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Pediatric Board Review 2006-2007 Session One: July 24, 200


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Title: Pediatric Board Review 2006-2007 Session One: July 24, 200

Pediatric Board Review 2006-2007 Session One
July 24, 2006 Session Two August 24,
2006 Session Three September 26, 2006
  • Aaron McGuffin, M.D.

  • Blueprints in Pediatrics 1998
  • Nelsons Pediatrics 17th Edition
  • PREP Questions 1999-2006
  • Up To Date

Scrabble Quiz AEINRST
  • This is the most common seven letter combination
    you can have on your rack. There are 8 different
    seven letter words bingos that can be spelled
    from this. Can you name one?
  • Anestri
  • Nastier
  • Ratines
  • Retains
  • Retinas
  • Retsina
  • Stainer
  • Stearin

Scrabble Quiz
  • There are 101 acceptable two letter word plays in
    Scrabble, 16 of which start with what letter?
  • A
  • AA, AB, AD, AE, AG, AH, AI, AL, AM, AN, AR, AS,
    AT, AW, AX, AY

Scrabble Quiz
  • The word ROOST has 4 anagrams, name them.

Question 1.2000
  • A TRUE statement about the epidemiology of
    measles is that
  • A. In countries with no immunization programs,
    the peak age of infection is infancy
  • B. In US immunization programs have reduced the
    incidence of infection by 80
  • C. Usually spread by direct contact with
    infectious droplets
  • D. Patients become contagious when the rash
  • E. Incubation period is 4-5 days from exposure to
    onset of symptoms
  • Answer C

Teaching Points 1.2000
  • Measles
  • Cough, coryza (inflammation of nasal mucosal
    membranes), fever, conjunctivitis, exanthem of
    red macules and papules and Koplik spots
  • Young children have OM, pneumonia, croup and
  • Acute encephalitis (11000) --gtPermanent brain
  • In US death 1-3/1000 due to respiratory of
    neurologic complications

Teaching Points 1.2000
  • Transmitted by direct contact with infectious
    droplets or LESS COMMONLY airborne spread
  • Since vaccine use in 1963 there has been a 99
    reduction in incidence in US
  • Children are contagious 4-5 days BEFORE rash
    appears to 4 days after appearance of rash
  • Incubation period is 8-12 days from exposure to
    onset of symptoms

(No Transcript)
Koplik Spots Henry Koplik (U.S. Physician, 1858
to 1927)
Question 2.2000
  • A previously healthy 2 year old is brought to ED
    because her mom is unable to awaken her for 45
    minutes. She has not been ill. PE reveals an
    afebrile, hypotonic child who withdraws her hand
    from painful stimuli but does not spontaneously
    open her eyes. RR is 36/min, BP is 92/64. What
    is the next best thing to obtain?
  • A. BUN
  • B. CXR
  • C. EKG
  • D. EEG
  • E. Toxicology screen
  • Answer E

Teaching Points 2.2000
  • Pneumonic for Causes of Altered Consciousness
    Tips from the Vowels
  • T-I-P-S-A-E-I-O-U
  • Trauma/Tumor
  • Infection/Inborn Errors/Insulin/hypoglycemia
  • Poisons
  • Shock
  • Alcohol/Abuse
  • Epilepsy/Encephalopathy
  • Intussusception
  • Opiates
  • Uremia

Question 3.2000
  • You have intubated an 8 month old with sepsis and
    apnea with a 4.0 endotracheal tube. Proper
    placement is confirmed by observing chest rise
    and auscultating symmetric breath sounds after
    bag and mask ventilation. Perfusion is lt3
    seconds, and heart rate is 120/minute. Five
    minutes later the RT tells you the oxygen
    saturation is 83 and the blood pressure and
    pulse are dropping. Breath sounds are absent on
    the right and the right chest is hypertympanitic.
    What is the most likely diagnosis?
  • A. Esophageal intubation
  • B. Incorrect ET size
  • C. Obstructed ET tube
  • D. Right main stem bronchus intubation
  • E. Right pneumothorax
  • Answer E

Teaching Points 3.2000
  • ET Tube Size (mm)
  • 16 Age(yr)/4
  • Preterm 2.5-3.0
  • Term 3.0-3.5
  • Infant 3.5-4.0
  • 1 year 4.0-4.5
  • 3 year 4.5-5.0
  • An uncuffed tube should be used in patients
  • lt8 years of age
  • Approximate distance of insertion measured at
    teeth or lips in cm
  • Internal Diameter X 3
  • Straight blades preferred for neonates and infants

Teaching Points 3.2000
  • Drugs that can be given by ETT after dilution
    with normal saline to 3-5 ml followed by positive
    pressure ventilation
  • LANE
  • Lidocaine
  • Atropine
  • 0.02mg/kg IV,IO 0.02-0.06mg/kg ET
  • Minimum dose is 1ml (0.1 mg) as it comes 0.1
  • Naloxone (Narcan)
  • 0.1 mg/kg/dose IM/ET/IV/IO to maximum 2mg/dose.
    May repeat every 2-3 minutes
  • Epinephrine
  • 0.1ml/kg of 11000 (0.1mg/kg) IV, IO, ET in
  • Use 110,000 (0.1-0.3ml/kg for all doses and
    routes) epinephrine via ETT for neonates only.
    Use high dose 11,000 epinephrine for ETT beyond
    neonatal period

Teaching Points 3.2000
  • Esophageal intubation essentially ruled out
    because of previous presence of rise and fall of
    chest and presence of breath sounds unilaterally
  • However, ET tube could have moved if they
    repositioned patient check depth marker at
  • If ETT tube is too small, air leaking around tube
    can impair efforts to ventilate but an audible
    air leak generally is heard with each positive
    pressure breath

Teaching Points 3.2000
  • Treatment for tension pneumothorax
  • Immediate needle decompression
  • Patient supine with head of bed at 30 degree
  • 18-20 gauge over the needle catheter
    (angiocatheter) inserted into the
  • 2nd intercostal space just over the top (Hey
    dude, this procedure is over the top , man!) of
    the 3rd rib at the midclavicular line
  • 5-10 ml syringe attached to angiocatheter and
    aspirated gently as needle is advanced
  • Loss of resistance or rush of air apparent as
    soon as pleural space is entered
  • If pneumothorax is confirmed a one-way drainage
    device should be attached
  • A chest tube should be placed after successful
    needle decompression

Needle Decompression
Question 4.2000
  • A 6 year old boy with severe factor VIII
    deficiency hemophilia develops increased swelling
    of the right distal forearm. There is not history
    of trauma. The peripheral circulation is normal
    and there is no joint involvement. The MOST
    important complication of bleeding in this
    location is
  • A. Blood loss
  • B. Muscular Damage
  • C. Neurologic Impairment
  • D. Tendon Shortening
  • E. Vascular Damage
  • Answer C

Teaching Points 4.2000
  • Children with hemophilia can develop severe
    peripheral neurologic deficits when hematomas
    compress nerves via compartment syndrome
  • In older children increasing pain out of
    proportion to size of hematoma, numbness and
    paresis are critical signs
  • Often there is no history of trauma in
  • Significant blood loss seen in hematomas of
  • Thigh or retroperitoneum

Teaching Points 4.2000
  • Routine venipuncture is safe as long as it is
    followed by
  • 5 minutes of firm finger pressure
  • Femoral or jugular venipuncture or arterial
    puncture should not be undertaken WITHOUT
  • What about IM immunizations
  • Ok as long as followed by 5 minutes of firm
    finger pressure
  • Large IM injections should be avoided (Decadron,
    Rocephin IM etc)

Teaching Points 4.2000
  • Tendon shortening only occurs with
  • Chronic, sever hemarthroses
  • Limited mobility
  • Nerve damage
  • Muscular damage is not frequent among children
    with hemophilia

Prepatellar Hematoma
Hematoma after IM injection
Question 5.2000
  • An ambulance team brings a 6 year old girl in an
    MVA to the ED. She had been unrestrained in the
    back seat. The girl is unresponsive on arrival
    and is bleeding profusely from a scalp wound. Her
    Glasgow Coma Scale is 3. What is the BEST initial
    step in evaluation and management?
  • A. Control profuse scalp bleeding
  • B. Establish IV access
  • C. Order portable cervical spine radiographs
  • D. Remove all clothing
  • E. Secure an adequate airway
  • Answer E.

Teaching Points 5.2000
Atlas C-1
Dens of Axis C-2
  • Priority during primary survey
  • Airway
  • Failure to provide oxygenated blood to the brain
    and other vital organs is the quickest killer of
    a trauma victim
  • Breathing
  • Circulation
  • Disability
  • Exposure
  • Any victim of head trauma with a GCS of ___ or
    less should be intubated immediately
  • 8
  • X-rays for cervical fractures
  • AP, Lateral and odontoid views

Odontoid View
Teaching Points 5.2000 Glasgow Coma Scales
Question 6.2000
  • A 2 week old presents with tachypnea, poor
    perfusion, gallop rhythm, diminished pulses, and
    hepatomegaly. ABG shows metabolic acidosis.
    Echocardiography reveals critical Aortic
    Stenosis. What intervention is most likely to
    stabilize the infants condition?
  • A. Dobutamine
  • B. Epinephrine
  • C. Nitric Oxide
  • D. 100 oxygen
  • E. Prostaglandin E-1
  • Answer E.

Teaching Points 6.2000
  • Severe CHF and cardiogenic shock in neonate,
  • Hypoplastic left heart
  • Critical congenital aortic stenosis
  • Critical neonatal coarctation of aorta
  • As ductus arteriosus closes, early compensatory
    RV contribution to systemic blood flow and
    perfusion to kidneys and other organs is lost
    ?rapidly developing severe metabolic acidosis ?
    myocardial and organ dysfunction
  • Therefore, need to keep duct OPEN with PGE1
    (alprostadil) EVEN TO AN INFANT 1-2 MONTHS OF AGE

Teaching Points 6.2000
  • Inotropic agents such as dobutamine or
    epinephrine may provide supportive therapy but
    will not be lifesaving
  • Nitric oxide is a pulmonary dilator used in PPH
    of newborn but is contraindicated in obstructive
    left sided heart lesions
  • Serious hypoxia is NOT a problem for infants with
    obstructive left sided lesions
  • Arterial pO2 may be normal initially in a sick
  • As PDA is opened the O2 will drop due to right
    ventricular flow to the body

Teaching Points 6.2000
  • Attempts to keep O2 HIGH ARE DETRIMENTAL as high
    inspired oxygen levels causes powerful PULMONARY
    ARTERIAL DILATION which steals RV output to the
    pulmonary arteries and away from the body
  • This steal factor NOT o2 induced ductal
    closure is the primary risk associated with use
    of supplemental O2 when PGE1 is used to keep duct
  • Some degree of pulmonary hypertension (i.e.
    small, tight, non-dilated arteries) is essential
    to promote systemic flow to the peripheral
    circulation via the ductus

Teaching Points 6.2000
  • Hypoplastic Left Heart
  • 2nd most common congenital cardiac lesion
    presenting in 1st week of life
  • Most common cause of death from CHD in 1st month
    of life
  • What are characteristics?
  • Hypoplasia of left ventricle
  • Hypoplasia of aortic root
  • Aortic valve atresia
  • Critical mitral valve stenosis or atresia
  • Result is a reduction or elimination of blood
    flow through left side of heart

Hypoplastic Left Heart
  • Ineffective left side of heart ? obligatory left
    to right shunt where?
  • Atrial level
  • And right to left shunting where?
  • Ductus arteriosus
  • Systemic flow is completely ductal dependent
  • How do coronary arteries get fed?
  • Retrograde coronary perfusion
  • As PDA closes neonates become critically ill ?
    CHF, cyanotic, tachycardic, tachypneic, rales
    (crackles) from pulmonary edema, and
    hepatomegaly poor peripheral pulses with
    vasoconstricted extremities.

Hypoplastic Left Heart
  • Cardiac Exam
  • Loud S2 (Marks beginning of diastole and is due
    to closure of semilunar valves primarily
    pulmonic valve slamming against increased blood
    volume and pressure)
  • S3 (Early diastole corresponds with end of first
    phase of rapid ventricular filling from atria and
    can be normal in children and young adults)

Hypoplastic Left Heart
  • Treatment
  • PGE1 (alprostadil) immediately to maintain ductal
    dependent systemic blood flow
  • Cardiac transplantation in the newborn period is
    primary treatment for HLHS
  • Scarcity of newborn organs available for
  • Life-long need for anti-rejection therapy
  • Average life span of the transplanted heart is
    limited (currently less than 15 years).
  • Most common treatment for HLHS is palliative
    "staged reconstruction"

Hypoplastic Left Heart
  • 1. Norwood operation performed 1st week
  • RV becomes the systemic or main ventricle pumping
    to the body.
  • Neoaorta is made from part of the pulmonary
    artery and the original, tiny aorta, is enlarged
    to provide blood flow to the body.
  • To provide blood flow to lungs, a small tube
    graft is placed either from the left subclavian
    or left innominate artery to the lung vessels
    (modified Blalock-Taussig shunt or from the RV
    to the lung vessels (Sano modification).

Hypoplastic Left Heart
  • 2. Bi-directional Glenn procedure
  • 3 to 6 months of age
  • SVC is taken off the heart and sewn directly to
    the pulmonary artery
  • 3. Fontan operation
  • 2 or 3 years of age
  • IVC is connected directly the blood from the
    pulmonary arteries

Question 7.2000
  • During a routine visit, a 14 year old overweight
    patient tells you he watches more than 25 hours
    of TV per week. What is the most appropriate
  • A. Parents should limit TV to no more than 2
  • B. TV commercials have little impact on selection
    of toys and food
  • C. Average adolescent spends 15 hours/week
    watching TV
  • D. Unclear relationship between TV viewing and
    risk of obesity
  • E. No relationship between TV viewing and

Teaching Points 7.2000
  • Children 2-11 22 h/week
  • Adolescents 12-17 20 h/week
  • Age 18, adolescent will have seen 200,000 violent
    acts and 18,000 murders on TV
  • Encourage parents to co-view programs with
  • Saturday morning commercials 50 food, 33 toys
  • 20 best selling toys are from TV shows based on
    the toys
  • Increased TV viewing significant factor leading
    to obesity
  • Increased TV viewing increased snacking

Deep Thoughts from Ryan
  • Dad, how long does it take a booger to form?
  • Booger Dried nasal mucus bogie in England
  • Medical Term
  • Rhinoliths

Question 8.2000
  • A male infant born at 36 weeks gestation had a
    left testicle palpable in the inguinal canal. At
    12 months of age, the left testicle has failed to
    descend into the scrotum. What is most
    appropriate care for this infant?
  • A. Observation until 2 years of age
  • B. Orchiopexy
  • C. Radionuclide scan of left testicle
  • D. Treatment with human chorionic gonadotropin
  • E. Treatment with testosterone

Teaching Points 8.2000
  • What percent of preterm male infants have an
    undescended testis
  • 30
  • Spontaneous descent into scrotum occurs
  • over next 3-6 months
  • What is the most reliable method to localize the
    undescended testis?
  • Laparoscopy
  • Orchiopexy, a surgery which places the testis
    into the scrotum is indicated for a testis that
    fails to descend by
  • 6 months of age and is performed at 9-12 months
    of age

Teaching Points 8.2000
  • At 6-12 months of age histological changes
    representing degeneration of the seminiferous
    tubules occurs? decrease in quality and quantity
    of spermatogenesis which is progressive
  • The longer the testis remains in its improper
    location the greater the fertility impairment
  • What percent of all testicular tumors occur in
    patients with an undescended testicle
  • 10
  • Orchiopexy improves fertility but DOES NOT change
    malignancy risk

Teaching Points 8.2000
  • Relocated testis has a 35-48 times greater risk
    of malignancy than normal testis
  • Does the normal testis also have an increased
  • YES, just not as high
  • Counsel parents to
  • Seek immediate attention for acute testicular
    pain due to risk of torsion
  • Perform monthly examination of both testes

Teaching Points 8.2000
  • Retractile testicles
  • Bilateral mostly
  • Found in children gt1 year of age, 5-6 year olds
    strong reflex
  • Due to strong cremasteric reflex
  • Milk them into scrotum
  • Warm room, frog leg position can make examination

Question 9.2000
  • A newborn female has an open neural tube defect,
    low set ears, VSD, and rib and vertebral column
    malformations. Which of the following MATERNAL
    conditions was most likely present during
  • A. Alcoholism
  • B. Diabetes mellitus
  • C. Hypothyroidism
  • D. Iodine deficiency
  • E. Syphilis

Teaching Points 9.2000
  • Early prenatal deficits malformations (3 fold
    increase), growth deficiency, stillbirth
  • The worse the diabetic control the more severe
    the defects
  • Cardiac VSD, TGA, dextrocardia
  • CNS Anencephaly, holoprosencephaly, spina
    bifida, hydrocephalus, caudal regression syndrome
  • Rib defects

Teaching Points 9.2000
  • Infants present with macrosomia due to
    hyperinsulinemia and excessive glucose
  • Both linear growth and weight are affected
  • If mom has severe vascular disease, can result in
  • Additional complications Hyperbilirubinemia,
    hypoglycemia, vascular thromboses, respiratory
    distress, birth injury due to macrosomia

  • Caused by a failure of the embryo's forebrain to
    divide to form bilateral cerebral hemispheres
    causing defects in face development face and in
    brain structure and function.
  • The "alobar" form of holoprosencephaly is shown
    here in which there is a single large ventricle,
    because there is no attempt to form separate
    cerebral hemispheres.
  • May be associated with trisomy 13 and rarely in
    association with maternal diabetes mellitus.

Spina Bifida
Spina Bifida
Teaching Points 9.2000
  • Fetal alcohol syndrome
  • What is the most common teratogen to which
    fetuses are exposed?
  • Alcohol
  • Which U.S. population has the highest incidence
    of children with FAS?
  • Native Americans
  • What is the incidence in U.S. (excluding Native
  • 11000
  • Affects 40 of children in women who drink more
    than 4-6 drinks per day

(No Transcript)
Fetal Alcohol Syndrome
Fetal Alcohol Syndrome
Fetal Alcohol Syndrome
Epicanthal Folds
Teaching Points 9.2000
  • Maternal hypothyroidism has little effect on
    fetus which produces its own thyroid hormone
  • Women with untreated hypothyroidism also give
    birth to NORMAL babies

Teaching Points 9.2000
  • Maternal iodine deficiency (rare in developed
    countries) ? fetal deficiency
  • Goiter
  • Mental retardation
  • Slightly increased head size due to
  • Myxedema hard edema due to increased mucins
    (proteoglycans) in the fluid of subcutaneous
    tissues of the brain
  • Hyperbilirubinemia due to
  • Delayed maturation of glucuronide conjugation
  • Feeding difficulties (choking spells, lack of
    interest, somnolence, sluggishness)

Teaching Points 9.2000
  • Respiratory difficulties due to
  • Large tongue, apneic episodes, noisy
    respirations, nasal obstruction
  • Retarded bone growth
  • Constipation
  • Umbilical hernia with large abdomen
  • Hypothermia and cold and mottled skin
  • Slow pulse
  • Genital and extremity edema
  • Pericardial effusion, murmur, cardiomegaly
  • Prompt treatment with iodine necessary to prevent
    mental retardation

Teaching Points 9.2000
  • Maternal syphilis
  • Fetus affected by
  • Transplacental transmission Treponema pallidum
  • Syphilis in untreated women can be transmitted to
    fetus at any time, fetal transfer most common
    during 1st year of maternal infection
  • 2/3 of live-born neonates with congenital
    syphilis are asymptomatic at birth.
  • Overt infection can manifest in the fetus, the
    newborn, or later in childhood.
  • Clinical manifestations after birth are divided
    arbitrarily into early ( 2 years of age) and late
    (gt2 years of age)

Teaching Points 9.2000
  • Fetal manifestations of Syphilis
  • Stillbirth
  • Neonatal death
  • Overt infection at birth, such as hydrops fetalis
    (abnormal accumulation serous fluid in fetal
  • Intrauterine death in 25 of affected infants,
    with perinatal mortality in an additional 25-
    30, if untreated

Teaching Points 9.2000
  • Early congenital manifestations of Syphilis
  • Quite variable, appear within the first 5 weeks
    of life
  • Cutaneous lesions frequently occur on the palms
    and soles if ulcerative in nature, they are
    highly contagious
  • Hepatosplenomegaly
  • Jaundice
  • Anemia
  • Snuffles (obstructed nasal respiration in
  • Metaphyseal dystrophy and periostitis often are
    noted on radiographs at birth

Teaching Points 9.2000
  • Late congenital manifestations
  • Develop from scarring related to early infection
    but can be prevented by treatment of the infant
    within the first three months of birth
  • Late findings include frontal bossing, short
    maxilla, high palatal arch, Hutchinson triad
    (Hutchinson teeth blunted upper incisors,
    interstitial keratitis, and eighth nerve
    deafness), saddle nose, and perioral fissures

Saddle Nose deformity in congenital syphilis
Hutchinson Teeth
Question 10.2000
  • A 5 year old male is hospitalized in January with
    fever and seizures. LP reveals clear CSF with 47
    WBCs/mm3 all of which are lymphocytes. On PE he
    appears obtunded but arouses with painful
    stimuli. Neurologic exam reveals no focal
    findings. Which diagnostic test is most likely to
    reveal this childs illness?
  • A. Bacterial culture of CSF
  • B. PCR test of CSF for HSV
  • C. Streptococcus pneumoniae bacterial antigen
    test of CSF
  • D. Viral culture of CSF
  • E. Viral culture of nasopharyngeal and rectal

Learning Points 10.2000
  • Exam findings are consistent with encephalitis
  • CSF findings are consistent with a viral etiology
  • Most likely cause is a sporadic case of herpes
    simplex virus
  • Viral cultures of CSF for HSV are RARELY positive
    beyond neonatal period
  • HSV is not found in cultures of sites outside the

Learning Points 10.2000
  • What is the treatment of choice for herpes
    encephalitis in a child?
  • IV Acyclovir 10 mg/kg/dose q8 for 14-21 days
  • What is the treatment of choice for neonatal
    herpes encephalitis?
  • IV Acyclovir 20 mg/kg/dose q8 for 14-21 days

Question 11.2000
  • An 18 year old girl presents for a RV. Exam
    reveals tanner stage 5 breasts with 2x2 cm
    nontender, smooth, mobile mass in left breast. It
    is located at the upper outer quadrant. The
    overlying skin is normal and there is no history
    of nipple discharge. Family history is negative
    for breast cancer. What is the most appropriate
    next step in evaluation of this breast mass?
  • A. Excisional biopsy
  • B. Fine-needle biopsy
  • C. Mammography
  • D. Reassurance and reevaluation in 4-6 months
  • E. Referral for surgical consultation

Teaching Points 11.2000
  • What is the diagnosis?
  • Fibroadenoma
  • Fibroadenomas are most common breast lesion in an
    adolescent female
  • Differential diagnosis breast masses
  • Fibrocystic changes
  • Cysts
  • Abscesses
  • Rarely, malignancy

Teaching Points 11.2000
  • Without family history of breast cancer in a 1st
    or 2nd degree relative, primary breast cancer is
    extremely rare in adolescents
  • Fewer than 1/1,000 of adolescent breast masses
    are malignant
  • Metastatic lesions from
  • Rhabdomyosarcoma, neuroblastoma, and lymphoma can
    occur, but rare.
  • If anxiety high can begin with what test
  • Ultrasound to differentiate between cystic and
    solid masses
  • FNA or biopsy can be done in adolescent with
    unusually large or atypical mass or who is highly
    anxious about malignant potential
  • Mammography never is indicated fir evaluation of
    a breast mass in teenagers because the dense
    breast tissue makes study difficult to interpret

Question 12.2000
  • A 15 year old girl complains of dysuria and
    abdominal pain for 2 days. She denies nausea,
    vomiting, flank pain and vaginal discharge.
    Menarche occurred to years ago and menses have
    been irregular. PE reveals SMR stage 4 genitalia,
    mild suprapubic tenderness, and otherwise normal
    findings. What is the most likely diagnosis?
  • A. Bacterial vaginosis
  • B. Candidal vulvovaginitis
  • C. Chlamydia urethritis
  • D. Pelvic inflammatory disease
  • E. Urinary tract infection

Teaching Points 12.2000
  • Bacterial vaginosis
  • Grayish discharge with pH gt4.5
  • Saline wet mount reveals gt20 clue cells and an
    absence of lactobacilli
  • An isolated Gardenerella vaginalis infection does
    not cause dysuria and lower abdominal pain
  • Candidal vaginosis
  • Whitish discharge
  • Chlamydia trachomatis
  • Causes dysuria if urethra involved
  • No abdominal pain UNLESS PID present
  • PID symptoms lower abdominal pain, cervical
    motion tenderness, adnexal tenderness fever,
    vomiting, diarrhea, irregular vaginal bleeding,
    increased vaginal discharge

Clue Cells
  • Vaginal epithelial cells that appear fuzzy
    without distinct edges under a microscope due to
    being coated with G. vaginalis
  • Clue cells flake off of the walls of the vagina
    and are found in vaginal smear.
  • Chemicals released by the bacteria that cause
    bacterial vaginosis (BV) may damage vaginal wall
    cells, causing them to flake off in greater
    numbers than usual.
  • When bacterial vaginosis is present, more than
    20 of the sample vaginal epithelial cells are
    clue cells.

Clue Cells
Question 13.2000
  • A 3 year old girl comes to the ER with
    temperature of 103.1o F and acute onset diarrhea.
    Stool is guaiac positive with leukocytes. There
    is no history of foreign travel and the child has
    not received antibiotics recently. What is the
    most likely organism?
  • A. Clostridium difficile
  • B. Giardia lamblia
  • C. Rotavirus
  • D. Salmonella enteritidis
  • E. Vibrio cholerae

Teaching Points 13.2000
  • Viral diarrhea
  • Low-grade fever, vomiting, large, loose watery
  • Most common cause
  • Rotavirus
  • Season predominance
  • Winter in United States

Teaching Points 13.2000
  • Bacterial Diarrhea
  • High fevers, small frequent stools with mucous or
  • What can happen if you treat Salmonella infection
    with antibiotics?
  • Prolong the carrier state
  • Which organism is seen after antibiotics?
  • Clostridium difficile
  • What organism is seen after ingestion of seafood
    or water?
  • Vibrio cholerae
  • Giardia lamblia results in chronic diarrhea with

Question 14.1000
  • You are evaluating a 4 week old boy for tearing
    of the right eye that has worsened over the past
    week. Physical exam reveals slight tearing but no
    evidence of purulent exudate or conjunctival
    erythema. All other findings are normal. The MOST
    appropriate initial management is
  • A. Administration of amoxicillin
  • B. Endoscopic dacrocystorhinostomy
  • C. Instillation of silver nitrate in the eyes
  • D. Observation with intermittent massage of the
  • E. Surgical dilation of the nasolacrimal duct

Teaching Points 14.2000
  • Congenital nasolacrimal duct obstruction is most
    common abnormality of infant lacrimal system, 5
  • What percent of those affected have bilateral
  • 30
  • Obstruction is usually found where?
  • Distal end
  • Pertinent negatives on exam
  • Conjunctival inflammation, photophobia,
    blepharospasm, corneal clouding

Question 68.1999
  • A previously health 1-year-old infant who weighs
    10 kg presents to your office with a fever of 39
    C (102.2 F). Her mother is very concerned about
    the childs intake and asks for guidance
    regarding caloric requirements during this
  • Of the following, the best estimate of the
    childs caloric requirements at this time is
  • 500 kcal/d plus 500 kcal due to the fever
  • 1,000 kcal/d plus 250 kcal due to the fever
  • 1,500 kcal/d
  • 1,500 kcal/d plus 250 kcal due to the fever
  • 2,000 kcal/d
  • Answer B

Question (68.1999)
  • What is the most effective indicator of whether a
    child is getting enough calories?
  • Growth Chart
  • Name 5 factors that affect a childs energy
    (calorie) requirements.
  • Basal metabolism calories (Maintenance at rest
    and fasting)
  • Growing calories
  • Exercise calories
  • Eating calories
  • Hypermetabolic states et al (See Table)

Calculation of Caloric Requirements Based on Body
Weight (68.1999)
Calculating Energy Lost in Fever (68.1999)
  • Formula
  • For each degree above 37o C, multiply by 12 of
    maintenance requirements per degree. Then add to
    original maintenance requirements for total
    energy needs.
  • Example 10 kg infant with 39o C temperature.
    Calculate total caloric requirements.
  • 10 kg X 100kcal/kg 1,000 kcal maintenance needs
  • 2o X 0.12(1,000kcal) 240 kcal
  • Total Needs 1,240 kcal

Question 69
  • A 5-year-old boy is brought to the emergency
    department after having been struck by an
    automobile. Physical examination reveals facial
    abrasions, abdominal tenderness, and gross blood
    at the urethral meatus. Pelvic radiography
    reveals a left-sided fracture of the superior
    pubic rami.
  • Of the following, the best procedure for INITIAL
    evaluation of the urinary tract in this patient
  • Bladder catheterization via the urethra
  • Computed tomography of the abdomen
  • Intravenous pyelography
  • Renal untrasonography
  • Retrograde urethrography
  • Answer E

Additional Caloric Requirements in Selected
Medical and Surgical Conditions (68.1999)
Question (69.1999)
  • In children who sustain multiple injuries in a
    vehicular crash what are the top two systems
    that are involved?
  • Central Nervous System 1
  • Genitourinary System 2
  • Blood at tip of penis suggests urethral injury.
  • Injury to the prostatomembranous portion of
    urethra associated with pelvic fracture is most
  • Isolated urethral injury in female is UNCOMMON.

Answer Explanations (69.1999)
  • Retrograde urethrography (E.) -Catheter placed
    just inside urethral meatus and dye inserted
  • Routine catheterization (A.) is contraindicated
    with blood at urethral meatus because
  • Procedure might convert a PARTIAL TEAR of meatus

Answer Explanations (69.1999)
  • Abdominal CT would be helpful for
  • Evaluating intrabdominal injuries
  • Splenic injury
  • Liver injury
  • Renal injury
  • Intravenous pyelography and Renal US will
    evaluate renal pathology but not evaluate
    suspected urethral injuries

Apgar Score (Virginia Apgar 1953)
Question 70
  • You are attending the emergency delivery by
    cesarean section of a primiparous woman. The
    gestation was complicated by pregnancy-induced
    hypertension. Deep variable fetal heart rate
    decelerations were noted during labor. At
    delivery, the infant is acrocyanotic with poor
    tone spontaneous movement and minimal
    respiratory effort are present.
  • Of the following, your INITIAL management is to
  • Ascertain the heart rate and assign a 1-minute
    Apgar score
  • Begin tactile stimulation and provide blow-blow
    oxygen supplementation
  • Dry all skin surfaces and clear the oropharynx
  • Initiate bag-mask ventilation
  • Insert an umbilical catheter and administer
  • Answer C

Learning Points (70.1999)
  • The body and head of an infant are immediately
    dried with a prewarmed towel to remove
  • Amniotic fluid
  • And to prevent
  • Evaporative heat loss which could lead to
  • Also provides gentle stimulation to infant

Learning Points (70.1999)
  • When suctioning, mouth or nose first and why?
  • Mouth to ensure nothing in oropharynx that could
    be aspirated as we are dealing with obligate nose
  • Suctioning also provides tactile stimulation
  • Score of 7 or more indicates
  • Score of 4-6 indicates
    INTERVENTION (Blowby, stimulation etc.)
  • Score 3 or less

Learning Points (70.1999)
  • When do you keep on taking Apgar scores?
  • When 5 minute is 6 or less
  • Additional scores should be assigned every 5
    minutes for up to 20 minutes or until two
    consecutive scores of 7 are obtained

Question 71
  • A 1-year-old boy has been treated with a
    low-phenylalanine diet for the past year after
    having been identified in infancy as having
    phenylketonuria. Despite appropriate dietary
    restriction of phenylalanine, he has developed
    neurologic symptoms.
  • Of the following, this child is MOST likely to be
    deficient in
  • Biotin
  • Cobalamin
  • Carnitine
  • Tegrahydrobiopterin
  • Thiamine
  • Answer D

Learning Points (71.1999)
  • PKU diagnosed by hyperphenylalaninemia in blood
    sample taken at 48 hours of age
  • Two types
  • Classical PKU has deficiency in phenylalanine
  • Deficiency of enzyme cofactor tetrahydrobiopterin
    (1-3 patients with hyperphenylalaninemia)
  • Involved in hydroxylation reactions for
    tryptophan and tyrosine ? OH-tryptophan and
    L-DOPA (Neurotransmitters)
  • Thus, phenylalanine restriction by itself in
    presence of cofactor deficiency WILL NOT prevent
    neurological damage

Learning Points (71.1999)
  • How do you diagnose tetrahydrobiopterin
  • Caused by recycling or synthesis defects
  • Measure pterin metabolites found in urine
  • Can also diagnose by a reduction in phenylalanine
    after IV or oral load of tetrahydrobiopterin

Learning Points (71.1999)
  • How do you treat tetrahydrobiopterin deficiency?
  • Administer tetrahydrobiopterin
  • Replace dopamine and serotonin as
    tetrahydrobiopterin poorly penetrates brain where
    neurotransmitters are formed
  • Also remember there are a small percentage of
    infants born with transient hyperphenylalaninemia
    which has no clinical consequence

Learning Points (71.1999)
  • Cobalamin is coenzyme foir methmalonyl CoA mutase
    whose deficiency results in
  • Methylmalonic aciduria
  • Carnitine used for transport of medium and long
    chain fatty acids across mitochondria
  • Carnitine deficient patients have muscle weakness
  • Thiamine deficiency results in
  • Beri beri
  • Biotin is cofactor for carboxylases that
    catabolize branched chain amino acids involved in
    fatty acid synthesis

Question 72
  • A 22-month-old girls is nonverbal. She sat alone
    at 7 months and walked by 13 months, but now
    exhibits a wide-based stance, no longer
    ambulates, and will not pick up or manipulate
    toys. Findings include height and weight at the
    50th percentile head circumference below the 5th
    percentile, with no increase over the past 8
    months normal fundi, and no organomegaly.
  • Of the following, the MOST likely diagnosis is
  • Adrenoleukodystrophy
  • Cerebral palsy
  • GM2 gangliosidosis (Tay-Sachs disease)
  • Hypothroidism
  • Rett syndrome
  • Answer E

Learning Points (72.1999)
  • Developmental Delay
  • Regression
  • Plateau
  • Progression
  • Good somatic growth but no head growth in 8
    months known as
  • Acquired microcephaly
  • Lost purposeful hand use when picking up objects
    known as
  • Dyspraxia

Learning Points (72.1999)
  • Rett syndrome (SSSH I dont have Rett syndrome)
  • Neurodegenerative disorder
  • Females only (male fetuses die in utero)
  • 110,000
  • X-linked dominant
  • Seizures
  • Spasticity
  • Scoliosis
  • Hand-wringing
  • Become severe spastic quadriplegics

Learning Points (72.1999)
  • Adrenoleukodystrophy
  • Proxisomal disorder only found in males
  • Defect in acyl CoA synthetase in peroxisomes
  • Cerebral form (50), adrenomyeloneuropathy
    (25), isolated Addison disease or symptomatic
  • Progressive demyelination of brain ?
  • Dementia, Blindness, Deafness, Decorticate state
  • Adrenal insufficiency

Learning Points (72.1999)
  • Tay-Sachs
  • Rapidly progressive neurodegenerative disorder
    due to lysosomal storage disorder (GM2,
    gangliosidosis) caused by deficiency in
  • Beta-hexosaminidase A enzyme
  • Onset before 9 months
  • Hypotonic, never walk, increased startle response
  • Fundoscopic exam reveals
  • Cherry red spot
  • What populations has this been found more
    frequently in?
  • Ashkenazi Jews
  • French Canadians

Learning Points (72.1999)
  • Congenital hypothyroidism
  • High likelihood for normal development if
    treatment started before 3 months of age
  • Can make up some developmental milestones if
    treatment begun before 6 months of age
  • Can see polyneurpathies and muscle weakness

Learning Points (72.1999)
  • Cerebral Palsy What are 4 types?
  • Spastic
  • Dyskinetic
  • Ataxic
  • Hypotonic
  • Must have impaired motor control to make this

Question 73
  • A 10-year-old boy who has hereditary
    spherocytosis has developed increasing fatigue
    and pallor over the past 5 days, and his
    hemoglobin concentration, which usually ranges
    between 10 and 11g/dL, now is 5.9g/dL.
  • Of the following, the MOST likely etiology of
    this decrease in hemoglobin is
  • Aplastic crisis
  • Folic acid deficiency
  • Hyperhemolytic crisis
  • Iron-deficiency anemia
  • Splenic sequestration
  • Answer A

Learning Points (73.1999)
  • Aplastic crisis is the most common cause of
    severe anemia in children with hereditary
    spherocytosis (HS)
  • What is the most common cause of such a crisis?
  • Parvovirus B19 ?erythema infectiosum (fever,
    chills, lethargy, nausea, vomiting, abdominal
    pain, respiratory symptoms, myalgias,
    arthralgias, slapped cheek rash)
  • Parvovirus selectively attacks erythroid
    precursor cells inhibiting their growth ?
    decreased reticulocytes and bilirubin as number
    of RBCs destroyed decreases daily

Learning Points (73.1999)
  • How long does the crisis typically last?
  • 10-14 days
  • Are WBCs and platelets affected as well?
  • Yes they can but it is usually much milder
  • When do you know someone is recovering from a lab
  • Presence of a reticulocytosis
  • Parvovirus infection in first half of pregnancy
    in patient with HS may cause fetal loss due to
    severe anemia

Learning Points (73.1999)
  • What percentage of kids with HS have mild or no
  • 90
  • How long is the life span of a RBC in a patient
    with HS?
  • 30 days
  • With this short of a lifespan hw does the body
    keep up?
  • Enhanced erythropoiesis

Learning Points (73.1999)
  • Folic acid and iron deficiency may exacerbate the
    anemia but this is a gradual decline in
  • Hyperhemolytic crisis without aplasia occurs in
    HS in children less than 6 years who have viral
  • Mild and transient increases in bilirubin,
    splenomegaly, anemia, reticulocytosis
  • Splenic sequestration is typical of sickle cell
    disease and is a minor component of hemolytic
    crisis associated with spherocytosis

Question 74
  • An 18-day-old term infant develops fever,
    lethargy, and focal seizures. Findings include
    an ill-appearing infant without exanthem,
    hepatomegaly, or jaundice. Analysis of
    cerebrospinal fluid reveals white blood cells,
    115/mm3 45 neutrophils 55 lymphocytes red
    blood cells, 40/mm3 glucose, 45 mg/dL protien
    200 mg/dL and negative Gram stain.
  • In addition to ampicillin and cefotaxime, the
    MOST appropriate treatment to begin at this time
  • Acyclovir
  • Amphotericin B
  • Dexamethasone
  • Metronidazole
  • vancomycin
  • Answer A

Learning Points (74.1999)
  • HSV is transmitted during delivery via contact
    with maternal secretions
  • Only 5 of adults in US have a history of genital
  • 20-25 are actively infected with HSV-2
  • What is the risk of an HSV infection in an infant
    born vaginally to a mother who has a 1st or
    primary genital infection?
  • 33-50
  • What is the risk in a mom with recurrent HSV?
  • 3-5

Learning Points (74.1999)
  • HSV in newborn
  • Generalized systemic infection involving liver
    and CNS in 25 cases
  • Localized CNS disease 35
  • Localized to skin, eyes, mouth 40

Learning Points (74.1999)
  • Disseminated HSV disease
  • 1st week of life
  • Liver and adrenals primarily involved
  • Irritability, seizures, respiratory distress,
    jaundice, vesicular rash, shock
  • What is the mortality rate even with treatment?
  • 50-60
  • What are the two most common causes of death in
    disseminated HSV?
  • HSV pneumonitis
  • Disseminated intravascular coagulopathy

Question 75
  • A 10-year-old girl has complained of intermittent
    left lower abdominal pain for 2 days. Previous
    evaluations, including a thorough physical
    examination, urinalysis, and complete blood
    count, have not revealed the cause. Tonight she
    is complaining of pain in the lower left abdomen
    that radiates into her left leg. There is no
    history of fever, vomiting, or diarrhea.
  • The MOST likely cause of this girls pain is
  • Appendicitis
  • Intussusception
  • Malrotation of the intestine
  • Nephrolithiasis
  • Ovarian torsion
  • Answer E

Teaching Points 75.1999
  • Ovarian torsion pain sharp lower abdominal pain
    radiating to ipsilateral extremity, occasional
  • US can assess ovaries
  • Surgical exploration to confirm diagnosis and
    prevent ovarian necrosis (and R/O appendicitis if
    not already done)
  • Left sided pain with appendicitis rare but seen
  • What is pain on right with palpation of the left
  • Rovsings Sign
  • What is the obturator sign?
  • Pain on internal rotation of the right hip, seen
    with pelvic appendix
  • What is the iliopsoas sign?
  • Pain on right hip extension, often seen with
    retrocecal appendix

Teaching Points 75.1999
  • Wrong age for intussusception (around 2 years of
  • Irritability, colicky abdominal pain, emesis
  • Impaired venous return ? bowel edema ? ischemia ?
    necrosis ? perforation
  • Rectal bleeding seen in what percentage of kids?
  • 80 in currant jelly form (blood plus mucous)
  • Most common location?
  • Ileocolic
  • Tubular mass palpable in what percentage of kids?
  • 80

Teaching Points 75.1999
  • Lead point should be sought out in neonates and
    children older than 5. Name lead points.
  • Meckels diverticulum
  • Intestinal polyp
  • Lymphoma
  • Foreign body
  • KUB Paucity gas in RLQ or evidence of
    obstruction with air fluid levels
  • Gastrograffin enema shows coiled-spring
    appearance to bowel which is diagnostic, and may
    treat as well 75 cases
  • IVFs with NS
  • Laporotomy with direct reduction if enema
    unsuccessful or peritoneal signs present and
    enema contraindicated due to concern of
  • Immediate recurrence rate 15

Question 76
  • A 13-year-old boy has a congested, itchy, and
    runny nose accompanied by itchy eyes. These
    symptoms usually occur in the fall, are
    unresponsive to over-the-counter decongestants,
    and his father has the same problems. Physical
    examination reveals pale, boggy nasal turbinates
    clear nasal discharge and dark circles under his
  • These findings are MOST consistent with
  • Allergic rhinitis
  • Infectious rhinitis
  • Nonallergic rhinitis with eosinophilia
  • Rhinitis medicamentosa
  • Vasomotor rhinitis
  • Answer A

Teaching Points 76.1999
  • Perennial rhinitis (year round)
  • Pets, dust mites, molds, cockroaches
  • Vasomotor rhinitis
  • Diagnosis of exclusion, chronic blockage or
    hypersecretion but negative skin tests and normal
    paranasal sinus imaging
  • Infectious rhinitis
  • Mucopurulent discharge, sneezing, limited
  • Rhinitis medicamentosa
  • Overuse topical decongestants
  • Nonallergic rhinitis with eosinophilia
  • Diagnosis of exclusion, negative skin tests,
    nasal smear positive for eosinophils

Pale turbinates http//
Question 77
  • A 5-month-old child is brought to the emergency
    department by her mother because she has been
    crying a lot for the past 24 hours. The mother
    denies any history of fever, trauma, or illness.
    Physical examination reveals a lethargic toddler
    who is very irritable when examined and who has
    mild tachycardia, scattered bruises over the
    chest, and ecchymosis behind the left ear.
  • The MOST appropriate management is to
  • Administer intravenous naloxone
  • Administer a 20 mL/kg bolus of intravenous normal
  • Obtain an abdominal radiograph
  • Obtain a complete blood count and blood culture
    and administer intravenous ceftriaxone
  • Obtain a computed tomographic scan of the head
    and a skeletal survey.
  • Answer E

Teaching Points 77.1999
  • Child abuse red flags
  • Inconsistent history
  • History not compatible with injury
  • Ecchymosis behind left ear is called
  • Battle sign
  • What does this indicate?
  • Basilar skull fracture
  • CSF leakage from nose or ear, periorbital
    ecchymosis (Raccoon Sign), blood behind the eat
    drum (hemotympanum) are also signs of basal skull

Battle Sign
Periorbital Ecchymosis (Raccoon
  • 15 month old with stage IV metastatic
    neuroblastoma and involvement of the periorbital
    tissues and resultant proptosis and orbital
  • Orbital metastases found in up to 20 of children
    with stage IV neuroblastoma.
  • Raccoon eyes appearance associated with
    neuroblastoma is probably related to obstruction
    of the palpebral vessels by tumor tissue in and
    around the orbit.
  • Differential diagnoses for periorbital edema and
  • Child abuse or trauma
  • Infection of the soft tissues associated with a
    spreading dental infection
  • Allergic reaction
  • Myxoedema
  • Lymphoma
  • Haemophilia


Question 78
  • An important component of the diagnostic
    assessment for any child suspected of having
    attention deficit hyperactivity disorder (ADHD)
    is the use of standardized behavior rating
    scales. Of the following, the BEST reason to use
    standardized behavior rating scales is that they
  • Are specific for diagnosing ADHD
  • Assist in monitoring treatment
  • Can be completed after a single classroom
  • Determine initial medication dosage
  • Predict response to medication
  • Answer B

Teaching Points 78.1999
Teaching Points 78.1999
Question 79
  • A 14-year-old boy who has allergic rhinitis
    reports that he frequently develops coughing and
    wheezing after about minutes of playing soccer.
    These symptoms improve after resting for 30
    minutes. Of the following, the drug that will
    give the BEST response in this patient if
    administered just prior to exercise is
  • Inhaled beta2-agonist
  • Inhaled corticosteroid
  • Oral beta2-agonist
  • Oral corticosteroid
  • Oral theophylline
  • Answer A

Teaching Points 79.1999
  • Exercise Induced Asthma
  • Bronchoconstriction during exercise
  • Typically within 15 minutes
  • Can occur during cool down as a lat-phase
    response up to 4-12 hours later
  • Cough, wheeze, SOB, dizzy, stomach pain
  • Occurs 80 patients with asthma
  • Occurs 50 patients with allergic rhinitis

Question 80
  • Ichthyosis vulgaris occurs in 3 to 5 of
    children. Coarse scales on the shins in the
    winter is the most common manifestation of this
    autosomal dominant disorder. It can be
    associated with widely disseminated scales on the
    trunk and extremities as well as keratosis
    pilaris on the upper arms, thighs, and cheeks. Of
    the following, the MOST effective treatment for
    the patients who have ichthyosis is
  • Benzoyl peroxide gel
  • Hydrophilic ointment
  • Lactic acid cream
  • Tretinoin cream
  • Triamcinolone cream
  • Answer C

Teaching Points 80.1999
  • Topical keratolytics induce desquamation and
    treat hyperkeratosis or thickened skin, scaling
    and xerosis
  • Icthyosis vulgaris 3-5 population after 6 months
    age scaling distal extremities, especially the
  • Autosomal dominant
  • Associated with keratosis pilaris (scaly
    follicular papules on upper arms, thighs, cheeks)

Teaching Points 80.1999
  • Keratolytics
  • Lactic Acid (with Ammonium Hydroxide) Lac-hydrin
  • Urea- Carmol
  • Glycolic acid
  • Alpha-hydroxy acids
  • Separate adherent scale from underlying stratum
    corneum of epidermis
  • Petroleum (vasoline) and hydrophilic ointments
    (Aquaphor, Cetaphil etc.) can be used as adjuncts

Question 81
  • A term infant is delivered vaginally to a healthy
    24-year-old primigravida. Immediately after
    birth, the infants respiratory effort is
    vigorous, but subcostal retractions and cyanosis
    persist. The abdomen is scaphoid in appearance.
    Bag and mask ventilation is initiated.
    Auscultation reveals decreased breath sounds on
    the left and heart tones that are louder on the
  • The MOST likely explanation for these findings is
  • Congenital cystic adenomatoid malformation of the
  • Dextrocardia with situs solitus
  • Diaphragmatic hernia
  • Esophageal atresia with tracheoesophageal fistula
  • Pneumothorax
  • Answer C

Teaching Points 81.1999
  • Decreased breath sounds on left, louder heart
    tones on right, consistent with mediastinal shift
    from space occupying lesion on left
  • Presence of scaphoid abdomen indicates abdominal
    contents are in left hemithorax

Teaching Points 81.1999
  • Failure of pleuroperitoneal canal to close during
    the eighth week of fetal life
  • 96 have defect in posterolateral lumbocostal
    triangle known as the