ITEM QUESTION CHOICES ANSWER RATIONALE SOURCE

1 How can infant’s perception and A. Crying when A. Crying when hungry Social and Emotional Centers for
cognition be demonstrated during the hungry or sleepy or sleepy ● Begins to smile at people Disease
first months of life? Demonstrated by B. Eye gazing, head ● Can briefly calm herself (may bring hands Control and
turning and to mouth and suck on hand) Prevention
sucking ● Tries to look at parent
C. Smiling when https://www.c
approached by Language/Communication dc.gov/ncbdd
mom or dad d/actearly/mil
● Coos, makes gurgling sounds
D. Waking up during estones/index
● Turns head toward sounds
feeding period .htm
Cognitive (learning, thinking, problem-solving)
● Pays attention to faces
● Begins to follow things with eyes and
recognize people at a distance
● Begins to act bored (cries, fussy) if activity
doesn’t change

Movement/Physical Development
● Can hold head up and begins to push up
when lying on tummy
● Makes smoother movements with arms
and legs

2 During early childhood, children should A. 12-16 hours C. 8-10 hours Toddler (1-3 yr) Nelson
sleep for how long without B. 11-13 hours Total sleep: average is 11-13 hr Textbook of
interruption? C. 8-10 hours Nighttime: average is 9.5-10.5 hr Pediatrics
 D. 5-7 hours Naps: average is 2-3 hr; decrease from 2 naps to 20th edition
1 at average age of 18 mo p. 113

Preschool (3-5 yr)

Nighttime: average is 9-10 hr
Naps decrease from 1 nap to no nap
Overall, 26% of 4 yr olds and just 15% of 5 yr olds
nap

*See table at Nelson for complete data

3 Baby Nicole already knows how to A. 4 months B. 9 months 9 months Centers for
play peek-a-boo. She copies sounds B. 9 months ● May be afraid of strangers Disease
and movements of others and points at C. 6 months ● May be clingy with familiar adults Control and
things. She is able to stand with D. 12 months ● Has favorite toys Prevention
support, crawl and get into sitting ● Understands “no”
● Makes a lot of different sounds like
position without support, and pulls to https://www.c
“mamamama” and “bababababa”
stand. She has met the milestones of dc.gov/ncbdd
● Copies sounds and gestures of others
what age? ● Uses fingers to point at things d/actearly/mil
● Watches the path of something as it falls estones/index
● Looks for things she sees you hide .html
● Plays peek-a-boo
● Puts things in his mouth
● Moves things smoothly from one hand to
the other
● Picks up things like cereal o’s between
thumb and index finger
● Stands, holding on
● Can get into sitting position
● Sits without support
● Pulls to stand
 ● Crawls

*See CDC table for complete data

4 The 9th month physical examination of A. Talk to parent A. Talk to parent General guidelines: Bates’ Guide
an infant is difficult to do. Which avoiding direct avoiding direct eye ● Approach the infant gradually, using a toy to Physical
endeavor is the LEAST likely way to eye contact with contact with child or ​object for distraction​. Examination
get the child’s cooperation? child ● Perform much of the examination with the and
B. Examine the child infant in the parent’s lap​. History-Takin
while on parent’s ● Speak softly to the infant or mimic the g 11th edition
lap infant’s sounds to attract attention. p. 776
C. Talk to the child ● If the infant is cranky, make sure he or she
with direct eye is well fed before proceeding.
contact ● Ask a parent about the infant’s strengths
D. Introduce the child to elicit useful developmental and
to a small parenting information.
washable toy ● Don’t expect to do a head-to-toe exam in
a specific order. Take what the infant
gives you and save the mouth and ear
exam for last.

5 What is/are the cause/causes of digital A. Chronic cardiac A. Chronic cardiac failure Nelson
clubbing? failure Textbook of
B. Acute respiratory An increase in ​hypoxia​ may activate local vasodilators, consequently Pediatrics
insufficiency increasing blood flow to the distal portion of the digits; however, in most 20th edition
C. Defective heart p. 1995
cases, ​hypoxia​ is absent in the presence of ​clubbing​, and many
valves
diseases with noted ​hypoxia​ are not associated with ​clubbing​.
D. Chronic hypoxia
and chronic lung
disease
6 Which statement is FALSE with A. Lower respiratory D. The receptors of chronic Cough is a reflex response of the lower Nelson
regards to the origin of chronic stimuli include coughs are mostly located respiratory tract to stimulation of irritant or cough Textbook of
coughs? excessive receptors in the airways’ mucosa. The most Pediatrics
 secretions, in the lower respiratory common cause in children is airway reactivity 20th edition
aspirated foreign tract. (asthma). p. 2027
material, inhaled
dust/gases. Because ​cough receptors also reside in the
B. Origin of coughs pharynx, paranasal sinuses, stomach, and
can also be a external auditory canal​, the source of a
response to persistent cough may need to be sought beyond
infectious agents the lungs.
or cigarette
smoke. Specific lower respiratory stimuli include
C. Nighttime cough excessive secretions, aspirated foreign
suggests upper material, inhaled dust particles or noxious
airway disease gases​, cold or dry air, and an inflammatory
such as sinusitis. response to infectious agents or allergic
D. The receptors of processes.
chronic coughs
are mostly located Posterior pharyngeal drainage combined with a
in the lower nighttime cough suggests chronic upper
respiratory tract. airway disease such as sinusitis​.

Additional useful information can include a

history of atopic conditions (asthma, eczema,
urticaria, allergic rhinitis), a seasonal or
environmental variation in frequency or intensity
of cough, and a strong family history of atopic
conditions, all suggesting an allergic cause;
symptoms of malabsorption or family history
indicating cystic fibrosis; symptoms related to
feeding, suggesting aspiration or
gastroesophageal reflux; a choking episode,
 suggesting foreign-body aspiration; headache or
facial edema associated with sinusitis; and a
smoking history in older children and adolescents
or the ​presence of a smoker in the house​.

7 Which one occurs during normal A. The aortic sac C. The paired dorsal aorta The aortic arch, head and neck vessels, proximal Nelson
cardiac development? gives rise to the will fuse to form the pulmonary arteries, and ductus arteriosus Textbook of
right and left 1st descending aorta. develop from the aortic sac, arterial arches, and Pediatrics
aortic arches. dorsal aortae. When the straight heart tube 20th edition
B. The 1st and 2nd develops, the ​distal outflow portion bifurcates p. 2159-2160
arches form the into the right and left 1st aortic arches​, which
common and join
internal carotid the paired dorsal aortae. ​The dorsal aortae will
arteries. fuse to form the descending aorta.​ The
C. The paired dorsal proximal aorta from the aortic valve to the left
aorta will fuse to carotid artery arises from the aortic sac.
form the
descending aorta. The 1st and 2nd arches largely regress by about
D. The 5th arch 22 days, with the ​1st aortic arch giving rise to
persists in the the maxillary artery​ and the ​2nd to the
mature circulation stapedial and hyoid arteries.
as a segment of
the aortic arch. The 3rd arches participate in the formation of the
innominate artery and the common and internal
carotid arteries.

The right 4th arch gives rise to the innominate

and right subclavian arteries, and the left 4th arch
participates in formation of the segment of the
 aortic arch between the left carotid artery and the
ductus arteriosus.

The 5th arch does not persist as a major

structure in the mature circulation.

The 6th arches join the more distal pulmonary

arteries, with the right 6th arch giving rise to a
portion of the proximal right pulmonary artery and
the left 6th arch giving rise to the ductus
arteriosus. The aortic arch between the ductus
arteriosus and the left subclavian artery is derived
from the left-sided dorsal aorta, whereas the
aortic arch distal to the left subclavian artery is
derived from the fused right and left dorsal aortae.
Abnormalities in development of the paired aortic
arches are responsible
for right aortic arch, double aortic arch, and
vascular rings.

8 Prostaglandin may be administered to A. Patients who B. Patient waiting for Before birth, oxygenation of the fetus with Nelson
patient with patent ductus arteriosus in cannot undergo surgical management of transposition of great arteries is only slightly Textbook of
which situation? surgical transposition of great abnormal, but after birth, once the ductus Pediatrics
management of arteries arteriosus begins to close, the minimal mixing of 20th edition
ventricular septal systemic and pulmonary blood via the patent p. 2224
defect. foramen ovale is usually insufficient and severe
B. Patient waiting for hypoxemia ensues, generally within the 1st few
surgical days of life.
management of
 transposition of When ​transposition is suspected, an infusion
great arteries. of prostaglandin E1 should be initiated
C. Ductus arteriosus immediately​ to maintain patency of the ductus
of a full term baby arteriosus and improve oxygenation (dosage:
which has not 0.01-0.20 μg/kg/min).
closed a week
after birth.
D. Ductus arteriosus
persists in a child
who is already 3
years old.

9 Which of the following statements is A. Acrocyanosis is a C. Cyanosis at rest is often Many infants and toddlers turn “blue around Nelson’s
true regarding cyanosis in the pediatric symptom of overlooked due to variations the lips” when crying vigorously or during Pediatrics,
age group? worsening cardiac in skin color of children breath-holding spells​; this condition must be 20th Edition,
functions in a carefully differentiated from ​cyanotic heart page 2163
newborn disease​ by inquiring about inciting factors, the
B. Turning blue length of episodes, and whether the tongue and
around the lips mucous membranes also appear cyanotic.
after crying Newborns often have cyanosis of their
vigorously is a extremities (acrocyanosis) when undressed
definitive sign of and cold​; this response to cold must be carefully
heart disease differentiated from ​true cyanosis, where the
C. Cyanosis at rest is mucous membranes are also blue.
often overlooked
due to variations
in skin color of
children
D. Mucous
membranes are
 spared or not
involved in true
cyanosis in
newborns

10 What are heart murmurs? A. They are signs of B. They are results of Cardiac murmur is a characteristic sound BRS Gross
leaflet prolapse audible vibrations caused generated by turbulence of blood flow through an Anatomy, 6th
radiating by increased turbulence orifice of the heart. Edition
anteriorly timed within the cardiac
B. They are results cycle
of audible
vibrations caused
by increased
turbulence timed
within the cardiac
cycle
C. They are the
differences
between two
cardiac chambers,
ventricles and
arteries
D. They are
progressive
attenuations of left
ventricle to left
atrial pressure
gradient
11 Which congenital malformation A. Trisomy 13 D. Congenital rubella Trisomy 13 (T13) and 18 (T18) are frequently (up https://www.n
syndrome is least associated with the B. Fetal alcohol to 80%) associated with multiple anomalies cbi.nlm.nih.go
development of ventricular septal syndrome including congenital heart defects (CHD) such as v/pmc/articles
defect? C. Down’s syndrome atrial or ventricular septal defects (ASD, VSD), /PMC552635
D. Congenital rubella patent ductus arteriosus (PDA), atrioventricular 2/
septal defect (AVSD), tetralogy of Fallot (TOF)
and others. https://embry
o.asu.edu/pa
The specific defects that have been observed ges/effects-pr
from prenatal alcohol exposure include defects to enatal-alcoho
the atrioventricular valves (tricuspid and mitral) l-exposure-ca
that allow blood to flow backward into the atria; rdiac-develop
ventricular septal defects, commonly known as a ment
“hole in the heart” between the left and right
ventricles; enlargement of the left ventricle, the https://www.n
primary pumping chamber in the heart; and an cbi.nlm.nih.go
increased risk of developing heart disease later in v/pubmed/21
adult life. 39542

Ventricular septal defect is a common cardiac

anomaly in Down syndrome.

Congenital rubella may also present with VSD.

However, the most common congenital heart
defect associated is PDA.

12 A patient presents with VSD in which A. Pulmonary B. Eisenmenger syndrome Eisenmenger syndrome (ES) is a constellation of https://www.n
blood is shunted from right to left arteriovenous symptoms that arise from a congenital heart cbi.nlm.nih.go
secondary to the development of fistula defect and result in large anatomic shunts. Due to
 pulmonary vascular disease. This B. Eisenmenger anatomic variations present at birth, v/books/NBK
condition is known as: syndrome hemodynamic forces initially result in a left-right 507800/
C. Ectopia cordis shunt, which develops into severe pulmonary
D. Ebstein anomaly arterial hypertension (PAH) and elevated vascular
resistance. Ultimately, ​due to increased
pulmonary vascular resistance, the
left-to-right shunt will become a right-to-left
shunt, resulting in significant hypoxemia and
cyanosis​.

13 The boot shaped sign seen in the A. The convergence D. The upturning of the The boot-shaped heart sign is a conventional https://pubs.r
radiographs of patients with Tetralogy behind the heart cardiac apex due to right radiographic finding in patients with TOF. ​The toe sna.org/doi/a
of Fallot is from: of the pulmonary ventricular hypertrophy and of the boot is formed by the upward pointing bs/10.1148/ra
vein, instead of by the concavity of the main cardiac apex​, which makes an acute angle with diol.2461041
draining into the pulmonary artery the diaphragm. ​The upturned cardiac apex is 673?journalC
left atrium ascribed to right ventricular hypertrophy​ and ode=radiolog
B. The shortening of occurs in 65% of patients with TOF. y
the left ventricular
inflow tract and
elongation of the
left ventricular
outflow tract
C. The contour of the
aorta deformed by
both pre and post
stenotic dilation,
and dilation of the
subclavian artery
D. The upturning of
the cardiac apex
 due to right
ventricular
hypertrophy and
by the concavity
of the main
pulmonary artery

14 This type of total anomalous A. Type IV TAPVR C. Type II TAPVR Nelson’s

pulmonary venous return involves B. Type I TAPVR Pediatrics,
pulmonary venous connection at the C. Type II TAPVR 20th Edition,
cardiac level. The pulmonary veins join D. Type III TAPVR page 2227
either the coronary sinus or the right
atrium. What type is this?

15 The most common major congenital A. TOF B. VSD VSD is the most common cardiac malformation Nelson’s
heart lesion is: B. VSD and accounts for 25% of congenital heart Pediatrics,
C. PDA disease. Defects may occur in any portion of the 20th Edition,
D. ASD ventricular septum, but most are of the page 2194
membranous type.
16 Which is not a component of the four A. VSD B. LVH The four components that make up the "tetralogy" BRS Gross
main defects in Tetralogy of Fallot? B. LVH include: Anatomy, 6th
C. Overriding aorta Edition
D. Pulmonary ● a ventricular septal defect (VSD);
stenosis ● pulmonary stenosis (subvalvar, valvar
and/or supravalvar);
● an overriding aorta; and.
● right ventricular hypertrophy

17 Which of the following correctly A. Choroid plexus → C.​ ​Choroid plexus → lateral ventricle → foramen of monroe → third Snell’s
describes the flow of CSF in children? lateral ventricle → ventricle → aqueduct of sylvius → fourth ventricle Clinical
aqueduct of Neuroanatom
sylvius → third The ventricles are four fluid-filled cavities located within the brain; these are the y, 7th Ed.,
ventricle → two lateral ventricles, the third ventricle, and the fourth ventricle (Fig. 16-1). The page 464-466
foramen of two lateral ventricles communicate through the interventricular foramina (of
monroe → fourth Monro) with the third ventricle. The third ventricle is connected to the fourth
ventricle ventricle by the narrow cerebral aqueduct (aqueduct of Sylvius). The fourth
B. Choroid plexus → ventricle, in turn, is continuous with the narrow central canal of the spinal cord
lateral ventricle → and,through the three foramina in its roof, with the subarachnoid space. The
foramen of central canal in the spinal cord has a small dilatation at its inferior end, referred
magendie → third to as the terminal ventricle (Fig. 16-1).
ventricle →
aqueduct of
sylvius → fourth
ventricle
C. Choroid plexus
→ lateral
ventricle →
foramen of
monroe → third
 ventricle →
aqueduct of
sylvius → fourth
ventricle
D. Choroid plexus →
lateral ventricle →
foramen of
luschka → third
ventricle →
foramen of
magendie →
fourth ventricle

18 Which of the following should a 1 year A. Go up the stairs ​C. Throw objects Harriet Lane
old child be able to do? one step at a time Handbook,
B. Can say two - Table 9.1;
word phrases https://www.u
 C. Throw objects nboundmedic
D. Makes a tower of ine.com/harri
two blocks etlane/view/H
arriet_Lane_
Handbook/30
9117/all/TAB
LE_9_1:_DE
VELOPMENT
AL_MILESTO
NES

19 A 5 year old child comes into your A. Benign rolandic ​C. Febrile seizure Febrile seizures ​are seizures that ​occur Nelson
clinic due to fever from a respiratory epilepsy between the age of 6 and 60 mo ​with a Textbook of
tract infection. While doing your exam, B. Infantile spasms temperature of 38°C (100.4°F) or higher​, that Pediatrics,
he develops a 10-second episode of C. Febrile seizure are ​not the result of central nervous system 20th Ed.,
generalized seizure. Which of the D. Lennox - gastaut infection or any metabolic imbalance​, and that page
following is the MOST likely diagnosis syndrome occur in the absence of a history of prior 2828-2829
afebrile seizures​.

A simple febrile seizure is a ​primary,

generalized, usually tonic–clonic, attack
associated with fever, lasting for a maximum
 of 15 min, and not recurrent within a 24-hr
period​.

A complex febrile seizure is more prolonged (>15

min), is focal, and/or reoccurs within 24 hr. Febrile
status epilepticus is a febrile seizure lasting
longer than 30 min. Some use the term simple
febrile seizure plus for those with recurrent febrile
seizures within 24 hr.

Most patients with simple febrile seizures ​have a

very short postictal state ​and ​usually return to
their baseline normal behavior and
consciousness within minutes of the seizure​.

20 The sleep-wake pattern is well A. Gestational age B. Presence of television Sleep–wake patterns are well developed at term. Nelson
developed at term. Alertness of the B. Presence of Because the level of alertness of a neonate Textbook of
neonate depends on the following television depends on many factors, including the ​time of Pediatrics,
factors. Which of the following is C. Time of last the last feeding​,​ room temperature​, and 20th Ed.,
LEAST contributory? feeding gestational age​, ​serial examinations ​are page 2792
D. Room critical when evaluating ​for ​changes in
temperature neurologic function​.

21 A child presents with cafe au lait spots, A. Von - Hippel B. Neurofibromatosis I Neurofibromatoses are autosomal dominant Nelson
axillary freckling, ‘ballotable’ nodules, Lindau disease disorders that cause tumors to grow on nerves Textbook of
and elevated lumps in the skin. Which B. Neurofibromatos and result in other abnormalities such as skin Pediatrics,
does this child MOST likely have? is I changes and bone deformities. 20th Ed., pp.
C. Neurofibromatosis 2874-2876
II NF-1 is the most prevalent type, with an incidence
of 1 in 3,000 live births, and is caused by
D. Sturge Weber dominant loss-of-function mutations in the NF-1
Disease gene. The disease is clinically ​diagnosed when
any 2 of the following 7 features ​are present:
(1) ​six or more café-au-lait macules larger than
5 mm in greatest diameter ​in p ​ repubertal
individuals ​and ​larger than 15 mm in greatest
diameter ​in ​postpubertal individuals​.
Café-au-lait spots ​are the ​hallmark of
neurofibromatosis ​and are ​present in almost
100% of patients​. (2) ​Axillary or inguinal
freckling ​consisting of ​multiple hyperpigmented
areas 2-3 mm in diameter​. The frequency of
axillary and inguinal freckling is reported to be
>80% by 6 yr of age. (3) ​Two or more iris Lisch
nodules​. Lisch nodules are hamartomas located
within the iris and are best identified by a slit-lamp
examination. They are present in more than 74%
of patients withNF-1 but are not a characteristic of
NF-2. (4) ​Two or more neurofibromas or 1
plexiform neurofibroma​. They are usually small,
rubbery lesions with a slight purplish discoloration
of the overlying skin. (5) A ​distinctive osseous
lesion ​such as s​ phenoid dysplasia ​(which may
cause pulsating exophthalmos) or ​cortical
thinning of long bones with or without
pseudoarthrosis ​(e.g., tibia). (6) O​ ptic gliomas
are present in approximately 15% of patients with
NF-1 and represent mostly low-grade
astrocytomas. They are the main central nervous
system tumor with a marked increased frequency
 in NF-1. (7) A 1st-degree relative with NF-1
whose diagnosis was based on the
aforementioned criteria.

22 Which of the following statements may A. A large head is B. Flattening of the skull If the brain is not growing, the skull will not Nelson
NOT be true? associated with a will need extensive grow​; therefore, a small head frequently reflects Textbook of
large brain investigation a small brain, or microcephaly. Conversely, ​a Pediatrics,
B. Flattening of the large head may be associated with a large 20th Ed., pp.
skull will need brain, or macrocephaly, ​which is most 2792
extensive commonly familial but may be from a disturbance
investigation of growth, neurocutaneous disorder (e.g.,
C. If the brain is not neurofibromatosis), chromosomal defect (e.g.,
growing, the skull Klinefelter syndrome), or storage disorder.
will not grow
D. Head size may be Alternatively, the ​head size may be increased
increased secondary to hydrocephalus or chronic
secondary to subdural hemorrhages​. Plagiocephaly, or
hydrocephalus flattening of the skull​, can be ​seen in normal
infants ​but may be particularly prominent in
hypotonic or weak infants, who are less mobile.

23 During examination of a 3 month old A. Startle D. Babinski Babinski sign occurs when stimulation of lateral Bates’ Guide
infant, you test his CNS by stroking the B. Rooting plantar aspect of the foot leads to extension to Physical
lateral surface of the sole. His big toe C. Moro (dorsiflexion or upward movement) of the big toe Examination,
then dorsiflexes and the other toes fan D. Babinski (hallux). Also, there may be fanning of the other 12th Ed.,
out. This demonstrates which reflex? toes. This suggests that there has been spread of page
the sensory input beyond the S1 myotome to L4 848-849;
and L5. An intact CST prevents such spread. Nelson
Textbook of
Pediatrics,
 In infants with at CST which is not fully 20th Ed.,
myelinated, the presence of a Babinski sign in the page 2798
absence of other neurological deficits is
considered normal up to 24 months of age.

The Moro or startle reflex is elicited by supporting

the infant in a semi erect position and then
allowing the infant’s head to fall backwards onto
the examiner’s hand. A normal response consists
of symmetric extension and abduction of the
fingers and upper extremities, followed by flexion
of the upper extremities and an audible cry. An
asymmetric response can signify a fractured
clavicle, brachial plexus injury, or hemiparesis.

Rooting reflex is elicited by stroking the perioral

skin at the corners of the mouth.The mouth will
open and the infant will turn the head toward the
stimulated side and suck.

24 Which will NOT give a positive A. Nasal/oropharyng B. Red dyes in food or Blood loss from the gastrointestinal tract is never Nelson
GUAIAC test in stools? eal bleeding drinks normal, but ​swallowed blood may be Textbook of
B. Red dyes in food misinterpreted as gastrointestinal bleeding​. Pediatrics,
or drinks Maternal blood may be ingested ​at the time of 20th Ed.,
C. Blood loss from birth or later by a nursing infant if there is page 1757
GI tract bleeding near the mother’s nipple. ​Nasal or
D. Maternal blood oropharyngeal bleeding ​is occasionally
ingested mistaken for gastrointestinal bleeding. ​Red dyes
in foods or drinks can turn the stool red but
 do not produce a positive test result for occult
blood.

25 Where is the location of our “hunger A. Medulla B. ​Hypothalamus The Hypothalamus Contains Hunger and Guyton and
and satiety centers? B. Hypothalamus Satiety Centers. Hall Textbook
C. Cerebral cortex Several neuronal centers of the hypothalamus of Medical
D. Amygdala participate in the control of food intake. The Physiology
lateral nuclei of the hypothalamus serve as a 13E.p890
feeding center, and stimulation of this area
causes an animal to eat voraciously
(hyperphagia). Conversely, destruction of the
lateral hypothalamus causes lack of desire for
food and progressive inanition, a condition
characterized by marked weight loss, muscle
weakness, and decreased metabolism. The
lateral hypothalamic feeding center operates by
exciting the motor drives to search for food.

26 Why do infants need to be “burped” A. Infants feel full C. ​Infants swallow air Gastrointestinal function varies with maturity; Nelson
after feeding? after feeding, burp during feeding, burp to what is a physiologic event in a newborn or infant Textbook of
to prevent prevent abdominal might be a pathologic symptom at an older age. A Pediatrics
vomiting distention fetus can swallow amniotic fluid as early as 12 wk 20E.p1757
B. Infants feel of gestation, but nutritive sucking in neonates first
comfortable after develops at about 34 wk of gestation. The
burping especially coordinated oral and pharyngeal movements
if they had full necessary for swallowing solids develop within
feeding the 1st few mo of life. Before this time, the tongue
C. Infants swallow air thrust is upward and outward to express milk from
during feeding, the nipple, instead of a backward motion, which
burp to prevent propels solids toward the esophageal inlet. By 1
 abdominal mo of age, infants appear to show preferences for
distention sweet and salty foods. Infants’ interest in solids
D. Have to place increases at approximately 4 mo of age. The
infants upright recommendation to begin solids at 6 mo of age is
position to prevent based on nutritional and cultural concepts rather
food regurgitation than maturation of the swallowing process.
Infants swallow air during feeding, and
burping is encouraged to prevent gaseous
distention of the stomach.

27 Which is considered the MOST A. High caloric intake B. ​Obesity OBESITY Diabetes in
important risk factor for type 2 diabetes B. Obesity The prevalence of obesity in the United States America, 3E.
mellitus? C. Family History increased considerably from 1994 to 2010. Chapter 13
D. Sedentary lifestyle Excessive body fat is the single largest risk factor Risk Factor
for type 2 diabetes. The diabetes risk associated for Diabetes
with excessive body fat, measured by BMI (the Type 2. PDF
ratio of body weight in kilograms to squared file
height in meters) or anthropometric indicators,
such as a waist circumference or skinfold
thickness, increases in a continuous fashion.
Clinical risk categories for BMI (normal weight
18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, and
obesity ≥30 kg/m2) are associated with a
stepwise increase in diabetes risk. However,
diabetes risk increases even within the normal
body weight range. In the NHS, the relative risk of
diabetes among women with BMI 23.0–24.9
kg/m2 was 2.67 (95% CI 2.13–3.34) compared to
women with BMI <23.0 kg/m2. Also, the majority
of diabetes cases develop in individuals at the
 normal weight and overweight ranges, not among
obese individuals.

28 What is the cause of diabetes A. Impaired D. ​Vasopressin

DI can be caused by two fundamentally different
insipidus? renin-angiotensin- deficiency https://www.n
defects: Inadequate/impaired secretion of AVP
aldosterone cbi.nlm.nih.go
from the posterior pituitary gland and
system v/pmc/articles
impaired/insufficient renal response to ADH. AVP,
B. Low serum /PMC474339
a neurohypophyseal nonapeptide, regulates body
sodium 1/
water and osmotic homeostasis. The
C. Abnormal atrial
AVP-neurophysin II gene (​AVP-NPII​) encodes
natriuretic peptide
AVP, which is synthesized in the supraoptic and
D. Vasopressin
paraventricular nuclei of the hypothalamus as a
deficiency
precursor complex of AVP, NPII, and
glycopeptides copeptin and is released as AVP
from neurons in the posterior pituitary. AVP and
its protein carrier, NPII, are released by
calcium-dependent exocytosis. AVP release may
occur due to nonosmotic stimuli also including
orthostatic hypotension or emetic reflexes
(manifested in nausea and vomiting).

The AVP system maintains water balance based

on serum osmolality and arterial blood volume via
the vasopressin-2-receptor (V2R). AVP activates
V2R at the basolateral membrane of the principal
cells in the distal convoluted tubule and collecting
duct of the kidney. This activates protein kinase A
which in turn phosphorylates aquaporin 2 (AQP2)
water channels in the intracellular vesicles.
Exocytic insertion of AQP2 vesicles into the cell
 membrane follows, and the collecting duct
becomes water permeable, thus concentrating
the urine.

29 A population of patients manifests as A. Tachycardia D. ​Non-suppression of The syndrome of impaired sensitivity to thyroid https://www.n
unresponsiveness of tissues to thyroid B. Presence of goiter thyroid-stimulating hormone (ISTH) is a condition of decreased cbi.nlm.nih.go
hormone and may be misdiagnosed as C. Fractional hormone tissue sensitivity to thyroid hormone action v/pmc/articles
the above disease. What distinguishes elevation of T4 usually caused by germline mutations of the /PMC479057
the thyroid unresponsive variant for the D. Non-suppression thyroid hormone receptor beta ​(THRB)​ gene. The 6/
above disease? of mutant receptor has lower binding affinity for
thyroid-stimulating thyroid hormone and, as a consequence, serum
hormone level thyroid-stimulating hormone (TSH) levels remain
nonsuppressed despite elevated thyroid
hormones.

30 Which is considered satisfactory when A. A normal serum B. ​Morning ACTH levels ACTH levels may be used to monitor adequacy of Nelson
monitoring adequacy of glucocorticoid and urine 2-3x the normal glucocorticoid replacement in primary adrenal Textbook of
replacement? electrolytes insufficiency; in congenital adrenal hyperplasia, pediatrics
B. Morning ACTH levels of precursor hormones are used instead 20E. p2710
levels 2-3x the (see Chapter 576). Blood samples for monitoring
normal should be obtained at a consistent time of day
C. Normal level of and in a consistent relation to (i.e., before or after)
serum cortisol the hydrocortisone dose. ​Normalizing ACTH
D. ACTH level within levels is unnecessary and can require
normal range excessive doses of hydrocortisone; generally
morning ACTH levels high in the normal range
to 3-4 times normal are satisfactory.​ Because
untreated or severely undertreated patients can
acutely decompensate during relatively minor
illnesses, assessment of symptoms (or lack
 thereof) must not be used as a substitute for
biochemical monitoring. During situations of
stress, such as periods of infection or minor
operative procedures, the dose of hydrocortisone
should be increased 2-3–fold. Major surgery
under general anesthesia requires high
intravenous doses of hydrocortisone similar to
those used for acute adrenal insufficiency.

31 Which factor establishes the diagnosis A. Preferential T3 C.​ Presence of Goiter https://www.n
of Grave disease? elevation cbi.nlm.nih.go
B. Thyrotropin v/pmc/articles
receptor-stimulati /PMC149254/
ng antibody
(TRSAB)
C. Presence of
Goiter
D. Accompanying
exophthalmos
 The hyperthyroidism of Graves' disease may be overt, biochemical or
subclinical. All patients exhibit a low or, in most cases, suppressed TSH. In the
face of an elevated free thyroxine (FT4) level, hyperthyroidism is confirmed.
However, 10% of patients will have an increased total or free T3 level in the face
of a normal FT4 and suppressed TSH level, a condition termed “T3 toxicosis.”
Confirmation of Graves' disease by an increased 24-hour radioiodine uptake
(RAIU) is recommended, because painless thyroiditis and Graves' disease have
occurred at different times in the same patient. Measurement of levels of
circulating TSH receptor antibody may eventually replace the need for the RAIU
for confirmation of the diagnosis.

32 Which one is increased in Anemia of A. Red Blood Cells C. Serum Ferritin The hemoglobin is <8 g/dL in approximately UpToDate
Chronic Disease? B. Hemoglobin one-fifth of cases and the RBCs are microcytic
C. Serum Ferritin and hypochromic in less than one-fourth of cases;
D. Mean Corpuscular these individuals may have concomitant iron
Volume deficiency. In these cases the MCV is rarely less
than 70 fL, the MCHC is normal to decreased,
and the red cell distribution width (RDW) is
normal to increased.
 Ferritin normal or increased; generally >100
mcg/L (normal ranges, 30 to 200 mcg/L [30 to
200 ng/mL] for women and 30 to 300 mcg/L [30 to
300 ng/mL] for men); in some countries the upper
threshold may be up to 400 mcg/L.

33 In a regular checkup by his A. Neuroblastoma C. Retinoblastoma Leukocoria includes any white pupillary reflex, Nelson
pediatrician, a 2 year-old boy was B. Congenital cataract also called cat eye reflex. Primary diagnostic Texbook of
noted to have a white pupillary reflex C. Retinoblastoma considerations in any child with leukocoria are Pediatrics,
rather than a normal red reflection D. Increased intracranial cataract, persistent hyperplastic primary vitreous, 19th Edition /
from incident light noted in his right pressure cicatricial retinopathy of prematurity, retinal UpToDate
eye. This child should be investigated detachment and retinoschisis, larval
for which condition? granulomatosis, and retinoblastoma.

Retinoblastoma is the most common intraocular

tumor of childhood. Nearly all cases are
diagnosed before five years of age; most present
before three years of age.

Leukocoria is the most common presenting

finding. Other common presenting symptoms
include strabismus, nystagmus, and red eye.

Approximately 20 to 60 percent of cases of

Leukocoria is accounted to Retinoblastoma.

34 What is the MOST COMMON cancer A. Chronic Lymphocytic B. Acute Myelogenous Acute Lymphoblastic Leukemia is diagnosed in Nelson's
in adolescents accounting for 25% of Leukemia Leukemia approximately 2,400 children younger than 15 Textbook of
newly diagnosed cancers in persons B. Acute Myelogenous years of age in the United States each year. ALL Pediatrics,
15-19 years old. Leukemia 20th Edition
 C. Acute Lymphocytic has a striking peak incidence at 2-3 years of age
Leukemia and occurs more in boys than in girls at all ages.
D. Hodgkin Lymphoma
Acute Myelogenous Leukemia accounts for 11%
of the cases of childhood leukemia. In the United
States, it is diagnosed in approximately 370
children annually. The relative frequency of AML
increases in adolescence, representing 36% of
cases of leukemia in 15-19 years olds.

Non-hodgkin lymphoma accounts for

approximately 60% of the lymphomas in children
and is the second most common malignancy in
patients age 15-35 years old.

35 An 18-year old boy consulted the clinic A. Pulmonary mass D. Thymoma Superior vena cava syndrome (SVCS) is usually Various
because of a supraclavicular B. Tuberculoma caused by extrinsic compression or invasion of Researches
adenopathy and signs of superior vena C. Sarcoidosis the superior vena cava (SVC) by malignant
cava syndrome. He has unexplained D. Thymoma tumors involving mediastinal structures.
shortness of breath, chronic coughs,
and feeling of having asthma. These Thymoma is the most common primary tumor
symptoms suggest an anterior arising in the anterior mediastinum and one of the
mediastinal mass, what is your well-known causes of SVCS. The vast majority of
diagnosis? SVCS cases caused by thymomas are developed
by the extrinsic compression of the superior vena
cava (SVC) rather than the direct vascular
invasion of the tumor.
36 If the bone marrow is compromised by A. Pallor from Anemia D. Multiple The bone marrow is the major storage organ for Nelson
malignancy, which signs and B. Bleeding from Lymphadenopathy mature neutrophils and contains about seven Essentials of
symptoms is LEAST likely noted? Thrombocytopenia times the intravascular pool of neutrophils. It Pediatrics,
C. Localized infection contains 2.5 to 5 times as many cells of myeloid 7th Edition /
from Leukopenia lineage as cells of erythroid lineage. Small Various
D. Multiple numbers of megakaryocytes, plasma cells, Researches
Lymphadenopathy histiocytes, lymphocytes, and stromal cells are
also stored in the marrow.

Presenting symptoms of bone marrow

suppression due to malignancy include pallor,
petechiae, bleeding, neutropenia.

37 What is the MOST common bone A. Rhabdomyosarcoma A. Rhabdomyosarcoma The most common soft tissue sarcoma, Nelson
tumor for children and adolescents B. Osteosarcoma rhabdomyosarcoma, accounts for approximately Textbook of
beyond 10 years of age? C. Neuroblastoma 3.5% of childhood cancers. These tumors may Pediatrics,
D. Ewing sarcoma occur at virtually any anatomic site but are usually 20th Edition
found in the head and neck (25%), orbit (9%),
genitourinary tract (24%), and extremities (19%);
retroperitoneal and other sites account for the
remainder of the primary sites. The incidence at
each anatomic site is related to both patient age
and tumor type.

38 Situation 1 - Infants feel more secure A. Infants who are C. Crying normally peaks at Crying or fusiness is present in all babies and Nelson
when their urgent needs are met. This constantly picked up and 4 weeks of age. reaches medical attention in about 20% of infants Textbook of
implies reciprocal maternal bonding. held in response to stress younger than 2 months. Although usually a Pediatrics,
cry less at one year. transient and normal infant behavior, crying is 21st Edition
Which of the following statements may B. Infants held in often associated with parental concern and
NOT be true? response to stress show distress.
 less aggressive behavior
at 2 years. On average, babies cry 2 hours per day, peaking
C. Crying normally peaks at 6 weeks of age. Premature infants will have
at 4 weeks of age. peak crying age at 6 weeks corrected age.
D. Babies carried close to
mom cry less in societies. Excessive crying or fussiness persisting longer
than 3-5 months may be associated with
behavioral problems in an older child (anxiety,
aggression, hyperactivity), decreased duration of
breastfeeding, or postnatal depression, but is
uncertain which is the cause or effect.

39 Which condition may be LEAST likely A. Postnatal depression ​C. Child’s nutrition
associated whether cause or effect
with crying and fussiness persisting B. Child abuse
longer than 3-5 months?
C. Child’s nutrition

D. Behavorial problems

40 Some researchers believe that A. Lactose intolerance ​B. Migraine

persistent crying is said to be an early A meta-analysis indicated that colic may be a https://emedi
manifestation of which one? B. Migraine form of migraine headache rather than, as has cine.medscap
been proposed, a GI condition. The analysis e.com/article/
C. Esophageal reflux
utilized 3 studies, one of which indicated that 927760-overv
there is a greater likelihood of colic in infants iew#a6
D. Cows milk allergy
whose mothers have migraine headaches and the
other two of which indicated that infants with colic
 are more likely to experience migraine in
childhood and adolescence.

41 Situation 2 – At 6-12 months, infant A. Lower front teeth D. Mandibular central The eruption of teeth typically is bilaterally Uptodate:
shows skeletal maturation and bone incisors symmetric, with the left and right teeth Anatomy and
age, advance in cognitive B. Two front teeth development
appearing at similar times. The ​mandibular
understanding and communications. central incisors​ are the first primary teeth to of teeth
C. Lower incisors
New tensions develop and parents find
erupt, usually between 6 and 10 months of
these challenging to manage. h​ttps://www.u
D. Mandibular central age. The maxillary central incisors erupt next,
ptodate.com/
incisors followed by the lateral incisors, first molars, contents/anat
canines, and second molars, in sequential omy-and-dev
Where do the initial tooth eruption order. elopment-of-t
occur? Starting with ____. he-teeth?sear
ch=Where%2
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20initial%20t
ooth%20erup
tion%20occur
%3F&source
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ault&display_
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42 Peek-a-boo at 9 months shows that A. Objects remain in C. Objects continue to exist ​The term "object permanence" is used to
object permanence is achieved. What specific assigned places even when not seen describe a child's ability to know that objects
do we mean by this? continue to exist even though they can no longer
B. One has to close eyes be seen or heard.
to see things better

C. Objects continue to
exist even when not seen

D. Type of toy objects

remain the same

43 At about this time, the infant clings to A. Separation anxiety B. Stranger anxiety Stranger anxiety​ is manifested by crying when an
her mom when someone tries to take unfamiliar person approaches. It is normal when it
her away from mom. What type of the B. Stranger anxiety starts at about 8 to 9 mo and usually abates by age
infant’s characteristic is being 2 yr. Stranger anxiety is linked with the infant’s
C. Transient substitution developmental task of distinguishing the familiar
demonstrated?
from the unfamiliar. Both the duration and intensity
D. Communication gap of the anxiety vary greatly among children.

Separation anxiety ​is fussing and crying when a

parent leaves the room. Some children scream and
have tantrums, refuse to leave their parents' side,
and/or have nighttime awakenings.

44 Situation 3 – A 3 year old boy was A. Papilloma virus B. Pox virus Molluscum contagiosum virus causes
brought to the clinic because of characteristic skin lesions consisting of single or,
multiple dome shaped umbilicated B. Pox virus more often, multiple, rounded, dome-shaped,
pearly nodules noted on his chin, pink, waxy papules that are 2-5 mm (rarely up to
chest, arms and a few scattered over 1.5 cm in the case of a giant molluscum) in
 his body. The lesions kept on C. No organism diameter. The papules are umbilicated and
multiplying though they had been there contain a caseous plug.
since two months ago. D. Varicella virus
Lesions may be located anywhere; however, a
predilection for the face, trunk, and extremities is
observed in children and a predilection for the
What type of organism is involved in groin and genitalia is observed in adults. Lesions
this case? are seldom found on the palms and are rarely
documented on the soles, oral mucosa, or
conjunctiva.

45 How will one get the lesions? A. Airborne/ aerosol B. Contact inoculation ​Molluscum contagiosum virus
B. Contact inoculation
transmission through direct skin contact
between children sharing a bath and
C. Wading in floods between athletes sharing gymnasium
D. Hereditary/familial equipment and benches has been
reported. An association between school
swimming pool use and molluscum
contagiosum infection has also been
reported.

46 What is this child having? A. Impetigo C. Molluscum Molluscum contagiosum virus causes Medscape
B. Larva migrans characteristic skin lesions consisting of single or,
C. Molluscum more often, multiple, rounded, dome-shaped,
D. Contact dermatitis pink, waxy papules that are 2-5 mm (rarely up to
1.5 cm in the case of a giant molluscum) in
 diameter. The papules are umbilicated and
contain a caseous plug.
The greatest incidence is in children younger than
age 5 years and in young adults. The peak
among the pediatric age group correlates with
casual contact, whereas the peak in young adults
correlates with sexual contact.

47 Situation 4 - 6 year old girl was A. Dyshidrotic B. Tinea pedis A recurrent, sometimes seasonal, blistering Nelson’s
brought to the clinic because of the eczema disorder of the hands and feet, acute Pediatrics
appearance of itchy macerated scaly B. Tinea pedis palmoplantar eczema (Dyshidrotic eczema) 20th ed and
plaques between her 4th and 5th small C. Acrodermatitis occurs in all age groups but is uncommon in Medscape
toes and in between her 2nd and big continua infancy. The pathogenesis is unknown, although
toes of both feet. These had been D. Contact dermatitis possible predisposing
present since a month ago. The girl to slippers factors include a history of atopy, exposure to
has sweaty feet and would wear contact allergens or irritants, or IV
closed shoes when going to school. At immunoglobulin therapy. The disease is
home, she liked to borrow her older characterized by recurrent crops of small,
sister’s slippers especially when she deep-seated “tapioca-like” vesicles, which are
cannot find her own. Her older sister intensely pruritic and may coalesce into tense
also has similar problems on her feet. bullae.

Which problem does this girl have? Juvenile plantar dermatosis occurs mainly in
prepubertal children with hyperhidrosis who wear
occlusive synthetic footwear. Weight-bearing
surfaces of the foot may be pruritic or painful and
develop a fissured or glazed appearance.
Immediate application of a thick emollient when
socks and shoes are removed or immediately
after swimming usually minimizes juvenile plantar
 dermatosis. Severe inflammatory cases may
require short-term (1-2 wk) application of a
medium- to high-potency topical steroid.

Tinea pedis (athlete’s foot), infection of the toe

webs and soles of the feet, is uncommon in
young children but occurs with some frequency
in preadolescent and adolescent males. Most
commonly, the lateral toe webs (3rd to 4th and
4th to 5th interdigital spaces) and the subdigital
crevice are fissured, with maceration and peeling
of the surrounding skin. An inflammatory vesicular
type of reaction may occur with T.
mentagrophytes infection. This type is most
common in young
children. The lesions involve any area of the foot,
including the dorsal surface, and are usually
circumscribed.

Acrodermatitis continua of Hallopeau is a chronic

form of pustular psoriasis characterized by
pustular eruptions of the tips of the fingers and
toes, which spare the underlying joints and bone

48 What diagnostic tool can be requested A. Culture/Sensitivity C. 10% potassium In suspected tinea pedis, order direct potassium Medscape
to document the impression? B. Tzanck smear hydroxide mount hydroxide (KOH) staining for fungal elements.
C. 10% potassium Usually, the fungal elements are easily identified
hydroxide mount from scaly lesions. Using counterstains may
D. Gram stain enhance the visibility of the hyaline hyphae found
in dermatophyte infections.
49 What advice can be given to patients A. Aerate the feet D. Wear open sandals and Treatment for mild infections includes simple Nelson’s
to manage the problem? and apply gentian apply antifungal cream measures such as avoidance of occlusive Pediatrics
violet footwear, careful drying between the toes after 20th ed
B. Wear socks after bathing, and the use of an absorbent antifungal Chapter 666
bathing so as not powder such as zinc undecylenate. Topical
to infect lesions therapy with an imidazole is curative in most
C. Soak in saline cases. Each of these agents is also effective
water for 15 mins against candidal infection. Several weeks of
then keep aerated therapy may be necessary, and low-grade,
D. Wear open chronic infections, particularly those caused by T.
sandals and apply rubrum, may be refractory. In refractory cases,
antifungal cream oral griseofulvin therapy may effect a cure, but
recurrences are common.

50 Situation 5 - An 18-year old student A. Mucoid stools C. ‘Rice water’ stools Following an incubation period of 1-3 days Nelson’s
worker from a nearby town was B. Bloody stools (range: several hours to 5 days), acute watery Pediatrics
brought to the emergency room C. ‘Rice water’ stools diarrhea and vomiting ensues. The onset may be 20th ed
because of painful abdominal muscle D. ‘Bulky white’ sudden, with profuse watery diarrhea, but some chapter 201
cramps, diarrhea, and dehydration. stools patients have a prodrome of anorexia and
The attending physician said he has abdominal discomfort and the stool may initially
cholera. be brown. Diarrhea can progress to painless
purging of profuse rice-water stools (suspended
His diagnosis of cholera was due to flecks of mucus) with a fishy smell, which is the
the history of eating shellfish and hallmark of the disease
characteristic of patient’s stool which
was _____
51 Which statement is NOT TRUE of A. Produces C. Produces bacterial Following ingestion of V. cholerae from the Nelson’s
​
Vibrio cholera? enterotoxins, the toxins which destroy environment, several changes occur in the vibrios Pediatrics
end result intestinal mucosal cells as they traverse the human intestine: increased 20th ed
increases cyclic expression of genes required for nutrient chapter 201
AMP. acquisition, downregulation of chemotactic
B. Adheres to the response, and expression of motility factors.
brush border of Together these changes allow the vibrios to reach
small intestinal a hyperinfectious state, leading to lower infectious
enterocytes doses required in secondarily infected persons.
C. Produces This hyperinfectivity may remain for 5-24 hr after
bacterial toxins excretion. Large inocula of bacteria (>108) are
which destroy required for severe cholera to occur; however, for
intestinal mucosal persons whose gastric barrier is disrupted, a
cells much lower dose (105) is required. If the vibrios
D. Must be ingested survive gastric acidity, they then colonize the
orally to cause small intestine through various factors such as
disease toxin coregulated pili and motility, leading to
efficient delivery of cholera toxin. The cholera
toxin consists of 5 binding B subunits and 1 active
A subunit. The B subunits are responsible for
binding to the GM1 ganglioside receptors located
in the small intestinal epithelial cells. After
binding, the A subunit is then released into the
cell, where it stimulates adenylate cyclase and
initiates a cascade of events. An increase in
cyclic adenosine monophosphate leads to an
increase in chloride secretion by the crypt cells,
which, in turn, leads to inhibition of absorption of
sodium and chloride by the microvilli. These
events eventually lead to massive purging of
 electrolyte rich isotonic fluid in the small intestine
that exceeds the absorptive capacity of the colon,
resulting in rapid dehydration and depletion of
electrolytes, including sodium, chloride,
bicarbonate, and potassium. Metabolic acidosis
and hypokalemia then ensue.

52 The mainstay for a more effective A. Reduced C. Oral rehydration solution Rehydration is the mainstay of therapy. Children Nelson’s
treatment of cholera is which one? osmolarity/ (ORS) with rice/cereals with mild or moderate dehydration may be treated Pediatrics
reduced salt ORS with oral rehydration solution (ORS) unless the 20th ed
B. Anti peristaltic patient is in shock, is obtunded, or has intestinal chapter 201
agent ileus. Vomiting is not a contraindication to ORS.
C. Oral rehydration Severely dehydrated patients require intravenous
solution (ORS) fluid, ideally with lactated Ringer solution. When
with rice/cereals available, rice-based ORS should be used during
D. Oral rehydration rehydration, because this fluid has been shown to
solution (ORS) be superior to standard ORS in children and
with glucose adults with cholera. Close monitoring is
based solution necessary, especially during the 1st 24 hr of
illness, when large amounts of stool may be
passed.

Situation 6 - !8-year old Anna consulted the clinic because of headache, nasal congestion, nasal discharge, halitosis, maxillary tooth discomfort and
afternoon fever. Her doctor diagnosed her to have bacterial sinusitis.

53 How is bacterial sinusitis differentiated A. Purulent to C. Fever about 39C, afternoon cough longer than 10 days, purulent nasal Nelson’s 21st
from viral sinusitis? From history, greenish nasal discharge for 3-4 ed pg. 8657
bacterial sinusitis manifests with discharge, chronic
fever, chronic The clinical diagnosis of acute bacterial sinusitis is based on history. Persistent
cough, tender symptoms of upper respiratory tract infection, including nasal discharge and
maxillary area cough, for longer than 10 days without improvement, or severe respiratory
 B. Clear, non symptoms, including temperature of at least 39°C (102°F) and purulent nasal
purulent nasal discharge for 3-4 consecutive days, suggest a complicating acute bacterial
discharge, chronic sinusitis.
cough, high fever
for more than 10
days
C. Fever about 39C,
afternoon cough
longer than 10
days, purulent
nasal discharge
for 3-4
consecutive days
D. Headache, facial
pain, bad breath,
pain bending
forward

54 For uncomplicated mild to moderate A. Trimethroprim D. Amoxicillin Nelson’s

bacterial sinusitis, which of the B. Cefixime 21st ed pg.
following antibiotics can be given? C. Azithromycin Initial therapy with amoxicillin (45 mg/kg/day divided bid) is adequate for most 8658
D. Amoxicillin children with uncomplicated mild to moderate severity acute bacterial sinusitis
55 If Anna becomes an untreated case of A. Epidural abscess D. Orbital cellulitis Periorbital cellulitis produces erythema and Nelson’s
bacterial sinusitis, she may develop B. Increased swelling of the tissues surrounding the globe, 21st ed pg.
proptosis, chemosis, decreased visual intracranial whereas ​orbital cellulitis involves the 8662
acuity, double vision, impaired pressure intraorbital structures and produces
extraocular movements and eye pain. C. Periorbital proptosis, chemosis, decreased visual acuity,
Having these symptoms, which is she cellulitis double vision and impaired extraocular
manifesting? D. Orbital cellulitis movements, and eye pain

Situation 7 - A 4-year old boy was brought to the clinic with mom because of hoarseness, ‘barking’ coughs, low grade fever and respiratory distress. Symptoms are
worse during night
56 What is the child having? A. Pharyngitis C. Croup Most patients have an upper respiratory tract Nelson’s
B. Epiglottitis infection with some combination of rhinorrhea, 21st ed pg.
C. Croup pharyngitis, mild cough, and low-grade fever for 8704
D. Foreign body 1-3 days before the signs and symptoms of upper
obstruction airway obstruction become apparent. The child
then develops the characteristic barking cough,
hoarseness, and inspiratory stridor. The
low-grade fever can persist, although
temperatures may occasionally reach 39-40°C
(102.2-104°F); some children are afebrile.

57 Which virus is associated with the A. Adenovirus

severity of this problem? B. Mycoplasma
C. Influenza A
D. Measles Virus

58 When are the symptoms expected to A. A month D. Within a week Symptoms are characteristically worse at night Nelson’s
resolve completely? B. In two weeks time and often recur with decreasing intensity for 21st ed pg.
C. 3 days several days and resolve completely within a 8704
D. Within a week week.

Situation 8 - Melanie 19/F has been experiencing cough and difficulty breathing for the past week since the rainy season started. She noted that cough and difficulty
breathing was worse during night time and in the early morning
59 What is expected to be reduced in the A. FEV1/FVC ratio C. FEV1 and FEV1/FVC Nelson’s
lung function test for an asthmatic and PEF ratio 21st ed pg.
individual? B. FEV1, FEV1/FVC 4954
ratio, PEF
C. FEV1 and
FEV1/FVC ratio
D. FEV1 and PEF

60
What is TRUE regarding the diagnosis a. Allergen challenge is C. Lung function tests can help to confirm the
of Asthma? necessary and should be diagnosis of asthma and to determine disease Nelson’s
undertaken by a severity. Forced expiratory airflow measures are Textbook of
specialist. helpful in diagnosing and monitoring asthma and Pediatrics,
in assessing efficacy of therapy. Lung function 20​th​ Edition.
b. Total serum IgE and testing is particularly helpful in children with Page 1099
specific IgE to enhaled asthma who are poor perceivers of airflow
allergen must be obstruction or when physical signs of asthma do
measured not occur until airflow obstruction is severe. Many
 asthma guidelines promote spirometric measures
c. The diagnosis of of airflow and lung volumes during forced
asthma must be expiratory maneuvers as standard for asthma
confirmed by objective assessment. Spirometry​ ​is a helpful objective
measurements of lung measure of airflow limitation). Spirometry is an
function essential assessment tool in children who are at
risk for severe asthma exacerbations and those
d. Chest
who have poor perception of asthma symptoms.
roentgenography is often
abnormal showing
hyperinflation even in
mild cases.

61 Katzung’s
61. What is TRUE regarding the a. Bronchodilators gives C. The drugs most used for management of asthma Basic and
treatment of asthma? rapid relief of symptoms are adrenoceptor agonists, or sympathomimetic Clinical
and also effective on the agents (used as “relievers” or bronchodilators) Pharmacolog
inflammatory process. and inhaled corticosteroids (used as “controllers” y, 13​th
or anti-inflammatory agents). Adrenoceptor Edition. Page
b. Bronchodilators are agonists are mainstays in the treatment of 512
sufficient to control asthma. Their binding to β receptors—abundant
asthma in patients with on airway smooth muscle cells
persistent symptoms
—stimulates adenylyl cyclase and increases the
c. Bronchodilators act formation of intracellular cAMP, thereby relaxing
primarily on the smooth airway smooth muscle and inhibiting release of
muscles and reverse the bronchoconstricting mediators from mast cells.
bronchoconstriction of
asthma
 d. Bronchodilators act
primarily on the smooth
muscles and reverse the
bronchodilation of asthma

Situation 9 – 14 year-old Mar is always absent from school because of frequent attacks of headaches, sometimes moderate, sometimes severe, with throbbing quality. His
headache is associated with nausea and vomiting. He also becomes sensitive to light and sounds.

62 Nelson’s
62. Why is it important to treat patients a. prevent further school C When the headaches become frequent, they Textbook of
especially those occurring for more absences convert into chronic daily headaches in up to 1% Pediatrics,
than 15 days? Because it is important of children. When headaches are occurring more 20​th​ Edition.
to __. b. prevent restrictions on than 15 days a month the risk of conversion to a Page 2867
social activities daily headache becomes more prominent.

c. block transformation to
chronic daily headaches

d. prevent limitation of
home activities

63 Nelson’s
Migraine can have associated aura, a. Tinnitus C The most common type of visual aura in children Textbook of
the typical ones include which and adolescents is ​photopsia ​(flashes of light or Pediatrics,
symptoms? b. Abdominal light bulbs going off everywhere). These 20​th​ Edition.
Page 2867
c. Photopsia photopsias are often multicolored and when gone,
the child may report not being able to see where
d. Motion sickness
the flash occurred.
64 Nelson’s
64. How long should the aura a. Less than 60 minutes B For a typical aura, the aura needs to be visual, Textbook of
associated with migraine last? but should not be more sensory, or dysphasic, lasting longer than 5 min Pediatrics,
and less than 60 min with the headache starting 20​th​ Edition.
b. Longer than 5 minutes within 60 min. Page 2867
but less than 60 minutes

c. 15 minutes at least

d. More than 60 minutes

Situation 10 – Eight hours after eating in a town fiesta, 18-year old Anna developed nausea and vomiting, headache, profuse diarrhea and low grade fever. Blood culture was
negative for growth but the stool culture was positive. Repeated blood culture remained negative while stool culture was positive even 2 weeks after the initial examination

65 Department
What was the MOST PROBABLE a. Shigella A Culture of both stool and rectal swab specimens of Health,
“growth” – in the stool culture? optimizes the chance of diagnosing ​Shigella North Dakota;
b. V. cholera infection. Culture media should include Shigellosis.
MacConkey agar as well as selective media such December,
c. Salmonella T.
as xylose-lysinedeoxycholate and 2018;
Salmonella-Shigella ​agar. Transport media
d. E. coli
should be used if specimens cannot be cultured Nelson’s
promptly. Appropriate media should be used to Textbook of
exclude ​Campylobacter s​ pp. and other agents. Pediatrics,
Studies of outbreaks and illness in volunteers 20​th​ Edition.
show that the laboratory is often not able to Page 1395
confirm the clinical suspicion of shigellosis even
when the pathogen is present.

​ higella ​infections are almost always limited to

S Jawetz’s
the gastrointestinal tract; bloodstream invasion is Medical
quite rare. Microbiology
 27​th​ Edition
A patient can pass Shigella in their stool for up to Page 238
four weeks (possibly longer in asymptomatic
people)

66 Nelson’s
66. One may NOT be true with regards a. Pathogenesis can be B Diarrhea is the reversal of the normal net Textbook of
to the usual pathogenesis of diarrhea? explained by secretory, absorptive status of water and electrolyte Pediatrics,
osmotic or motility absorption to secretion. Such a derangement can 20​th​ Edition.
abnormalities be the result of either an osmotic force that acts in Page
the lumen to drive water into the gut or the result 1393-1394
b. Type of bacteria would of an active secretory state induced in the
determine the enterocytes. In the former case, diarrhea is Harrison’s
consistency of the osmolar in nature, as is observed after the Principle of
secretions ingestion of nonabsorbable sugars such as Internal
lactulose or lactose in lactose malabsorbers. Medicine, 20​th
c. Water movement is
Instead, in the typical active secretory stae, Edition Page
determined by both active
enhanced anion secretion (mostly by the crypt 1180-1181
and passive fluxes of
cell compartment) is best exemplified by
solutes : sodium, emedicine.m
enterotoxin-induced diarrhea.
potassium, glucose edscape.com
/article
d. There is disturbed
967738-overv
intestinal water solutes
iew
and transport.
67 In Typhoid fever, where is the site of A. Intestinal tract ​D.​ ​Lymphoid tissue Nelson's
multiplication of the bacteria? B. Blood vessels Textbook of
C. Liver Pediatrics
D. Lymphoid tissue 20th ed
p1388 - 1392

68 Situation 11 - Six (6) boys attended a A. Eschericia coli C.​ ​Vibrio cholera Most cases of cholera are mild or inapparent. Nelson's
fiesta in a remote barrio where along B. Shigella Among symptomatic cases, approximately 20% Textbook of
with the food, were served water from dysenteriae develop severe dehydration that can rapidly lead Pediatrics
a local spring. The following day, all 6 C. Vibrio cholera to death. Following an incubation period of 1-3 20th ed p
boys almost simultaneously developed D. Salmonella typhi days (range: several hours to 5 days), acute 1401
abdominal pain, nausea, vomiting, and watery diarrhea and vomiting ensues. The onset
profuse watery diarrhea, described as may be sudden, with profuse watery diarrhea, but
rice water stool. They were all rushed some patients have a prodrome of anorexia and
to the hospital where fluid replacement abdominal discomfort and the stool may initially
therapy was instituted and their be brown. Diarrhea can progress to painless
conditions stabilized. purging of ​profuse rice-water stools
(suspended flecks of mucus) with a fishy
Which bacteria could have caused the smell, which is the hallmark of the disease​.
patients’ diarrhea?
69 Which characteristics distinguish this A. Motility B. Oxidase positive The disease is caused by Vibrio cholerae, a Nelson's
bacteria from the rest of other B. Oxidase positive Gram-negative, comma shaped bacillus, Textbook of
bacteria? C. Gram-negative subdivided into serogroups by its somatic O Pediatrics
bacilli antigen. Of the more than 200 serogroups, only 20th ed p
D. Lactose fermenter serogroups O1 and O139 have been associated 1400
with epidemics, although some non-O1,
non-O139 V. cholerae strains (e.g., O75 and
O141) are pathogenic and can cause small
outbreaks.

E. coli: ​oxi -​, gram -, lac +, motile

S. dysenteriae: ​oxi -​, gram -, lac -, nonmotile
V. cholera: ​oxi +​, gram -, lac -, motile
S. typhi: ​oxi -​, gram -, lac +, motile

70 Which statement may NOT be true of A. It is caused by a C. Secretions/diarrhea Watery diarrhea can be further classified as Sweetser S.
this type of diarrhea called a secretory secretagogue stops when fasting is osmotic or secretory in origin. Osmotic diarrhea is Evaluating the
diarrhea? binding to a observed due to the ingestion of poorly absorbed ions or patient with
diarrhea: a
receptor on the sugars. ​Secretory diarrhea is due to disruption
case-based
surface epithelium of epithelial electrolyte transport.​ Two ways to
 of the bowel distinguish an osmotic from a secretory process is approach.
stimulating colonic by response to fasting and calculating the fecal Mayo Clin
mucosal secretion osmotic gap. ​An essential characteristic of Proc​.
2012;87(6):596
B. It gives out a large osmotic diarrhea is that stool volume
–602.
volume of decreases with fasting, whereas secretory
doi:10.1016/j.
secretions diarrhea typically continues unabated with mayocp.2012.
persisting even fasting​. 02.015
with fasting
C. Secretions/diarr
hea stops when
fasting is
observed
D. This occurs when
the intestinal
epithelial cell
solute transport
system is in active
stage

71 Situation 12 - Danica, 14/F, came into A. Endometrial D.​ ​Prostaglandin Primary dysmenorrhea, characterized by the Nelson's
the clinic for lower abdominal pain. tissue is found on stimulates absence of any specific pelvic pathologic Textbook of
She says it often occurs during her first ectopic locations vasoconstriction and condition, is by far the more commonly occurring Pediatrics
and second day of menses. She is just B. Underlying contractions form, accounting for approximately 90% of cases. 20th ed p 967
concerned that this episode is more structural After ovulation, withdrawal of progesterone
severe compared to her usual ones. abnormality of the results in synthesis of prostaglandins by the
She denies sexual activity. Abdominal cervix endometrium, which stimulate local
and pelvic examination is normal. C. Presence of vasoconstriction, uterine ischemia and pain,
foreign body in and smooth muscle contraction, explaining
What is the pathology in primary the uterine cavity both uterine and gastrointestinal symptoms​.
dysmenorrhea? Because of the association with ovulation,
 D. Prostaglandin primary dysmenorrhea typically presents at least
stimulates 12 mo after menarche.
vasoconstriction
and contractions Secondary dysmenorrhea results from underlying
pathology such as anatomic abnormality, or
infection such as pelvic inflammatory disease.
However, the most common cause of secondary
dysmenorrhea in adolescents is endometriosis, a
condition in which implants of endometrial tissue
are found outside the uterus, most commonly
near the fallopian tubes and ovaries. Often there
are other family members with endometriosis.
Although characteristically there is severe pain at
at the time of menses, adolescents can present
with noncyclic pain as well.

72 What is NOT TRUE regarding A. External genital D.​ ​Internal pelvic Nelson's
physical examination for this case? examination is examination is done for Textbook of
done routinely sexually active girls Pediatrics
B. Internal pelvic 20th ed p 967
examination is
done routinely
C. Abdominal
examination is
done routinely
D. Internal pelvic Although primary dysmenorrhea is almost always
examination is the cause, a careful history and physical
done for examination is required for adolescents who
sexually active present with pelvic pain.​ An internal pelvic exam
girls is not required in females who are not
 sexually active and whose presentation is
consistent with primary dysmenorrhea.
Constipation can vary cyclically in many females,
especially those with irritable bowel syndrome,
and often significantly contributes to the pain.

73 What is TRUE regarding medications A. Medication is A. Medication is Treatment for primary dysmenorrhea is aimed at Nelson's
of dysmenorrhea? needed before needed before the decreasing levels of prostaglandins, preferably Textbook of
the first day of first day of menses before they are produced. Thus, the mainstay Pediatrics
menses treatment is with prostaglandin synthetase 20th ed p 968
B. Medication is inhibition by either nonsteroidal antiinflammatory
needed until the drugs, hormonal contraception, or a
last day of gonadotropin-releasing hormone agonist
menstruation beginning at, or preferably the day prior to,
C. Medication is menstruation​. The high doses of around the
needed beyond clock treatment are rarely needed for more than
the last day of the 1st 2 days.
menstruation
D. Medication is
rarely needed
beyond the first
day of menses

74 Situation 13 – A 3 years old boy was A.​ H

​ yperlipidemia A.​ H
​ yperlipidemia Small amounts of protein are found in the urine of Nelson 7th
admitted to the Pediatric Emergency healthy children (<4 mg/m​2​/hour or U​Pr​/C​ r ​<0.2). Edition
room for abdominal enlargement. B.​ H
​ ypoalbuminemia Nephrotic proteinuria in children is defined as
Physical examination also revealed protein greater than 40 mg/m​2​/hour or U P​ r/Cr ​>2.0.
C.​ H
​ ypertension
facial and bipedal edema. Immediately Proteinuria between these levels is mildly to
a urinalysis was ordered revealing moderately elevated but not nephrotic.
D.​ E
​ dema
 proteinuria of 3+ and microscopic Nephrotic syndrome (NS) is characterized by
hematuria. persistent
heavy proteinuria (mainly albuminuria) (>2
What is NOT indicated in the triad of g/m​2​/24 h);
clinical findings for Nephrotic hypoproteinemia (serum albumin <3.0 g/dL);
Syndrome? hypercholesterolemia (>250 mg/dL); and edema.

75 What is the MOST common cause of a.​ ​Diffuse Mesangial B. ​ ​Minimal Change Disease Minimal change nephrotic syndrome (MCNS)​ is the
childhood Nephrotic Syndrome for this Sclerosis most common histologic form of primary NS in
child belonging to the less 6 age children. More than 80% of children less than 7 years
b.​ ​Minimal Change of age with NS have MCNS. Children 7 to 16 years old
group?
Disease with NS have a 50% chance of having MCNS. Males
are affected more frequently than females (2:1).
c.​ ​Focal Segmental
Focal segmental glomerulosclerosis (FSGS)
Glomerulosclerosis
accounts for approximately 10% to 20% of children
with primary NS. It may present like MCNS or with less
impressive proteinuria.
 d.​ ​Membranous SGS may develop from MCNS or represent a separate
Nephropathy entity. A circulating factor that increases glomerular
permeability is found in some patients with FSGS.
More than 35% of children with FSGS progress to
renal failure.

Membranoproliferative glomerulonephritis (MPGN)

is characterized by hypocomplementemia with signs of
glomerular renal disease. MPGN represents 5% to
15% of children with primary NS, is typically persistent,
and has a high likelihood of progression to renal failure
over time.

Membranous nephropathy​ represents less than 5%

of children with primary NS. It is seen most commonly
in adolescents and children with systemic infections,
such as hepatitis B, syphilis, malaria, and
toxoplasmosis, or on specific medica
ions (gold, penicillamine).

76 What treatment may be initiated for a a.​ F

​ luid restriction b.​ S
​ teroid therapy Because greater than 80% of children less than
child 1-8 years with onset of 13 years of age with primary NS have
uncomplicated nephrotic even without b.​ S
​ teroid therapy steroid-responsive forms (chiefly MCNS), steroid
diagnostic renal biopsy? therapy may be initiated without a renal
c.​ S
​ odium restriction
biopsy if a child has typical features of NS.
Typical therapy for MCNS is prednisone, 2
d.​ L
​ oop diuretics
mg/kg/day (60 mg/m​2​/24 h, maximum 60 mg/day),
provided once a day or split into multiple doses.
Over 90% of children who respond to steroids do
so within 4 weeks. Responders should receive
 steroids for 12 weeks. A renal biopsy is indicated
for nonresponders because steroid resistance
decreases the chance that MCNS is the
underlying disease. Frequent relapses or steroid
resistance may necessitate additional
immunosuppressive therapy.

77 Situation 14 – Mike who is 4 months of a.​ ​Dimercaptosuccinic c.​ ​Kidney and Urinary Renal and bladder ultrasound imaging is typically https://pediatr
age was brought in the Pediatric acid (DMSA) Renal Scan Bladder ultrasound done in children < 3 years of age after their first ics.aappublic
Emergency Room for fever and febrile urinary tract infection. Some clinicians do ations.org/co
b.​ ​Voiding imaging on children up to 7 years of age or older.
irritability. Septic work up revealed a Renal and bladder ultrasonography​ helps ntent/pediatri
Urinary Tract Infection. Diagnosis was Cystourethrogram cs/early/2011
exclude obstruction and hydronephrosis in children
confirmed with a positive urine culture (VCUG) with febrile UTIs and is typically done within a week /08/24/peds.2
result. Empirical antibiotic were started of diagnosing UTI in infants. Ultrasonography is 011-1330.full.
c.​ ​Kidney and Urinary done within 48 hours if infants do not respond
immediately. pdf
Bladder ultrasound quickly to antimicrobials or if their illness is
unusually severe. Beyond infancy, ultrasonography
For children with their first episode of may be done in the few weeks after the UTI American
d.​ ​Abdominal and Pelvic
febrile UTI, What is the initial diagnosis. RBUS also provides an evaluation of the Academy of
MRI
recommended imaging study for renal parenchyma and an assessment of renal size Pediatrics
evaluation of kidney and bladder that can be used to monitor renal growth. Clinical
anatomy? Practice
Guidelines

78 What imaging modality shows either a.​ ​Abdominal and Pelvic b.​ ​Dimercaptosuccinic acid Nuclear scanning with technetium labeled https://pediatr
acute pyelonephritis or renal scarring MRI (DMSA) Renal Scan dimercaptosuccinic acid has greater sensitivity for ics.aappublic
when positive? detection of acute pyelonephritis and later ations.org/co
b.​ ​Dimercaptosuccinic scarring than does either RBUS or voiding ntent/pediatri
acid (DMSA) Renal Scan cystourethrography (VCUG). The scanning is cs/early/2011
useful in research, because it ensures that all /08/24/peds.2
 c.​ ​Kidney and Urinary subjects in a study have pyelonephritis to start 011-1330.full.
Bladder Ultrasound with and it permits assessment of later renal pdf
scarring as an outcome measure. The findings on
d.​ ​Voiding nuclear scans rarely affect acute clinical American
Cystourethrogram management, however, and are not Academy of
(VCUG) recommended as part of routine evaluation of Pediatrics
infants with their first febrile UTI. Clinical
Practice
VCUG should not be performed routinely after the Guidelines
first febrile UTI; VCUG is indicated if RBUS
reveals hydronephrosis, scarring, or other
findings that would suggest either high-grade
VUR or obstructive uropathy, as well as in other
atypical or complex clinical circumstances

79 Once imaging studies have identified a.​ ​Abdominal and Pelvic b.​ ​Voiding ​VCUG remains the diagnostic test of choice for https://www.n
to the child to have Pyelonephritis, MRI Cystourethrogram (VCUG) the detection of VUR and its use is widespread in cbi.nlm.nih.go
What is the next step? clinical practice. VUR is detected in 25% to 40% v/pmc/articles
b.​ ​Voiding /PMC294124
of children presenting with a first episode of
Cystourethrogram 5/
(VCUG) pyelonephritis.​ ​Multiple studies have shown no
significant difference in the rate of detection of
c.​ ​Kidney and Urinary VUR with a VCUG performed early (within one
Bladder Ultrasound week) or late (2-3 weeks) after an episode of acute
pyelonephritis. The recommendation to perform
d.​ ​Dimercaptosuccinic
routine VCUG after febrile UTIs was based on
acid (DMSA) Renal Scan
studies linking the presence of reflux to the risk
for pyelonephritis and related renal scarring.
80 Situation 15 – Amelita, 16 years old, a.​ ​For more than 3 c.​ B
​ y age of 16 years Primary amenorrhea is defined as the failure https://www.n
came to the clinic for delayed months of initiation of menses by age 14 in the cbi.nlm.nih.go
menarch. She had no other subjective absence of secondary sexual characteristics v/books/NBK
complaints. The rest of her history was b.​ B
​ y age of 14 years
or the ​absence of menarche by age 16 554469/
unremarkable. Her breast and pubic
c.​ B
​ y age of 16 years
regardless of the presence of normal
hair development were both Tanner
 stage 4. The rest of her physical d.​ ​For more than 1 growth and development of secondary
examination findings were normal. month sexual characteristics.

What is TRUE regarding the definition

Primary Amenorrhea? No menstrual
flow ​_____.

81 What laboratory finding would suggest A. Decreased level B. Elevated levels of All individuals with primary amenorrhea and
primary gonadal failure? of Prolactin Follicle Stimulating plasma FSH levels higher than 40mIU/mL have Comprehensi
B. Elevated levels of Hormone no functioning ovarian follicles in the gonadal ve
Follicle tissue. Thus in women with primary amenorrhea, gynecology
Stimulating the diagnosis of gonadal failure can be
Hormone established if the FSH levels are consistently
C. Decreased level elevated, without requiring ovarian tissue
of luteinizing evaluation.
hormone There is negative hypothalamic-pituitary action of
D. Elevated level of estrogen and inhibin is not present, gonadotropin
thryroid levels are markedly elevated, with FSH levels
stimulating being higher than LH.
hormone

82 In the approach to clinical evaluation A. FSH C. Pregnancy test Diagnostic tests in the patient presenting with Nelson’s
of amenorrhea , what KEY laboratory measurement amenorrhea should be tailored to her history and pediatrics
test should be performed first B. LH measurement physical exam. However, a urine pregnancy test
regardless of history or sexual activity? C. Pregnancy test should be done regardless of history.
D. Pelvic ultrasound

83 Situation 16 - Becky, 6 year-old,came A. Optic Tract Tumor B. Hypothalamic Major CNS diseases associated with true
in to the OPD for breast development. hamartomas precocious puberty include tuberculosis, Comprehensi
 Mother said that she noted breast B. Hypothalamic encephalitis,trauma, secondary hydrocephalus, ve
enlargement at the start of the year but hamartomas neurofibromatosis, granulomas, hamartoma of the Gynecology
its continuous rapid development had C. Astrocytomas hypothalamus, teratomas, craniopharyngiomas,
her really worried. During further D. ependymomas cranial irradiation, and congenital brain defects,
evaluation, you noted her to have such as hydrocephalus and cysts in the area of
breast and pubic hair development at the third ventricle. The pathophysiology whereby
Tanner Stage 3. CNS disease produces precocious puberty is
What is the MOST common brain poorly understood. It is known that hamartomas
lesion that causes central precocious may secrete GnRH; this secretion is not subject
puberty? to the normal physiologic inhibition that occurs
during childhood.

84 What is the BEST imaging modality A. Cranial B. Cranial MRI MRI may be indicated to look for a tumor or a medscape
that will aid in the diagnosis of radiography hamartoma after hormonal studies indicate a
Precocious puberty from organic brain B. Cranial MRI diagnosis of central precocious puberty.
lesion? C. Cranial CT-scan
D. Cranial
Ultrasound

85 What presentation increases the A. Presence of A. Presence of sexual These patients present with precocious
likelihood of hypothalamic sexual precocity precocity in (abnormally early) development of the https://raredis
hamartoma? in school-aged school-aged children physical changes associated with puberty. eases.org/rar
children School-aged children (3-6 years old) e-diseases/hy
B. Rapidly pothalamic-h
progressive amartoma/
sexual precocity
in very young
children
C. Rapidly
progressive
 sexual precocity
in school-aged
children
D. Presence of
sexual precocity
in young children

86 Situation 17 - John noticed that A. It is the induction A. It is the induction of Allergic reactions require exposure and then Medscape
everytime he took a walk through their of allergic disease allergic disease sensitization to allergens. To be sensitized, the
rice fields or visit their animal barn he predisposing predisposing patient must be exposed to allergens for a period
felt swelling, erythema of his eyelids individuals to individuals to of time. Sensitization to highly allergenic indoor
and developed attacks of rhinitis. It specific allergens specific allergens allergens can occur in children younger than 2
took several years before he B. It is the activation years old. Sensitization to outdoor allergens
developed this sensitivity and his of specific B cells usually occurs when a child is older than 3-5
doctor was suggesting that he undergo that can prevent years old, and the average presentation is 9-10
desensitization. allergens year.
What is sensitization? C. It is the swelling of
the secretory
granules of the
human mast cells.
D. It is the binding of
the IgE to human
mast cells and
basophils for
antigen specific
activation

87 Why would animal danders and rice A. Sticky mucosal D. Entrapment of pollens The purpose of the nose is to filter, humidify, and medscape
stalks pollens cause rhinitis rather than secretions and and digestion of outer core regulate the temperature of inspired air. Rhinitis
respiratory tract infections? mucosal by enzymes results from a local defense mechanism in the
 turbinates nasal airways that attempts to prevent irritants
protrusion and allergens from entering the lungs.
B. Large size of the
allergens retained
within the nose
C. Presence of
variable number
of eosinophils
D. Entrapment of
pollens and
digestion of outer
core by enzymes

88 That night, John sprayed insecticides A. It may head to A. It may head to L aryngeal edema, the most feared Nelson’s
across his and on his bed to avoid obstruction in epiglottis obstruction in epiglottis and complication of HAE, can cause complete Pediatrics
being bitten by the farm insects and ad larynx larynx respiratory obstruction. Although life-threatening 20th ed
bugs. However upon waking up, he B. It may lead to attacks are infrequent, more than half of
developed generalized wheals/hives intractable bronchospasm patients with HAE experience laryngeal
and pending angioedema. What will ending with death involvement at some time during their lives.
happen if NOT treated immediately? C. There is presence
of vascular collapse
D. Hypopharynx and
trachea may also be
obstructed

89 Situation 18 – Rodney consulted the a. Contact urticaria c. Acute urticaria Drugs and foods are the most common Nelson’s
clinic because of development of B. Food hypersensitivity causes of acute urticaria. Allergy skin testing Pediatrics
generalized wheals and hives the day reaction for foods can be helpful in sorting out causes 20th ed
prior to consultation. He remembered C. Acute urticaria of acute urticaria, especially when supported
eating shrimps wrapped in lumpia D. Chronic urticaria by historical evidence. The role of an
 wrappers the day before. He had offending food can then be proven by
history of similar occurrences a year elimination and careful challenge in a
ago when they attended a birthday controlled setting. In the absence of
party of his aunt whose lunch menu information implicating an ingestant cause,
were mostly seafood. skin testing for foods and implementation of
elimination diets are generally not useful for
89. What is Rodney having? either acute or chronic urticaria. Patients with
delayed urticaria 3-6 hr after a meal
consisting of mammalian meat should be
evaluated for IgE to
galactose-alpha1,3-galactose (“alpha-gal”), a
carbohydrate moiety.

90 Which food DOES NOT cause A. Low fat milk D. tang orange juice
wheals/hives? b. Four season juice
c. Fresh buko juice
D. Tang orange juice

91 Which antihistamine SHOULD NOT A. Loratadine c. hydroxyzine Older oral antihistamines (eg, hydroxyzine 10 to Nelson’s
be given if reviewing for an exam? b. Levocetirizine 25 mg q 4 to 6 hours; diphenhydramine 25 to 50 Pediatrics
c. Hydroxyzine 20th ed
 D. Fexofenadine mg q 6 hours) are sedating but inexpensive and
sometimes quite effective.

Loratadine, fexofenadine, and cetirizine are

also effective and are preferable because of
reduced frequency of drowsiness and longer
duration of action

92 Situation 19 – 8 year old Anna was A. Hemoptera venom D. pollen extracts

playing in the garden while Mom was (wasps/bees)
preparing the flowers for festival in B. Drugs (Non steroidal
Baguio. The next day, upon waking up, medications)
she noted development of wheals and c. Food (peanuts, milk,
hives all over his legs, face an arms. eggs)
D. Pollen extracts
What could be the predisposing factors (flowers, grass, trees)
of her wheals/hives?

93 Anna also expressed a ‘lump’ on her A. Bronchial constriction B. Laryngeal edema Laryngeal edema, the most feared nelson’s
throat. What could be the cause of B. Laryngeal edema complication of HAE, can cause complete pediatrics
this? C. Bronchial asthma respiratory obstruction. Although life-threatening 20th ed.
D. Bronchial obstruction attacks are infrequent, more than half of P1130
patients with HAE experience laryngeal
involvement at some time during their lives.
94 Which statement MAY NOT be TRUE A. Eruptions are d. Eruptions persist even A typical hive is an erythematous, pruritic raised Nelson’s
of urticarial symptoms? intensely pruritic beyond 48 hours. wheal that blanches with pressure, is transient, Pediatrics
B. If scratched and and resolves without residual lesions, unless the 20th ed
rubbed, lesions tend to area was intensely scratched.
coalesce to giant hives Individual lesions usually last 20 min to 3 hr,
C. A non pitting deeper and rarely more than 24 hr. The lesions
edematous angioedema often disappear only to reappear at another
may be present site. Angioedema involves the deeper
d. Eruptions persist even subcutaneous tissues in locations such as the
beyond 48 hours. eyelids, lips, tongue, genitals, dorsum of the
hands or feet, or wall of the gastrointestinal
(GI) tract.

95 A.​ P
​ resence of
Situation 20: leukemia cells C. Anemia and The diagnosis of ALL is strongly suggested by Nelson’s
thrombocytopenia peripheral blood findings that indicate bone marrow Pediatrics
B.​ P ​ resence of
5 yo boy with down syndrome was failure. Anemia and thrombocytopenia are seen in 19​th​ ed. P.
atypical
diagnosed with acute lymphoblastic most patients. Leukemic cells might not be reported in
lymphocytes 1734
leukemia (ALL) by his doctor. Genetic the peripheral blood in routine laboratory
C.​ ​Anemia and examinations.
modification are required for disease
thrombocytopenia
expression.
D.​ ​Total leucocyte Many patients with ALL present with total leukocyte
Nelson’s
count <10,000/ul
counts of < 10,000/ μ L. In such cases, the leukemic Pediatrics
cells often are reported initially to be atypical 20​th​ ed.
What would be the initial presentation lymphocytes, and it is only on further evaluation that
of a patient with acute lymphocytic the cells are found to be part of a malignant clone. P.2438
leukemia in peripheral blood studies? When the results of an analysis of peripheral blood
suggest the possibility of leukemia, the bone marrow
should be examined promptly to establish the
diagnosis. It is important that all studies necessary to
confirm a diagnosis and adequately classify the type of
 leukemia be performed, including bone marrow
aspiration and biopsy, flow cytometry, cytogenetics,
and molecular studies.

a. ALL is suggested by a complete blood count (CBC)

that demonstrates anemia and thrombocytopenia. The
white blood cell (WBC) count is variable.

(1) WBC is high in one third of cases (> 50,000

cells/mm3), normal in one third of cases, and low in
one third of cases (< 10,000cells/mm3).
BRS Pedia
(2) Leukemic blasts (i.e., lymphoblast s) are often
seen.
Chap.14
(3) Note : A normal CBC doe s not rule out leukemia.
p.425

96 A.​ I​ ncreased
What signs and symptoms would intracranial B. Pallor, puritic/petechial On physical examination, findings of pallor, Nelson’s
reflect bone marrow failure? skin lesions, mucous listlessness, purpuric and petechial skin lesions, or Pediatrics
pressure,
membrane hemorrhage mucous membrane hemorrhage can reflect bone 19​th​ ed. P.
papilledema,
marrow failure (Chapter 487 ). The proliferative nature
retinal 1734
of the disease may be manifested as
hemorrhages lymphadenopathy, splenomegaly, or, less commonly,
B.​ P ​ allor, hepatomegaly. In patients with bone or joint pain, there
puritic/petechial may be exquisite tenderness over the bone or
 skin lesions, objective evidence of joint swelling and effusion.
mucous Nonetheless, with marrow involvement, deep bone Nelson’s
membrane pain Pediatrics
hemorrhage 20​th​ ed.
may be present but tenderness will not be elicited.
C.​ ​Easy Rarely, patients show signs of increased intracranial P.2438
bruisability,fever, pressure that indicate leukemic involvement of the
mediastinal CNS. These include papilledema (see Fig.487-3 ),
distress retinal hemorrhages, and cranial nerve palsies.
D.​ ​Bone or joint Respiratory distress usually is related to anemia but
pain, tenderness can occur in patients with an obstructive airway
over the bone, problem (wheezing) due to a large anterior mediastinal
mass (e.g., in the thymus or nodes). This problem is
joint swelling and
most typically seen in adolescent boys with T-cell ALL.
effusion
T-cell ALL also has a higher leukocyte count.

97
What diagnostic test can be done to A. Cytogenetic/molecular B. Bone marrow evaluation ALL is diagnosed by a bone marrow evaluation that Nelson’s
diagnose ALL? studies demonstrates > 25% of the bone marrow cells as a Pediatrics
homogeneous population of lymphoblasts. Staging of 19​th​ ed. P.
B. Bone marrow ALL is based partly on a cerebrospinal fluid (CSF)
1734
evaluation examination. If lymphoblasts are found and the CSF
leukocyte count is elevated, overt CNS or meningeal
C. Peripheral blood
leukemia is present. This finding reflects a worse stage
studies Nelson’s
and indicates the need for additional CNS and
systemic therapies. The staging lumbar puncture may
Pediatrics
D. Flow cytometry 20​th​ ed.
be performed in conjunction with the first dose of
intrathecal chemotherapy, if the diagnosis of
P.2438
leukemia has been previously established from bone
marrow evaluation. The initial lumbar puncture should
be performed by an experienced proceduralist,
 because a traumatic lumbar puncture is associated
with an increased risk of CNS relapse.

98 A.​ L
​ ymph node
Situation 21: A 19yo young boy biopsy D. Chest radiography Any patient with persistent, unexplained
consulted the clinic with his parents lymphadenopathy unassociated
B.​ C ​ T scans of the
because of the ff systemic ‘B’ Nelson’s
neck, chest, with an obvious underlying inflammatory or infectious
symptoms: unexplained fever >38C, Pediatrics
abdomen process should undergo chest radiography to identify
weight loss >10% over 6 months and 19​th​ ed. P.
C.​ ​Bone marrow the presence of a large mediastinal mass before
drenching night sweats. There is also 1741
aspiration/biopsy undergoing lymph node biopsy. Formal excisional
presence of supraclavicular D.​ ​Chest biopsy is preferred over needle biopsy
lymphadenopathy and mediastinal radiography
involvement. to ensure that adequate tissue is obtained, both for
light microscopy and for appropriate
immunohistochemical and molecular studies.

What diagnostic procedure should be

INITIALLY requested?

99
The disease arises from lymphoid A. Non Hodgkin C. Hodgkin Lymphoma Hodgkin Lymphoma: Systemic symptoms, Nelson’s
tissue and spread to adjacent lymph lymphoma classified as B symptoms that are considered Pediatrics
nodes with hematogenous spread important in staging, are unexplained fever >38C 20​th​ ed.
associated with the systemic B. Tuberculosis (100.4F), weight loss >10% total body weight over
symptoms. What is the patient having? 6months, and drenching night sweats. P.2445
C. Hodgkin Lymphoma

D. Thymoma
Patients commonly present with painless,
nontender,firm,rubbery,cervical or supraclavicular
lymphadenopathy and usually some degree of
mediastinal involvement.
100 A.​ T
​ umor bulk
Which is the LEAST poor prognostic B.​ E​ xtralymphatic C. Presence of bone Poor prognostic features include tumor bulk, Nelson’s
features of Hodgkin Lymphoma? disease marrow infiltration stage at diagnosis, extra lymphatic disease and Pediatrics
C.​ ​Presence of presence of B symptoms. 20​th​ ed.
bone marrow
P.2248
infiltration
D.​ ​Stage of
diagnosis