I.
MULTIPLE CHOICE
For each of the following questions, shade on your answer sheet the letter of the answer that BEST
answers the question.
1. Which of the following statements is TRUE about vaccination?
a. Anaphylaxis to any previous dose of a vaccine contraindicates future doses of the vaccine.
b. MMR vaccine is contraindicated in children with anaphylaxis to eggs.
c. An infant born two weeks prematurely should be vaccinated two weeks later compared with full
term infants.
d. Children receiving corticosteroids (≥2 mg/kg/day or ≥20 mg/day of prednisone or equivalent)
for 14 or more days may receive live vaccines immediately after therapy has been discontinued.
2. A 4-month old with leukemia is brought to you for possible immunization. The patient is on the
induction phase of chemotherapy. Which of the following vaccines may be given?
a. DTP
b. Hepatitis B
c. IPV
d. All of the above
3. Which of the following statements is TRUE about the clinical manifestations and complications of
typhoid fever?
a. Diarrhea, toxicity, and complications such as disseminated intravascular complications are rare in
infancy.
b. Relative bradycardia, neurologic manifestations, and gastrointestinal bleeding, are commonly
seen in both adults and children with typhoid fever.
c. Intestinal perforation and peritonitis may be accompanied by a sudden rise in pulse rate,
hypotension, marked abdominal tenderness and guarding. A rising white blood cell count
with a left shift may be seen.
d. Neurologic complications are very rare and occur in <1% of patients.
4. Which of the following statements is TRUE about the diagnosis of typhoid fever?
a. The mainstay in the diagnosis of typhoid fever is the Widal test.
b. Thrombocytopenia may be a marker of severe illness and accompany DIC.
c. Leukocytosis is rare in young children with typhoid fever, and a WBC count above 20,000 almost
always rules out typhoid fever.
d. Widespread antibiotic prescribing does not affect the sensitivity of cultures in diagnosing typhoid
fever.
5. The septicemic phase of leptospirosis may present as which of the following?
a. Fever, shaking chills, lethargy, severe headache, malaise, nausea, vomiting
b. Extreme muscle tenderness, which is most prominent in the lower extremities, lumbosacral
spine, and abdomen
c. Conjunctival suffusion with photophobia and orbital pain (in the absence of chemosis and
purulent exudate), generalized lymphadenopathy, and hepatosplenomegaly
d. Pharyngitis, pneumonitis, arthritis, carditis, cholecystitis, and orchitis
e. All of the above
6. Which of the following statements is TRUE about icteric leptospirosis?
a. Abnormal electrocardiograms are present in <10% of cases.
b. Thrombocytopenia occurs in <10% of cases.
c. Hemorrhagic manifestations are rare but when present may include epistaxis, hemoptysis,
and gastrointestinal and adrenal hemorrhage.
d. The jaundice results from hepatocellular necrosis, hence liver function usually remains abnormal
even after recovery.
7. Initiation of treatment of leptospirosis before the 7th day will probably shorten the clinical course
and decrease the severity of the infection. Which of the following is/are acceptable antibiotics for
leptospirosis?
a. Parenteral penicillin G (6–8 million U/m2/day divided every 4 hr IV for 7 days) is recommended.
b. Tetracycline (10–20 mg/kg/day divided every 6 hr PO or IV for 7 days) is an alternative for
patients allergic to penicillin.
c. Oral amoxicillin is an alternative therapy for children <9 years of age.
d. A&B only
e. All of the above.
8. Which illness(es) typically follow(s) a biphasic pattern or course?
a. Dengue fever
b. Leptospirosis
c. Both A and B
d. Neither A nor B
9. Which of the following refers to the stage of dengue hemorrhagic fever with circulatory failure,
thready pulse, narrow pulse pressure, hypotension, and cold, clammy skin?
a. I
b. II
c. III
d. IV
10. The clinical manifestations of dengue hemorrhagic fever are all of the following EXCEPT
a. Hypoalbuminemia
b. Thrombocytopenia
c. Bleeding episodes
d. Narrow pulse pressure
11. Induration of _____ is considered positive regardless of BCG status using 5 TU PPD-S or 2TU RT23
Mantoux test read at _____ hours.
a. 5 mm; 24-48 hours
b. 8 mm; 24-48 hours
c. ≥10 mm; 24-48 hours
d. 5 mm; 48-72 hours
e. ≥10 mm; 48-72 hours
12. In which of the following situations should you request for a gastric and/or sputum AFB smear
and/or culture?
a. All children suspected of tuberculosis, prior to initiating treatment.
b. Children with primary complex, prior to initiating treatment.
c. Multidrug resistance suspected in the absence of a culture-positive case, or TB considered
but cannot be diagnosed by other criteria.
d. Newborn of a mother with pulmonary tuberculosis.
e. All of the above.
13. You are the DRI resident, and one of your patients is a newborn of a mother with no pre-natal checkups and who was diagnosed with pulmonary tuberculosis on admission at the OBAS. She is only on
day one of anti-TB medications. According to the PPS TB consensus, which of the following will be
your management of the baby?
a. Admit the baby to the NICU since the baby should be separated from his mother until she has
completed two weeks of therapy.
b. Do PPD and CXR at once; give initial treatment with isoniazid or rifampicin.
c. Do PPD, CXR, gastric AFB smear and culture; give initial treatment with isoniazid. rifampicin,
pyrazinamide and streptomycin.
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d. Do PPD and CXR at once; give initial treatment with isoniazid. rifampicin, pyrazinamide and
streptomycin.
e. Do PPD, CXR, gastric AFB smear and culture; give initial treatment with isoniazid or rifampicin.
14. The mother of the patient on the next bed also has pulmonary tuberculosis, but she was diagnosed at
8 months AOG and had more than two weeks of treatment. According to the PPS TB consensus, which
of the following is TRUE about the management of this patient?
a. No diagnostics or treatment is necessary.
b. Do PPD at 4-6 weeks of age and start initial treatment with isoniazid.
c. Do PPD, CXR, gastric AFB smear and culture; give initial treatment with isoniazid. rifampicin, and
pyrazinamide.
d. If PPD is negative, there is no need to repeat the test and the initial treatment you started should
be discontinued immediately.
15. According to the 2008 PPS Clinical Practice Guidelines for Childhood Tuberculosis, which of the
following patients should be treated with a 4-drug regimen (2 months of HRZS or HRZE followed by 4
months of HR)?
a. Children with primary pulmonary tuberculosis or tuberculosis of the peripheral lymph nodes
where drug resistance is suspected
b. Children with extensive pulmonary disease, including parenchymal lesions, endobronchial
tuberculosis, upper lobe infiltrates, consolidation, cavitation, or extensive pleural effusion
c. Adolescents ≥ 15 years old
d. All of the above
e. None of the above
16. In which of the following conditions is the use of corticosteroids NOT indicated?
a. Tuberculous pericarditis
b. Tuberculous meningitis, regardless of stage
c. Miliary tuberculosis
d. Skeletal tuberculosis
17. A two-year-old boy without any immunizations is brought to you by his mother because his playmate
had measles. She is worried about his chances of getting measles. Which of the following will you tell
the mother?
a. His playmate is infectious only when the rash appears up to the day after its onset. (His playmate
is infectious 3 days before the rash appears up to 4–6 days after its onset.)
b. He has less than 50% chance of getting measles. (Approximately 90% of the exposed susceptible
individuals develop measles.)
c. Face to face contact is necessary for transmission of measles. (Face-to-face contact is not
necessary because viable virus may be suspended in air up to 1 hr after a source case leaves a
room. Secondary cases have been reported in physicians' offices and in hospitals by spread of
aerosolized virus.)
d. The vaccine is effective in prevention or modification of measles if given within 72 hr of
exposure.
18. What is the most common complication of measles?
a. Acute otitis media
b. Pneumonia
c. Encephalitis
d. Myocarditis
19. Which of the following is true about subacute sclerosing panencephalitis?
a. It results from direct damage to the brain by the virus. (Measles encephalitis in
immunocompromised patients results from direct damage to the brain by the virus. It appears to
result from a persistent infection with an altered measles virus that is harbored intracellularly in
the CNS for several years.)
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b. A patient with measles at an early age is less likely to develop SSPE.
c. Clinical manifestations of SSPE begin 7–13 yr after primary measles infection.
d. The first stage of SSPE is the development of massive myoclonus.
20. Which of the following statements is NOT TRUE about the lesions of varicella?
a. Simultaneous presence of lesions in various stages of evolution is characteristic of varicella
b. Distribution of the rash is predominantly central or centripetal
c. Corneal involvement and serious ocular disease is common
d. Lesions involving the mucosa of oropharynx and vagina are also common
21. Which of the following statements is NOT TRUE about roseola?
a. More than 95% of roseola cases occur in children younger than 3 yr, with a peak at 6–15 mo of
age.
b. Seizures may occur in 5–10% of children with roseola during the febrile stage.
c. Rash develops during defervescence or within a few hours of fever resolution.
d. The rash fades after 1 week.
Case 1: Jane
Jane is a 4-month old infant brought to your clinic. Her mother observes that Jane frequently regurgitates
previously ingested milk. Her mother also notes that she easily develops cough and colds.
22. You suspect infant gastroesophageal reflux. If your diagnosis is correct, when do you expect her
condition to resolve?
a. Before 6 months of age
b. At 6-12 months of age
c. At 12-24 months of age
d. After 24 months of age
23. The following are the other symptoms that you will probably elicit in Jane’s history EXCEPT
a. Below optimal weight again
b. Stridor
c. Laryngitis
d. Irritability
e. None of the above
24. The important differential diagnoses to rule out in Jane’s case are the following EXCEPT
a. Milk allergy
b. Increased intracranial pressure
c. Pyloric stenosis
d. Inborn errors of metabolism
e. None of the above
(End of Case 1)
25. Which of the following statements is TRUE about gastroenteritis?
a. Enteropathogens cause non-inflammatory diarrhea through direct invasion of the intestine.
b. Hemolytic-uremic syndrome is an immune-mediated extra-intestinal manifestation of
Shigella dysenteriae and E. coli.
c. Treatment of the causative organism is the cornerstone of management in infants and children
with diarrhea.
d. Ampicillin is the recommended antibiotic to treat cholera.
26. Which of the following statements is NOT TRUE about chronic diarrhea?
a. When diarrhea lasts >2 wk, it is considered chronic.
b. Malabsorption may present as chronic diarrhea accompanied by weight loss and fat in the stool.
c. The first step in the management of chronic diarrhea is to shift to a lactose-free diet.
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d. Sorbitol, which is a nonabsorbable sugar, is found in apple, pear, and prune juices, and can cause
diarrhea in toddlers.
Case 2: Noah
Noah is a 6-week old infant brought to your clinic for generalized jaundice. His mother says that jaundice
was present at birth and became deeper and more generalized since then. Aside from this, Noah is
asymptomatic. He is feeding well and has good activity. Physical exam reveals acholic stools. Bilirubin
levels showed a total of 24 mg/dL with the direct bilirubin fraction at 15 mg/dL.
27. You consider a possible biliary atresia vs. idiopathic neonatal hepatitis in Noah’s case. Biliary atresia
is characterized by the following, which differentiates it from neonatal hepatitis.
a. It has a familial incidence.
b. It is more common in premature infants.
c. Hepatobiliary tree ultrasound shows the triangular cord sign.
d. There is severe diffuse hepatocellular disease on liver biopsy.
e. All of the above.
28. You anticipate the following clinical impairments in an infant with prolonged neonatal cholestasis
such as Noah EXCEPT
a. Malabsorption of dietary long-chain triglycerides
b. Malabsorption of water-soluble vitamins
c. Malabsoprtion of fat-soluble vitamins
d. Micronutrient deficiency
e. Cholesterol retention
29. Anticipating these possible impairments, your medical management of Noah’s case will include the
following EXCEPT
a. Use of a medium-chain triglyceride containing formula
b. Oral supplementation of fat-soluble vitamins
c. Giving twice the recommended daily allowance of water-soluble vitamins
d. Start ursodeoxycholic acid
e. None of the above
30. Unfortunately Noah’s operation was eventually unsuccessful, and as you followed him up, you noted
progressive hepatic damage. At 2 years old, Noah developed portal hypertension. The following is the
most common presentation of portal hypertension, which you should anticipate in Noah’s case.
a. Hepatomegaly
b. Bleeding from esophageal varices
c. Splenomegaly
d. Jaundice
e. Ascites
31. Noah was then brought to the ER suddenly for acute variceal hemorrhage. The following will be part
of his management.
a. Fluid resuscitation
b. Vitamin K administration
c. Somatostatin infusion
d. Endoscopic elastic band ligation for persistent bleeding
e. All of the above
(End of Case 2)
32. A 4‐week‐old boy has been vomiting all of his feedings for the last 2 days. His mother reports
decreased urine output but no fever. On physical examination, he is alert, appears hungry, and is
moderately dehydrated. Abdominal examination reveals a small mass in the epigastrium. When he is
offered a bottle, he takes it vigorously and then vomits forcefully. You order laboratory tests. Of the
following, the MOST likely abnormality to expect is
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a.
b.
c.
d.
e.
hyperchloremia
hyperkalemia
hypernatremia
metabolic acidosis
metabolic alkalosis
33. A 12‐year‐old girl presents to the emergency department with abdominal pain. Her parents report
that she awakened with a temperature of 101°F (38.4°C) this morning, complained of abdominal
pain, and has vomited twice. There is no diarrhea, and there are no sick contacts. She reports nausea
and no interest in food or drink. She was previously entirely healthy. Of the following, the finding that
MOST indicates the need for immediate surgical intervention is
a. abdominal distention
b. hyperactive bowel sounds
c. pain in the right lower quadrant
d. rigidity of the abdominal wall
e. voluntary guarding
34. Which of the following statements is NOT TRUE about acute appendicitis?
a. Localized abdominal tenderness is the single most reliable finding in the diagnosis of acute
appendicitis.
b. Patients should not be given painkillers since this practice changes diagnostic accuracy
and interferes with surgical decision-making.
c. The operation should proceed semi-electively within 12–24 hours of diagnosis.
d. Children with appendicitis are typically at least mildly dehydrated and require preoperative fluid
resuscitation to correct hypovolemia and electrolyte abnormalities.
35. In 99% of full-term infants, meconium is passed within ____ hours of birth.
a. 6
b. 14
c. 24
d. 48
36. The following are distinguishing factors between functional constipation and Hirschsprung disease
EXCEPT
a. The onset of constipation is typically in the neonatal period in Hirschsprung disease, while the
onset is after two years of age in functional constipation.
b. Abdominal distention and poor weight gain are rare in functional constipation and common in
Hirschsprung disease.
c. Rectal examination shows an empty ampulla in functional constipation, and stool in the
ampulla in Hirschsprung disease.
d. Barium enema shows a transition zone and delayed evacuation (>24 hr) in Hirschsprung disease.
37. The following are TRUE of the common cold EXCEPT
a. Systemic symptoms such as myalgia and fever are absent or mild.
b. In a young child who has 6 episodes of colds a year, work-up for immunodeficiency is
indicated.
c. Children in daycare centers are more susceptible to colds.
d. The onset of cold symptoms occurs up to 3 days after the initial viral infection.
38. Symptomatic treatment is the mainstay of management of the common cold. The following are
recommended symptomatic therapies for colds EXCEPT
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a.
b.
c.
d.
topical or oral nasal decongestants
mild analgesics
first generation antihistamines
inhalation of warm, humidified air
39. How can bacterial sinusitis be contrasted with uncomplicated viral upper respiratory infections?
a. In bacterial sinusitis, the nasal or postnasal discharge is always purulent while in viral infections,
the nasal discharge is clear.
b. In bacterial sinusitis, fever concurrent with postnasal discharge lasts at least 3-4 days
while in viral infections, fever resolves in 48 hours and is followed by respiratory
symptoms.
c. The presence of fever and constitutional symptoms rules out a viral upper respiratory infection.
d. It is difficult to differentiate them clinically and in children < 6 years of age, imaging studies are
necessary to confirm bacterial sinusitis.
40. A three-year-old boy is brought to the emergency room at 4 am in distress, drooling, and with his
neck hyperextended. The patient was still playing this morning, and he developed a fever and sore
throat a few hours ago. Chest x-ray is positive for the “thumb sign”. Your primary impression is
a. Croup
b. Foreign body obdtruction
c. Peritonsillar abscess
d. Acute epiglottitis
41. After a few minutes, your triage resident brings in a 13‐month‐old boy who has a bad cough and noisy
breathing. He went to sleep normally with only mild symptoms of an upper respiratory tract infection
and awakened at 3 am with noisy breathing. He has a "barking cough," and on auscultation, you notice
stridor with every breath. In addition to giving nebulized racemic epinephrine, the treatment most
likely to improve the patient’s condition is
a. ceftriaxone intramuscularly
b. dexamethasone orally or intramuscularly
c. humidified oxygen by face mask
d. nebulized albuterol
e. complaining to the triage resident
42. Which among the following statements is TRUE about aspiration of gastric contents?
a. If you suspect a large volume aspiration, ABG and chest x-ray should be done even if the
patient is asymptomatic.
b. Bronchodilators and corticosteroids are usually helpful.
c. Antibiotics are not necessary even in hospitalized or chronically ill patients.
d. Hypoxemia, atelectasis, pneumonitis and pulmonary edema will occur earlier, be more severe and
last longer with alkali aspiration.
43. Which of the following is TRUE about diagnostics in pneumonia?
a. Repeat chest x-rays are required for proof of cure for patients with uncomplicated pneumonia.
b. Atypical pneumonia due to C. pneumoniae or M. pneumonia is associated with higher WBC count,
erythrocyte sedimentation rate (ESR), and C–reactive protein (CRP) compared with
pneumococcal pneumonia. (Ang tama: baliktad, mas mataas sa pneumococcal pneumonia)
c. Culture of sputum is necessary in the diagnosis of pneumonia in young children. (Ang tama:
Culture of sputum is of little value in the diagnosis of pneumonia in young children.)
d. Blood cultures are positive in only 10% of children with pneumococcal pneumonia.
44. You are the triage officer at the ER. Which of the following patients with pneumonia will you NOT
consider for admission?
a. Patient A: age <6 mo
b. Patient B: patient is vomiting
c. Patient C: given amoxicillin at the local health center without response
d. Patient D: parents are noncompliant with treatment
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e. None (i.e. You will consider hospitalization in all of these patients.)
Case 3: Pia
Pia is a 5-year old girl with cerebral palsy who was brought to the PER for respiratory distress. She was
noted to have a 3-day history of fever and bouts of coughing. On PE, she had an RR of 40, T of 38.7˚C, with
harsh breath sounds and rales all over on auscultation.
45. The most consistent clinical manifestation of pneumonia is
a. tachypnea
b. use of accessory muscles of respiration
c. fever
d. cough
e. crackles on chest auscultation
46. Which of the following is the most probable pathogen in Pia’s case?
a. Streptococcus pyogenes
b. Streptococcus pneumoniae
c. Staphylococcus aureus
d. respiratory syncitial virus
e. parainfluenza virus
(End of Case 3)
47. Which of the following statements about atelectasis is NOT TRUE?
a. Atelectasis alone can cause fever.
b. The chest appears flat on the affected side. Dullness to percussion and feeble or absent breath
sounds are also noted.
c. Frequent changes in the child's position, deep breathing, and chest physiotherapy may be
beneficial.
d. Continuous positive airway pressure (CPAP) may improve atelectasis.
48. The following findings are suggestive of an exudative pleural effusion EXCEPT
a. protein level >3.0 g/dL
b. fluid to serum protein ratio > 0.5
c. fluid to serum lactic dehydrogenase ratio > 0.6
d. pH > 7.20
49. The pleural effusion is an empyema if
a. bacteria are present on Gram stain
b. the pH is <7.20
c. there are >100,000 neutrophils/μL
d. all of the above
50. The following are complications you should watch out for in a patient with empyema EXCEPT
a. bronchopleural fistulas and pyopneumothorax
b. purulent pericarditis
c. peritonitis
d. meningitis, arthritis, and osteomyelitis
e. none of the above
51. Which of the following correctly describes the clinical manifestations of a pneumothorax?
a. Pneumothorax may cause pain, dyspnea, and cyanosis. In infancy, symptoms and physical
signs may be difficult to recognize.
b. The area of the pneumothorax is dull to percussion.
c. The larynx, trachea, and heart may be shifted toward the affected side.
d. All of the above.
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52. Which of the following substances may cause dark urine WITHOUT RBCs?
a. Metronidazole
b. Salicylates
c. Ibuprofen
d. Methemoglobin
e. All of the above
53. You are asked to evaluate a 15 year‐old boy who presented to the emergency department with gross
hematuria that began the day before. He ran his first marathon yesterday. He reports no dysuria,
urgency, frequency, or abdominal or flank pain. His vital signs and physical examination findings are
normal. Urinalysis reveals: 0 to 2 red blood cells; and 0 to 2 white blood cells. Creatinine is 2.7 mg/dL
(238.7 mcmol/L). His complete blood count is normal. Of the following, the MOST likely cause of his
hematuria and renal failure is
a. hemoglobinuria
b. immunoglobulin A nephropathy
c. myoglobinuria
d. urinary tract obstruction
e. urolithiasis
54. A 10‐year‐old girl presents to the emergency department with a 1‐day history of brown urine. She
reports no dysuria, urgency, frequency, or abdominal or flank pain. Blood pressure is 165/97 mm Hg.
On physical examination, there is moderate periorbital edema. Urinalysis reveals moderate blood and
4+ protein. The serum complement 3 (C3) concentration is low, and the C4 concentration is normal.
Of the following, the MOST likely cause of this girl's hematuria is
a. focal segmental glomerulosclerosis
b. immunoglobulin A nephropathy
c. postinfectious acute glomerulonephritis
d. urolithiasis
Case 4: Diego
Diego is a 5/M admitted at the PER for oliguria and tea-colored urine. On admission, his BP is 150/100.
He has periorbital and slight bipedal edema. Laboratory tests show decreased C3 levels.
55. Diego’s management includes the following EXCEPT
a. fluid restriction
b. diuretic therapy
c. ten-day course of Penicillin
d. calcium-channel blockers as needed
e. none of the above
56. Diego recovers completely, and on follow-up one month later, you note the following physical exam
and laboratory findings. Which one is/are cause/s for alarm?
a. urinalysis with RBCs of 8-10/hpf
b. urinalysis with protein of +1
c. low C3 levels
d. B & C only
e. none of the above
(End of Case 4)
Case 5: Julio
Julio is a 6/M admitted at the PER for generalized edema with a markedly swollen scrotum. On
admission, his BP is 90/60. Initial laboratory findings show a urinalysis with protein of +3 and a serum
albumin level of 23 mg/dL.
57. Julio’s management includes the following EXCEPT
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a.
b.
c.
d.
e.
sodium restriction
judicious diuretic use
steroid therapy
A & B only
none of the above
58. Julio was started on prednisone at 60 mg/m2/day, and after 4 weeks, his symptoms have improved
and proteinuria has also resolved. You decrease the prednisone dose to 40 mg/m2/day. After 1 week
on follow-up, you notice that Julio again has generalized edema, and on urinalysis, protein is +3. His
illness may now be classified as
a. steroid-resistant
b. steroid-dependent
c. frequent relapser
d. A or B is correct
e. none of the above
(End of Case 5)
A subset of patients will relapse while on alternate-day steroid therapy or within 28 days of stopping
prednisone therapy. Such patients are termed steroid dependent. Patients who respond well to
prednisone therapy but relapse ≥4 times in a 12-mo period are termed frequent relapsers. Children who
fail to respond to prednisone therapy within 8 wk are termed steroid resistant. Steroid-resistant
nephrotic syndrome is usually FSGS (80%), MCNS (20%), and rarely mesangial proliferative.
Steroid-dependent patients, frequent relapsers, and steroid-resistant patients may be candidates for
alternative agents, particularly if the child suffers severe corticosteroid toxicity (cushingoid appearance,
hypertension, cataracts, and/or growth failure).
59. A three-year-old girl developed an acute attack of bronchial asthma that was followed in two weeks
by general edema. Her blood pressure is normal. Urinalysis shows clear, yellow urine with 2-5 RBCs
per high power field and 4+ protein. Her cholesterol is 402 mg/dl, serum albumin is 9 g/dl, ASO titer
1:16, and C3 92 mg/dl. Her condition can be explained by
a. poststreptococcal glomerulonephritis
b. membranoproliferative glomerulonephritis
c. minimal lesion nephrotic syndrome
d. focal segmental glomerulosclerosis
60. Juan is a 3 year old boy who came at the emergency room with no urine output for 24 hours. He has
been having diarrhea for the past 5 days associated with vomiting and on and off fever. Physical
examination revealed an irritable child with BP= 80/50, HR=132/min, RR=20 bpm and temperature
of 38.2’C with sunken eyeballs, dry lips and buccal mucosa and poor peripheral piulses. What is the
initial fluid management in Juan’s case?
a. Give a bolus of crystalloid solution.
b. Limit fluids to insensible water loss.
c. Give a stat dose of furosemide at 2 mkd.
d. Institute peritoneal dialysis.
61. ALL of the following cause pre-renal failure EXCEPT:
a. severe dehydration
b. massive gastrointestinal bleeding
c. interstitial nephritis
d. congestive heart failure
62. A 2-year-old male presents with vomiting, diarrhea, and fever. A urinalysis shows pyuria and
hematuria, and a culture grows greater than 105 colonies of E. coli. He responded well to hydration
and intravenous antibiotics. Which among the following imaging studies, if any, is appropriate during
the acute phase of the infection?
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a.
b.
c.
d.
CT scan of the abdomen
Renal and bladder ultrasound
VCUG
No imaging study is warranted.
The goal of imaging studies in children with a UTI is to identify anatomic abnormalities that
predispose to infection. In children with clinical pyelonephritis (febrile UTI), a renal sonogram should
be obtained to rule out hydronephrosis and structural urinary abnormalities; sonography also may
suggest acute pyelonephritis by demonstrating an enlarged kidney. Power Doppler sonography has
been slightly more sensitive but is unreliable in identifying all cases. Sonography demonstrates many
but not all renal scars. Normally, the difference in renal lengths between the two kidneys is less than 1
cm, and a larger disparity may be an indication of impaired renal growth. One should remember that in
a child with acute pyelonephritis, a small kidney may be enlarged because of the infection, giving the
erroneous impression that the kidneys are equal in size. Renal sonography also is sensitive for
detecting nephronia and pyonephrosis, a condition that may require prompt drainage of the collecting
system by percutaneous nephrostomy.
Case 6: Daniel
Daniel is a 15/M presenting at the PER with vomiting and abdominal pain. His mother tells you that he
recently seems to be very thirsty and goes to the bathroom frequently to void. CBG is 456 mg/dL and he
has +3 ketones in the urine. You suspect diabetic ketoacidosis.
63. You immediately start intravenous rehydration. The following are TRUE of rehydration in Daniel’s
case EXCEPT
a. An initial bolus of 20 cc/kg glucose-free isotonic solution should be given, and repeated as
needed.
b. Subsequent fluids used should be hypotonic to correct intracellular dehydration.
c. Aside from correcting dehydration, rehydration lowers glucose levels by improving renal
perfusion and enhancing renal excretion.
d. Once glucose levels decline to 180 mg/dL, osmotic diuresis stops, and rehydration accelerates
without a further increase in infusion rate.
e. none of the above
64. Daniel’s initial electrolytes show a Na of 130 meq/L. You know that this is most probably not his true
Na level, and is due to hyperglycemic osmolar dilution. What is his corrected Na level?
a. 136
b. 138
c. 140
d. 142
e. none of the above
The initial serum sodium is usually normal or low because of the osmolar dilution of hyperglycemia
and the effect of an elevated sodium-free lipid fraction. An estimate of the reconstituted, or “true,”
serum sodium for any given glucose level above 100 mg/dL (5.6 mmol/L) is calculated as follows:
[Na + (glucose -100)*1.6] / 100
where glucose is in mg/dL, or
[Na + (glucose -5.6)*1.6] / 5.6
where glucose is in mmol/L.
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The sodium should increase by about 1.6 mmol/L for each 100 mg/dL decline in the glucose. The
corrected sodium is usually normal or slightly elevated and indicates moderate hypernatremic
dehydration. If the corrected value is greater than 150 mmol/L, severe hypernatremic dehydration may
be present and may require slower fluid replacement. The sodium should steadily increase with
therapy. Declining sodium may indicate excessive free water accumulation and the risk of cerebral
edema.
65. On follow-up after 1 week, you see Daniel again in your continuity clinic. His mother asks you for
nutritional advice. The following are TRUE regarding nutritional management in Daniel’s case
EXCEPT
a. There are no special additional nutritional requirements for the diabetic child other than those
for optimal growth and development.
b. In outlining a nutritional plan, Daniel’s food preferences must be considered.
c. Carbohydrate counting will be important as this will allow Daniel to adjust his insulin dosage to
his mealtime carbohydrate intake.
d. It is recommended that Daniel should increase his intake of simple sugars such as sucrose
since these are rapidly absorbed and easily metabolized.
e. none of the above
66. Daniel also asks about exercise. He says that he is part of his school’s basketball team and is afraid
that he will have to stop playing. You tell him and his mother the following EXCEPT
a. It is perfectly alright for diabetic children to play basketball.
b. Regular exercise improves glucoregulation by increasing insulin receptors.
c. Vigorous exercise is even recommended in poorly controlled diabetics.
d. A major complication of exercise in diabetic patients is hypoglycemia during or within hours after
activity.
e. none of the above
67. The following are typical clinical manifestations of congenital hypothyroidism EXCEPT
a. Fever
b. Prolonged physiologic jaundice
c. Feeding and respiratory difficulties
d. Macrocytic anemia refractory to treatment with hematinics
e. Large abdomen, usually with an umbilical hernia
68. The following are TRUE regarding management of hypothyroidism EXCEPT
A. Early diagnosis and adequate treatment of congenital cases from the first weeks of life result in
normal growth and intelligence.
B. When hypothyroidism occurs after 2 years of life, the prognosis is much better even if diagnosis
and treatment has been delayed.
C. Oral L-thyroxine is the treatment of choice.
D. In older children, after catch-up growth is complete, the growth rate provides an excellent index
of the adequacy of therapy.
E. none of the above
69. During a health supervision visit with a 12‐year‐old girl, you palpate a firm thyroid gland. Free
thyroxine is elevated, thyroid‐stimulating hormone is less than 0.01 mcIU/mL (normal, 0.5 to 5.0
mcIU/mL), and triiodothyronine is elevated. She has fine, smooth skin and finger and tongue tremor.
The following are expected in her condition EXCEPT
a. Irritability and emotional lability
b. Tachycardia, palpitations, dyspnea, and cardiac enlargement
c. Mitral regurgitation
d. Constipation
e. Storm may be precipitated by trauma, parturition, infection, or surgery
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70. Evaluation of the immune system should be done in children with the following clinical
manifestations EXCEPT
a. two or more serious respiratory or documented bacterial infections (cellulitis, draining otitis
media, pneumonia, lymphadenitis) within one year
b. six or more ear infections within one year
c. serious infections occurring at unusual sites (liver, brain abscess)
d. infections with unusual pathogens (Aspergillus, Serratia marcescens, Nocardia, Burkholderia
cepacia), infections with common childhood pathogens but of unusual severity, and the need for
intravenous antibiotics to successfully treat an infection usually treated with oral antibiotics
e. failure to thrive with or without chronic diarrhea
71. A 12‐month‐old boy is brought to the OPD because of severe eczema. His parents state that their
son's eczema started soon after birth and has not responded to topical corticosteroids. The parents
also are concerned that the infant has had frequent otitis media, sinus infections, and one episode of
pneumonia requiring hospitalization last month. During your review of the laboratory studies
performed, you notice that the infant has thrombocytopenia (20x103/mcL [20x109/L]) and small
platelets. Of the following, the MOST likely diagnosis for this infant is
a. Bruton (X‐linked) agammaglobulinemia
b. chronic granulomatous disease
c. DiGeorge syndrome
d. Wiskott‐Aldrich syndrome
e. X‐linked severe combined immunodeficiency
72. Which among the following diseases will cause urine that has a mousy or musty odor?
a. PKU
b. Trimethyaminuria – rotten fish odor
c. MSUD
d. Tyrosinemia – cabbage like
73. Which among the following inborn errors of metabolism, if any, commonly presents with normal
serum pH and bicarbonate values?
a. Urea cycle defect
b. Organic acidemia
c. Defect in gluconeogenesis
d. None of the above; absence of metabolic acidosis rules out an inborn error of metabolism
74. A 7‐year‐old boy presents with a 3‐year history of rhinorrhea and nasal congestion. He experiences
daily nasal symptoms that are often severe enough to limit his outdoor activity. On physical
examination, you note infraorbital swelling, a transverse nasal crease, boggy turbinates, and clear
rhinorrhea. Which among the following statements is TRUE about his condition?
a. His condition commonly coexists with asthma.
b. Postnasal drip commonly causes chronic cough.
c. His condition is strongly associated with snoring, sleep abnormalities, and daytime fatigue.
d. Both uncontrolled AR and the adverse effects of sedating medications may diminish cognitive
function and learning.
e. All of the above.
75. The following are MAJOR clinical features for the diagnosis of atopic dermatitis EXCEPT:
a. chronic relapsing course
b. elevated serum IgE levels
c. presence of a family history of atopic disease
d. scaly, erythematous, maculopapular rashes on the flexural areas in adolescents
e. pruritus
76. The following are true about the management of atopic dermatitis EXCEPT:
a. Hydration hinders transepidermal penetration of topical glucocroticoids.
b. Systemic antihistamines offer minimal benefit and are used only in severe cases.
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c. Topical glucocorticoids are frequently the cornerstone of anti-inflammatory treatment.
d. Lukewarm soaking baths followed by the application of an occlusive emollient gives symptomatic
relief.
77. Which among the following are the most potent and effective medications used to treat both the acute
(administered systemically) and chronic (administered by inhalation) manifestations of asthma?
a. Corticosteroids
b. Inhaled beta-agonists
c. Leukotriene modifiers
d. Methylxanthines
78. The following are recommended in the management of acute asthma exacerbations in the hospital
setting EXCEPT
a. Supplemental oxygen
b. Chest physiotherapy and mucolytics
c. Frequently or continuously administered inhaled bronchodilator
d. Systemic corticosteroid therapy
e. Inhaled ipratropium bromide
79. A 15-year-old female consults at the ER for bipedal edema and decreased urine output. On history,
you found out that several weeks before the onset of edema and oliguria, the patient already had lowgrade fever associated with joint pains for which analgesics provided only temporary relief. She had
poor appetite, weight loss and easy fatigability. On PE, you noted an erythematous rash on the nasal
bridge and cheeks which the patient dismissed as something that appeared after she stayed under
the sun for too long. The diagnosis of SLE requires fulfillment of 4 out of 11 criteria serially or
simultaneously, which include(s)
a. malar rash
b. serositis
c. neurologic disorder
d. all of the above
80. Depending on the affected target organs, treatment of SLE may include the following, EXCEPT:
a. corticosteroids
b. antimalarials (Hydroxychloroquine is given for patients with cutaneous manifestations.)
c. cytotoxic agents
d. none of the above
81. Which among the following is the recommended treatment for otitis externa?
a. Topical otic preparations containing neomycin with either colistin or polymyxin and
corticosteroids
b. Application of mineral oil
c. Oral amoxicillin
d. Oral amoxicillin with clavulanic acid
82. During clinic rounds with medical students, you see a 2‐year‐old girl who has otitis media. One of the
students asks about the potential complications of otitis media. Among the following, the statement
you are MOST likely to make is that
a. there is no need to refer for surgical management when acute otitis media is recurrent despite
appropriate medical therapy
b. treatment guidelines for otitis media with effusion recommend the use of oral corticosteroids
c. antihistamines, mucolytics, and decongestants are effective in otitis media
d. fever, headache, or lethargy, or any central nervous system sign should make you suspect
an intracranial complication
e. when an intracranial complication is suspected, immediate lumbar puncture should be done
83. Which among the following is a characteristic history or PE finding in otitis media?
a. acute ear pain, often severe, accentuated by manipulation of the pinna or by pressure on the
tragus
b. there is edema of the ear canal, erythema, and thick, clumpy otorrhea
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c. irritability, a change in sleeping or eating habits, and, occasionally, holding or tugging at
the ear
d. the tympanic membrane is normal
84. On your DRI rounds at Ward 15, you see a newborn with superficial epidermal inclusion cysts that
contain laminated keratinized material. You tell the intern who is going on rounds with you that
when found in the middle of the palate, they are called Epstein pearls. What are these lesions?
a. Sebaceous hyperplasia
b. Milia
c. Erythema toxicum neonatorum
d. Infantile acropustulosis
85. Another newborn on her second day of life has lesions are firm, yellow-white, 1–2 mm papules or
pustules with a surrounding erythematous flare. What will you do?
a. Refer to Dermatology.
b. Admit to NICU and start IV antibiotics.
c. Isolate the patient and observe for a few more days.
d. Advise the mother that there is nothing to worry about because the rash will disappear
without medications.
86. A 2-month old develops a scaly rash on his scalp with involvement of the eyebrows and postauricular areas. Similar lesions are seen on his axillae. What is the most likely diagnosis?
a. Atopic dermatitis
b. Irritant dermatitis
c. Candidal dermatitis
d. Seborrheic dermatitis
87. What advice do you give to the mother in #86?
a. Oral antihistamines should be started.
b. Topical steroids are necessary in most cases.
c. Scalp lesions may be controlled with an antiseborrheic shampoo.
d. Avoidance of moisture is the cornerstone of treatment.
88. Which among the following skin conditions may result in acute poststreptococcal glomerulonephritis
as a complication?
a. Candidal dermatitis
b. Folliculitis
c. Impetigo
d. Staphylococcal scalded skin syndrome
89. Which among the following is part of the management for cellulitis?
a. Empiric therapy with an antistaphylococcal antibiotic and an aminoglycoside in neonates.
b. Lumbar puncture in infants below one year of age if signs of systemic toxicity are present.
c. Oxacillin if fever, lymphadenopathy, or constitutional signs are present.
d. Immobilization and elevation of an affected limb.
e. All of the above.
90. Which among the following should be part of the evaluation of a child suspected of having scoliosis?
a. Thorough history and physical examination
b. Careful neurologic examination
c. Forward bending or Adams test
d. Examination for café-au-lait spots, a sacral dimple, midline cutaneous abnormalities
e. All of the above
91. Which among the following statements about osteomyelitis is TRUE?
a. Almost all neonates with osteomyelitis are febrile and are toxic-looking.
b. Blood culture is usually not necessary in patients with osteomyelitis.
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c. ESR and CRP may be of value in assessing response to therapy or identifying complications.
d. Absence of lytic bone changes on x-rays done in the first week of illness rules out osteomyelitis.
e. Cefazolin is the recommended empiric treatment for osteomyelitis in patients who are not
immunized against Hemophilus influenza b.
For #92-95: The following are the ABG values of a 6 month old infant intubated for pneumonia. At this
time, the patients vital signs are stable and there is good air entry and chest rise.
pH 7.53
pCO2 29.4
pO2 62.4
FiO2 21%
92. What is the primary acid-base problem of this patient?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
93. What is the predicted pH based on the measured pCO2?
a. 7.38
b. 7.43
c. 7.48
d. 7.53
e. None of the above
94. What associated/secondary acid-base problem does this patient have?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
e. The patient has no associated/secondary acid-base problem.
95. What is the computed base change?
a. Base deficit of 4.02
b. Base deficit of 8.02
c. 0 (no base deficit and no base excess)
d. Base excess of 4.02
e. Base excess of 8.02
96. Which among the following is the BEST response to this ABG?
a. Decrease the respiratory rate on the ventilator.
b. Increase the peak inspiratory pressure on the ventilator.
c. Give 10 cc/kg pNSS fluid bolus.
d. Give 2 meq/kg sodium bicarbonate.
e. Start inotropic support.
97. Refer to the ECG tracing above. This patient has
a. premature atrial contractions
b. premature ventricular contractions
c. ventricular tachycardia
d. ventricular fibrillation
ECG for #97
For items 98-100: Refer to ECG tracing #1. This is the tracing of a 6-month-old male with a chief
complaint of cyanosis.
98. What is the heart rate, and what is the rhythm?
a. 100 bpm; sinus bradycardia
b. 100 bpm; regular sinus rhythm
c. 150 bpm; regular sinus rhythm
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d. 150 bpm; supraventricular tachycardia
e. 200 bpm; supraventricular tachycardia
99. What is the axis? Is the axis normal or is there axis deviation?
a. +75˚; normal axis
b. -75˚; left axis deviation
c. -75˚; extreme axis deviation
d. +135˚; normal axis
e. +135˚; right axis deviation
100.
Is there chamber enlargement? If so, which chamber is enlarged?
a. There is no chamber enlargement.
b. Yes; there is right ventricular hypertrophy.
c. Yes; there is left ventricular hypertrophy.
d. Yes; there is combined ventricular hypertrophy.
II.
MATCHING TYPE
Shade the letter of the BEST answer on your answer sheet. This is a BONUS section. Each item is worth
0.5 point.
Set A: Classify the following laboratory parameters as to whether they indicate pre-renal or
intrinsic renal failure.
e. Pre-renal failure
f. Intrinsic renal failure
101.
102.
103.
104.
urine sodium > 40 meq/L
urine specific gravity > 1.020
fractional excretion of sodium > 2%
urine osmolality > 500 mOsm
B
A
B
A
Set B: Match the following findings with the viral exanthem they are associated with and with the
appropriate description.
a.
b.
c.
d.
Forchheimer spots
Nagayama spots
Koplik spots
Rose spots
Diseases they are associated with:
105. Typhoid fever
106. Rubella
107. Measles
108. Roseola
Description:
109. Tiny, rose-colored lesions found on examination of the throat
110. Discrete red lesions with bluish white spots in the center on the inner aspects of the cheeks at the
level of the premolars
111. Macular or maculopapular rash visible around the 7th–10th day of the illness, and lesions may
appear in crops of 10–15 on the lower chest and abdomen and last 2–3 days
112. Ulcers at the uvulopalatoglossal junction
Set C: Which among the following congenital infections is BEST described by the statement?
a. congenital toxoplasmosis
b. congenital rubella syndrome
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c. congenital cytomegalovirus
d. congenital herpes
113.
114.
115.
116.
This typically presents as a characteristic triad of chorioretinitis, hydrocephalus, and cerebral
calcifications.
Asymptomatic congenital infection is likely the leading cause of sensorineural hearing loss, which
occurs in approximately 7% of all infants, whether symptomatic at birth or not.
Patent ductus arteriosus is the most frequently reported cardiac defect, occurring in 78% of
patients.
Infants infected during delivery or postpartum may present with disease localized to the skin,
eyes, or mouth; encephalitis with or without skin, eye, or mouth (SEM) disease; or disseminated
infection involving multiple organs, including the brain, lungs, liver, heart, adrenals, and skin.
Set D: Which among the following etiologic agents of pharyngitis is commonly associated with the
following?
a.
b.
c.
d.
117.
118.
119.
120.
adenovirus pahryngitis
coxsackievirus pharyngitis
EBV pharyngitis
streptococcal pharyngitis
hepatosplenomegaly
herpangina
rheumatic fever
pharyconjunctival fever
C
B
D
A
Set E: Which among the following etiologic agents of pneumonia is being described?
a. S. pneumoniae
b. S. aureus
c. M. pneumoniae
d. H. influenzae B
e. respiratory syncitial virus
121.
122.
123.
124.
may be complicated by pneumatocoeles and empyema
spreads along the bronchial tree similar to viral pneumonia
focal lobar involvement
bilateral interstitial infiltrates
B
C
A
E
BONUS MULTIPLE CHOICE QUESTION
125. You are evaluating a 7‐year‐old boy for hematuria and proteinuria. As part of the evaluation, you
measure serum electrolytes. The serum creatinine is 1.1 mg/dL (97.2 mcmol/L). Of the following,
the MOST accurate serum creatinine measurements for children of normal physical development
are (All measurements mg/dL [mcmol/L])
a. 3 months old: 0.3 (26.5); 2 years old: 0.4 (35.4); 7 years old: 1.0 (88.4); 17 years old: 1.0
(88.4)
b. 3 months old: 0.6 (53.0); 2 years old: 0.8 (70.7); 7 years old: 1.0 (88.4); 17 years old: 1.2
(106.1)
c. 3 months old: 0.3 (26.5); 2 years old: 0.4 (35.4); 7 years old: 0.6 (53.1); 17 years old: 0.9
(79.6)
d. 3 months old: 0.6 (53.0); 2 years old: 0.4 (35.4); 7 years old: 0.7 (61.9); 17 years old: 0.7
(61.9)
e. 3 months old: 0.7 (61.9); 2 years old: 0.8 (70.7); 7 years old: 0.7 (61.9); 17 years old: 0.7
(61.9)
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