2017 WISE with Rationale Flashcards
“Which of the following EINC practices encourage early breastfeeding initiation?
A. Immediate & thorough drying of the baby
B. Properly timed cord clamping & cutting
C. First embrace of the mother & baby
D. Non-drug pain relief for the mother before offering anesthesia”
C
“Prev Ped 2018 p14
The recommended EINC practice for immediate care of the normal newborn are a series of time-bound interventions at the time of birth that can be enforced immediately in all health care settings. It emphasizes the step by step performance of a sequence of four core actions which are:
- Immediate and thorough drying of the newborn
- Early skin to skin contact between mother and newborn
- Properly timed cord clamping and cutting
- Nonseparation of newborn and mother for early breastfeeding.
These time sensitive interventions should not be pre-empted nor undermined by other interventions. Unnecessary interventions in newborn care include routine separation from the mother, foot printing, appplication of various substances to the cord, and giving pre-lacteals or artificial milk formula or other breast milk substitutes.”
“After immediate & thorough drying of the newborn, what is the next step in EINC which also contributes to providing warmth / heat to the infant?
A. Early skin to skin contact between the mother & the baby
B. Proper swaddling of the newborn with clean linen
C. Early bathing of the newborn with warm water
D. Exposure of the newborn to a radiant heat warmer”
A
“Prev Ped 2018 p14
The recommended EINC practice for immediate care of the normal newborn are a series of time-bound interventions at the time of birth that can be enforced immediately in all health care settings. It emphasizes the step by step performance of a sequence of four core actions which are:
- Immediate and thorough drying of the newborn
- Early skin to skin contact between mother and newborn
- Properly timed cord clamping and cutting
- Nonseparation of newborn and mother for early breastfeeding.
These time sensitive interventions should not be pre-empted nor undermined by other interventions. Unnecessary interventions in newborn care include routine separation from the mother, foot printing, appplication of various substances to the cord, and giving pre-lacteals or artificial milk formula or other breast milk substitutes.”
"A newborn was delivered via emergency caesarian section due to fetal distress. At birth, he was noted to be pale, non-reactive to stimuli, with slightly flexed extremities, a HR of 70 beats / minute, & RR of 40 breaths / minute. What is his APGAR score? A. 3 B. 4 C. 5 D. 6 "
B
"A - 0 P - 1 G - 0 A - 1 R - 2
= 4
Nelson 21st p872 Table 113.2 Apgar evaluation of newborn infants
Heart rate
0 - absent
1 - below 100
2 - over 100
Respiratory effort
0 - absent
1 - slow, irregular
2 - good, crying
Muscle tone
0 - limp
1 - some flexion of extremities
2 - active motion
Response to catheter in nostril (tested after the oropharynx is clear)
0 - no response
1 - grimace
2 - cough or sneeze
Color
0 - blue, pale
1 - body pink, extremities blue
2 - completely pink
”
“A term newborn was gasping & apneic at birth, with a HR of 80 beats / minute. What is the most appropriate intervention within the first minute of life?
A. Intubate as soon as possible
B. Do vigorous stimulation
C. Give oxygen support at 5 LPM
D. Start positive pressure ventilation”
D
“Nelson 21st p926
In term infants after stimulation, if no respirations are noted, or if the heart rate is <100 BPM, PPV should be given through a tightly fitted and appropriately sized bag-mask device. PPV should be initiated at pressures of approximately 20cm H2O at a rate of 40-60 breaths per minute, initially with 21% FiO2 for full term infants.
“
“What is the most important & effective action in neonatal resuscitation?
A. Perform chest compressions to improve circulation
B. Ventilate the baby’s lungs to prevent respiratory failure
C. Administer fluids for adequate volume requirement
D. Administer epinephrine to prevent cardiac failure”
B
“Nelson 21st p926
Failure to initiate or sustain respiratory effort is fairly common at birth, with 5-10% of births requiring some intervention. Infants with primary apnea respond to stimulation by establishing normal breathing. Infants with secondary apnea require some ventilatory assistance in order to establish spontaneous respiratory effort. Secondary apnea usually originates in the CNS as a result of asphyxia or peripherally because of neuromuscular disorders.
The steps in neonatl resuscitation follows the ABCs: anticipate and establish a patent airway by positioning the baby with the head slightly extended, sniffing position, and suctioning if secretions are blocking the airway; B initiae breathing first by using tactile stimulation, followed by PPV with a bag-mask device and ETT insertion should the baby remain apneic or PPV is not achieving effective ventilation; and C, maintain the circulation with chest compressions and medications, if needed. “
"A 2-day old female, term, delivered via NSD, was discharged on the 36TH hour of life. She was purely breastfed with good suck & activity. However, jaundice was noted on the 30TH hour of life. To assess her transition to life at home & monitor for other problems, she should be brought back to her pediatrician after how many days? A. 1-3 B. 4-6 C. 7-9 D. 10-12"
A
”"”Prev Ped 2018 p15 Appendix 2. Discharge and followup of healthy term newborns
The Philippine Society of Newborn Medicine lists the following minimum criteria for discharging newborns within 48hrs
- Uncomplicated antepartum, intrapartum, and postpartum courses for both mother and newborn
- Vaginal delivery, singleton, completed 37 weeks AGA
- Normal and stable VS during the preceding 12hrs
- Has urinated and passed at least one stool
- Has documented proper latch, milk transfer, swallowing, infant satiety and absence of nipple discomfort
- Normal PE
- No evidence of significant jaundice in first 24hrs of life
- Educability and ability of parents to care for their child (recognize signs of illness, care of the umbilical cord/skin/genitalia, maternal confidence in feeding her infant and parents’ understanding of the importance of ffup visit or emergency consultation
- Must followup within the next 48hrs”””
"The most common causes of readmissions among newborns discharged very early from birthing facilities are hyperbilirubinemia, sepsis, dehydration, &: A. Bowel disturbances B. Hepatitis infection C. Ophthalmic ointment reaction D. Missed congenital anomalies"
D
"At what age in weeks is a physiologic decrease in hemoglobin content observed in term infants? A. 1-4 B. 4-8 C. 8-12 D. 12-16"
C
”"”Nelson 21st p2516
At birth, normal full-term infants have higher hemoglobin (Hb) levels and larger red blood cells (RBCs) than do older children and adults. However, within the 1st wk of life, a progressive decline in Hb level begins and then persists for 6-8 wk. The resulting anemia is known as the physiologic anemia of infancy.”””
“Which of the following features is TRUE of breast milk jaundice?
A. It is usually seen within the first week of life.
B. If breastfeeding is continued, the bilirubin levels gradually decreases.
C. If breastfeeding is discontinued, the bilirubin levels falls rapidly but usually returns to high levels with resumption of breastfeeding.
D. There is significant elevation of conjugated bilirubin.”
B
”"”Breastfeeding jaundice
- 3rd-4th DOL
- Inadequate supply of breastmilk leading to increased enterohepatic circulation
- Tx: Increase breastfeeding to 8-10x/day
Breast milk jaundice
- 1st-2nd week of life
- Glucoronidase in breast milk increases enterohepatic circulation
- Tx: Increase breastfeeding frequency, phototherapy"""
"What is the most important neonatal factor predisposing to infection? A. Low birth weight B. Maternal infection C. Septic delivery D. Meconium aspiration"
A
“Nelson 21st p1005 HAI
Premature and VLBW infants often have prolonged hospitalizations are are particularly prone to healthcare-acquired infections because of their inefficient innate immunity, deficient skin barriers, presence of indwelling catheters and other devices, and prolonged endotracheal intubation.
Nelson 21st p1012 Perinatal infections
Factors influencing which colonized infants will experience disease are not well understoon, but include prematurity, underlying illness, invasive procedures, inoculum size, virulence of the infecting organism, genetic predisposition, the innate immune system, host response, and transplacental maternal antibodies. “
“A term infant was born after a normal pregnancy. However, the delivery was complicated by marginal placental separation. On the 12TH hour of life, he passed out bloody meconium although he appeared to be well. Which of the following tests should be prioritized to determine the cause of bleeding?
A. Barium enema
B. Apt test
C. Gastric lavage with normal saline
D. Upper GI series”
B
“Nelson 21st p912
Vomitus containing dark blood is usually a sign of serious illness, but the benign possibility of swallowed maternal blood associated with the delivery process should also be considered. Tests for maternal vs fetal hemoglobin (Apt tests) can help discriminate between these possibilities. “
“Which of the following statements is INCORRECT in the diagnosis of NEC?
A. A high index of suspicion is necessary.
B. The finding of pneumatosis intestinalis is diagnostic of NEC.
C. A positive occult blood is essential to establish the diagnosis.
D. The presence of portal venous gas is a sign of severe disease.”
C
”"”Nelson 21st p951-952
A very high risk of suspicion in treating preterm at-risk infants is cruical. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started. Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation.
Ultrasound with doppler flow assessment may be useful to evaluate for free fluid, abscess and bowel wall thickness, peristalsis, and perfusion. “””
“In contrast to classic BPD, which of the following features is NOT seen in the new BPD?
A. A disease primarily of infants with birthweight < 1 kg
B. Affects more mature preterm with RDS & treated with positive pressure ventilation
C. May be seen in infants with little or no lung disease at birth
D. Characterized by progressive respiratory failure over the first few weeks of life
“
B
“Nelson 21st p936-937
The new BPD is a disease primarily of infants with birthweight <1000g who were born at 28wk AOG, some of whom have little or no lung disease at birth but over the 1st weeks of age experience progressive respiratory failure.
Infants with the new BPD are born at a more immature stage of distal lung development, and lung hsitrology demonstrates variable saccular wall fibrosis, minimal airway disease, abnormal pulmonary microvasculature development, and alveolar simplification. Although the etiology remains incompletely understood, the histopathology of BPD indicates interference with normal alveolar septation and microvascular maturation.”
"What is the expected weight in kg of an 8-month old male: A. 5 B. 6 C. 7 D. 8"
D
“3600 + (2x500) + 3400 = 8000 = 8kg
Fundamentals of pediatrics p122 Table 8-1 Useful mnemonic for common growth standards
Weight
0-6 months: age in months x 600 + birth weight (g)
6-12 months: 3600 + (age in months after 6 months x 500) + birth weight (g)
1-6 years: age in years x 2 + 8 (kg)
7-12 years: 1/2 [(age in years x 7) - 5)] (in kg)
Length
0-3 months: birth length + 9cm
4-6 months: birth length + 9cm + 8cm
7-9 months: birth length + 9cm + 8cm + 5cm
10-12 months: birth length + 9cm +8cm + 5cm + 3cm
Length/height
2-12 years: age in years x 6 + 77 (cm)
Mid-parental height
All ages, boys: 1/2 [(paternal + maternal height) + 13] (in cm)
All ages, girls: 1/2 [(paternal + maternal height) - 13)] (in cm)”
"What is the expected head circumference in cm of a 1-year old female whose head circumference at birth is 34 cm? A. 36 B. 37 C. 38 D. 39"
D
“34+10 = 44
Nelson 21st p135
By the first birthday, birthweight has tripled, length has increased by 50%, and head circumference has increased by 10cm. “
“At what age in months do the Moro, asymmetric tonic neck & tonic labyrinthine reflexes usually disappear?
A. 2
B. 3
C. 4
D. 5”
D
”"”Nelsons 21st p3059 Table 608.2 Timing of selected primitive reflexes
Palmar grasp
- onset 28 wk AOG
- fully developed 32 wk AOG
- duration 2-3mo postnatal
Rooting
- onset 32wk AOG
- fully developed 36wk AOG
- less prominent after 1 mo postnatal
Moro
- onset 28-32wk AOG
- fully developed 37wk AOG
- duration 5-6mo postnatal
Tonic neck
- onset 35wk AOG
- full developed 1 mo postnatal
- duration 6-7 mo postnatal
Parachute
- onset 7-8mo postnatal
- fully developed 10-11mo postnatal
- remains throughout life “””
"At what age in months can a child hop on one foot, imitate a cross, put on buttons & describe feelings such as fatigue and / or anger? A. 36 B. 42 C. 48 D. 54 "
C
”"”Nelson 21st p142 Table 23.1 Emerging patterns of behavior from 1-5yr of age
24 months / 2 years
Motor: Runs well, walks up and down stairs 1 step at atime, opens doors, climbs on furniture, jumps
Adaptive: Makes tower of 7 cubes (6 at 21mo), scribbles in circular pattern, imitates horizontal strokes, folds paper once imitatively
Language: Puts 3 words together (subject, verb, object)
Social: Handles spoon well, often tells about immediate experiences, helps to undress, listens to stories when shown pictures
30 months
Motor: Goes up stairs alternating feet
Adaptive: Makes tower of 9 cubes, makes vertical and horizontal strokes, but generally will not join them to make cross, imitates circular stroke, forming closed figure
Language: Refers to self by pronoun “”"”I””””, knowns full name
Social: Helps put things away, pretends in play
36 months / 3 years
Motor: Rides tricycle, stands momentarily on 1 foot
Adaptive: Makes tower of 10 cubes, imitates construction of “”"”bridge”””” of 3 cubes, copies circle, imitates cross
Language: Knows age and sex, counts 3 objects correctly; repeats 3 numbers or a sentence of 6 syllables, most of speech intelligible to strangers
Social: Plays simple games in parallel with other children, helps in dressing (unbuttons clothing and puts on shoes), washes hands
48 months / 4 years
Motor: Hops on 1 foot, throws ball overhand, uses scissors to cut out pictures, climbs well
Adaptive: Copies bridge from model, imitates construction of “”"”gate”””” of 5 cybes, copies cross and square, draws man with 2-4 parts besides head, identifies longer of 2 lines
Language: Counts 4 pennies accurately, tells story
Social: Plays with several children, with beginning of social interaction and role playing, goes to toilet alone
60 months / 5 years
Motor: Skips
Adaptive: Draws triangle from copy, names heavier of 2 weights
Language: Names 4 colors, repeats sentence of 10 syllables, counts 10 pennies correctly
Social: Dresses and undresses, asks questions about meaning of words, engages in domestic roleplaying “””
“Gender identity is generally fixed at what age in years?
A. 1
B. 2
C. 4
D. 5”
B
“Nelson 21st p1021
Gender identity develops early in life and is generally fixed by 2-3 yr of age. Children first learn to identify their own and others’ sex (gender labeling), then learn that gender is most often stable over time (gender constancy), and finally learn that gender is typically permanent (gender consistency). What determines gender identity is largely unknown, but it is thought to be an interaction of biologic, environmental, and sociocultural factors. “
"At what age in months are the two hallmarks of development – locomotion & stranger anxiety, evident? A. 2 B. 4 C. 7 D. 9 "
D
”"”Nelson 21st p135 6-12 months
Physical development
Many infants begin crawling and pulling to stand around 8mo, followed by cruising. Some walk by 1 year. These gross motor skills expand infants’ exploratory range and create new physical dangers, as well as opportunities for learning.
Emotional development
The advent of object permanence (9mo) corresponds with qualitative changes in social and communicative development. Infants look back and forth between an approaching stranger and a parent and may cling or cry anxiously, demonstrating stranger anxiety. “””
“Which of the following features is considered a more dramatic sign of maturation among males during middle childhood?
A. Hypertrophy of the lymphoid tissues
B. Increase in muscular strength
C. Loss of deciduous teeth
D. Growth of the midface & lower face”
C
”"”Nelson 21st p146
Growth of the midface and lower face occurs gradually, loss of deciduous (baby) teeth is a more dramatic sign of maturatin, beginning at around 6yr of age. Replacement with adult teeth occurs at a rate of around 4 per year, so that by 9yr of age, children will have 8 permanent incisors and 4 permanent molars. Premolars erupt by 11-12 yr of age. Lymphoid tissues hypertrophy and reach maximal size, often giving rise to impressive tonsils and adenoids. “””
"A 5-year old boy consulted because of developmental delay. He was born full term via NSD with APGAR scores of 4, 6 & 8. The physical & neurologic examinations were unremarkable. On developmental evaluation, he was able to creep upstairs & run short distances, imitate vertical & circular strokes, utter at least 10 words with meaning, & remove his shorts. What is his approximate developmental age in months? A. 24 B. 36 C. 48 D. 60 "
B
“Nelson 21st p142 Table 23.1 Emerging patterns of behavior from 1-5yr of age
24 months / 2 years
Motor: Runs well, walks up and down stairs 1 step at atime, opens doors, climbs on furniture, jumps
Adaptive: Makes tower of 7 cubes (6 at 21mo), scribbles in circular pattern, imitates horizontal strokes, folds paper once imitatively
Language: Puts 3 words together (subject, verb, object)
Social: Handles spoon well, often tells about immediate experiences, helps to undress, listens to stories when shown pictures
30 months
Motor: Goes up stairs alternating feet
Adaptive: Makes tower of 9 cubes, makes vertical and horizontal strokes, but generally will not join them to make cross, imitates circular stroke, forming closed figure
Language: Refers to self by pronoun “”"”I””””, knowns full name
Social: Helps put things away, pretends in play
36 months / 3 years
Motor: Rides tricycle, stands momentarily on 1 foot
Adaptive: Makes tower of 10 cubes, imitates construction of “”"”bridge”””” of 3 cubes, copies circle, imitates cross
Language: Knows age and sex, counts 3 objects correctly; repeats 3 numbers or a sentence of 6 syllables, most of speech intelligible to strangers
Social: Plays simple games in parallel with other children, helps in dressing (unbuttons clothing and puts on shoes), washes hands
48 months / 4 years
Motor: Hops on 1 foot, throws ball overhand, uses scissors to cut out pictures, climbs well
Adaptive: Copies bridge from model, imitates construction of “”"”gate”””” of 5 cybes, copies cross and square, draws man with 2-4 parts besides head, identifies longer of 2 lines
Language: Counts 4 pennies accurately, tells story
Social: Plays with several children, with beginning of social interaction and role playing, goes to toilet alone
60 months / 5 years
Motor: Skips
Adaptive: Draws triangle from copy, names heavier of 2 weights
Language: Names 4 colors, repeats sentence of 10 syllables, counts 10 pennies correctly
Social: Dresses and undresses, asks questions about meaning of words, engages in domestic roleplaying”
“Which of the following statements is TRUE of stuttering?
A. It is most likely to occur during the preschool years.
B. It will persist in the majority of cases.
C. The most common cause is an underlying CNS infection.
D. It is associated with significant developmental delay.”
A
“Nelson 21st p281-282
Developmental stuttering is a childhood speech disorder that is not associated with stroke, traumatic brain injury, or other possible medical conditions and that interrupts the normal flow of speech through repeated or prolonged sounds, syllables, or single syllable words.
DSM-5 refers to this disorder as childhood onset fluency disorder, and impact on functional behavior is a component of the psychiatric diagnosis of this condition.
If there is a positive family history for stuttering, if symptoms are present for >4wk, and if the dysfluencies are impacting a child’s social, behavioral, and emotional functioning, referral is warranted. Although there is no cure for stuttering, behavioral therapies are available that are developed and implemented by speech and language pathologists.
Treatment in preschool age-children has been shown to improve stuttering. For school-age children, treatment includes not only improving fluency but also concommittants of the condition. This includes recognizing and accepting stuttering and appreciating others’ reaction to the child when stuttering, managing secondary behaviors, and addressing avoidance behaviors. “
“What is the most frequent initial manifestation of autism spectrum disorder?
A. Odd & repetitive behaviors
B. Language delay
C. Absence of typical play patterns
D. Aggression & bullying”
B
“The teacher of a 5-year old male observed that he does not seem to listen when spoken to directly & usually does not finish assigned chores. He often loses things necessary for activities. Furthermore, he talks excessively & would often blurt out an answer before a question is completed. Which of the following conditions should be considered?
A. Absence seizures
B. Autism spectrum disorder
C. Disruptive conduct disorder
D. Attention-deficit hyperactivity disorder”
D
”"”Nelson 21st p262
ADHD is the most common neurobehavioral disorder of childhood and among the most prevalent chronic health conditions affecting school-aged children.
ADHD is characterized by inattention, including increased distractability and difficulty sustaining attention; poor impulse control and decreased self-inhibitory capability; and motor overactivity and motor restlessness.
Affected children usually experience academic underachievement, problems with interpersonal relationships with family members and peers, and low self-esteem. “””
"A 16-year old female had frequent irritable moods & insomnia for the past 3 weeks. She recently transferred from a provincial high school to a large private school for girls in Manila. She missed her friends from the province & cried frequently. She eventually lost interest in making friends & school activities, & got low grades. She hardly ate & lost weight. She said she can disappear in this world because no one will notice her absence. What is the most probable diagnosis? A. Major depressive disorder B. Social anxiety disorder C. Severe adjustment disorder D. Panic disorder"
A
“Nelsons 21st p218 Table 39.1 DSM-5 diagnostic criteria for major depressive episode
A. Five or more of the following symptoms have been present during the same 2wk period and represent a change from previous functioning; at least 1 of the symptoms is either depressed mood or loss of interest or pleasure
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, emotional, or other important areas of functioning
C. The episode is not attributable to the physiologic effects of a substance or to another medical condition
D. The occurence of a major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and other unspecified schizophrenia spectrum and other psychotic disorders
E. There has never been a manic or hypomanic episode.
DSM 5 p286-287 Adjustment disorder
A. The development of emotional or behavioral symptoms in response to an identifiable stressor occuring within 3 months of the onset of the stressor
B. The symptoms or behaviors are clinically significant
C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting disorder
D. The symptoms do not represent normal bereavement
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months
Specify whether:
- With depressed mood: Low mood, tearfulness, feelings of hopelessness are predominant
- With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant
- With mixed anxiety and depressed mood: A combination of depression and anxiety is preodminant
- With disturbance of conduct
- With mixed disturbance of emotions and conduct: Both emotional symptoms (depression, anxiety), and a disturbance in conduct are predominant
- Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder
DSM 5 p288
If an individual has symptoms that meet criteria for a major depressive disorder in response to a stressor, the diagnosis of an adjustment disorder is not applicable. The symptom profile of major depressive disorder differentiates it from adjustment disorders. “
"What is the first visible sign of puberty in females? A. Growth of genital hair B. Beginning of menstruation C. Appearance of breast buds D. Growth acceleration"
C
“Nelson 21st p1014
In males the first visible sign of puberty and the hallmark of SMR 2 is testicular enlargement, beginning as early as 9.5yr, followed by the development of pubic hair. This is followed by penile growth during SMR 3. Peak growth occurs when testes volumes reach approximately 9-10cm3 during SMR 4.
In females, typically the first visible sign of puberty and the hallmark of SMR 2 is the appearance of breast buds (thelarche) between 7 and 12 yr of age. A significant minority of females develops pubic hair (pubarche) prior to thelarche. Menses typically begin within 3 yr of thelarche during SMR 3-4 (average age 12.5yr, normal range 9-15yr).
Females attain a peak height velocity of 8-9cm/yr at SMR 2-3, approximately 6mo before menarche. Males typically begin their growth acceleration at a later SMR stage, achieve a peak height velocity of 9-10cm later in the course of puberty (SMR 3-4), and continue their linear growth for approximately 2-3yr after females have stopped growing.”
"A male noted that his pubic hair became darker & started to curl, his penis was longer, & his testes were larger. What is his sexual maturity rating? A. 2 B. 3 C. 4 D. 5"
B
“Nelson 21st p1015 Table 132.3 Sexual maturity rating stages in males
SMR 1
- pubic hair: none
- penis: preadolescent
- testes: preadolescent
SMR 2
- pubic hair: scant, long, slightly pigmented
- penis: minimal change/enlargement
- testes: enlarged scrotum, pink, texture altered
SMR 3
- pubic hair: darker, starting to curl, small amount
- penis: lengthens
- testes: larger
SMR 4
- pubic hair: resembles adult type byt less quantity, coarse, curly
- penis: larger, glans and breadth increase in size
- testes: larger, scrotum dark
SMR 5
- pubic hair: adult distribution, spread to medial surface of thighs
- penis: adult size
- testes: adult size “
“Which of the following statements is TRUE of early adolescence?
A. Consolidation of sexual identity occurs.
B. There is a continuous struggle for acceptance of greater autonomy.
C. There is ambivalence as well as bids for increased independence.
D. There are increased sexual drives / urges with experimentation & questions about sexual orientation.”
C
“Choice A: Late adolescence
Choice B: Middle adolesence
Choice D: Middle adolescence
Nelson 21st p1015 Table 132.1 Milestones in early, middle, and late adolescent development
Early adolescence (10-13 yr)
Cognitive and moral
- concrete operations
- egocentricity
- unable to percieve long-term outcome of current decisions
- follow rules to avoid punishment
Self-concept/identity formation
- preoccupied with changing body
- self-consciousness about appearance and attractiveeness
Family
- increased need for privacy
- exploration of boundaries of dependence vs independence
Peers
- same-sex peer affiliations
Sexual
- increased interest in sexual anatomy
- anxieties and questions about pubertal changes
- limited capacity for intimacy “
“Which of the following statements is TRUE of teen pregnancies?
A. Most teenagers do not have major medical complications & deliver healthy infants.
B. The probability of twin pregnancies is higher compared to older women.
C. The majority of teen mothers deliver via caesarean section.
D. Stillbirths & miscarriages are seen in more than half of the cases.”
A
“Nelson 21st p1075
Although pregnant teens are at a higher-than-average risk for some complications of pregnancy, most teenagers have pregnancies that are without major complications, delivering healthy infants.
Teen mothers have low rates of age-related chronic disease (diabetes or hypertension) that may affect the outcomes of pregnancy. They also have lower rates of twin pregnancies than older women. They tolerate childbirth well with few operative interventions.
However, compared with 20-39 year old mothers, teens have higher incidences of low birthweight infants, preterm infants, neonatal deaths, passage of moderate to heavy fetal meconium during parturition, and infant deaths within one year after birth.
The higher rates of poor outcomes occur in the youngest and most economically disadvantaged mothers.
Gastroschisis, although rare, has a much higher incidence in infants of teen mothers, for reason that are unclear. Teen mothers also have higher rates of anemia, pregnancy-associated hypertension, and eclampsia.
The youngest teens also have a higher incidence of poor weight gain during their pregnancy. This correlates with a decrease in birthweights of their infants. Poor maternal weight gain also has correlated strongly with teens’ late entrance into prenatal care and with inadequate utilization of prenatal care. Sexually active teens have higher rates of STIs than older sexually active women. “
“A 16-year old female was a victim of statutory rape. The incident happened a day prior to consultation. Which of the following interventions is appropriate?
A. Pregnancy test upon parental consent
B. Antimicrobial prophylaxis
C. Vaginal lavage with saline solution
D. Anxiolytics for at least a week”
B
"A 5-year old male was found unconscious at home by his father while her grandmother was cooking on a wood-burning stove emitting smoke inside their home. He eventually awakened in the hospital but was confused, tachypneic, & tachycardic with traces of vomitus. What environmental substance should be considered? A. Hydrogen cyanide B. Nitrogen dioxide C. Carbon monoxide D. Hydrogen sulfide"
C
“Nelson 21st p620
Inhalation injury should be sustpected in a patient confined to a closed space, with a history of an explosion or decreased level of consciousness, or with evidence of carbon deposits in the oropharynx or nose, singed facial hair, and carbonaceous sputum
Evaluation aims at early identification of inhalation airway injuries, which may result from:
- Direct heat (greater problems with steam burns)
- Acute asphyxia
- CO poisoning
- Toxic fumes, including cyanides from combustible plastics.
Sulfur and nitrogen oxides and alkalis formed during the combustion of synthetic fabrics produce corrosive chemicals that may erode mucosa and cause significant tissue sloughing.
Signs of CNS toxicity caused by asphyxia or carbon monoxide poisoning vary from irritability to depression:
- Mild CO poisoning (<20% HbCO) - slight dyspnea, headache, nausea, decreased visual acuity and higher cerbral functions
- Moderate CO poisoning (20-40% HbCO) - irritability, agitation, nausea, dimness of vision, impaired judgment, rapid fatigue
- Severe (40-60% HbCO) - confusion, hallucination, ataxia, collapse, acidosis, coma
CO poisoning should be assumed until the tests are performed, and is treated for 100% oxygen. Significant CO poisoning requires hyperbaric O2 therapy.
Cyanide poisoning should be suspected if a metabolic acidosis persists despite adequate fluid resuscitation, or in environments containing synthetic polymers. “
“A 3-year old male ingested a battery with playing with it. Imaging studies confirmed its presence in the esophagus. Why is it considered a true emergency requiring endoscopic removal?
A. It can cause tissue necrosis due to continued electrical discharge.
B. The battery contains poisonous toxins which can be lethal.
C. Choking will ensue & the battery will not be expelled from the GIT.
D. The coating of the battery has mercury which is neurotoxic.”
A
”"”Nelson 21st p1943
Treatment of esophageal foreign bodies usually merits endoscopic visualization of the object and underlying mucosa and removal of the object using an appropriately designed foreign body-retrieving accessory instrument through the endoscope and with an endotracheal tube protecting the airway.
Sharp objects in the esophagus, multiple magnets or single magnet with a metallic object, or foreign bodies associated with respiratory symptoms mandate urgent removal within 12hr of presentation.
Button batteries, in particular, must be emergently removed within 2hr of presentation regardless of the timing of the patient’s last oral intake because they induce mucosal injury in as little as 1hr of contact time and involve all esophageal layers within 4hr
Asymptomatic blunut objects and coins lodged in the esophagus can be observed for up to 24hr in anticipation of passage into the stomach. “””
"Nipple pain is among the most common complaints of breastfeeding mothers. This is most commonly due to: A. Mastitis B. Inadequate milk supply C. Engorgement D. Poor infant positioning "
D
”"”Nelson 21st p322
Nipple pain is one of the most common complaints of breastfeeding mothers in the immediate postpartum period. Poor infant positioning and improper latch are the most common reasons for nipple pain beyond the mild discomfort felt early in breastfeeding. “””
“A first-time mother asked for practical tips in weaning. Which of the following recommendations is CORRECT?
A. The infant should learn to drink from a cup at around 12 months of age.
B. Phytate intake should be increased to enhance mineral absorption.
C. Give at least 30 ounces per day of cow milk.
D. Give no more than 2 ounces per day of unsweetened fruit juices.”
A
”"”Nelson 21st p326 Table 56.7. Important principles for weaning
- Begin at 6 mo of age.
- At the proper age, encourage a cup rather than a bottle.
- Introduce 1 new food at a time.
- Energy density should exceed that of breast milk.
- Iron-containing foods (meat, iron-supplemented cereals) are required.
- Zinc intake should be encouraged with foods such as meat, dairy products, wheat, and rice.
- Phytate intake should be low to enhance mineral absorption.
- Breast milk should continue to 12 mo of age; formula or cow’s milk is then substituted.
- Give no more than 24 oz/day of cow’s milk.
- Fluids other than breast milk, formula, and water should be discouraged.
- Give no more than 4-6 oz/day of 100% fruit juice; no sugarsweetened beverages.”””
“Why should bedtime feeding bottles be discouraged?
A. It increases the risk for aspiration & GERD.
B. The practice is associated with dental carries.
C. Absorption is decreased at night.
D. Bedtime feeding is directly related to obesity.”
B
”"”Nelson 21st p326
Bottle weaning should begin around 12-15 mo, and bedtime bottles should be discouraged because of the association with dental carries. Unless being used at mealtime, the sippy cup should only contain water to prevent caries. Sugar-sweetened beverages and 100% fruit juice should also be discouraged from being used in bottles in all infants at all times.”””
"A 17-year old male is 5 feet tall & weighs 50 kg. Based on his BMI, he is considered: A. Underweight B. Normal C. Overweight D. Obese"
B
”"”5 feet = 152.4cm = 1.52m
BMI = 21.64
Patient is 17 years old, so we can use adult criteria. BMI is normal
Nelson 21st p346
Adults with a BMI >=30 meet the criterion for obesity, and those with a BMI 25–30 fall in the overweight range.
Obesity and overweight are defined using BMI percentiles for children >=2 yr old and weight/length percentiles for infants <2 yr old. The criterion for obesity is BMI >=95th percentile and for overweight si BMI between 85th and 95th percentiles.
“””
"A 4-year old female was seen at the OPD with the following features: skin-&-bone appearance, old man facies, prominent rib cage & shoulders, loose skin on the upper arms & thighs, & loose buttocks with absent muscle mass. What is the most probable diagnosis? A. Marasmus B. Kwashiorkor C. Marasmus-kwashiorkor D. Acute severe malnutrition"
A
”"”Nelson 21st p336
Severe acute malnutrition is defined as severe wasting and/or bilateral edema. Other terms are marasmus (severe wasting), kwashiorkor (characterized by edema), and marasmic-kwashiorkor (severe wasting and edema).
Severe wasting is most visible on the thighs, buttocks, and upper arms, as well as over the ribs and scapulae, where loss of fat and skeletal muscle is greatest. Wasting is preceded by failure to gain weight and then by weight loss. The skin loses turgor and becomes loose as subcutaneous tissues are broken down to provide energy. The face may retain a relatively normal appearance, but eventually becomes wasted and wizened. The eyes may be sunken from loss of retroorbital fat, and lacrimal and salivary glands may atrophy, leading to lack of tears and a dry mouth. Weakened abdominal muscles and gas from bacterial overgrowth of the upper gut may lead to a distended abdomen. Severely wasted children are often fretful and irritable.”””
"What is the most characteristic manifestation of niacin deficiency? A. Dementia B. Dermatitis C. Diarrhea D. Dehydration"
B
“Nelson 21st p368-369
After a long period of deficiency, the classic triad of dermatitis, diarrhea, and dementia appears. Dermatitis, the most characteristic manifestation of pellagra, can develop suddenly or insidiously and may be initiated by irritants, including intense sunlight.”
"What is the most common cause of death among children with severe, uncorrected thiamine deficiency? A. Wernicke encephalopathy B. Cardiac failure C. Megaloblastic anemia D. Pseudotumor cerebri"
B
”"”Nelson 21st p365-366
Death from thiamine deficiency usually is secondary to cardiac involvement. The initial signs are cyanosis and dyspnea, but tachycardia, enlargement of the liver, loss of consciousness, and convulsions can develop rapidly.”””
"A 2-year old female was seen at the ER due to cramping peri-umbilical pain, nausea & vomiting. In the past month, he had repeated episodes of painless, bright red rectal bleeding & brick-colored stools. What is the most probable diagnosis? A. Volvulus B. Malrotation C. Intussusception D. Meckel diverticulum"
D
”"”Nelson 21st p1954-1955
The majority of symptomatic Meckel diverticula are lined by an ectopic mucosa, including an acid-secreting mucosa that causes intermittent painless rectal bleeding by ulceration of the adjacent normal ileal mucosa.
Less often, a Meckel diverticulum is associated with partial or complete bowel obstruction. The most common mechanism of obstruction occurs when the diverticulum acts as the lead point of an intussusception. The mean age of onset of obstruction is younger than that for patients presenting with bleeding.”””
“A 11-month old male had diarrhea for the past 2 days. At the ER, he drank eagerly, was restless & irritable. He weighed 7 kg, had sunken eyeballs, dry lips, clear breath sounds & flat abdomen. The skin pinch goes back slowly. What is the most appropriate initial management?
A. ORS (volume per volume) after each loose bowel movement
B. 400-600 ml ORS to be given in the first 4 hours
C. 30 ml ORS per kg to be given in 1 hour
D. 70 ml ORS per kg to be given in 4 hours”
B
“Moderate dehydration. Treat with IMCI plan B
Choice A is plan A
Choice B is plan B (although recommended is to give 450-600ml ORS)
Choice C and D is plan C
Nelsons 21st p429 Table 70.1. Clinical evaluation of dehydration
- Mild dehydration (<5% in an infant, <3% in an older child) - normal or increased pulse, decreased urine output, thirsty, normal physical findings
- Moderate dehydration (5-10% in an infant, 3-6% in an older child) - tachycardia, little or no urine output, irritable/lethargic, sunken eyes and fontanel, decreased tears, dry mucus membranes, mild delay in elasticicty (skin turgor), delayed capillary refill (>1.5 sec), cool and pale
- Severe dehydration (>10% in an infant, >6% in an older child) - peripheral pulses either rapid and weak or absent, decreased BP, no urine output, very sunken eyes and fontanel, no tears, parched mucuous membranes, delayed elasticity (poor skin turgor), very delayed capillary refil (>3 sec), cool and mottled, depressed consciousness
IMCI 2014 Chart Booklet p19 Plan B: Treat some dehydration with ORS
In the clinic, give recommended amount of ORS over a 4 hour period
Determine the amount of ORS to give during the first 4hrs Weight <6kg, up to 4mos: 200-450ml Weight <10kg, 4-12mos: 450-800ml Weight <12kg, 12mos-2yrs: 800-960ml Weight 12-19kg, 2-5yrs: 960-1000ml "
"A 3-week old male had intermittent vomiting. On examination, a firm, movable, olive-shaped, hard mass was palpable in the mid-epigastric region. What imaging study can best help confirm the diagnosis? A. Scout film of the abdomen B. Abdominal ultrasound C. Manometry D. Abdominal CT scan "
B
”"”Nelsons 21st p1947 Pyloric stenosis
The diagnosis has traditionally been established by palpating the pyloric mass. The mass is firm, movable, approximately 2cm in length, olive-shaped, hard, best palpated from the left side, and located above and to the right of the umbilicus in the mid-epigastrium beneath the liver edge.
Two imaging studies are commonly used to establish the diagnosis. Ultrasound examination confirms the diagnosis in the majority of cases. Criteria for diagnosis include pyloric thickness 3-4mm, an overall pyloric length 15-19mm, and a pyloric diameter of 10-14mm. Ultrasonography has a sensitivity of approximately 95%. When contrast studies are performed, they demonstrate an elongated pyloric channel (string sign), a bulge of pyloric muscle into the antrum (shoulder sign) and parallel streaks of barium seen in the narrowed channel, producing a double tract sign. “””
"Which of the following features best distinguishes Hirschsprung’s disease from functional constipation? A. Failure to thrive B. Encopresis C. Enterocolitis D. Onset after 2 years of age "
C
“Nelson 21st p1962 Table 358.9 Distinguishing features of Hirschsprung disease and functional constipation
FUNCTIONAL CONSTIPATION
Onset after 2 yrs Encopresis common Failure to thrive uncommmon Enterocolitis none Forced bowel traning usual
Abdominal distension uncommon Poor weight gain rare Rectum filled with stool Rectal examination: stool in rectum No malnutrition
Anorectal manometry reveals relaxation of internal anal sphincter
Rectal biopsy is normal
Barium enema shows massive amounts of stool with no transition zone
HIRSCHSPRUNG DISEASE
Onset at birth Encopresis very rare Failure to thrive possible Enterocolitis possible Forced bowel training: none
Abdominal distension common Poor weight gain common Rectum empty Rectal examination: explosive passage of stool Malnutrition: possible
Anorectal manometry reveals failure of internal anal sphincter relaxation
Rectal biopsy shows no ganglion cells
Barium enema shows transition zone with delayed evacuation of barium”
“A 2-day old term female had bilious emesis, feeding intolerance & distended abdomen. He had not passed out meconium. The plain abdominal radiograph showed distended bowel loops with a paucity of air in the rectum. What is the underlying pathology?
A. Invagination of the upper portion of the bowel into the lower part
B. Absence of ganglion cells in the submucosal & myenteric plexus
C. Large pellets of meconium blocking the colon
D. Exact cause is unknown but is believed to be multi-factorial”
B
“Choice A is intussussception: No mention of bloody stools in the question
Choice C is meconium ileus, which presents with ground-glass appearance on abdominal radiography
Nelson 21st p1962-1963
Hirschsprung disease is usually diagnosed in the neonatal period secondary to a distended abdomen, failure to pass meconium, and/or bilious emesis or aspirates with feeding intolerance. In 99% of healthy full-term infants, meconium is passed within 48hr of birth. Hirschsprung disease should be suspected in any full-term infant (the disease is unusual in preterm infants) with delayed passage of stool.
Hirschsprung disease is the result of an absence of ganglion cells in the bowel wall, extending proximally and continuously from the anus for a variable distance. The absence of neural innervation is a consequence of an arrest of neuroblast migration from the proximal to distal bowel. Without the myenteric and submucosal plexus, there is inadequate relaxation of the bowel wall and bowel wall hypertonicity, which can lead to intestinal obstruction.
Rectal suction biopsy is the gold standard for diagnosing Hirschsprung disease. An unprepared contrast enema is most likely to aid in the diagnosis in children older than 1mo of age because the proximal ganglioonic segment might not be significantly dilated in the first few wk of life. “
“A term male presented with jaundice on the third day of life with good suck & activity. The jaundice persisted into the third week of life. At this time, his stools were noted to be greyish in color. The definitive confirmation of the diagnosis can be established by:
A. Serologic tests for TORCH & hepatitis
B. Abdominal CT scan
C. HIDA scan
D. Surgical exploration
“
D
“Nelson 21st p2098-2099
Abdominal ultrasound is a helpful diagnostic tool in evaluating neonatal cholestatis because it identifies choledocholithiasis, perforation of the bile duct, or other structural abnormalities of the biliary tree such as choledochal cyst. In patients with biliary atresia, ultrasound can detect associated anomalies such as abdominal polysplenia and vascular malformations.
Percutanous liver biopsy is the most valuable procedure for evaluation of neonatal hepatobiliary diseases and provides the most reliable discriminatory evidence.
All patients with biliary atresia should undergo exploratory laparotomy and direct cholangiography to determine the presence and site of obstruction. “
“A 10-month old male presented with recurrent episodes of postprandial regurgitation, irritability, arching, choking / gagging, feeding aversion & hoarseness on crying. In the past 4 months, he was diagnosed with pneumonia thrice & was treated with antibiotics. What is the most probable diagnosis?
A. Allergy to the complementary foods given
B. Esophageal atresia
C. Gastroesophageal reflux disease
D. Sepsis”
C
“Nelson 21st p1935
Infantile reflux manifests more often with regurgitation (typically postprandially), signs of esophagitis (irritability, arching, choking, gagging, feeding aversion) and resulting failure to thrive. Symptoms resolve spontaneously in the majority of infants by 12-24mo.
Olderchildren can have regurgitation during the preschool years; this complaint diminishes somewhat as children age, and complaints of abdominal and chest pain supervene in later childhood and adolescents.
Occasional children present with food refusal or neck contortions (arching, turning of head) designated sandifer syndrome. “
“A 16-year old male, your regular patient since school-age, came for his annual adolescent check-up. As part of the adolescent health care, which of the following tasks is NOT necessary?
A. Tanner staging
B. Complete blood count
C. Examination of the spine to checking for scoliosis
D. Complete history taking (HEEADSS)”
B
”"”CBC not necessary since the patient has been your regular patient since school-age and presumably has had his CBC for middle adolescence at his annual checkup at 14 years old.
Prev Ped 2018 p16
During the annual visit, the adolescent should undergo the following:
- Complete history-taking to screen for risks and protective factors using the tool HEEADSSS
- Physical examination. In addition to the routine physical examinatinon, the following should be done:
- Tanner staging/SMR
- breast examination
- examination of the spine and shoulders, check for scoliosis and kyphosis
- inspection of the genitals and anus - Screening procedures
- CBC at every stage of adolesence
- UA on first encounter
- Vaginal wet mount, PAP smear for sexually active females
- Serologic test for syphilis for sexually active males, nonculture test for gonorrhea and chlamydia for sexually active males and females - Immunization update
- Anticipatory guidance and counseling
- Self breast examination for females
- healthy lifestyle: physical activity, diet, avoidance of alcohol, smoking, drug abuse
- sexual behavior and risk of acquiring STIs
- injury and accident prevention: use of sports protetive gear, seat belts, no driving under the influence of alcohol, no smoking in bed, no hand gun use
“””
"A 2-year old female came to the OPD to update her immunizations. She has received 3 doses each of Hepatitis B, DPT, IPV, HiB & PCV13, & 1 dose each of measles, varicella & MMR. Which of the following vaccines should be given? A. Varicella B. DPT/IPV/HiB C. MMR D. Rotavirus "
B
“Who among the following patients can be dewormed?
A. A 4-year old female with weight-for-height below -3z score
B. A toddler with a 2-day history of fever (39.3oC)
C. A school-aged child with profuse diarrhea
D. An 8-year old male who was hospitalized last week with pneumonia”
D
”"”Prev Ped 2018 p10-11
The WHO and DOH both recommend the use of either albendazole or mebendazole in the following doses and schedule
Albendazole
12-23 months: 200mg SD every 6 months
24 months and above: 400mg SD every 6 months
Mebendazole
12 months and above: 500mg SD every 6 months
Deworming must not be done in children with the following:
- severe malnutrition
- high grade fever
- profuse diarrhea
- abdominal pain
- serious illness
- previous hypersensitivity to antihelminthic drug “””
“A mother brought her 1year old son to the clinic because she is concerned that he cannot walk independently. She further disclosed that her first child, who is now an adolescent, was able to walk at one year of age which further adds to her anxiety. What is the appropriate next step?
A. Refer the child to a physical therapist
B. Investigate the cause of delay in the motor development
C. Tell her it is normal & observe if he is still unable to walk by 18 months of age
D. Explain that her first child had advanced gross motor development while the second child has delayed fine motor skills
“
C
”"”Gross motor red flag for not walking is 15 months (Prev Ped 2018 p19) or 18 months (Nelsons 21st p 158 Table 28.2)
Prev Ped 2018 p19
As children grow and develop, one needs to be mindful that each child develops at his/her own pace and the range of what is considered to be “”"”normal”””” is quite wide. However, there are absolute indicators often referred to as red flags that identify developmental markers suggesting the need for further neurodevelopmental evaluation”””
"At what age in years should routine blood pressure measurement in a well child start? A. 1 B. 3 C. 5 D. 7 "
B
”"”Prev Ped 2018 p7
The Pediatric Nephrology Society of the Philippines recommends routine BP measurement annualy for all children >3 years of age and adolescents. BP however should also be checked in every encounter on all ill patients and all patients at risk such as those with obesity, those taking medications known to increase BP, those with renal disease, history of aortic arch obstruction, diabetes. “””
“What is the recommended storage period for breast milk?
A. 4 hours refrigerated at 4oC
B. 24 hours at room temperature of < 25oC
C. 8 days at the freezer compartment of a 2-door refrigerator
D. 6 months at deep freezer with constant temperature of -20oC”
D
“Prev Ped 2018 p26
Breastmilk storage period
- Room temperature (<25C) - 4 hours
- Room temperature (>25C) - 1 hour
- Referigerator (4C) - 8 days
- Freezer compartment of a 1 door refrigerator - 2 weeks
- Freezer compartment of a 2 door refrigerator - 3 months
- Deep freezer with a constant temperature -20C - 6 months”
"A 5-year old male presented with high grade fever, swollen right eyelid, proptosis, limitation of movement of the eye, & edema of the conjunctiva. The empiric treatment should include: A. Ophthalmic steroids B. Ocular antihistamines C. Vancomycin & cefotaxime D. Incision & drainage"
C
“Preseptal cellulitis - no proptosis, normal ocular movements, normal pupil function
Orbital cellulitis - proptosis, limitation of eye movement, edema of the conjunctiva, inflammation and swelling of the eyelids with potentially decreased visual acuity
Nelson 21st p3392 Orbital cellulitis
Inflammation of the tissues of the orbit, characterized by the triad of proptosis, painful limitation of movement of the eye, and potentially decreased visual acuity, is termed orbital cellulitis. Edema of the conjunctiva (chemosis) and inflammation and swelling of the eyelids may be seen.
Ortbital cellulitis must be recognized promptly and treated aggressively. Hospitalization and systemic antibiotic therapy are indicated.
Antimicrobial agents should begin with IV ampicillin-sulbactam OR IV clindamycin plus ceftriaxone, cefepine or cefotaxime. In cases where there is suspicion for intracranial extension, vancomycin plus cefotaxime/ceftriaxone plue metronidazole should be given. “
“Retinopathy of prematurity has been specifically identified to result from which of the following factors?
A. Prematurity
B. Oxygen administration
C. Low birth weight < 1200 grams
D. Vascular endothelial growth factor”
D
“Nelson 21st p3377
Beginning at 16wk of gestation, retinal angiogenesis normally proceeds from the optic disk to the periphery, reaching the outer rim of the retina nasally at about 36wk and extending temporally by approximately 40wk. Injury to this process results in various pathologic and clinical changes.
The risk factors associated with ROP are not fully known, but prematurity and associated retinal immaturity at birth represent the major factors. Oxygenation, respiratory distress, apnea, bradycardia, heart disease, infection, hypercarbia, acidosis, anemia, and the need for transfusion are thought by some to be contributory factors. Generally the lower the gestational age, the lower the birthweight, and the sicker the infant, the greater the risk for ROP.
The basic pathogenesis of ROP is still unknown. Exposure to the extrauterine environment, including the necessarily high inspired oxygen concentrations, produces cellular damage, perhaps mediated by free radicals. Later in the course of the disease, peripheral hypoxia develops and vascular endothelial growth factors (VEGFs) are produced in the nonvascularized retina. These growth factors stimulate abnormal vasculogenesis, causing neovascularization to occur. Because of poor pulmonary function, a state of relative retinal hypoxia occurs. This causes upregulation VEGF, which, in susceptible infants, can cause abnormal fibrovascular growth. This neovascularization may then lead to scarring and loss of vision. “
“The current guidelines for the diagnosis of acute otitis media are more restrictive compared to the earlier recommendations. Which of the following features is NOT a diagnostic criterion?
A. Acute onset of symptoms
B. Presence of middle ear effusion
C. Signs of acute middle ear inflammation
D. Localized swelling of the ear canal”
D
”"”Nelson 21st p3421
A diagnosis of AOM according to the 2013 American Academy of Pediatrics guidelines should be made in children who present with:
1. Moderate to severe bulging of the TM or new onset otorrhea not caused by otitis externa
2. Mild bulging of the TM and recent (<48hr) onset of ear pain or intense TM erythema
A diagnosis of AOM should not be made in children without middle ear effusion.
Both AOM and OME are accompanied by physical signs of middle ear effusion, namely the presence of a least 2 of 3 TM abnormalities: white, yellow, amber, or blue discoloration; opacification other than that cause by scarring; decreased or absent mobility.
To support a diagnosis of AOM instead of OME in a child with MEE, distinct fullness or bulging of the TM may be present, with or without accompanying erythema, or, at a minimum, MEE should be accompanied by ear pain that appears clinically important.
In otitis media with effusion (OME), bulging of the TM is absent or slight or the membrane may be retracted; erythema is also absent or slight but may increase with crying or with superficial trauma to the external auditory canal incurred in clearing the canal of cerumen. “””
"A woman has 2 brothers with hemophilia A. What is the risk of hemophilia among her children? A. 25% for males B. 50% for males C. 25% for females D. None will be affected"
A
“Nelson 21st p2595
The genes for factors VIII and IX are carried near the terminus of the long arm of the X chromosome and are therefore X linked traits
Nelson 21st p645
In X linked disorders, males are more commonly affected than females. Female carriers of these disorders are generally unaffected, or if affected, they are affected more mildly than males.
In each pregnancy, female carriers have a 25% chance of having an affected son, a 25% chance of having a carrier daughter, and a 50% chance of having a child that does not inherit the mutated X linked gene.
Since affected males pass the X chromosome to all their daughters and their Y chromosomes to their sons, they have a 50% chance of having an unaffected son dthat does not carry the disease and a 50% chance of having a daughter who is a carrier. Male-to-male transmission excludes X linked inheritanec but is seen with autosomal dominant and Y-linked inheritance. “
"An infant has a midline cleft lip, polydactyly, ocular hypertelorism, microphthalmia, low set malformed ears, microcephaly & hypoplastic ribs. He most likely has: A. Patau syndrome B. Edwards syndrome C. Down syndrome D. Pierre-Robin syndrome"
A
”"”Trisomy 13, Patau syndrome
- Cleft lip often midline; flexed fingers with postaxial polydactyly; ocular hypotelorism, bulbous nose; low-set, malformed ears; microcephaly; cerebral malformation, especially holoprosencephaly; microphthalmia, cardiac malformations; scalp defects; hypoplastic or absent ribs; visceral and genital anomalies
- Early lethality in most cases, with a median survival of 12 days; ~80% die by 1 year; 10-year survival ~13%.
- Survivors have significant neurodevelopmental delay.
Trisomy 18, Edwards syndrome
- Low birthweight, closed fists with index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, narrow hips with limited abduction, short sternum, rocker-bottom feet, microcephaly, prominent occiput, micrognathia, cardiac and renal malformations, intellectual disability
- ~88% of children die in the 1st year; 10-year survival ~10%.
- Survivors have significant neurodevelopmental delay.”””
“Which of the following statements is TRUE of the manifestations of inborn errors of metabolism?
A. The affected infant is normal at birth & becomes symptomatic later on in life.
B. The majority of conditions are inherited as autosomal dominant traits.
C. Most genetic metabolic conditions are lethal.
D. The early appearance of clinical symptoms is inversely related to disease severity.”
A
"Delayed puberty in males is the absence of pubertal development at what age in years? A. 10 B. 12 C. 14 D. 16"
C
”"”Nelson 21st p2907
Delayed puberty is a failure of development of any pubertal feature by 13 yr of age in females and 14 yr of age in males
Delay or absence of puberty is caused by
- Constitutional delay: a variant of normal
- Hypogonadotropic hypogonadism: low gonadotropin levels as a result of a defect of the hypothalamus/pituitary gland
- Hypergonadotropic hypogonadism: high gonadotropic levels as a result of a lack of negative feedback because of a gonadal problem. Females may have isolated absence of adrenarche with normal breast development “””
"The thyroid profile of a 10-year old male showed increased T3 & T4 with decreased TSH. Which of the following clinical features is expected? A. Lid lag stare B. Mental retardation C. Delayed puberty D. Stunted growth"
A
“Nelson 21st p2930
Most pronounced differences in children may be related to growth and neuropsychologic systems. Tremulousness, headache, mood disturbances, behavioral swings, difficulties in sleep, decrease in attention span, hyperactivity, and a decline in school performance are common findings in childhood.
Stare and lid lag are common eye findings caused by increased sympathetic activity and can be seen in thyrotoxicosis of any cause, not just Graves diesease. In general, ocular symptoms in children with Graves tend to be milder than in adults, and they improve with the restoration of euthyroidism.
Childern with hyperthyroidism have an increase in cardiac output. Tachycardia, palpitations, increased systolic BP, and a widened pulse pressure are common cardiac manifestation. The skin is smooth and flushed, with excess sweating. Proximal muscle weakness is common.
Thyroid hormone stimulates bone resorption, leading to low bone density and increased fracture risk in patients with chronic hyperthyroidism. “
