Pediatric M.C.

Q’s Review
DR/NABIL [Link] BARQOUNI
Assistant professor in IUG College of Medicine

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 GAZA 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 appears
E. Incubation period is 4-5 days from exposure to onset of symptoms
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 diarrhea
Acute encephalitis (1:1000) -->Permanent brain injury
In US death 1-3/1000 due to respiratory of neurologic complications
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

Recognised complications of measles include all except :

A. Encephalitis.
B. Fébrile convulsions.
C. Diarrhoea.
D. Infertility in males.
E. Corneal ulceration.
All the following are recognized complications of chickenpox EXCEPT :
(A) Reyes syndrome
(B) Encephalitis
(C) Pneumonia
(D) Hemorrhagic vesicles
(E) Orchitis

Toxic shock syndrome (TSS) is associated with all of the following findings
EXCEPT :

(A) Vomiting and diarrhea

(B) Disorientation
(C) Increased platelet count
(D) Elevated liver function tests
(El Elevated blood urea nitrogen

1
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

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

The MOST common site of Pseudomonas colonization in ICU is:

A. Central venous catheters

B. Foley catheters
C. Peripheral intravenous catheters
D. Surgical wounds
E. Tracheostomy tubes

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 <3 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

2
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…
<8 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

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 mg/ml
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 1:1000 (0.1mg/kg) IV, IO, ET in non-neonates
Use 1:10,000 (0.1-0.3ml/kg for all doses and routes) epinephrine via ETT for neonates
only. Use high dose 1:1,000 epinephrine for ETT beyond neonatal period

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
teeth/lips
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

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” 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

3
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

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 hemophiliacs
Significant blood loss seen in hematomas of…
Thigh or retroperitoneum

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…
PRIOR FACTOR REPLACEMENT
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)
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
Improve our Science Program
Improve Social Science

The MOST common cause of acute laryngotracheobronchitis in children that also

causes many cases of bronchiolitis and pneumonia among young infants is:

A. Adenovirus
B. Influenza virus
C. Parainfluenza virus
D. Respiratory syncytial virus
E. Rhinovirus

4
Which of the following laboratory findings is unusual in patients with simple (
nutritional ) rickets ?

(A) Aminoaciduria
(B) Hyperphosphaturia
(C) Elevated levels of serum alkaline phosphatase
(D) Hypercalciuria
(E) Hypophosphatemia

An ambulance team brings a 6 year old girl 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

Which of the following sets of blood gas values is most compatible with acute
aspirine poisoning in a 16 month old child:

a-PH 7.60, pco2 40 mmHg, Hco3 40 mmol/L

b-PH 7.50, pco2 40 mmHg, Hco3 30 mmol/L
c-PH 7.25, pco2 20 mmHg, Hco3 8 mmol/L
d-PH 7.20, pco2 45 mmHg, Hco3 20 mmol/L
e-PH 7.00, pco2 35 mmHg, Hco3 8 mmol/L

Hirschsprung's disease:

A. Is confined to the rectum and sigmoid colon

B. Often presents with large hard stool
C. Abdominal distension and vomiting relieved by rectal stimulation and
explosive release of watery stool
D. Usually associated with soiling
E. Barium study is the most reliable for diagnosis

Accepted indication for the removal of adenoids in childhood is:

a. Mouth breathing
b. Serious post nasal obstruction
c. Nasal escape of air in speech
d. Inspiratory snoring
e. Recurrent otitis media

5
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 infant’s condition?
A. Dobutamine
B. Epinephrine
C. Nitric Oxide
D. 100% oxygen
E. Prostaglandin E-1

Severe CHF and cardiogenic shock in neonate, think LEFT SIDED LESIONS
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

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 neonate
As PDA is opened the O2 will drop due to right ventricular flow to the body

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 open
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

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

6
 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 transplantation
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"

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

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

7
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

Relocated testis has a 35-48 times greater risk of malignancy than normal testis
Does the normal testis also have an increased risk?
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

Retractile testicles
Bilateral mostly
Found in children >1 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 easier

Intussuception in childhood:

A. Has as the earliest sign the passage of red current jelly stools
B. Has a peak incidence in the first 3 months of life
C. Requires operative reduction in the majority of cases
D. May be initiated by ameckel's diverticulum
E. It has association with umbilical hernia

Necrotizing enterocolitis is associated with all of the following except:

A. Congenital heart disease

B. Prematurity with respiratory distress syndrome
C. Maternal diabetes mellitus
D. Breast feeding
E. Polycythaemia

Medical indication for circumcision in children include:

A. Hypospadias
B. 3 month infantile colic
C. Recurrent ballanitis
D. Ambiguous genitalla
E. Cryptorchidism

8
In congenital diaphragmatic hernia:

A. Hernias most commonly occur on the left

B. Persistent fetal circulation occurs uncommonly
C. Associated congenital anomalies are common
D. Most present between 12 and 24 hours of age
E. Pulmonary hypoplasia is rarely the cause of death

The average time of closure of the anterior fontanel is:

A. 12 months
B. 14 months
C. 16 months
D. 18 months
E. 22 months

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
pregnancy?
A. Alcoholism
B. Diabetes mellitus
C. Hypothyroidism
D. Iodine deficiency
E. Syphilis

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
Infants present with macrosomia due to hyperinsulinemia and excessive glucose
availability
Both linear growth and weight are affected
If mom has severe vascular disease, can result in IUGR
Additional complications: Hyperbilirubinemia, hypoglycemia, vascular thromboses,
respiratory distress, birth injury due to macrosomia
Holoprosencephaly
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.

9
 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 Americans)
1:1000
Affects 40% of children in women who drink more than 4-6 drinks per day

The arthritis of acute rheumatic fever usually:

A. Is monoarticular
B. Heals without deformity
C. Appears after the fever subsides
D. Is seen only in patients with concurrent carditis
E. Involves large and small joints equally

Which of the following support the diagnosis innocent murmur:

A. Present only in diastole

B. Fixed splitting of second heart sound
C. Is loud in high out put states
D. Heard allover the praecordium
E. The venous hum is best heard at the apex

A 4 month old with vitamin D deficiency rickets would be expected to show all of the
following except:

A. Craniotabes
B. Bow legs
C. Rosary
D. Low serum phosphate level
E. High alkaline phosphate levels

Maternal hypothyroidism has little effect on fetus which produces its own thyroid
hormone
Women with untreated hypothyroidism also give birth to NORMAL babies

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…

10
 Delayed maturation of glucuronide conjugation
Feeding difficulties (choking spells, lack of interest, somnolence, sluggishness)

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

The following are causes of jaundice EXCEPT:

A. Congenital hypothyroidism.
B. Wilson's disease.
C. Pityriasis rosea.
D. Alagille Syndrome.
E. Alpha-1-antitrypsin deficiency.

All of the following are true about kwashiorkor except:

A. The presence of edema

B. Rash in sun exposed areas
C. Hypoalbuminemia
D. Weak muscles
E. An increased susceptibility to infection

The following are single gene disorders Except:

A. Cystic fibrosis.
B. Galactosemia.
C. Duchenne muscular dystrophy.
D. Marfan syndrome.
E. Turner syndrome.

The risk of neonatal jaundice is increase by all except:

A. Prematurity.
B. Trisomy 21.
C. Elective caesarean section.
D. Congenital hypothyroidism.
E. Cephalohaematoma.

11
All of the following are recognized causes of hypertension in childhood except:

A. Chronic glomerulonephritis
B. Renal vein thrombosis
C. Neuroblastoma
D. Peripheral pulmonary artery stenosis
E. Congenital adrenal hyperplasia

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 child’s illness?
A. Bacterial culture of CSF
B. PCR test of CSF for HSV
C. [Link] bacterial antigen test of CSF
D. Viral culture of CSF
E. Viral culture of nasopharyngeal and rectal swabs

A 11 year old girl complains of dysuria and abdominal pain for 2 days. She denies
nausea, vomiting, flank pain and vaginal discharge, 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

A 3 year old girl comes to the ER with temperature of 40.0o C 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

Viral diarrhea
Low-grade fever, vomiting, large, loose watery stools
Most common cause…
Rotavirus
Season predominance…
Winter in United States

12
 Bacterial Diarrhea
High fevers, small frequent stools with mucous or blood
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 malabsorption

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 duct
E. Surgical dilation of the nasolacrimal duct

Congenital nasolacrimal duct obstruction is most common abnormality of infant lacrimal

system, 5% affected
What percent of those affected have bilateral obstruction?
30%
Obstruction is usually found where?
Distal end
Pertinent negatives on exam
Conjunctival inflammation, photophobia, blepharospasm, corneal clouding

The following can be the cause of a non-blanching rash except:

A. Idiopathic thrombocytopenic purpura.

B. Roseola infantum.
C. Henoch-Schönlein purpura.
D. Haemolytic uraemic syndrome.
E. Meningococcal sepsis.

Regarding nocturnal enuresis all true except:

Is more common in girls.

Can be a presenting feature of D.M.
Can be a presenting feature of D.I.
Emotional disturbance can be a cause.
Desmopressin is used in the treatment.

13
 In acute bronchiolitis:

A. Ribavirin is the treatment of choice for hospitalized cases

B. Lung volume is usually decreased
C. Bronchodilators are usually effective
D. Feeding difficulties are common
E. Upper air way obstruction is a common feature

The following congenital heart lesions are "Acyanotic" except:

A. Ventricular septal defect.

B. Atrial septal defect.
C. Patent ductus arteriosus.
D. Aortic stenosis
E. Transposition of the great arteries

Hemolytic uremic syndrome is characterized by all of the following except:

A. Microangiopathic hemolytic anaemia

B. Familial cases
C. Thrombocytopenia
D. E-coli (0157:H7) infection
E. All of the above

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 child’s intake and asks
for guidance regarding caloric requirements during this illness.

Of the following, the best estimate of the child’s caloric requirements at this time is

A. 500 kcal/d plus 500 kcal due to the fever

B. 1,000 kcal/d plus 250 kcal due to the fever
C. 1,500 kcal/d
D. 1,500 kcal/d plus 250 kcal due to the fever
E. 2,000 kcal/d

What is the most effective indicator of whether a child is getting enough calories?
Growth Chart
Name 5 factors that affect a child’s energy (calorie) requirements.
Basal metabolism calories (Maintenance at rest and fasting)
Growing calories
Exercise calories
Eating calories

14
 Hypermetabolic states et al (See Table)

Calculation of Caloric Requirements Based on Body Weight

Calculating Energy Lost in Fever
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
Additional Caloric Requirements in Selected Medical and Surgical Conditions

Skin peeling occurs in all of the following conditions except:

A. Burns.
B. Kawasaki disease.
C. Scarlet fever.
D. Toxic shock syndrome.
E. Erythema infectiosum (slapped cheek disease).

In neonatal RDS (respiratory distress syndrome) all are true except:

A. Surfactant is useful in the treatment.

B. It is common in infants below 28 weeks gestation.
C. Antenatal steroids are beneficial.
D. Maternal opiate abuse increases the risk.
E. Maternal diabetes increases the risk.

In children with cerebral palsy all are true except:

A. Associated with a degree of learning impairment.
B. Birth asphyxia is the most common cause.
C. Hand preference before 12 months can be a useful sign.
D. The spastic form is the most common clinical type.
E. Management should adopt a multidisciplinary approach.

Which of the following condition is one type of haemoglobinopathies:

A. G6PD deficiency.
B. von Willebrand disease.
C. Spherocytosis.
D. Pyruvate kinas deficiency .
E. Sickle cell disease.

15
 All of theses neuromuscular disorders are "genetic diseases" except:

A. Duchenne muscular dystrophy.

B. Myotonic dystrophy.
C. Spinal muscular atrophy.
D. Guillain Barre syndrome.
E. Frierich's Ataxia

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 is

A. Bladder catheterization via the urethra

B. Computed tomography of the abdomen
C. Intravenous pyelography
D. Renal untrasonography
E. Retrograde urethrography

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 common.
Isolated urethral injury in female is UNCOMMON.

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 into a COMPLETE
TRANSECTION

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

16
 Potter phenotype may be due to:

A. Renal agenesis
B. Renal dysplasia
C. Obstructive uropathy
D. Severe amniotic fluid leak
E. All of the above

In pyloric stenosis all are true except:

A. Is more common in boys.

B. Surgery is the usual treatment.
C. Infants often have a metabolic alkalosis.
D. Constipation can be a presenting feature.
E. A barium meal is usually performed to confirm the diagnosis.

The following can cause failure to thrive except:

A. Celiac disease.
B. Cystic fibrosis.
C. Emotional neglect.
D. Gastro-oesophageal reflux.
E. Otitis media.

The following are causes of polyhydramnios except:

A. Maternal diabetes mellitus.

B. Potter syndrome.
C. Anencephaly.
D. Oesophageal atresia.
E. Spina bifida.

APGAR Score (Virginia Apgar 1953)

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

A. Ascertain the heart rate and assign a 1-minute Apgar score

B. Begin tactile stimulation and provide blow-blow oxygen supplementation
C. Dry all skin surfaces and clear the oropharynx
D. Initiate bag-mask ventilation
E. Insert an umbilical catheter and administer naloxone

17
 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 hypothermia
Also provides gentle stimulation to infant

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 breathers
Suctioning also provides tactile stimulation
Score of 7 or more indicates…
WELL NEWBORN  ROUTINE CARE AND OBSERVATION
Score of 4-6 indicates…
MILD TO MODERATE DEPRESSION, NEED MORE INTERVENTION (Blowby,
stimulation etc.)
Score 3 or less…
SEVERE DEPRESSION, NEED TO INTUBATE, CV SUPPORT, BAG-MASK
VENTILATION

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

The following are inherited in an X-linked manner all are true except:

A. Duchenne muscular dystrophy.

B. Haemophilia A.
C. Cystic fibrosis.
D. G6PD deficiency.
E. Hunter syndrome.

Concerning chickenpox all are false except:

A. The incubation period is 7 days.

B. Aspirin is a useful anti-pyretic.
C. Transmission is usually by contact or airborne.
D. Encephalitis not a recognized complication.
E. There is no effective vaccine.

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 Regarding Kawasaki's disease:

A. Purulent Conjunctivitis is a recognized

feature.
B. It is caused by a spirochaete organism.
C. It is a cause of coronary artery aneurysms.
D. Fever is not a typical feature.
E. Is associated with profound
thrombocytopenia

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

A. Biotin
B. Cobalamin
C. Carnitine
D. Tetrahydrobiopterin
E. Thiamine

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

A. Adrenoleukodystrophy
B. Cerebral palsy
C. GM2 gangliosidosis (Tay-Sachs disease)
D. Hypothroidism
E. Rett syndrome

Of the following, the MOST likely etiology of this decrease in hemoglobin is

A. Aplastic crisis
B. Folic acid deficiency
C. Hyperhemolytic crisis
D. Iron-deficiency anemia
E. Splenic sequestration

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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 is

A. Acyclovir
B. Amphotericin B
C. Dexamethasone
D. Metronidazole
E. vancomycin

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 girl’s pain is

A. Appendicitis
B. Intussusception
C. Malrotation of the intestine
D. Nephrolithiasis
E. Ovarian torsion

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 eyes.

These findings are MOST consistent with

A. Allergic rhinitis
B. Infectious rhinitis
C. Nonallergic rhinitis with eosinophilia
D. Rhinitis medicamentosa
E. Vasomotor rhinitis

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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

A. Administer intravenous naloxone

B. Administer a 20 mL/kg bolus of intravenous normal saline
C. Obtain an abdominal radiograph
D. Obtain a complete blood count and blood culture and administer intravenous
ceftriaxone
E. Obtain a computed tomographic scan of the head and a skeletal survey.

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

A. Inhaled beta2-agonist
B. Inhaled corticosteroid
C. Oral beta2-agonist
D. Oral corticosteroid
E. Oral theophylline

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

A term infant is delivered vaginally to a healthy 24-year-old primigravida. Immediately

after birth, the infant’s 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 right.
The MOST likely explanation for these findings is
A. Congenital cystic adenomatoid malformation of the lung
B. Dextrocardia with situs solitus
C. Diaphragmatic hernia
D. Esophageal atresia with tracheoesophageal fistula
E. Pneumothorax

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