Celiac disease?
The phenotype in the newborn can include short stature, prominent ears, webbing of the neck, and edema of
the hands and feet, but many newborns are phenotypically normal ( Fig. 81-16 ). Older children and adults have
short stature and exhibit variable dysmorphic features. Congenital heart defects (40%) and structural renal
anomalies (60%) are common. The most common heart defects are bicuspid aortic valves, coarctation of the aorta,
aortic stenosis, and mitral valve prolapse. The gonads are generally streaks of fibrous tissue (gonadal dysgenesis).
There is primary amenorrhea and lack of secondary sexual characteristics. These children should receive regular
endocrinologic testing (see Chapter 587 ). Patients tend to be of normal intelligence but are at increased risk for
behavioral problems and deficiencies in spatial and motor perception. Guidelines for health supervision for children
with Turner syndrome are published by the AAP. (Chapter 81, Nelson’s 18th edition)
95. A 12 years old boy presented on routine urinalysis with +4 protein. Evaluation was done and on first
morning urine sample there were trace of protein for 3 consecutive days. This confirms.
a. Transient proteinuria
b. Postural proteinuria
c. Nephrotic syndrome
d. Fixed proteinuria
C
Nephrotic syndrome. The urinalysis reveals 3+ or 4+ proteinuria; microscopic hematuria may be present in 20%
of children. Spot urine protein/creatinine ratio exceeds 2.0 and urinary protein excretion exceeds 3.5 g/24 hr in
adults and 40 mg/m2/hr in children. The serum albumin level is generally <2.5 g/dL, and the serum cholesterol and
triglyceride levels are elevated. C3 and C4 levels are normal. Renal biopsy is not required for diagnosis in most
children.(Chapter 527.1, Nelson’s 18th edition)
Transient proteinuria. The majority of children found to have a positive urinary dipstick for protein will have
normal dipstick values on repeated measurements. Of the 10% of children found to have proteinuria by a single
dipstick measurement, only 1% had persistent proteinuria when measured on 4 separate occasions. This
phenomenon, called transient proteinuria, may be caused by a temperature >38.3°C (101°F)), exercise,
dehydration, cold exposure, heart failure, seizures, or stress. The proteinuria usually does not exceed 2+ on the
dipstick. The mechanism of transient proteinuria is unknown. No evaluation or therapy is needed for children with
this benign condition.(Chapter 524, Nelson’s 18th edition)
Fixed proteinuria.
Individuals found to have significant proteinuria on a first morning urine sample on 3
consecutive days (>1+ on dipstick, or protein/creatinine ratio >0.2) have fixed proteinuria. Fixed proteinuria
indicates renal disease and may be caused by either glomerular or tubular disorders.
Orthostatic (Postural) proteinuria.
Orthostatic proteinuria is the most common cause of persistent
proteinuria in school-aged children and adolescents, occurring in up to 60% of children with persistent proteinuria.
Individuals with orthostatic proteinuria excrete normal or minimally increased amounts of protein in the supine
position. In the upright position, urinary protein excretion is increased up to 10-fold, up to 1,000 mg/24 hr (1 g/24
hr)…. The absence of proteinuria (dipstick negative or trace for protein and UPr/Cr ratio <0.2) in the first morning
urine sample for 3 consecutive days confirms the diagnosis of orthostatic proteinuria. (Chapter 525, Nelson’s 18th
edition)
96.
Note from sars:
1) May question nga ba on diphtheria? Meron, pero di ko maalala
2) May question nga ba on Chlamydia and Gonorrhea? Wala akong maalala na may ganitong question. May
tanong sa Chlamydia in newborn na ang sagot ay erythromycin.
3) May question na parang ang sagot ay Mycoplasma… di ko sure.
4) Tama ba… may question that goes something like “Apart from Candida, the next most common fungal
infection is…” or something to that effect? Tapos parang Cryptococcus ata ang sagot? Yap, next most
common fungal infection in AIDS or immunocompromised yata.
5) May isa pang question on pyloric stenosis yap, yung baby na may recurrent vomiting tsaka may double
bubble sign
Note from mark: Sars, if ever na maalala mo itong mga concern ko. Hahahaha… wala akong maalala sa mga
comment ni sir Mark ^_^
a. may isa pang question about OSA pero di ko marecall ng buo. Parang ung choices mo sa #34 ay nagsama
b. May question regarding vesicles that located on the back and trunk. Yung lesion is on the same side.
Varicella yung sagot ko. (I’m not really sure)
c. May samplex question regarding hyponatremia pero in nephrotic syndrome naman. Yung choices iba pero
its still about shift of water and sadium.
d. May question regarding hyperK/hypoMg?/and other symptoms na ang choices ay RTA, Barter, Gittleman
e. May question ba regarding tumor with round cell on histologic examination?
f. Wala na talaga ako ma-extract  zero balance na sis!