Pediatric Board Review / Orthodontic Courses by Indian Dental Academy

Pediatric Board Review
2006-2007
Session One: July 24, 2006
Session Two: August 24, 2006
Session Three: September 26, 2006
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY

Leader in continuing dental education

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

Scrabble Quiz
AEINRST
This is the most common seven letter
combination you can have on your rack. There
are 8 different seven letter words bingos that
can be spelled from this. Can you name one?
Anestri
Nastier
Ratines
Retains
Retinas
Retsina
Stainer
Stearin
Scrabble Quiz
There are 101 acceptable two letter word
plays in Scrabble, 16 of which start with
what letter?
A
AA, AB, AD, AE, AG, AH, AI, AL, AM, AN,
AR, AS, AT, AW, AX, AY
Scrabble Quiz
The word ROOST has 4 anagrams, name
them.
ROOTS
ROTOS
TOROS
TORSO

Question 1.2000
A TRUE statement about the epidemiology of
measles is that
A. In countries with no immunization programs, the
peak age of infection is infancy
B. In US immunization programs have reduced the
incidence of infection by 80%
C. Usually spread by direct contact with infectious
droplets
D. Patients become contagious when the rash
appears
E. Incubation period is 4-5 days from exposure to
onset of symptoms
Answer C
Teaching Points 1.2000
Measles
Cough, coryza (inflammation of nasal mucosal
membranes), fever, conjunctivitis, exanthem
of red macules and papules and Koplik spots
Young children have OM, pneumonia, croup
and diarrhea
Acute encephalitis (1:1000) -->Permanent
brain injury
In US death 1-3/1000 due to respiratory of
neurologic complications
Transmitted by direct contact with infectious
droplets or LESS COMMONLY airborne spread
Since vaccine use in 1963 there has been a 99%
reduction in incidence in US
Children are contagious 4-5 days BEFORE rash
appears to 4 days after appearance of rash
Incubation period is 8-12 days from exposure to
onset of symptoms

Koplik Spots
Henry Koplik (U.S. Physician, 1858 to 1927)
Question 2.2000
A previously healthy 2 year old is brought to ED
because her mom is unable to awaken her for
45 minutes. She has not been ill. PE reveals an
afebrile, hypotonic child who withdraws her
hand from painful stimuli but does not
spontaneously open her eyes. RR is 36/min, BP
is 92/64. What is the next best thing to obtain?
A. BUN
B. CXR
C. EKG
D. EEG
E. Toxicology screen
Answer E
Pneumonic for Causes of Altered Consciousness:
Tips from the Vowels
T-I-P-S-A-E-I-O-U
Trauma/Tumor
Infection/Inborn Errors/Insulin/hypoglycemia
Poisons
Shock
Alcohol/Abuse
Epilepsy/Encephalopathy
Intussusception
Opiates
Uremia
Question 3.2000
You have intubated an 8 month old with sepsis and apnea
with a 4.0 endotracheal tube. Proper placement is confirmed
by observing chest rise and auscultating symmetric breath
sounds after bag and mask ventilation. Perfusion is <3
seconds, and heart rate is 120/minute. Five minutes later
the RT tells you the oxygen saturation is 83% and the blood
pressure and pulse are dropping. Breath sounds are absent
on the right and the right chest is hypertympanitic. What is
the most likely diagnosis?
A. Esophageal intubation
B. Incorrect ET size
C. Obstructed ET tube
D. Right main stem bronchus intubation
E. Right pneumothorax
Answer E

ET Tube Size (mm) =
[16 + Age(yr)]/4
Preterm 2.5-3.0
Term 3.0-3.5
Infant 3.5-4.0
1 year 4.0-4.5
3 year 4.5-5.0
*An uncuffed tube should be used in patients
<8 years of age
Approximate distance of insertion measured at teeth
or lips in cm =
Internal Diameter X 3
Straight blades preferred for neonates and infants
Drugs that can be given by ETT after dilution with
normal saline to 3-5 ml followed by positive
pressure ventilation
LANE
Lidocaine
Atropine
0.02mg/kg IV,IO; 0.02-0.06mg/kg ET
Minimum dose is 1ml (0.1 mg) as it comes 0.1 mg/ml
Naloxone (Narcan)
0.1 mg/kg/dose IM/ET/IV/IO to maximum 2mg/dose. May
repeat every 2-3 minutes
Epinephrine
0.1ml/kg of 1:1000 (0.1mg/kg) IV, IO, ET in non-neonates
Use 1:10,000 (0.1-0.3ml/kg for all doses and routes) epinephrine
via ETT for neonates only. Use high dose 1:1,000 epinephrine for
ETT beyond neonatal period

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

Treatment for tension pneumothorax
Immediate needle decompression
Patient supine with head of bed at 30 degree
18-20 gauge over the needle catheter (angiocatheter)
inserted into the
2
nd
intercostal space just over the top (Hey dude, this
procedure is over the top , man!) of the 3
rd
rib at the
midclavicular line
5-10 ml syringe attached to angiocatheter and aspirated
gently as needle is advanced
Loss of resistance or rush of air apparent as soon as
pleural space is entered
If pneumothorax is confirmed a one-way drainage device
should be attached
A chest tube should be placed after successful needle
decompression
Needle Decompression
Question 4.2000
A 6 year old boy with severe factor VIII deficiency
hemophilia develops increased swelling of the right
distal forearm. There is not history of trauma. The
peripheral circulation is normal and there is no joint
involvement. The MOST important complication of
bleeding in this location is:
A. Blood loss
B. Muscular Damage
C. Neurologic Impairment
D. Tendon Shortening
E. Vascular Damage
Answer C
Children with hemophilia can develop severe
peripheral neurologic deficits when hematomas
compress nerves via compartment syndrome
In older children increasing pain out of proportion
to size of hematoma, numbness and paresis are
critical signs
Often there is no history of trauma in
hemophiliacs
Significant blood loss seen in hematomas of
Thigh or retroperitoneum

Routine venipuncture is safe as long as it is
followed by
5 minutes of firm finger pressure
Femoral or jugular venipuncture or arterial
puncture should not be undertaken WITHOUT
PRIOR FACTOR REPLACEMENT
What about IM immunizations
Ok as long as followed by 5 minutes of firm finger
pressure
Large IM injections should be avoided (Decadron,
Rocephin IM etc)
Tendon shortening only occurs with
Chronic, sever hemarthroses
Limited mobility
Nerve damage
Muscular damage is not frequent among
children with hemophilia
Prepatellar Hematoma
Hematoma after IM injection
Question 5.2000
An ambulance team brings a 6 year old girl in an
MVA to the ED. She had been unrestrained in the
back seat. The girl is unresponsive on arrival and is
bleeding profusely from a scalp wound. Her
Glasgow Coma Scale is 3. What is the BEST initial
step in evaluation and management?
A. Control profuse scalp bleeding
B. Establish IV access
C. Order portable cervical spine radiographs
D. Remove all clothing
E. Secure an adequate airway
Answer E.

Priority during primary survey
Airway
Failure to provide
oxygenated blood to the
brain and other vital organs
is the quickest killer of a
trauma victim
Breathing
Circulation
Disability
Exposure
Any victim of head trauma with a
GCS of ___ or less should be
intubated immediately
8
X-rays for cervical fractures
AP, Lateral and odontoid views
Dens of Axis C-2
Atlas C-1
Odontoid View
Glasgow Coma Scales
INFANTS & TODDLERS CHILDRENS & ADULTS
EYE
OPENING
Spontaneous 4 EYE
OPENING
Spontaneous 4
To Voice 3 To Voice 3
To Pain 2 To Pain 2
None 1 None 1
BEST
VERBAL
RESPONSE
Smiles, Interacts 5 BEST
VERBAL
RESPONSE
Oriented 5
Consolable 4 Confused 4
Cries to Pain 3 Inappropriate Words 3
Moans to Pain 2 Incomprehensible Words 2
None 1 None 1
BEST
MOTOR
RESPONSE
Normal spontaneous movement 6 BEST
MOTOR
RESPONSE
Obeys Commands 6
Localizes Pain 5 Localizes Pain 5
Withdraws to Pain 4 Withdraws (Pain) 4
Abnormal Flexion 3 Flexion (Pain) 3
Abnormal Extension 2 Extension (Pain) 2
None 1 None 1 www.indiandentalacademy.com
Question 6.2000
A 2 week old presents with tachypnea, poor
perfusion, gallop rhythm, diminished pulses, and
hepatomegaly. ABG shows metabolic acidosis.
Echocardiography reveals critical Aortic Stenosis.
What intervention is most likely to stabilize the
infants condition?
A. Dobutamine
B. Epinephrine
C. Nitric Oxide
D. 100% oxygen
E. Prostaglandin E-1
Answer E.
Severe CHF and cardiogenic shock in
neonate, think LEFT SIDED LESIONS
Hypoplastic left heart
Critical congenital aortic stenosis
Critical neonatal coarctation of aorta
As ductus arteriosus closes, early
compensatory RV contribution to
systemic blood flow and perfusion to
kidneys and other organs is lost
rapidly developing severe metabolic
acidosis myocardial and organ
dysfunction
Therefore, need to keep duct OPEN
with PGE
1
(alprostadil) EVEN TO AN
INFANT 1-2 MONTHS OF AGE
Inotropic agents such as dobutamine or
epinephrine may provide supportive therapy but
will not be lifesaving
Nitric oxide is a pulmonary dilator used in PPH of
newborn but is contraindicated in obstructive left
sided heart lesions
Serious hypoxia is NOT a problem for infants
with obstructive left sided lesions
Arterial pO2 may be normal initially in a sick
neonate
As PDA is opened the O2 will drop due to right
ventricular flow to the body
Attempts to keep O2 HIGH ARE DETRIMENTAL as
high inspired oxygen levels causes powerful
PULMONARY ARTERIAL DILATION which steals
RV output to the pulmonary arteries and away from
the body
This steal factor NOT o2 induced ductal closure is
the primary risk associated with use of
supplemental O2 when PGE1 is used to keep duct
open
Some degree of pulmonary hypertension (i.e. small,
tight, non-dilated arteries) is essential to promote
systemic flow to the peripheral circulation via the
ductus

Hypoplastic Left Heart
2
nd
most common congenital
cardiac lesion presenting in 1
st

week of life
Most common cause of death
from CHD in 1
st
month of life
What are characteristics?
Hypoplasia of left ventricle
Hypoplasia of aortic root
Aortic valve atresia
Critical mitral valve stenosis or atresia
Result is a reduction or elimination
of blood flow through left side of
heart
Ineffective left side of heart
obligatory left to right shunt where?
Atrial level
And right to left shunting where?
Ductus arteriosus
Systemic flow is completely ductal
dependent
How do coronary arteries get fed?
Retrograde coronary perfusion
As PDA closes neonates become
critically ill CHF, cyanotic,
tachycardic, tachypneic, rales
(crackles) from pulmonary edema,
and hepatomegaly; poor peripheral
pulses with vasoconstricted
extremities.

Cardiac Exam
Loud S2 (Marks beginning
of diastole and is due to
closure of semilunar
valves; primarily pulmonic
valve slamming against
increased blood volume
and pressure)
S3 (Early diastole
corresponds with end of
first phase of rapid
ventricular filling from atria
and can be normal in
children and young adults)
Treatment:
PGE
1
(alprostadil) immediately to maintain ductal
dependent systemic blood flow
Cardiac transplantation in the newborn period is
primary treatment for HLHS
Scarcity of newborn organs available for
transplantation
Life-long need for anti-rejection therapy
Average life span of the transplanted heart is limited
(currently less than 15 years).
Most common treatment for HLHS is palliative
"staged reconstruction"
1. Norwood operation: performed 1
st
week
RV becomes the systemic or main ventricle
pumping to the body.
Neoaorta is made from part of the pulmonary
artery and the original, tiny aorta, is enlarged to
provide blood flow to the body.
To provide blood flow to lungs, a small tube graft
is placed either from the left subclavian or left
innominate artery to the lung vessels (modified
Blalock-Taussig shunt: or from the RV to the lung
vessels (Sano modification).

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

Question 7.2000
During a routine visit, a 14 year old overweight
patient tells you he watches more than 25 hours of
TV per week. What is the most appropriate advice?
A. Parents should limit TV to no more than 2 hours/day
B. TV commercials have little impact on selection of toys
and food
C. Average adolescent spends 15 hours/week watching
TV
D. Unclear relationship between TV viewing and risk of
obesity
E. No relationship between TV viewing and snacking
ANSWER A
Children 2-11 22 h/week
Adolescents 12-17 20 h/week
Age 18, adolescent will have seen 200,000 violent
acts and 18,000 murders on TV
Encourage parents to co-view programs with
children
Saturday morning commercials; 50% food, 33%
toys
20 best selling toys are from TV shows based on
the toys
Increased TV viewing significant factor leading to
obesity
Increased TV viewing = increased snacking

Deep Thoughts from Ryan
Dad, how long does
it take a booger to
form?
Booger: Dried nasal
mucus; bogie in
England
Medical Term:
Rhinoliths
Question 8.2000
A male infant born at 36 weeks gestation had a left
testicle palpable in the inguinal canal. At 12 months
of age, the left testicle has failed to descend into
the scrotum. What is most appropriate care for this
infant?
A. Observation until 2 years of age
B. Orchiopexy
C. Radionuclide scan of left testicle
D. Treatment with human chorionic gonadotropin
E. Treatment with testosterone
ANSWER B
What percent of preterm male infants have an
undescended testis
30%
Spontaneous descent into scrotum occurs
over next 3-6 months
What is the most reliable method to localize the
undescended testis?
Laparoscopy
Orchiopexy, a surgery which places the testis into
the scrotum is indicated for a testis that fails to
descend by
6 months of age and is performed at 9-12 months of age
At 6-12 months of age histological changes
representing degeneration of the seminiferous
tubules occurs decrease in quality and quantity
of spermatogenesis which is progressive
The longer the testis remains in its improper
location the greater the fertility impairment
What percent of all testicular tumors occur in
patients with an undescended testicle
10%
Orchiopexy improves fertility but DOES NOT
change malignancy risk
Relocated testis has a 35-48 times greater
risk of malignancy than normal testis
Does the normal testis also have an
increased risk?
YES, just not as high
Counsel parents to:
Seek immediate attention for acute testicular
pain due to risk of torsion
Perform monthly examination of both testes

Retractile testicles
Bilateral mostly
Found in children >1 year of age, 5-6 year
olds strong reflex
Due to strong cremasteric reflex
Milk them into scrotum
Warm room, frog leg position can make
examination easier

Question 9.2000
A newborn female has an open neural tube
defect, low set ears, VSD, and rib and
vertebral column malformations. Which of
the following MATERNAL conditions was
most likely present during pregnancy?
A. Alcoholism
B. Diabetes mellitus
C. Hypothyroidism
D. Iodine deficiency
E. Syphilis
ANSWER: B
Early prenatal deficits: malformations (3 fold
increase), growth deficiency, stillbirth
The worse the diabetic control the more
severe the defects
Cardiac: VSD, TGA, dextrocardia
CNS: Anencephaly, holoprosencephaly,
spina bifida, hydrocephalus, caudal
regression syndrome
Rib defects

Infants present with macrosomia due to
hyperinsulinemia and excessive glucose
availability
Both linear growth and weight are affected
If mom has severe vascular disease, can
result in IUGR
Additional complications: Hyperbilirubinemia,
hypoglycemia, vascular thromboses,
respiratory distress, birth injury due to
macrosomia
Holoprosencephaly
Caused by a failure of the
embryo's forebrain to divide to
form bilateral cerebral
hemispheres causing defects in
face development face and in
brain structure and function.
The "alobar" form of
holoprosencephaly is shown here
in which there is a single large
ventricle, because there is no
attempt to form separate cerebral
hemispheres.
May be associated with trisomy 13
and rarely in association with
maternal diabetes mellitus.
Spina Bifida
Spina Bifida
Fetal alcohol syndrome
What is the most common teratogen to which fetuses
are exposed?
Alcohol
Which U.S. population has the highest incidence of
children with FAS?
Native Americans
What is the incidence in U.S. (excluding Native
Americans)
1:1000
Affects 40% of children in women who drink more
than 4-6 drinks per day
Fetal Alcohol Syndrome
Epicanthal Folds
Maternal
hypothyroidism has
little effect on fetus
which produces its
own thyroid hormone
Women with
untreated
hypothyroidism also
give birth to NORMAL
babies
Maternal iodine deficiency (rare in developed
countries) fetal deficiency
Goiter
Mental retardation
Slightly increased head size due to
Myxedema [hard edema due to increased mucins
(proteoglycans) in the fluid] of subcutaneous tissues
of the brain}
Hyperbilirubinemia due to
Delayed maturation of glucuronide conjugation
Feeding difficulties (choking spells, lack of
interest, somnolence, sluggishness)

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

Maternal syphilis
Fetus affected by
Transplacental transmission Treponema pallidum
Syphilis in untreated women can be transmitted to
fetus at any time, fetal transfer most common during
1
st
year of maternal infection
2/3 of live-born neonates with congenital syphilis are
asymptomatic at birth.
Overt infection can manifest in the fetus, the
newborn, or later in childhood.
Clinical manifestations after birth are divided
arbitrarily into early ( 2 years of age) and late (>2
years of age)
Fetal manifestations of Syphilis
Stillbirth
Neonatal death
Overt infection at birth, such as hydrops
fetalis (abnormal accumulation serous fluid in
fetal tissues)
Intrauterine death in 25% of affected infants,
with perinatal mortality in an additional 25-
30%, if untreated
Early congenital manifestations of Syphilis
Quite variable, appear within the first 5 weeks of life
Cutaneous lesions frequently occur on the palms and
soles; if ulcerative in nature, they are highly
contagious
Hepatosplenomegaly
Jaundice
Anemia
Snuffles (obstructed nasal respiration in newborn)
Metaphyseal dystrophy and periostitis often are noted
on radiographs at birth
Late congenital manifestations
Develop from scarring related to early
infection but can be prevented by treatment
of the infant within the first three months of
birth
Late findings include frontal bossing, short
maxilla, high palatal arch, Hutchinson triad
(Hutchinson teeth [blunted upper incisors],
interstitial keratitis, and eighth nerve
deafness), saddle nose, and perioral fissures
(rhagades)
Saddle Nose
deformity in
congenital syphilis
Hutchinson Teeth
Question 10.2000
A 5 year old male is hospitalized in January with
fever and seizures. LP reveals clear CSF with 47
WBCs/mm
3
all of which are lymphocytes. On PE
he appears obtunded but arouses with painful
stimuli. Neurologic exam reveals no focal findings.
Which diagnostic test is most likely to reveal this
childs illness?
A. Bacterial culture of CSF
B. PCR test of CSF for HSV
C. Streptococcus pneumoniae bacterial antigen test of
CSF
D. Viral culture of CSF
E. Viral culture of nasopharyngeal and rectal swabs
ANSWER B
Learning Points 10.2000
Exam findings are consistent with encephalitis
CSF findings are consistent with a viral etiology
Most likely cause is a sporadic case of herpes
simplex virus
Viral cultures of CSF for HSV are RARELY
positive beyond neonatal period
HSV is not found in cultures of sites outside the
CNS

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

Question 11.2000
An 18 year old girl presents for a RV. Exam
reveals tanner stage 5 breasts with 2x2 cm
nontender, smooth, mobile mass in left breast.
It is located at the upper outer quadrant. The
overlying skin is normal and there is no history
of nipple discharge. Family history is negative
for breast cancer. What is the most appropriate
next step in evaluation of this breast mass?
A. Excisional biopsy
B. Fine-needle biopsy
C. Mammography
D. Reassurance and reevaluation in 4-6 months
E. Referral for surgical consultation
ANSWER D
What is the diagnosis?
Fibroadenoma
Fibroadenomas are most common breast
lesion in an adolescent female
Differential diagnosis breast masses:
Fibrocystic changes
Cysts
Abscesses
Rarely, malignancy

Without family history of breast cancer in a 1
st
or 2
nd
degree
relative, primary breast cancer is extremely rare in
adolescents
Fewer than 1/1,000 of adolescent breast masses are
malignant
Metastatic lesions from
Rhabdomyosarcoma, neuroblastoma, and lymphoma can occur, but
rare.
If anxiety high can begin with what test
Ultrasound to differentiate between cystic and solid masses
FNA or biopsy can be done in adolescent with unusually large
or atypical mass or who is highly anxious about malignant
potential
Mammography never is indicated fir evaluation of a breast
mass in teenagers because the dense breast tissue makes
study difficult to interpret
Question 12.2000
A 15 year old girl complains of dysuria and
abdominal pain for 2 days. She denies nausea,
vomiting, flank pain and vaginal discharge.
Menarche occurred to years ago and menses
have been irregular. PE reveals SMR stage 4
genitalia, mild suprapubic tenderness, and
otherwise normal findings. What is the most
likely diagnosis?
A. Bacterial vaginosis
B. Candidal vulvovaginitis
C. Chlamydia urethritis
D. Pelvic inflammatory disease
E. Urinary tract infection
ANSWER E.
Bacterial vaginosis
Grayish discharge with pH >4.5
Saline wet mount reveals >20% clue cells and an absence
of lactobacilli
An isolated Gardenerella vaginalis infection does not cause
dysuria and lower abdominal pain
Candidal vaginosis
Whitish discharge
Chlamydia trachomatis
Causes dysuria if urethra involved
No abdominal pain UNLESS PID present
PID symptoms: lower abdominal pain, cervical motion
tenderness, adnexal tenderness; fever, vomiting, diarrhea,
irregular vaginal bleeding, increased vaginal discharge

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

Clue Cells
Question 13.2000
A 3 year old girl comes to the ER with
temperature of 103.1
o
F and acute onset
diarrhea. Stool is guaiac positive with
leukocytes. There is no history of foreign travel
and the child has not received antibiotics
recently. What is the most likely organism?
A. Clostridium difficile
B. Giardia lamblia
C. Rotavirus
D. Salmonella enteritidis
E. Vibrio cholerae
ANSWER D.
Viral diarrhea
Low-grade fever, vomiting, large, loose
watery stools
Most common cause
Rotavirus
Season predominance
Winter in United States
Bacterial Diarrhea
High fevers, small frequent stools with mucous or
blood
What can happen if you treat Salmonella infection
with antibiotics?
Prolong the carrier state
Which organism is seen after antibiotics?
Clostridium difficile
What organism is seen after ingestion of seafood or
water?
Vibrio cholerae
Giardia lamblia results in chronic diarrhea with
malabsorption

Question 14.1000
You are evaluating a 4 week old boy for tearing of
the right eye that has worsened over the past
week. Physical exam reveals slight tearing but no
evidence of purulent exudate or conjunctival
erythema. All other findings are normal. The MOST
appropriate initial management is
A. Administration of amoxicillin
B. Endoscopic dacrocystorhinostomy
C. Instillation of silver nitrate in the eyes
D. Observation with intermittent massage of the duct
E. Surgical dilation of the nasolacrimal duct
ANSWER D
Congenital nasolacrimal duct obstruction is most
common abnormality of infant lacrimal system, 5%
affected
What percent of those affected have bilateral
obstruction?
30%
Obstruction is usually found where?
Distal end
Pertinent negatives on exam
Conjunctival inflammation, photophobia, blepharospasm,
corneal clouding

Question 68.1999
A previously health 1-year-old infant who weighs 10 kg presents
to your office with a fever of 39 C (102.2 F). Her mother is
very concerned about the childs intake and asks for guidance
regarding caloric requirements during this illness.

Of the following, the best estimate of the childs caloric
requirements at this time is

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

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

Calculation of Caloric Requirements
Based on Body Weight (68.1999)
Body Weight Caloric Requirement
10 kg 100 kcal/kg
11 to 20 kg 1,000 kcal + 50
kcal/kg for each kg
above 10 kg
20 kg 1,500 kcal + 20
kcal/kg for each kg
above 20 kg
Calculating Energy Lost in Fever
(68.1999)
Formula
For each degree above 37
o
C, multiply by 12%
of maintenance requirements per degree. Then
add to original maintenance requirements for
total energy needs.
Example: 10 kg infant with 39
o
C temperature.
Calculate total caloric requirements.
10 kg X 100kcal/kg= 1,000 kcal maintenance needs
2
o
X 0.12(1,000kcal) = 240 kcal
Total Needs = 1,240 kcal
Question 69
A 5-year-old boy is brought to the emergency department after
having been struck by an automobile. Physical examination reveals
facial abrasions, abdominal tenderness, and gross blood at the
urethral meatus. Pelvic radiography reveals a left-sided fracture of
the superior pubic rami.

Of the following, the best procedure for INITIAL evaluation of the
urinary tract in this patient is

A.Bladder catheterization via the urethra
B.Computed tomography of the abdomen
C.Intravenous pyelography
D.Renal untrasonography
E.Retrograde urethrography

Answer: E
Additional Caloric Requirements in Selected
Medical and Surgical Conditions (68.1999)
Condition Maximum Amount of
Additional Calories Required
Hypermetabolic state
due to recent surgery
20%
Multiple trauma 25%
Severe infection 50%
Third-degree burns
(<20% of body)
100%
Uncomplicated
starvation
50%
Question (69.1999)
In children who sustain multiple injuries in a
vehicular crash what are the top two systems
that are involved?
Central Nervous System #1
Genitourinary System #2
Blood at tip of penis suggests urethral injury.
Injury to the prostatomembranous portion of
urethra associated with pelvic fracture is most
common.
Isolated urethral injury in female is UNCOMMON.
Answer Explanations (69.1999)
Retrograde urethrography (E.) -Catheter
placed just inside urethral meatus and dye
inserted
Routine catheterization (A.) is
contraindicated with blood at urethral
meatus because
Procedure might convert a PARTIAL TEAR of
meatus into a COMPLETE TRANSECTION
Answer Explanations (69.1999)
Abdominal CT would be helpful for
Evaluating intrabdominal injuries
Splenic injury
Liver injury
Renal injury
Intravenous pyelography and Renal US
will evaluate renal pathology but not
evaluate suspected urethral injuries
Apgar Score
(Virginia Apgar 1953)
Component of
Apgar Score
Score (Check at 1 and 5 minutes)
0 1 2
Heart Rate None <100
beats/min
>100
beats/min
Respiratory
Effort
None Weak cry Lusty cry
Muscle Tone Limp Some flexion Well flexed
Reflex
Irratibility
No response Some motion Vigorous
response
Color Uniformly Blue Acrocyanosis Completely
pink
Question 70
You are attending the emergency delivery by cesarean section of a
primiparous woman. The gestation was complicated by pregnancy-
induced hypertension. Deep variable fetal heart rate decelerations
were noted during labor. At delivery, the infant is acrocyanotic with
poor tone; spontaneous movement and minimal respiratory effort are
present.

Of the following, your INITIAL management is to

A.Ascertain the heart rate and assign a 1-minute Apgar score
B.Begin tactile stimulation and provide blow-blow oxygen
supplementation
C.Dry all skin surfaces and clear the oropharynx
D.Initiate bag-mask ventilation
E.Insert an umbilical catheter and administer naloxone

Answer: C
Learning Points (70.1999)
The body and head of an infant are
immediately dried with a prewarmed towel
to remove
Amniotic fluid
And to prevent
Evaporative heat loss which could lead to
hypothermia
Also provides gentle stimulation to infant
When suctioning, mouth or nose first and why?
Mouth to ensure nothing in oropharynx that could be
aspirated as we are dealing with obligate nose
breathers
Suctioning also provides tactile stimulation
Score of 7 or more indicates
WELL NEWBORN ROUTINE CARE AND
OBSERVATION
Score of 4-6 indicates
MILD TO MODERATE DEPRESSION, NEED MORE
INTERVENTION (Blowby, stimulation etc.)
Score 3 or less
SEVERE DEPRESSION, NEED TO INTUBATE, CV
SUPPORT, BAG-MASK VENTILATION

When do you keep on taking Apgar
scores?
When 5 minute is 6 or less
Additional scores should be assigned every
5 minutes for up to 20 minutes or until
two consecutive scores of 7+ are obtained
Question 71
A 1-year-old boy has been treated with a low-phenylalanine diet for
the past year after having been identified in infancy as having
phenylketonuria. Despite appropriate dietary restriction of
phenylalanine, he has developed neurologic symptoms.

Of the following, this child is MOST likely to be deficient in

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

Answer: D
PKU diagnosed by hyperphenylalaninemia in
blood sample taken at 48 hours of age
Two types:
Classical PKU has deficiency in phenylalanine
hydroxylase
Deficiency of enzyme cofactor tetrahydrobiopterin
(1-3% patients with hyperphenylalaninemia)
Involved in hydroxylation reactions for tryptophan and
tyrosine OH-tryptophan and L-DOPA
(Neurotransmitters)
Thus, phenylalanine restriction by itself in presence of
cofactor deficiency WILL NOT prevent neurological
damage
How do you diagnose tetrahydrobiopterin
deficiency?
Caused by recycling or synthesis defects
Measure pterin metabolites found in urine
Can also diagnose by a reduction in
phenylalanine after IV or oral load of
tetrahydrobiopterin
How do you treat tetrahydrobiopterin
deficiency?
Administer tetrahydrobiopterin
Replace dopamine and serotonin as
tetrahydrobiopterin poorly penetrates brain
where neurotransmitters are formed
Also remember there are a small
percentage of infants born with transient
hyperphenylalaninemia which has no
clinical consequence

Cobalamin is coenzyme foir methmalonyl CoA
mutase whose deficiency results in
Methylmalonic aciduria
Carnitine used for transport of medium and long
chain fatty acids across mitochondria
Carnitine deficient patients have muscle weakness
Thiamine deficiency results in
Beri beri
Biotin is cofactor for carboxylases that catabolize
branched chain amino acids involved in fatty
acid synthesis
Question 72
A 22-month-old girls is nonverbal. She sat alone at 7 months and
walked by 13 months, but now exhibits a wide-based stance, no
longer ambulates, and will not pick up or manipulate toys.
Findings include: height and weight at the 50
th
percentile; head
circumference below the 5
th
percentile, with no increase over the
past 8 months; normal fundi, and no organomegaly.

Of the following, the MOST likely diagnosis is

A.Adrenoleukodystrophy
B.Cerebral palsy
C.GM
2
gangliosidosis (Tay-Sachs disease)
D.Hypothroidism
E.Rett syndrome
Answer: E
Developmental Delay
Regression
Plateau
Progression
Good somatic growth but no head growth
in 8 months known as
Acquired microcephaly
Lost purposeful hand use when picking up
objects known as
Dyspraxia

Rett syndrome (SSSH I dont have Rett syndrome)
Neurodegenerative disorder
Females only (male fetuses die in utero)
1:10,000
X-linked dominant
Seizures
Spasticity
Scoliosis
Hand-wringing
Become severe spastic quadriplegics
Adrenoleukodystrophy
Proxisomal disorder only found in males
Defect in acyl CoA synthetase in peroxisomes
Cerebral form (50%),
adrenomyeloneuropathy (25%), isolated
Addison disease or symptomatic (25%)
Progressive demyelination of brain
Dementia, Blindness, Deafness, Decorticate state
Adrenal insufficiency
Tay-Sachs
Rapidly progressive neurodegenerative disorder due to
lysosomal storage disorder (GM2, gangliosidosis)
caused by deficiency in
Beta-hexosaminidase A enzyme
Onset before 9 months
Hypotonic, never walk, increased startle response
Fundoscopic exam reveals
Cherry red spot
What populations has this been found more frequently
in?
Ashkenazi Jews
French Canadians

Congenital hypothyroidism
High likelihood for normal development if
treatment started before 3 months of age
Can make up some developmental milestones
if treatment begun before 6 months of age
Can see polyneurpathies and muscle
weakness
Cerebral Palsy: What are 4 types?
Spastic
Dyskinetic
Ataxic
Hypotonic
Must have impaired motor control to make
this diagnosis
Question 73
A 10-year-old boy who has hereditary spherocytosis has developed
increasing fatigue and pallor over the past 5 days, and his
hemoglobin concentration, which usually ranges between 10 and
11g/dL, now is 5.9g/dL.

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

A.Aplastic crisis
B.Folic acid deficiency
C.Hyperhemolytic crisis
D.Iron-deficiency anemia
E.Splenic sequestration
Answer: A
Aplastic crisis is the most common cause of severe
anemia in children with hereditary spherocytosis
(HS)
What is the most common cause of such a crisis?
Parvovirus B19 erythema infectiosum (fever, chills,
lethargy, nausea, vomiting, abdominal pain, respiratory
symptoms, myalgias, arthralgias, slapped cheek rash)
Parvovirus selectively attacks erythroid precursor cells
inhibiting their growth decreased reticulocytes and
bilirubin as number of RBCs destroyed decreases daily
How long does the crisis typically last?
10-14 days
Are WBCs and platelets affected as well?
Yes they can but it is usually much milder
When do you know someone is recovering from
a lab standpoint?
Presence of a reticulocytosis
* Parvovirus infection in first half of pregnancy
in patient with HS may cause fetal loss due to
severe anemia

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

Folic acid and iron deficiency may exacerbate
the anemia but this is a gradual decline in
hemoglobin
Hyperhemolytic crisis without aplasia occurs in
HS in children less than 6 years who have viral
syndromes
Mild and transient increases in bilirubin,
splenomegaly, anemia, reticulocytosis
Splenic sequestration is typical of sickle cell
disease and is a minor component of hemolytic
crisis associated with spherocytosis
Question 74
An 18-day-old term infant develops fever, lethargy, and focal
seizures. Findings include: an ill-appearing infant without
exanthem, hepatomegaly, or jaundice. Analysis of cerebrospinal
fluid reveals white blood cells, 115/mm
3
; 45% neutrophils; 55%
lymphocytes; red blood cells, 40/mm
3
; glucose, 45 mg/dL; protien
200 mg/dL; and negative Gram stain.

In addition to ampicillin and cefotaxime, the MOST appropriate
treatment to begin at this time is

A.Acyclovir
B.Amphotericin B
C.Dexamethasone
D.Metronidazole
E.vancomycin
Answer: A
HSV is transmitted during delivery via contact with
maternal secretions
Only 5% of adults in US have a history of genital herpes
20-25% are actively infected with HSV-2
What is the risk of an HSV infection in an infant born
vaginally to a mother who has a 1
st
or primary genital
infection?
33-50%
What is the risk in a mom with recurrent HSV?
3-5%
MOST HSV-INFECTED INFANTS ARE BORN TO WOMEN
WITH NO HISTORY OF GENITAL HERPES AND NO
SIGNS OF INFECTION DURING PREGNANCY OR AT
DELIVERY
HSV in newborn
Generalized systemic infection involving liver and
CNS in 25% cases
Localized CNS disease 35%
Localized to skin, eyes, mouth 40%
UP TO 33% OF INFANTS WITH DISSEMINATED
OR LOCALIZED CNS DISEASE WILL HAVE NO
SKIN, EYES OR MOUTH INVOLVEMENT
Disseminated HSV disease
1
st
week of life
Liver and adrenals primarily involved
Irritability, seizures, respiratory distress,
jaundice, vesicular rash, shock
What is the mortality rate even with treatment?
50-60%
What are the two most common causes of
death in disseminated HSV?
HSV pneumonitis
Disseminated intravascular coagulopathy
Question 75
A 10-year-old girl has complained of intermittent left lower
abdominal pain for 2 days. Previous evaluations, including a
thorough physical examination, urinalysis, and complete blood
count, have not revealed the cause. Tonight she is complaining of
pain in the lower left abdomen that radiates into her left leg.
There is no history of fever, vomiting, or diarrhea.

The MOST likely cause of this girls pain is

A.Appendicitis
B.Intussusception
C.Malrotation of the intestine
D.Nephrolithiasis
E.Ovarian torsion
Answer: E
Ovarian torsion pain: sharp lower abdominal pain radiating
to ipsilateral extremity, occasional vomiting
US can assess ovaries
Surgical exploration to confirm diagnosis and prevent
ovarian necrosis (and R/O appendicitis if not already done)
Left sided pain with appendicitis rare but seen
What is pain on right with palpation of the left called?
Rovsings Sign
What is the obturator sign?
Pain on internal rotation of the right hip, seen with pelvic appendix
What is the iliopsoas sign?
Pain on right hip extension, often seen with retrocecal appendix
Wrong age for intussusception (around 2 years
of age)
Irritability, colicky abdominal pain, emesis
Impaired venous return bowel edema
ischemia necrosis perforation
Rectal bleeding seen in what percentage of kids?
80%; in currant jelly form (blood plus mucous)
Most common location?
Ileocolic
Tubular mass palpable in what percentage of
kids?
80%

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

Question 76
A 13-year-old boy has a congested, itchy, and runny nose
accompanied by itchy eyes. These symptoms usually occur in the
fall, are unresponsive to over-the-counter decongestants, and his
father has the same problems. Physical examination reveals pale,
boggy nasal turbinates; clear nasal discharge; and dark circles
under his eyes.

These findings are MOST consistent with

A.Allergic rhinitis
B.Infectious rhinitis
C.Nonallergic rhinitis with eosinophilia
D.Rhinitis medicamentosa
E.Vasomotor rhinitis
Answer: A
Perennial rhinitis (year round)
Pets, dust mites, molds, cockroaches
Vasomotor rhinitis
Diagnosis of exclusion, chronic blockage or
hypersecretion but negative skin tests and normal
paranasal sinus imaging
Infectious rhinitis
Mucopurulent discharge, sneezing, limited pruritus
Rhinitis medicamentosa
Overuse topical decongestants
Nonallergic rhinitis with eosinophilia
Diagnosis of exclusion, negative skin tests, nasal
smear positive for eosinophils
Pale turbinates
http://www.entusa.com/Nasal%20Photos/Chronic_Allergic_Rhinitis_15.jpg
Question 77
A 5-month-old child is brought to the emergency department by her
mother because she has been crying a lot for the past 24 hours.
The mother denies any history of fever, trauma, or illness. Physical
examination reveals a lethargic toddler who is very irritable when
examined and who has mild tachycardia, scattered bruises over the
chest, and ecchymosis behind the left ear.

The MOST appropriate management is to

A.Administer intravenous naloxone
B.Administer a 20 mL/kg bolus of intravenous normal saline
C.Obtain an abdominal radiograph
D.Obtain a complete blood count and blood culture and administer
intravenous ceftriaxone
E.Obtain a computed tomographic scan of the head and a skeletal
survey.
Answer: E
Child abuse red flags
Inconsistent history
History not compatible with injury
Ecchymosis behind left ear is called
Battle sign
What does this indicate?
Basilar skull fracture
CSF leakage from nose or ear, periorbital
ecchymosis (Raccoon Sign), blood behind the
eat drum (hemotympanum) are also signs of
basal skull fracture
Battle Sign
www.aic.cuhk.edu.hk/web8/Battle
Periorbital Ecchymosis
(Raccoon Eyes)
www.indianpediatrics.net/sep2005/sep-949.HTM
15 month old with stage IV metastatic
neuroblastoma and involvement of
the periorbital tissues and resultant
proptosis and orbital ecchymosis
Orbital metastases found in up to
20% of children with stage IV
neuroblastoma.
Raccoon eyes appearance associated
with neuroblastoma is probably
related to obstruction of the palpebral
vessels by tumor tissue in and around
the orbit.
Differential diagnoses for periorbital
edema and ecchymosis
Child abuse or trauma
Infection of the soft tissues associated
with a spreading dental infection
Allergic reaction
Myxoedema
Lymphoma
Haemophilia

Hemotympanum
me.hawkelibrary.com/hemotympanum/26_M
Question 78
An important component of the diagnostic assessment for
any child suspected of having attention deficit hyperactivity
disorder (ADHD) is the use of standardized behavior rating
scales. Of the following, the BEST reason to use standardized
behavior rating scales is that they

A.Are specific for diagnosing ADHD
B.Assist in monitoring treatment
C.Can be completed after a single classroom observation
D.Determine initial medication dosage
E.Predict response to medication

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

A.Inhaled beta
2
-agonist
B.Inhaled corticosteroid
C.Oral beta
2
-agonist
D.Oral corticosteroid
E.Oral theophylline

Answer: A
Exercise Induced Asthma
Bronchoconstriction during exercise
Typically within 15 minutes
Can occur during cool down as a lat-phase
response up to 4-12 hours later
Cough, wheeze, SOB, dizzy, stomach pain
Occurs 80% patients with asthma
Occurs 50% patients with allergic rhinitis
Question 80
Ichthyosis vulgaris occurs in 3% to 5% of children. Coarse scales
on the shins in the winter is the most common manifestation of
this autosomal dominant disorder. It can be associated with
widely disseminated scales on the trunk and extremities as well as
keratosis pilaris on the upper arms, thighs, and cheeks. Of the
following, the MOST effective treatment for the patients who have
ichthyosis is

A.Benzoyl peroxide gel
B.Hydrophilic ointment
C.Lactic acid cream
D.Tretinoin cream
E.Triamcinolone cream
Answer: C
Topical keratolytics induce desquamation and
treat hyperkeratosis or thickened skin, scaling
and xerosis
Icthyosis vulgaris 3-5% population after 6
months age scaling distal extremities, especially
the shins
Autosomal dominant
Associated with keratosis pilaris (scaly follicular
papules on upper arms, thighs, cheeks)
Keratolytics
Lactic Acid (with Ammonium Hydroxide) Lac-hydrin
Urea- Carmol
Glycolic acid
Alpha-hydroxy acids
Separate adherent scale from underlying
stratum corneum of epidermis
Petroleum (vasoline) and hydrophilic ointments
(Aquaphor, Cetaphil etc.) can be used as
adjuncts
Question 81
A term infant is delivered vaginally to a healthy 24-year-old
primigravida. Immediately after birth, the infants respiratory
effort is vigorous, but subcostal retractions and cyanosis persist.
The abdomen is scaphoid in appearance. Bag and mask
ventilation is initiated. Auscultation reveals decreased breath
sounds on the left and heart tones that are louder on the right.

The MOST likely explanation for these findings is

A.Congenital cystic adenomatoid malformation of the lung
B.Dextrocardia with situs solitus
C.Diaphragmatic hernia
D.Esophageal atresia with tracheoesophageal fistula
E.Pneumothorax
Answer: C
Decreased breath
sounds on left, louder
heart tones on right,
consistent with
mediastinal shift from
space occupying
lesion on left
Presence of scaphoid
abdomen indicates
abdominal contents
are in left hemithorax
Failure of pleuroperitoneal canal to close
during the eighth week of fetal life
96% have defect in posterolateral
lumbocostal triangle known as the
Foramen of Bochdalek
Defect can occur on left side (85%), right
side (13%), both side (2%)
Typically diagnosed with prenatal
ultrasound
Vincent A. Bochdalek:
Czechoslovakian
anatomist
(1801-1883)
Clinical symptoms dependent on degree of
pulmonary hypoplasia
Reduction in bronchial divisions, bronchioles,
and alveoli in both lungs due to the herniated
intrathoracic contents
Alveoli immature with thickened septae
reduced capillary-air interface and impaired gas
exchange
Pulmonary vasculature is abnormal with
thickened walls due to smooth muscle
hyperplasia persistent pulmonary
hypertension

Cystic adenomatoid formation
Rare congenital cystic disease with mass of
cysts lined with proliferative bronchial or
cuboidal epithelium
May be symptomatic in first week
Congenital Diaphragmatic Hernia
Bochdalek hernia
Opening on the left side of the
diaphragm. The stomach and
intestines usually move up into
the chest cavity.

Morgagni hernia
A Morgagni hernia involves an
opening on the right side of
the diaphragm. The liver and
intestines usually move up into
the chest cavity.
Congenital Diaphragmatic Hernia
Initial Film
After NG placement and suction,
bowel loops are revealed in left chest
Question 82
A 14-year-old girl underwent kidney transplantation 4 months ago.
She was well until 1 week ago, when she developed malaise,
fatigue, a low-grade fever, and mild dyspnea on exertion.
Findings include: temperature, 38.3 C (101.3 F); fine bibasilar
rales on auscultation of her lungs; bilateral diffuse interstitial
infiltrates on chest radiography; blood gas analysis, PO
2
of 80 torr.

The MOST likely pathogen is:

A.Aspergillus fumigatus
B.Cytomegalovirus
C.Haemophilus influenzae type B
D.Mycobacterium tuberculosis
E.Pseudomonas aeruginosa
Answer: B
CMV infections can be transmitted by:
Oral secretions
Urine
Human milk
Sex
Blood transfusion
Bone marrow and organ transplants
Therefore, major source of infection would be the
donors kidney
Transplant recipients at highest risk for developing CMV
are those LACKING CMV antibodies to CMV and receive
an organ from a donor who is seropositive for CMV.
All of the others can cause pneumonia, but occur less
frequently than CMV.

Thank you

For more details please visit


Pediatric Board Review / Orthodontic Courses by Indian Dental Academy

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pediatric Board Review / Orthodontic Courses by Indian Dental Academy

Uploaded by

Copyright:

Available Formats

Pediatric Board Review

You might also like