1 A newborn FT was noted to be pale at 4th month of life

University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

Aurora Boulevard, Quezon City

DEPARTMENT OF PEDIATRICS

QUESTIONS AND ANSWERS FOR MEDICAL BOARD REVIEW

FEBRUARY 2005

CHOOSE THE BEST ANSWER:

1 A newborn FT was noted to be pale at 4th month of life. Iron is unlikely in this condition because

infants have sufficient stores to meet their iron requirement for:

A. 2-3 months

B. 46 months

C. 7-8 months

D. 10-12 months

(Problem Solving) - GIT

B – It is by 6 months that iron should be supplemented among healthy full terms.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, p. 156)

2 The breastfed baby of a pure vegetarian mother may develop:

A. Xerophthalmia

B. Diarrhea & Dementia

C. Osteomalacia

D. Anemia


D - Strict Vegan diets contain no eggs, meat or milk products making this deficient in Vitamin B 12.

(Chap. 446 p. 1612)

Nursing Vegan mothers must be given B12 to prevent. Methylmalonic academia and anemia in their infants. (166)

(A) Xerophthalmia is Vitamin A deficiency and for which Vitamin A rich sources are the vegetables.

(B) Diarrhea and dementia are signs of niacin deficiency (Pellagra) B vitamins come from grains and vegetables.

(C) Osteomalacia is Vitamin D deficiency (Rickets)

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chap. 446 Table 44-I)

3 By 6th month of age micronutrients must be started. Foremost among these is that nutrient that prevents:

A. Xerophthalmia

B. Scurvy

C. Anemia

D. Goiter


C - All nutrient needs of infants must be met by 6 months. But during this time breast milk volume and iron stores may not be adequate to accommodate the demands of growth – Iron deficiency anemia may ensue.


4. Chronic intake of carotenoids may result in:

A. Pseudotumor cerebri

B. Yellow skin and sclerae

C. Yellow skin

D. Cranial nerve palsy

(Recall) - GIT

C - Carotene (yellow pigment); carotenemia although non-toxic is due to deposition of carotene pigments in the skin but not the sclerae,

(B) Icteresia and jaundice is yellowish discoloration of the sclerae and skin secondary to deposition of bilirubin due to a pathology in Bilirubin metabolism hemolytic of hepatobiliary disease

(A and D) Pseudotumor cerebri and cranial nerve palsy are CNS manifestations of Vitamin A toxicity after chronic intake of >100,000/u/day vitamin A.


5. A 3-hour old newborn with a prenatal history of maternal hydramnios was noted to have frothing of mouth and nose with circumoral cyanosis. You anticipate that:

A. There is inability to pass the nasogastric tube

B. Presence of scaphoid abdomen

C. Referral to ENT will be done

D. All of the above


A - In early onset respiratory distress, inability to pass an NGT suggests esophageal atresia with TEF.

This is a surgical problem not seen by ENT

(C) maternal polyhydramnios is more associated with TEF rather than diaphragmatic hernia (B)

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004,Chapter 300)

6. Which of the micronutrients does not have recognized anti-infective properties?

A. Vitamin A

B. Vitamin D

C. Iron

D. Zinc

(Recall) - GIT

B - Deficiency of any essential nutrient may result in failure to thrive and accompanying lack of immune protection. However, infections are more common in children with Vitamin. A, Iron, Zinc deficiencies. These 3 have roles in the immune system.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 44)

7. A 1-1/2 year old is discovered to have a bottle of alkali solution in his mouth. The bottle was noted to be half empty. No external signs on the child's face were seen. Your advice is to bring the child to the

ER. There must be prior administration of:

A. Emetic

B. Antiemetic

C. Milk

D. Laxative


C - Milk calms the child and dilutes the alkali

(A) don’t induce emesis

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, (Chapter 308.2)

8. A 3 year old accidentally ingested a coin. A chest x-ray was taken. In contrast to foreign body trachea, the coin in the esophagus as seen on radiograph will show:

A. Edge of the coin in AP view

B. Edge of coin on lateral view

C. Flat surface in AP view

D. A and C


D - ( Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 308.1)

9. The WHO recommends the use of ORS in developing countries to have a sodium concentration of

_____ mmol/L:

(

A. 90

B. 100

C. 110

D. 120

Recall) - GIT

A - 90 mmol/l

Above 90 is hyperosmolar

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004, p. 250)

10. A 3-week old with essentially normal birth history had episodes of intermittent vomiting after feeding.

If pyloric stenosis is being considered, you expect the following EXCEPT:

A. Hypochloremic alkalosis

B. Bilous vomiting

C. Gastric peristaltic wave

D. Olive-shaped RUQ mass in abdominal palpation


C - The hallmark of gastric obstruction is non-bilious vomiting.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 310)

11. A one day old had bilous vomiting. He was noted to be slightly jaundiced. The abdomen was not distended but there was occasional visible peristaltic nerves on the abdominal wall. Plain abdomen xray showed double-bubble sign. The obstruction is on what level?

A. Distal esophagus

B. Gastric

C. Duodenal

D. Colonic


C - (Nelson’s Textbook of Pediatrics, 17 th ed, 2004, p. 1233)

When the obstruction is in the duodenum beyond the Ampula of Vater – vomitus is bilous. The

Ampulla of Vater is the site where bile exits.

12. A 2-year old with head trauma underwent a neurosurgical procedure. At the PICU he had massive

hematemesis. You would consider:

A. Curling’s ulcer

B. H. pylori infection

C. Cushing’s ulcer

D. B and C


C - ( Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 316.1)

Gastric hypersecretion is associated with head trauma and severe CNS disorders

(A) Curling’s ulcers are associated with severe burns

(B) The course is too acute for H. pylori infection

13. An 11 year old Tanner stage 2 female developed epigastric pain / 8 hours later there was fever nausea and vomiting. She passed 2 soft bowel movements. In the clinic, she limps and abdominal palpation, there was generalized guarding. Most likely, she has:

A. Pelvic inflammatory disease

B. Ruptured ectopic pregnancy

C. Appendicitis

D. Mesenteric adenitis


C - All choices are differentials of appendicitis

(A) PID presents with vaginal discharge

(B) Pregnancy is unlikely for Tanner 2

(D) Mesenteric adenitis follows a week of respiratory infection

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chapter 324)

14. A 2 year old previously well child had intermittent crying episodes and projectile vomiting 12 hours ago. There was gassy abdominal distention and passage of maroon-colored stools. You would:

A. Give antiamebics and antiemetics

B. Do abdominal x-ray and refer to surgery

C. Give antibiotics



B - The diagnosis is intussusception

(A) and (C) are not employed in intussusception

(Nelson Textbook of Pediatrics, 17 th ed, 2004)

15. The GI malignancy prevented by immunization is:

A. Gastric carcinoma

B. Colonic carcinoma

C. Hepatic carcinoma

D. Pancreatic carcinoma

(Recall) - GIT

C - Hepatitis B directly increases the risk of Hepatocarcinoma in later life. This is prevented by vaccination. There are no known vaccines for preventing the onset of the other cancers. Gastric cancer from H. pylori gastritis is well documented. So far there are no H. pylori vaccines.


16. Prolonged antibiotic therapy can result to bleeding with the following laboratory results:

A. Normal PT, normal PTT

B. Prolonged PT, prolonged PTT

C. Prolonged PT, normal PTT

D. Normal PT, prolonged PTT

(Problem Solving) – Hema/Onco

C - Prolonged antibiotic therapy can lead to gut sterilization leading to reduced synthesis of Vitamin

K – dependent clotting factors (Factors II, VII, IX & X, protein C and protein S). This reduction of clotting factors of the extrinsic limb of coagulation will lead to prolongation of Prothrombin Time with normal PTT.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004)

17. The CBC of a 7-yer old male with epistaxis and ecchymoses revealed Hgb 67 g/dl, Hct 18%, WBC

50,000, Neutrophils 5%, Lymphoblast 95%, Platelet Count 20,000. What is you primary consideration?

A. Aplastic anemia

B. Acute lymphocytic leukemia

C. Disseminated intravascular coagulation

D. Idiopathic thrombocytopenic purpura


B - The anemia and thrombocytopenia are due to decreased production of erythroid and megakaryocytic precursors resulting from blastic proliferation in the bone marrow. Aplastic anemia (Choice a) is associated with pancytopenia. DIC (Choice C) doesn’t produce leukocytosis and blasts in the peripheral smear. It is associated with the coagulation mechanism, not the hematopoietic cells.

ITP (Choice D) is only associated with thrombocytopenia. No leukocytosis and blasts are seen in the peripheral smear.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004)

18. Recurrent gum bleeding was noted in a 7-year old female. CBC and platelet count are normal,

A. ITP

B. Hypoprothrombinemia

C. TTP

D. Von Willebrand Disease


D - Von Willebrand disease is a disorder associated with mucocutaneous hemorrhages. The disorder is due to deficiency of Von Willebrand factor, a glycoprotein that is synthesized in megakaryocytes and endothelial cells. During normal hemostasis VWF adheres to the endothelial matrix after vascular damage. Changes in the conformation of VWF cause platelets to be an adhere to VWF resulting to platelet activation and recruitment of additional platelets. VWF also serves as the carrier protein for plasma factor VIII. Severe deficiency of VWF can cause prolongation of bleeding time and PTT. ITP (Choice A) results only to prolonged BT because the coagulation phase is not affected. Hypoprothrombinemia (Choice B) results to decreased synthesis of Vitamin K – dependent factor causing prolonged PT. ITP (Choice C) is a form of microangiopathic hemolytic anemia with thrombocytopenia.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, Chap. 469)

19. A 10-kg child with iron deficiency anemia should receive:

A. 20 mg elemental iron

B. 30 mg elemental iron

Prothrombin time is normal but bleeding time and partial thromboplastin time are prolonged. The most likely diagnosis is:

C. 60 mg elemental iron

( Recall)

D. 70 mg elemental iron

– Hema/Onco

C - The therapeutic dose of elemental iron is 6 mkd.


20. The following statement is true regarding brain tumors in childhood:

A. Hereditary syndromes are associated with increased incidence of brain tumors in 25% of cases

B. Cranial exposure to ionizing radiation is associated with increased incidence of brain tumor

C. Supratentorial tumors predominate among children aged 1-10 years

D. In general, there is a slight predominance of supratentorial tumor location in children

(Recall) – Hema/Onco

B - Cranial exposure to ionizing radiation has been shown to be associated with increased incidence of brain tumors. This has been observed in pediatric acute lymphocytic leukemia who underwent craniospinal prophylaxis. Hereditary syndrome (Choice A) are associated with increased incidence only in 5% of cases. Supratentorial tumors predominate during the 1 st year of life thus

Choice C is incorrect. Generally, infratentorial tumors predominate slightly over supratentorial tumors making Choice D incorrect.


21. Neuroblastoma is a condition characterized by the following:

A. Malignancy most frequently diagnosed in infancy

B. Mixed embryonal neoplasm composed of three elements: blastoma, epithelia and stroma

C. Classically presents with leukocoria

D. Diagnosis does not require a biopsy but is established characteristical clinical findings


A - Neuroblastoma is an embryonal cancer of the peripheral sympathetic nervous system. It is the third most common pediatric cancer accounting for about 8% of pediatric cases. It is the most common malignancy in infancy accounting for 28-39% of neonatal malignancies. Mixed embryonal neoplasm composing of three elements (Choice B) pertai ns to Wilm’s tumor. Leukoria

(Choice C) is the characteristic clinical presentation of retinoblastoma. Diagnosis does not require a biopsy (Choice D) in retinoblastoma since characteristic ophthalmologic findings are sufficient. (Ne lson’s Textbook of Pediatrics, 17 th ed, 2004, Chap. 490)

22. Among the following tumors, the one with the best over-all survival rate is:

A. Wilm’s tumor

B. NonHodgkin’s lymphoma

C. Hepatoblastoma

D. Neuroblastoma


A - Prognosis of neuroblastoma is generally good. Survival in low risk group is 91-100%; average group 75-98% Stage 4S carries 100% survival with supportive care only because the tumor regresses spontaneously. Wilm’s tumor (Choice A) prognostic factors are tumor size, stage and histology. More than 60% of patients with all stages generally survive. NonHodgkin’s lymphoma (Choice B) is considered disseminated disease from the time of diagnosis.

Hepatoblastoma (Choice C) if unresected carries survival rate of 60%.


23. Which of the following patterns noted on continuous monitoring of fetal heart rate is most indicative of fetal distress?

A. Baseline variability with periodic acceleration

B. Increasing baseline variability

C. Early deceleration without baseline variability

D. Late deceleration without baseline variability

(Problem Solving) - Neonatology

D - Baseline variability with or without periodic acceleration of the heart rate is a sign of fetal well- being. Increasing baseline variability may represent early compromise of fetal oxygenation. The early deceleration pattern is due to pressure of the anterior fontanelle on the cervix and is not a sign of fetal distress. The variable deceleration pattern indicates umbilical cord compression.

The late deceleration pattern signifies fetal hypoxemia.

(Behrman, ed. 13, p. 368)

24. A healthy premature infant who weighs 950 g (2 lb, 1 1/2 oz) is fed undiluted breast milk to provide

120 cal/kg per day. Over ensuing weeks the baby is most apt to develop:

A. Hypernatremia

B. Hypocalcemia

C. Blood in the stool

D. Metabolic acidosis


(Behrman, ed. 113, pp. 162-163)

B - Breast milk has much less calcium and phosphorus than do commercial formulas.

25. An infant weighing 1400 g (3 lb) is born at 32 weeks gestation in a delivery room that has an ambient temperature of 24'C. Within a few minutes of birth, this infant is likely to exhibit all the following

EXCEPT:

A. Pallor

B. Shivering

C. A fall in body temperature

D. Increased respiratory rate


B - A room temperature of 24’C provides a cold environment for preterm infants weighing less than

1500 g. Aside from the fact that these infants emerge from a warm intrauterine environment. In order to bring body temperature back to normal they must increase their metabolic rate; ventilation in turn, must increase proportionally to ensure adequate oxygen supply. Infants rarely shiver in response to a need to increase heat production.

(Behrman, ed. 113, p. 363)

26. Initial examination of a full tem infant weighing less than 2500 g (5 lb, 8 oz) shows edema over the dorsum of her hands and feet. Which of the following findings would support a diagnosis of Turner's syndrome?

A. A liver palpable to 2 cm below the costal margin

B. Tremulous movements and ankle clonus

C. Redundant skin folds at the nape of the neck

D. A transient, longitudinal division of the body into a red half and a pale half


C - Turner’s syndrome is a genetic disorder with the 45XO karyotype being most common. At birth affected infants have low weights, short stature, edema over the dorsum of hands and feet and loose skin folds at the nape of the neck.

(Behrman, ed. 13, pp. 264-266. 1236-1237)

27. Object permanence is not present in a 2 months old, whose response to dropping a ball is:

A. Staring descending as the ball descends

B. Eyes descending as the ball hits the ground

C. Crying when the ball hits the ground

D. Smiling at the game of the hide-and-seek


A - Out of sight out of mind is the characteristic response of a 2 month old. Object permanence appears at approximately 8 months of age. This is also called object constancy.

(Nelson Textbook of Pediatrics, 15 th ed, Chap. 11))

28. The ability to manipulate small objects with the pincer grasp is usually noted at what age?

A. 0 to 2 months

B. 3 to 5 months

C. 6 to 7 months

D. 8 to 9 months

(Recall) - Neonatology

D - The pincer grasp, which is noted at age 8 to 9 months, along with increasing mobility, enables an infant to explore the environment.

(Nelson Textbook of Pediatrics, 17 th ed, 2004)

29. A developmentally normal child who is able to run, build a tower of two cubes, pretend play with a doll and speak in two-word sentences is what age?

A. 19 months

B. 15 months

C. 14 months

D. 24 months


A - (See Table 11-3, Chapter 11, Nelson Textbook of Pediatrics, 15 th ed)

30. A developmentally normal child who is just able to sit without support, transferobjects from hand to hand, and speak in a monosyllabic babble is probably what age?

A. 2 months

B. 4 months

C. 9 months

D. 6 months


D - (Nelson Textbook of Pediatrics, 15 th ed, See Table 11-3, Chap 11)

31. This primitive reflex is observed in a normal one year old:

A. Tonic neck reflex

B. Parachute reflex

C. Palmar grasp

D. Placing reflex

(Recall) - Neurology

B - Among these 4 choices, it is B that persists normally beyond the neonatal period. In fact, the parachute reflex persists for life.


32. Which of the following case scenarios merit an EEG as an initial test as part of the

neurodiagnostic evaluation?

A. Febrile seizure

B. First non-febrile seizure

C. Meningitis

D. Intracranial SOL

(Problem Solving) - Neurology

B - While the first febrile seizure is generally a benign one, an EEG is requested if it recurs. The EEG provides characterization of seizure types which allows for the specific medical or surgical management. A lumbar puncture with CSF analysis would have confirmed meningitis. A brain

CT scan would have demonstrated the intracranial SOL.

(Nelson’s Textbook of Pediatrics, 17 th ed. ; Behrman, Kliegman & Jenson, 2004, p. 1978)

33. A 2-year old boy was admitted because of low to moderate grade fever of 3 weeks, on and off frontal

headache of 1 week, squinting of 1 day, one episode of generalized seizure of 2 minute duration 6 hours

prior to admission. No medical consult done. No medications given except paracetamol. Which of the

following clinical consideration is NOT COMPATIBLE with this history?

A. Acute meningococcal meningitis

B. TB meningitis

C. Cryptococcal meningitis

D. Brain abscess of otogenic origin


A - Except for A, all the rest are compatible of the history, presenting with the clinical manifestations of at least 2 weeks.

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 965 ; 2040-44)

34. A mother calls to inform you that her previously well 4-year old child has been complaining of headaches for about a month. For the past two weeks he has been keeping his hand in a tilted position, and for the past few days he has been vomiting in the morning. The most likely diagnosis is:

A. Meningitis

B. Degeneration brain disease

C. Brain abscess

D. Brain tumor


D - Frequently, meningitis or CNS infections will present with fever, headache, and signs of irritability.

Brain abscess, because it behaves like an intracranial SOL, will present as low grade fever, headache, and localizing signs. The hallmark of neurodegenerative disease is progressive deterioration of neurologic functions with loss of speech, vision, hearing, or locomotion, often associated with seizures, feeding difficulties, and impairment of intellect. Generally, brain tumors present with signs and symptoms relating to increased intracranial pressure (vomiting, lethargy, irritability) and focal neurologic deficits. Within the 1 st year of life, supratentorial tumors predominate and include, most commonly, choroids plexus complex tumors and teratomas. From

1-10 years of age, infratentorial tumors predominate, owing to the high incidence of juvenile pilocytic astrocytoma and medulloblastoma. After 10 years of age, supratentorial tumors again predominate, with the diffuse astrocytomas, most common.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, pp. 1703, 2029, 2038, 2047)

35. Clinical evidence backs up the use of IV dexamethasone as an adjunctive therapy in acute meningitis caused by _____:

A. Neisseria meningitidis

B. Streptococcus pneumoniae

C. Hemophilia influenza

D. Listeria monocytogenes

(Recall) - Neurology

C - Data support the use of IV dexamethasone, 0.15 mg/kg/dose given every 6 hours x 2 days with bacterial meningitis caused by Hemophilus influenzae type b, but not with other bacterial causes, in terms of less fever, lower CSF protein and lactate levels, and a reduction in permanent auditory nerve damage, as manifested by sensoneural loss.


36. A 12-year old child is admitted because of the sudden onset of coma. The child had been well until about 6 hours prior to admission, when he began to complain of a headache. The headache became more severe, and the child lapsed into coma. Physical examination: T = 38.2'C, flaccid and comatose.

CSF: bloody: after centrifugation, the fluid appears xanthochromic, RBC = 3,000, WBC 7/mm3 , protein

400 mg/dl, glucose is 62 mg/dl. The most likely etiology of the coma is:

A. Intraventricular hemorrhage

B. Subarachnoid hemorrhage

C. Viral encephalitis

D. Subdural effusion


B - The event is something acute, dramatic, catastrophic so the choices would only be between A and B.

Intracranial bleeding may occur in the subarachnoid space or the bleeding may be primarily located in the parenchyma of the brain. Subarachnoid bleeding characterized by severe headache, nuchal rigidity, and progressive low of consciousness, and intracerebral bleeding is a common event in premature infant (intraventricular hemorrhage). Rupture of an arteriovenous malformation (AV mal) may occur at any age, and causes severe headache, vomiting, nuchal rigidity caused by subarachnoid bleeding, progressive hemiparesis and a focal or generalized seizure.

(Nelson’s Textbook of Pediatrics, 17 th ed, 2004, pp. 2036, 562)

37. The metaphyseal ends of long bones are common sites of osteomyelitis. This condition occurs because:

A. Relative anoxia promotes bacterial growth

B. There is blood pooling and reduced phagocytic activity

C. They are closer to the skin surface

D. They are common sites of trauma

(Problem Solving) – Musculoskeletal Disorders

B -The unique anatomy and circulation of the ends of long bones results in the predilection for localization of blood borne bacteria. In the metaphysic, nutrient arteries branch into non-anastomosing capillaries under the physics, which make a sharp loop before entering venous sinusoids draining into the marrow. Blood flow in this area is sluggish and provides an ideal environment for bacterial seeding.

(Nelson ’s Textbook of Pediatrics, 17 th ed., 2004, pp. 2297-2298)

38. It is the most common primary malignant bone tumor in children and adolescents, which shows a

"sunburst" pattern on radiographs:

A. Ewing sarcoma

B. Osteosarcoma

C. Osteochondroma

D. Osterblastoma

(Recall) – Musculoskeletal Disorders

B - Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, followed by Ewing sarcoma. In children younger than 10 years of age, Ewing sarcoma is more common than osteosarcoma. Both tumor types occur most frequently in the 2 nd

(Ref. Nelson ’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1717)

decade of life.

39. An adolescent male basketball enthusiast consults you with a painful bump below his right knee. He denies fever or trauma. Which of the following is the most likely diagnosis?

A. Legg-Calve Perthes Disease

B. Osteoid osteoma

C. Osgood-Schlatter disease

D. Osteomyelitis


C – Osgood-Schlatter disease occurs in active children, particularly during late childhood or adolescence, especially in athletes, and consists of the tearing of cartilage from the tibial tuberosity by the ligamentum patellae. The child presents with pain and swelling at the site of one or both tibial tubercles. Rest, restriction of activities, and occasionally, a knee immobilizer may be necessary combined with isometric exercise program. Complete resolution of symptoms through physiologic healing (physeal closure) of the tibia tubercle usually requires 12-24 months.

(Nelson ’s Textbook of Pediatrics, 17 th ed., 2004, pp. 2272).

40. An overweight adolescent male complains of pain in the medial aspect of his knee. He denies trauma, and he has not had a fever. The most likely diagnosis is:

A. Toxic synovitis

B. Legg-Calve-Perthes disease

C. Medial collateral ligament strain

D. Slipped capital femoral epiphysis


D - Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder with an unknown cause, in which there is a displacement of the femoral head from the femoral neck prior to epiphyseal closure. Common in obese adolescent boys, it presents with pain, limp, or refusal to walk. The pain may be referred to the knee or thigh. Legg-Calve-Perthes Disease, avascular necrosis of the femoral head presents with joint stiffness, hip and pain in the hip, thigh, knee, or groin of several weeks to months. Boys between 1-12 years (average 7 years) are most commonly affected. Toxic synovitis is a transient inflammatory arthritis of the hip associated with fever.

(Nelson ’s Textbook of Pediatrics, 17 th ed., 2004, pp. 2276-2279)

41. This statement is NOT true about infective endocarditis:

A. In 90% of cases, the causative agent is recovered from the first 2 blood cultures

B. Timing of phlebotomy is important because bacteremia occurs only during the febrile state

C. Antimicrobial pretreatment of the patients reduces the yield of blood cultures to 50-

60%

D. Laboratory should be notified that endocarditis is suspected so that the blood can be cultures on enriched media for more than 7 days

(Problem Solving) - Cardiovascular

B - Timing of collection is not important because bacteremia can be expected to be relatively constant.

(A) It is true that in 90% of cases, the causative agent is recovered from the first 2 blood collection

(C ) It is true that pretreatment with antimicrobials of the patients with bacterial endocarditis reduces the yield of blood culture to 50-60%

(D) It is true that the laboratory should be notified that endocarditis is suspected so that if necessary the blood can be cultured on enriched media for longer than 7 days to detect nutritionally deficient and fastidious bacteria or fungi. And laboratory should be notified that the patient has received antibiotics so that more sophisticated methods can be used to recover the offending organisms.

(Nelson ’s Textbook of Pediatrics, 17 th ed, 2004)

42. Painless small erythematous or hemorrhagic lesion on the palms and soles are classic lesion in:

A. Osler nodic

B. Janeway lesions

C. Roth spots

D. Spincter Hemorrhages

(Recall) - Cardiovascular

B - Janeway lesion are painless small erythematous or hemorrhagic lesions on the palms and soles.

(A) Osler nodes are tender pea-sized intradermal nodule in the pads of the fingers and toes. These lesions may represent vasculitis produced by circulating antigen antibody complexes

(C ) Sphincter hemorrhages are linear lesions beneath the nodes

(D) Roth spots – immune complex phenomena and seen in the eyes


43. Neonatal circulation is NOT characterized by:

A. In the presence of cardiopulmonary disease PDA may remain patent

B. Foramen ovale may persistently be functional

C. The wall thickens and muscle mass of the neonatal (L) and (R ) ventricles are almost equal

D. The pulmonary vasculature is insensitive to changed pO4 and PC02 levels an acidosis


D - the pulmonary vasculature is very reactive to changes in pCO2, pO2 and pH by vigorous vascular constriction

(A) in the presence of cardiopulmonary disease resulting to hypoxemia may cause the PDA to remain open. Normal PDA functionally closes by the 10-15 th hour of life

(B) Foramen ovale is functionally closed by the 3 rd months of life

(C ) the wall thickness and muscle mass of the ventricles right and left are almost equal. Without the placenta, and the closure of the ductus venosus, the left ventricle is now coupled to the high resistance systemic circulation whereas the right ventricle is now coupled with the low resistance pulmonary circulation and the wall is slightly thickened as well


44. The clinical manifestation of large VSD in neonatal patients does not include:

A. Systolic murmur may not be audible

B. Dyspnea

C. Profuse perspiration

D. Recurrent pulmonary infection


A - systolic murmur may not be audible this occurs only in small VSD this is due to the fact that the left to right shunt may be minimal because of the higher right sided pressure

(B) Dyspnea happens because of excessive blood flow and pulmonary hypertension

(C ) profuse perspiration is a sign of heart failure secondary to high level of left ventricular output heart rate and stroke volume are increased mediated by an increased level of sympathetic nervous system stimulation and activity thus increasing the circulation of catecholamines combined with increased work of breathing resulting in the elevation of in total body oxygen consumption often beyond the oxygen transport ability of the circulation

(D recurrent respiratory infection secondary to the presence of “wet” lung syndrome that serves as a niduos infection coupled with the disruption of the mucociliary clearance these will be responsible for the recurrence of URTI


45. Which of the following cardiac anomaly is NOT present in Tetralogy of Fallot?

A. Pulmonary stenosis

B. ASD

C. Overriding of the aorta

D. Right ventricular hypertrophy

(Recall) - Cardiovascular

B - Atrial septal defect is NOT seen in patients with TOF. It is ventricular septal defect (VSD) is the defect that is part of the defect and the VSD is frequently non restrictive and large frequently located just below the aortic valve.

(A) Pulmonary stenosis leads to the obstruction of the Right ventricular outflow. The pulmonary valve annulus may be of nearly normal size or may be quite small in size. The valve itself is bicuspid and occasionally is the only site of the stenosis. In cases where the right ventricular outflow tract is completely obstructed, pulmonary blood flow may be supplied by a patent ductus arteriosus (PDA) and by major aortopulmonary collateral arteries arising from the aorta

(C ) Over riding of the aorta is part of the congenital defect

(D) Right ventricular hypertrophy is due to the degree of right ventricular outflow obstruction


46. A 3-year old boy was admitted to the ER because of difficulty of breathing. History revealed that he developed high grade fever and sore throat 24 hours prior to consult with associated difficulty of swallowing. Physical examination showed a very toxic looking boy, highly febrile, with labored breathing and hyper extended neck and drooling of the saliva. The most plausible diagnosis of the above case is:

A. Acute infectious laryngitis

B. Acute epiglottitis

C. Acute laryngotracheobronchitis

D. Acute bacterial tracheitis

(Problem Solving) - Respiratory

B - Acute epiglotittis

This is a potentially lethal condition characteristically presenting with acute fulminating course of high grade fever, sore throat, dyspnea and rapidly progressing respiratory obstruction.

Drooling of the saliva is frequently present and is due to difficulty of swallowing. Hyperextension of the neck is due to his attempt to maintain the patency of the airway. This fatal disease is frequently caused by H. influenzae.

(A) Acute infectious laryngitis is frequently caused by viral agents and the disease is usually mild and non fatal. The onset of the disease is usually characterized by an upper respiratory tract infection during which sore throat, cough and hoarseness appear. Respiratory distress is unusual except in the very young infants where the airways are very compliant and small in caliber.

(C) Acute laryngotracheobronchitis “croup” is again frequently caused by viruses. Most of the patients will present with upper respiratory tract infection with a combination of rhinorrhea, pharyngitis, mild cough and low grade fever for 1-3 days before the appearance of the signs and symptoms of upper airway obstruction. It starts with “barking” cough ,hoarseness and inspiratory stridor which characteristically becoming worse at night and often recurring with decreasing intensity for several days and completely resolves with in a week.

(D) Acute bacterial trachietis this entity is a form of bacterial infection of the upper airway and does not involve the epiglottis. It is capable of causing life threatening airway obstruction. It is frequently caused by staphylococcus aureus and other organisms like Moraxella catarrhalis, nontypable H. Influenzae and anaerobic organisms have been implicated. It frequently occurs in children younger than 3 years of age.

A patient seen at the pediatric OPD clinic because of prolonged har sh “barky” cough that lingered behind after a bout of viral infection not responsive to treatment i.e. bronchodilators and mucolytics and disappears when the patient is asleep.


47. The mechanism of hypoxia in pulmonary edema is:

A. V/Q mismatch


C - diffusion impairment

B. Hypoventilation

C. Diffusion impairment

D. R-L shunt

In pulmonary edema there is fluid that acts as a barrier between the alveolo-capillary membrane which increases the travel time of the O2 from the alveoli to the capillary thus hindering the diffusion of the gas through the membrane and subsequently lowers theO2 levels in the circulation.

V/Q mismatch as a cause of hypoxemia occurs in two stages: V ventilation when there will be less O2 delivered to the alveoli due to airflow obstruction as it happens in pneumonia Q

(perfusion) hypoxemia occurs despite adequate oxygenation if the circulation is blocked as in pulmonary embolism

Hypoventilation – could cause low O level due to decreased amount of O2 delivered in to the alveoli due to central causes – (CNS depression or infection) or due to low levels of O2 in the atmosphere due to high altitude

R-L shunt this happens particularly in patient with cardiac shunts where a high percentage of the cardiac output returns to the general circulation without passing through the lungs. Or this can occur in cases of intrapulmonary shunts as well


48. The common infectious cause/s of bronchiectasis is/are:

A. Pertussis

B. Klebsiella pneumoniae

C. Streptotoccus pneumoniae

D. H. influenzae

(Recall) - Respiratory

A - Pertussis

Infections due to Bordatella pertussis, measles, rubella, togavirus, respiratory syncytial virus and

Mycobacterium tuberculosis induce chronic inflammation, progressive bronchial wall damage and dilatation of the bronchial tree. The common thread in the pathogenesis of bronchiectasis is difficulty clearing secretions and recurrent infections.


49. The pathologic findings of bronchopulmonary dysplasia (BPD) consist of the following:

A. Decreased alveolarization

B. Decreased alveolar septation

C. Minimal airway disease


(Recall ) - Respiratory

D - all of the above

BPD is a result of lung injury in infants requiring mechanical ventilation and supplemental oxygenation. It is apparent that patients with BPD have decreased alveolarization, alveolar septation and minimal airway disease all of which suggest arrest in lung development. The lung injury occurring in children is due to an interaction of multiple factors. Since RDS is a disease of progressive alveolar collapse, Atelectasis which is affected by insufficient PEEP together with ventilator-induced increased lung volume and regional overdistention promotes injury.

Oxygen promotes injury by producing free radical that cannot be metabolized by immature antioxidant systems. Therefore, mechanical ventilation and /or oxygen injure the preterm lung by affecting alveolar and vascular development. Moreover, inflammation as measured by

circulating neutrophils and macrophage in the alveolar fluid and pro-inflammatory cytokines contribute to the progression of the lung injury.


50. A patient is considered to have intermittent asthma when the following is/are present:

A. PEFR variability = <20%

B. PEFR 60-79% of predicted

C. FEVI <60%

D. PEFR variability = 20-30%


A - PEFR variability =<20%

Peak expiratory flow rate variability is a measure of the stability of the airways and it is considered as a diagnostic tool to predict the success of one’s treatment PEFR variability =<20% is still within normal limits. Intermittent asthma has normal PEFR and PEFR variability values.

Symptoms of these patients are very infrequent

(B) Once PEFR is 60-79% of the predicted, it only means that airway obstruction is present [(N)

PEFR = ≥ 80% of the predicted] and signals that the patient belongs to the moderate persistent category

(C ) FEV1 (forced expiratory volume in one second) is a measure of airflow obstruction. And the value of <60% indicates that the patient belongs to the category of severe persistent asthma.

(D) PEFR variability =20-30% means that airways are still unstable and asthma is not well controlled and the patient belongs to the mild persistent asthma category


51. An 8-year old presents with sneezing, clear rhinorrhea, and nasal itching. P.E. findings show boggy, pale nasal edema with a clear discharge. The most likely diagnosis is:

A. Foreign body

B. Vasomotor rhinitis

C. Neutrophilic rhinitis

D. Allergic rhinitis

(Problem Solving) – Immunology/Allergology

D - Allergic rhinitis is often seasonal and associated with allergic conjunctivitis. Eosinophils predominate in the nasal secretions.

( Nelson’s Textbook of Pediatrics, 17thed, 2004, pp. 759-760)

52. The mother of 7-year old girl with acute strep throat calls to report that within 15 minutes after the first dose of oral penicillin you prescribed, she is complaining of itching and has developed hives. Which of the following should you recommend?

A. Give her oral antihistamines and call again if not improved within 30 minutes

B. Bring her to your office or the nearest emergency room

C. Substitute erythromycin for penicillin

D. Bring her to the nearest emergency room once difficulty of breathing is experienced


B - The urticarial reaction described in the question may develop into anaphylaxis which requires emergency treatment. Aside from this, penicillin should be stopped and a substitute non-penicillin appropriate antibiotic chosen.

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004,Chap 137, pp. 781-782)

53. A child has abdominal pain, arthritis, microscopic hematuria, and a purpuric rash only on the lower extremities. Which of the following is the most likely diagnosis?

A. Meningococcemia

B. Varicella

C. Henoch-Schonlein vasculitis

D. Post streptococcal glomerulonephritis


C -The purpura on the lower extremities suggests Henoch-Schonlein Vasculitis. Meningococcemia is generalized. Varicella gives papulo-vesicular lesions which are likewise generalized. Erythema nodosum is the cutaneous lesion usually found on the lower extremities in post-strep infection.

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004,pp. 794, 826-828)

54. A 2-day old neonate with vomiting of bilous material since birth was brought to your hospital. X-rays taken showed “double-bubble”.

A. Metabolic problems must be addressed initially

B. Schedule for emergency laparotomy

C. Do upper GI series

D. Intubate once seen


A - (Nelson’s Textbook of Pediatrics,, 17 th ed, 2004, pp. 1233-1234)

55. A 24-hour old neonate is brought to the ER because of inability to pass meconium in 24 hours. He does not have vomiting or distention. Your recommendation would be to:

A. Do suction rectal biopsy

B. Request for barium enema

C. Request for abdominal x-ray

D. Observe the patient


D - (Nelson’s Textbook of Pediatrics, 17 th ed, 2004, pp. 1232-1241)

56. A 7-day old 900 gram pre-term has been noted to have abdominal distention with gastric retention.

OGT drainage is 10 cc in 24 hours and stool occult blood is positive. Abdominal x-ray showed pneumatosis intestinalis. This patient should:

A. Undergo immediate surgery

B. Have intensive medical therapy

C. Peritoneal drainage

D. Have a blood culture.


B - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 590-591)

57. A live 30 weeks of gestation baby boy was born via cesarean section to a diabetic mother. Grunting and tachypnea was noted on the 6 th hour of life. After receiving therapeutic measures, the patient improved. However on the 4 th day of life, lethargy, apnea and poor muscle tone was noted. Transfontanel cranial ultrasonography was done and showed increased echogenecity at the thalamocapsular region with ventricular dilatation. What is the grade of this patient’s germinal matrix hemorrhage?

A. Grade 1

B. Grade 2

C. Grade 3

D. Grade 4


D - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 563)

58. Which of the following chest radiographic findings can be found in mild ventricular septal defect?

A. Small heart

B. Increased pulmonary vascularity

C. Increased size of the aorta

D. Left atrial enlargement


B - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 1509)

59. Meconium aspiration in utero is explained by:

A. Obstruction of fetal airways

B. Chemical property of meconium

C. Intrauterine infection

D. Chronic fetal asphyxia


D - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 547, 583-584)

60. A key predictor for death or brain damage after an asphyxial episode:

A. HIE Sarnat Stage 2

B. Failure to establish spontaneous respiration by 15 minutes

C. Onset of seizure within the first 24 hours of life

D. Establishment of adequate oral feedings by 48 days of life



61. In a newborn suspected of having choanal atresia, respiratory distress may be relieved by:

A. Opening the mouth

B. Intubation

C. Bag and mask ventilation

D. Administering O2


A - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 1387)

62. The most common clinical manifestation of Persistent Pulmonary Hypertension is:

A. Respiratory distress

B. Pallor

C. Cyanosis

D. Apnea


C - (Nelson ’s Textbook of Pediatrics, 17 th ed, 2004, pp. 585)

63. Which of the following statements regarding the diagnosis of intrauterine infection is/are accurate?

A. IgM in neonatal serum may be used as a screening tool

B. Total IgM has a low rate of both false positive and false negative results

C. IgM titers may have low specificity and low sensitivity

D. IgG rising titers in infancy are not helpful


A - (Nelson Textbook of Pediatrics, 17 th ed, 2004)

64. Thyrotoxicosis in the first day of life is most likely to occur in an infant born to a mother

A. With untreated hypothyroidism

B. With untreated Grave’s disease

C. With Grave’s disease being treated with antithyroid medications

D. Receiving iodides as therapy for chronic Thyrotoxicosis



65. A 6-year old male was brought to the OPD because of jaundice of 5 days associated with anorexia of one week. A hepatitis profile done on him revealed the following:

Anti-HAV (IgM) -

HBsAg

Anti-HBc

Anti-HBe

Anti-HBs

-

-

-

-

Reactive

Non-reactive

Non-reactive

Non-reactive

Non-reactive

The patient Had a recent:

A. HAV and HBV infection

B. HAV infection with a post infection of HBV

C. HAV infection with HBV immunity

D. HAV infection and post infection of HAV

(Problem Solving) – Infectious Diseases

C – (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1324-1329)

66. A 9-month old female was brought to the OPD because of watery diarrhea, yellowish, non-bloody, nonmucoid stools, with no pus nor RBC’s. Her anterior fontanel is slightly sunken. The most likely organism to cause this type of diarrhea is:

A. ETEC

B. Vibrio cholera

C. Rotavirus

D. Norwalk virus


C – (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1324-1329)

67. Which of the following is TRUE of candidal infection?

A. Diaper dermatitis is the most common infection caused by candida

B. With improved survival of very LBW infants, candidemia has become less frequent n

NICU’s

C. Fluconazole is the drug of choice for the treatment of systemic candiciasis

D. Most cases of candidemia is Immunocompromised patients are due to non-candida albicans spp.


A - ( Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1012-1013)

68. Which of the following statements is NOT TRUE of Amebiasis?

A. The infective stage is the Entamoeba histolytica cyst

B. The pathogenic stage is the Entamoeba histolytica trophozoite form

C. A carrier of E. histolytica cysts should be treated

D. It is the most common cause of bloody stools

(Recall) – Infectious Diseases

D - (Ref. Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1123-1125)

69. Which of the following diseases has the greatest capacity to be a “pandemic?”

A. HIV

B. Influenza

C. Measles

D. Hepatitis B


B - ( Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1072-1074)

70. A newborn was found to have the following anomalies: hydrocephalus, cicatricial scarring over the

6 th -7 th left intercostals, malformed feet (fusion and maldevelopment of both feet). Which congenital infection shows these findings at birth?

A. HIV

B. CMV

C. Parovovirus B19

D. Varicella-Zoster virus


D - ( Nelson’s Textbook of Pediatrics, 17 th ed., 2004, p. 1059)

71. Which of the following features is TRUE of all infants born to HIV-infected women?

(Problem Solving)

C - (

A. They will have low CD4 cell counts

B. They will eventually develop AIDS

C. They will have antibodies to HIV

D. They will be infected with HIV

– Infectious Diseases

Nelson’s Textbook of Pediatrics, 17 th ed., 2004, p. 1161)

72. One of the following is LEAST associated with ascaris infection in humans:

A. Intestinal obstruction

B. Loeffler’s syndrome

C. Iron deficiency anemia

D. Pancreatitis


C - ( Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1156)

73. Which of the following does NOT RESULT from a vesicoureteral reflux?

A. Hypertension

B. Chronic failure

C. Proteinuria

D. Dilatation of the ureters

(Problem Solving) – Nephro/GU

C - Vesicoureteral reflux results from valvular incompetence at the uretero vesicular junction as a result of a shortened segment of ureter within the bladder wall. It is often associated with other genitourinary anomalies. Vesicoureteral reflux can result in chronic renal failure, dilatation of the ureters, hypertension and urinary tract infections. Proteinuria results from glomerular injury.

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004,pp. 1790-1794)

74. The triad of microangiopathic hemolytic anemia, renal failure, and thrombocytopenia is characteristic of which one of the following?

A. Membranous lupus nephritis

B. Focal glomerulonephritis secondary to sepsis

C. Acute post-streptococcal glomerulonephritis

D. Hemolytic-uremic syndrome

(Recall) – Nephro/GU

D -The name gives the answer away.

( Nelson’s Textbook of Pediatrics, 17 th ed, 2004,pp. 1746-1747)

75. A 2-year old male developed an upper respiratory tract infection that was followed in 2 weeks by general edema. His blood pressure is normal. Urinalysis reveals 2-5/hpf and +4 protein. His BUN is 19 mg/dl, creatinine 0.6 mg/dl, cholesterol 402 mg/dl, serum albumin 0.9 g/dl, ASO=200, and C3=92 mg/dl.

The most likely diagnosis would be:

A. Poststreptococcal glomerulonephritis

B. Membranous glomerulonephritis

C. Minimal lesion nephrotic syndrome

D. Focal sclerosis

(Problem Solving) – Nephro/GU

C - Hypoalbuminemia, proteinuria, edema and hyperlipidemia constitute the nephrotic syndrome.

Hypertension, azotemia, edema or hematuria would suggest nephritis but may also be encountered in minimal lesion nephrotic syndrome. This patient has nephrotic syndrome, not nephritis.

( Nelson’s Textbook of Pediatrics, 17thed, 2004,pp. 1740-1746 ; 1753-1757)

76. The recommended age to perform corrective surgery in a child with a unilateral undescended testes is:

A. The first 6 months of life

B. Between 21 and 18 months of age

C. Between 5 and 7 years of age

D. Before puberty

(Recall) – Nephro/GU

B - Corrective surgery performed between 12 and 18 months of age represents a safe balance between anesthetic risk, allowance of time for the testes to descend, and the risks of leaving a testis in the abdomen.

( Nelson’s Textbook of Pediatrics, 17thed, 2004,pp. 1817-1820)

77. Maternal varicella results in severe neonatal varicella when maternal infection takes place during:

A. The 1 st trimester

B. The 2 nd trimester

C. The 3 rd trimester

D. The week before and after delivery


D - Birth within 1 week before or after the onset of maternal varicella frequently results in the newborn developing varicella, which may be severe. The risk to the newborn is dependent on the amount of maternal anti-VZV antibody that the fetus acquired transplacentally before birth. If the internal between maternal chickenpox and parturition is less than 1 week, the newborn will be unlikely to have protective VZV antibody and neonatal chickenpox may be exceptionally severe.

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, p. 1058)

78. A 2-year old has a positive tuberculin test (15 mm induration). Which of the following would be suggestive of “military tuberculosis?”

A. Fever

B. Hepatosplenomegaly

C. Hilar adenopathy on chest x-ray

D. Cough


B - “Miliary tuberculosis” suggests lymphohematogenous spread or disseminated form of TB, occurring is distant sites, including liver, spleen, skin and other organs aside from the lungs. Fever and cough are non-specific manifestations of TB which may be found in other diseases, while hilar adenopathy on chest x-ray, may be found in primary pulmonary TB.

(Nelson’s Textbook of Pediatrics, pp. 962-964)

79. A 3-year old nonimmunized child is seen at the OPD and diagnosed as having measles. There is an

8-month old nonimmunized sibling at home. Appropriate management of this sibling would include:

A. A modifying dose of gammaglobulin

B. A preventive dose of gammaglobulin

C. Immediate immunization with live attenuated measles vaccine

D. Immediate immunization with killed measles vaccine


A - Passive immunization with immune globulin is effective for prevention and attenuation of measles within 6 days of exposure. Susceptible household and hospital contacts who are <12 months of age or who are pregnant should receive immune globulin (modifying dose, 0.25 ml/kg; maximum

15 ml) IM as soon as possible after exposure, but within 5 days. Immunocompromised persons should receive immune globulin (preventive dose, 0.5 ml/kg ; maximum 15 ml) IM regardless of immunization status.

80. An 8-year old male consulted the OPD because of high grade fever and sore throat. The pertinent

P.E. findings were: hyperemic oropharynx, enlarged tonsils with exudates, petecchiae on the soft palate and painful, enlarged cervical lymphadenopathies. This patient is most likely suffering from:

A. Streptococcus pyogenes

B. Epstein Barr Virus

C. Adenovirus

D. Corynebacterium diphtheria


C - (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 870-879)

81. An 8-month old boy presents with failure to thrive, thrush, lymphadenopathy, and pneumocystis carinii pneumonia. He most likely has:

A. Severe malnutrition

B. Acute leukemia

C. HIV infection

D. X-linked hypogammaglobulinemia

(Recall) - Infectious Diseases

C - These constellation of manifestation are associated with HIV infection. The clinical manifestations of HIV infection vary widely among infants, children, and adolescents. In most infants, PE findings at birth are normal. Initial symptoms are subtle, such as lymphadenopathy and hepatosplenomegaly, or non-specific such as failure to thrive, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush, and may be distinguishable only by their persistence.

Whereas systemic and pulmonary findings are common in the United States and Europe, chronic diarrhea, wasting, and severe malnutrition predominate in Africa. Symptoms found more commonly in children than adults with HIV infection include recurrent bacterial infections, chronic parotid swelling, lymphocytic interstitial pneumonitis (LIP), and early onset of progressive neurologic deterioration. The HIV classification system is used to categorize the stage of pediatric disease by using 2 parameters: clinical status, and degree of immunologic impairment

(absolute CD4 lymphocyte count or the percentage of CD4 cells).

Category A (Mild Symptoms):

Children with at least 2 mild symptoms such as:

lymphadenopathy

parotitis

hepatomegaly

splenomegaly

dermatitis

recurrent or persistent sinusitis or otitis media

Category B (Moderate Symptoms):

lymphocytic interstitial pneumonitis (LIP)

oropharyngeal thrush persisting for <2 months

recurrent or chronic diarrhea

persistent fever >1 month

hepatitis

recurrent herpes simplex stomatitis or HSV esophagitis or pneumonitis

disseminated varicella (i.e., with visceral involvement)

cardiomegaly

nephropathy

Category C (Severe Symptoms):

Children with 2 serious infections (i.e., sepsis, meningitis, pneumonia) in a 2 year period

esophageal or lower respiratory tract candidiasis

cryptococcosis

cryptosporidiosis (>1 mo)

encephalopathy

malignancies

disseminated myocobacterial infection

pneumocystis carinii pneumonia (PCP)

cerebral toxoplasmosis (onset after 1 month of age)

severe weight loss

The Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in the pediatric population. The peak incidence of PCP occurs at age 3-6 months with the highest mortality rate in children <1 year of age.

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1112-1113)

82. In our country, the first dose of live attenuated measles vaccine should be administered:

A. at 4 months of age

B. at 6-9 months of age

C. at 12-15 months of age

D at 18-24 months of age


B - The attack rate of measles among the susceptibles in <1 year is 80% (DOH Philippines 2000), such that even if vaccine efficacy at 6 months is just 50% and at 9 months it is 85%, we give it as early as 6 months, during which time transplacentally acquired maternal antibodies for measles would already be at its nadir.

(DOH Philippines 2000)

83. Neonatal bacterial sepsis is most commonly caused by which one of the following organisms (in the

Philippines):

A. Group B streptococci

B. Pseudomonas aerugenosa

C. Streptococcus pneumoniae

D. E. coli


D - In our country, gram (-) organisms are the most common causes of neonatal bacterial sepsis (2:1) compared with the gram positive organisms. The gram negative enteric bacilli like E. coli are the more common causative agents. Pseudomonas aerugenosa, a gram negative bacilli, is a common nosocomial pathogen.

(Textbook of Pediatrics and Child Health, Del Mundo, Fe et. al (eds.) 4 th ed, 2000, p. 265)

84. The first clinical manifestation of tetanus neonatorum usually is:

A. Fever

B. Vomiting

C. Spasms

D. Difficulty sucking and swallowing


D - Neonatal tetanus is generalized in type and starts as progressive difficulty in sucking and irritability.

(Textbook of Pediatrics and Child Health, Del Mundo, Fe, et al (eds.), 4 th ed, 2000, p. 469)

85. The usual course of pertussis in an infant is characterized by:

A. 4 – 5 days of high grade fever followed by cough and whooping

B. sudden onset of fever, cough, and whooping

C. rhinitis and possibly low grade fever, followed by gradual worsening of cough and finally whooping

D. gradual onset of cough, followed by abrupt onset of fever and whooping


C - Pertussis is a 6-week disease, divided into catarrhal (congestion, rhinorrhea, then low grade fever, lacrimation, conjunctival suffusion), paroxysmal, and convalescent stages.

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, p. 909)

86. The findings of sudden onset of fever, petecchial rash, and BP = 70/50 in a 5 year old child is most suggestive of infection with:

A. Neisseria meningitidis

B. Hemophilus influenzae

C. Staphylococcus aureus

D. Streptococcus pneumoniae

(Problem Solving) - Infectious Diseasess

A - These findings are compatible with meningococcemia caused by Neisseria meningitides which can progress rapidly over hours to septic shock. The other etiologic agents, while they may cause a similar picture these are usually in relation to DIC which would manifest over a longer period of time, not in a matter of hours.


87. Of the following parasitic infections, which is most likely to present with intestinal obstruction?

A. Trichuris trichura

B. Necator americanus

C. Ascaris lumbricoides

D. Enterobius vermicularis


C - A large mass of Ascaris lumbricoides leads to intestinal obstruction. Rectal prolapse is associated with Trichuris trichura. Heavily infected children with Necator americanus suffer from intestinal blood loss resulting in iron deficiency, which can lead to anemia as well as protein malnutrition.

Pruritus ani is associated with enterobiasis.

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1156-1159)

88. A 10-month old child has a temperature of 3940’C for 4 days without other signs. On the 4 th day, a maculopapular rash appears, and the temperature returns to normal. The most likely diagnosis is:

A. scrub typhus

B. roseola

C. rubeola

D. echoviral infection

(Recall ) - Infectious Diseases

B - (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 1069-1072)

89. Which of the following is the chemoprophylactic antimicrobial given to intimate contacts of a 7-year old with meningococcal meningitis?

A. Rifampin

B. aqueous Pen G

C. Isoniazid

D. Erythromycin

(Problem Solving) - Infectious Diseases

A - (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 898-899)

90. The clinical manifestations in DHF are secondary to the pathogenetic mechanism of:

A. direct invasion of the virus to the different organ system

B. hypersensitivity reaction

C. immune enhancement

D. adherence of the viruses to the endothelial cells


C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, p. 561)

91. In a case of DHF (Grade 3) who is bleeding profusely, which of the following fluids (all available) would you give?

A. properly typed & X-matched fresh whole blood

B. properly typed & X-matched fresh plasma

C. D5LRS

D. D5NSS

(Problem Solving) - Infectious Diseases

A - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, p. 569 - 571)

92. The following CSF analysis results are compatible with which of the following clinical entities?

CSF Results: Opening pressure = 300 mm H2O

WBC = 296 (segs: 10% ; lymphos : 90%)

Protein = 2 g/L

CSF sugar / RBS = 20%



(Problem Solving)

B -

C. Japanese B encephalitis

D. Febrile seizures

– Infectious Diseases

(Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 965, 2040-2044)

93. On the 3 rd day of treatment for Hemophilus influenzae meningitis, an eight month old child who had been alert is noted to be lethargic. Serum electrolytes reveal the following:

Na = 120 mEq/L

Cl = 83 mEq/L

K = 3.1 mEq/L

BUN = 2 mg/dl

The most likely cause of the lethargy and hyponatremia in this patient:

A. Acute renal failure

B. Congestive heart failure

C. Syndrome of inappropriate ADH secretion

D. Subdural effusions


C - (Nelson’s Textbook of Pediatrics, 17 th Ed, 2004, p. 200)

94. A 28 year old primigravida mother, who had a past history of adequately treated PTB, gave birth to a healthy 3 kg baby. Which of the following preventive measures against TB would you take?

A. Separate the baby from the mother for another month

B. Separate the baby from the mother and give INH for 3 months

C. Give BCG only

D. Give BCG now but separate the baby from the mother for a month


C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 2000 pp. 516-525)

95. A 2-year old boy was admitted because of low to moderate grade fever of 3 weeks, on and off frontal headache of 1 week, squinting of 1 day, one episode of generalized seizure of 2 minute duration 6 hours prior to admission. No medical consult done. No medications given except paracetamol. Which of the following clinical consideration is NOT COMPATIBLE with this history?



C. Cryptococcal meningitis

D. Brain abscess of otogenic origin


A - (Nelson’s Textbook of Pediatrics, 17 th ed., 2004, pp. 965, 2040-2044)

For Nos. 96 to 100:

Mario is 2 ½ years old, brought to the Well Child Clinic for his regular visit. On physical exam, he had the following anthropometric measurements: Weight - 15 kgs, Height – 90 cms, Head

Circumference – 48 cms. On developmental screening, he was able to do the following: could stand momentarily on one foot, draw a circle and imitate a cross, talk in simple sentences and tell a story. Mother claimed that he is dry by night.

96. Describe the nutritional status of Mario:

A. not stunted, not wasted

B. mildly stunted, not wasted

C. not stunted, mildly wasted

D. Mildly stunted, mildly wasted

(Problem Solving) - Neurodev

A - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, pp. 78-80)

97. The head circumference of Mario is:

A. normal

B. below normal

C. above normal

D. variation of normal

(Problem Solving) – Neurodev

A - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, p. 80)

98. Based on developmental screening, his development is:

A. normal

B. delayed

C. advanced

D. deviant

(Problem Solving) - Neurodev

C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4

99. The approximate developmental age of Mario is:

A. 2 years old

B. 2 ½ years old th ed, 2000, pp. 83-112)

C. 3 years old

D. 3 ½ years old

(Problem Solving) – Neurodev

C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, pp. 83-112)

100. At 2 years of age, Mario had a height of 85 cms. How tall would he be when he becomes an adult?

A. 4 feet 6 inches

B. 5 feet

C. 5 feet 6 inches

D. 6 feet

(Recall) - Neurodev

C - (Textbook of Pediatrics & Child Health, Del Mundo, et al (eds.), 4 th ed, 2000, pp 78-80)

1 A newborn FT was noted to be pale at 4th month of life

Related documents

Products

Support

1 A newborn FT was noted to be pale at 4th month of life

Related documents

Add this document to collection(s)

Add this document to saved

Suggest us how to improve StudyLib