ASIPP Pediatric Questions Flashcards
1
Q
- A 2-year-old child cannot raise his arm completely on
the right and has torticollis. He has no other congenital
abnormalities. Which of following is the most likely
diagnosis?
A. Slipped capital femoral epiphysis
B. Juvenile rheumatoid arthritis
C. Sprengel deformity
D. Amold-Chiari malformation
E. Cerebral palsy
A
- Answer: C
Explanation:
(Seidel, 5/e, p 762.)
A child with Sprengel deformity
cannot raise one arm completely due to a small and
elevated scapula. Torticollis (wry neck due to shortening
of the sternocleidomastoid muscle) often accompanies the
deformity. Adolescents with slipped capital femoral
epiphysis (SCFE) are often obese African American males
who present with thigh or knee pain. SCFE is a disorder of
unknown etiology that causes posterior and medial
displacement of the femoral head. Children with juvenile
rheumatoid arthritis (JRA) present with fever, salmoncolored
rash, arthritis, hepatosplenomegaly, nodules,
pericarditis, and iridocyclitis (may lead to blindness).
There is no diagnostic test for JRA, but the disease resolves
by puberty in the majority of children. Arnold-Chiari
malformation is an abnormality of neural tube closure.
Cerebral palsy (CP) is a nonprogressive disorder
resulting from a perinatal insult; it causes either a spastic
paresis of the limbs or extrapyramidal symptoms (chorea,
athetosis, ataxia). Patients with CP often have an
associated seizure disorder, mental retardation, and speech
or sensory defi cits
2
Q
1665.The most common cause of chronic pediatric pelvic pain is A. Giardia infection B. Endometriosis C. Psychogenic D. Sexual abuse in young childhood E. PME (Pelvic Migraine Equivalent)
A
- Answer: B
Source: Goodwin J, Board Review 2005
3
Q
1666.The most common form of abdominal pain in children is A. Abdominal Migraine B. Endometriosis C. Recurrent Abdominal Pain D. Irritable Bowel Syndrome E. Gas
A
- Answer: C
Source: Goodwin J, Board Review 2005
4
Q
1667. Which of the following fracture types is more suspicious of child abuse? A. Epiphyseal B. Diaphyseal C. Growth plate D. Metaphyseal E. Torus
A
- Answer: D
Explanation:
Metaphyseal fractures, such as bucket handle and corner
fractures are more likely in abuse situations. Other
common fi ndings in abuse include posterior rib, sternum,
spinous process fractures and fractures of different ages.
Source: Boswell MV, Board Review 2004
5
Q
1668. The most common malignant bone tumor in children is A. Osteosarcoma B. Ewing’s sarcoma C. Neuroblastoma D. Wilm’s tumor E. Leukemia
A
- Answer: A
Explanation:
Malignancies of the bone, with an average annual
incidence rate of 8.7 per million children younger than 20
years of age, comprised about 6% of childhood cancer. In
the US, 650-700 children and adolescents younger than 20
years of age are diagnosed with bone tumors each year of
which approximately 400 are osteosarcoma and 200 are
Ewing’s sarcoma. The two types of malignant bone cancer
that predominated in children are osteosarcomas and
Ewing’s sarcomas, about 56% and 34% of the malignant
bone tumors, respectively
Source: Boswell MV, Board Review 2004
6
Q
1669.Two weeks after a viral syndrome, a 9-year-old girl
presents to your clinic with a complaint of several days
of drooping of her mouth. In addition to the drooping of
the left side of her mouth, you note that she is unable to
completely shut her left eye. Her smile is asymmetric, but
her examination is otherwise normal. This girl likely has
A. Guillain-Barre syndrome
B. Botulism
C. Cerebral vascular accident
D. Brainstem tumor
E. Bell’s palsy
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, p 1893. McMillan, 3/e, p 1963.
Rudolph, 21/e, p 2366.
Bell’s palsy is an acute, unilateral facial nerve palsy that
begins about 2 weeks after a viral infection. The exact
pathophysiology is unknown, but it is thought to be
immune. On the affected side, the upper and lower face are
typically paretic, the mouth droops, and the patient cannot
close the eye. Treatment consists of maintaining moisture
to the affected eye (especially at night) to prevent keratitis.
Complete, spontaneous resolution occurs in about 85% of
cases, 10% of cases have mild residual disease, and about
5% of cases do not resolve.
Source: Yetman and Hormann
7
Q
1670. The most common form of abdominal pain in children is A. Pelvic infl ammatory disease B. Recurrent abdominal pain C. Abdominal migraine D. Mesenteric adenitis E. Appendicitis
A
- Answer: B
Explanation:
A. Pelvic infl ammatory disease is common in adult
females
B. Recurrent abdominal pain is the 2nd most common
benign pain syndrome in children, with an incidence of
about 10%.
C. Abdominal migraine is rare
D. Mesenteric adenitis is in the differential for
appendicitis.
E. Appendicitis is the most common reason for
exploratory laparotomy, with an incidence of 4/1000
children under the age of 14 years.
Source: Boswell MV, Board Review 2004
8
Q
1671. The most accurate pain assessment tools for preverbal children are A. Spatial scales B. Facial scales C. Numerical scales D. Physiologic measurements E. McGills Pain Questionnaire
A
- Answer: D
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
9
Q
- Your 6-year-old son awakens at 1:00 A.M. screaming. He
has been hyperventilating, tachycardic, and has dilated
pupils. He cannot be consoled, does not respond, and
is unaware of his environment. After a few minutes, he
returns to normal sleep. He recalls nothing the following
morning. The most likely diagnosis is
A. Seizure disorder
B. Night terrors
C. Drug ingestion
D. Psychiatric disorder
E. Migraine headache
A
- Answer: B
Explanation:
Reference: Behrman, 16/e, pp 16, 1829. McMillan, 3/e, p - Rudolph, 21/e, pp 34, 418, 2273.
Night terrors are most common in boys between the ages
of 5 and 7 years. The child awakens suddenly, appears
frightened and unaware of his surroundings, and has the
clinical signs outlined in the question. He cannot be
consoled by the parents. After a few minutes, sleep returns,
and the patient cannot recall the event in the morning.
Sleepwalking is common in these children. Exploring the
family dynamics for emotional disorders may be helpful;
usually pharmacologic therapy is not required, and family
reassurance is indicated.
Source: Yetman and Hormann
10
Q
1673.A 9-year-old child has developed headaches that are
more frequent in the morning and are followed by
vomiting. Over the previous few months, his family has
noted a change in his behavior (generally more irritable
than usual) and his school performance has begun to
drop. Imaging of this child is most likely to reveal a lesion
that is
A. Subtentorial
B. Supratentorial
C. Intraventricular
D. In the spinal canal
E. In the peripheral nervous system
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 1858-1862. McMillan, 3/e,
pp 1511-1513. Rudolph, 21/e, pp 2207-2210.
Between 50 and 60% of tumors of the nervous system in
children 4 to 11 years old are infrartentorial (posterior
fossa) and include cerebellar and brainstem tumors, often
either medulloblastoma or cerebellar astrocytoma. In
adults and infants, most intracranial tumors originate
above the tentorium; only 25 to 30% of brain tumors in
adults are subtentorial.
Source: Yetman and Hormann
11
Q
- Spina bifida occult is a congenital abnormality that is
present in what percent of the population?
A. 5%
B. 10%
C. 20%
D. 40%
E. 50%
A
- Answer: C
Explanation:
Isolated, clinically insignifi cant spina bifi da occult is
present in approximately 20% of the population
Source: Boswell MV, Board Review 2004
12
Q
1675. The most common benign pediatric pain syndrome is A. Headache B. Chest pain C. Limb pain D. Back pain E. Abdominal pain
A
- Answer: A
Explanation:
headache
Source: Boswell MV, Board Review 2004
13
Q
- The examination of a newborn’s back reveals a quartersize
“lump” of soft tissue overlying the lower spine.
Evaluation with ultrasound of this lesions may
A. Ebstein pearl
B. Mongolian spot
C. Cephalohematoma
D. Omphalocele
E. Occult spina bifi da
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, p 1803-1806. McMillan, 3/e, p
223-224. Rudolph, 21/e, p2185.
Mongolian spot is not related to any abnormality. Virtually
any abnormality (except Mongolian spots) over the lower
spine points to the possibility of occult spinal dysraphism.
This designation includes a number of spinal cord and
vertebral anomalies that frequently produce severe loss of
neurologic function, particularly in the region of the back,
the lower extremities, and the urinary system. Examples of
these abnormalities are subcutaneous
lipomeningomyelocele, diastematomyelia, hamartoma,
lipoma, tight fi lum terminale, tethered cord, dermal and
epidermal cysts, dermal sinuses, neurenteric canals, and angiomas. Occasionally, the loss of neurologic function
from such anomalies is mild and, as a result, easily
overlooked. Prompt evaluation of these lesions via CT,
MRI, or ultrasound is indicated.
Source: Yetman and Hormann
14
Q
- With regard to the fetal circulation
A. the right ventricle ejects one-third of the ventricular
output
B. it is arranged in series
C. placental blood is well oxygenated
D. 50 percent of the blood entering the pulmonary artery is
shunted to the aorta
E. 20 percent of the blood entering the pulmonary artery is
shunted to the aorta
A
- Answer: C
Explanation:
(Miller, 4/e. p 2078.)
The right ventricle ejects two-thirds of the combined
ventricular output. The adult circulation is arranged in
series; the fetal circulation is in parallel. Blood returning
from the placenta is well oxygenated. Approximately 95
percent blood entering the pulmonary artery is shunted
through the ductus arteriosus to the aorta.
Source: Curry S.
15
Q
1678.The maximum dose of bupivacaine for continuous epidural infusion in the neonate is A. 0.4 mg/kg /hour B. 0.8 mg/kg /hour C. 1.5 mg/kg /hour D. 5 mg/kg /hour E. 7 mg/kg /hour
A
- Answer: A
Explanation:
0.4 mg/kg/hr
Source: Boswell MV, Board Review 2004
16
Q
- A 4-year-old child falls from the back of a three-wheeled
vehicle, hitting his head. He experiences no loss of
consciousness. In the emergency room, he is alert and
oriented without focal fi ndings on examination. He has
blood behind his left tympanic membrane. CT scan of the
skull is likely to show
A. Subdural hematoma
B. Epidural hematoma
C. Intraventricular hemorrhage
D. Basilar skull fracture
E. Hydrocephalus
A
- Answer: D
Explanation:
Reference: Behrman, 16/e, p 1961. McMillan, 3/e, p 611.
Rudolph, 21/e, p2242-2244.
The history, signs, and symptoms as outlined in the
question are characteristics of a basilar skull fracture.
Those patients with rupture of the tympanic membrane
allowing otorrhea and those with rhinorrhea after the
injury are at increased risk of complications of infection.
For these children, a semi-upright position and
observation for 72 h for evidence of increased intracranial
pressure or infection without use of prophylactic
antibiotics is appropriate. Cerebrospinal fl uid (CSF)
drainage frequently stops within 72h. Drainage beyond 72
h can require surgical closure; the risk of complications
such as infection increases after this time.
Source: Yetman and Hormann
17
Q
1680.Of all of the scales described to measure pain in small
children, which scale is used best for children from 3 to
12 years of age
A. McGrath’s scale (nine faces depicting varying degrees
of pain)
B. Oucher scale
C. Visual analog scale (VAS)
D. McGill’s questionnaire
E. Numeric Pain Scale
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
18
Q
- A 9-year-old girl is brought to you with the complaint of
severe intermittent headaches for the last several months.
The physical examination, including a careful neurologic
examination, is normal. The following characteristics
support the diagnosis of childhood migraine in this
patient:
A. Strong family history of migraine
B. Frequently isolated to the occipital region
C. Frequently associated with attention defi cit hyperactive
disorder
D. Duration of headache more than 24h
E. Persistence of headache after sleep
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 1832-1834. McMillan, 3/e,
pp 679-680, 1931-1932, 2027-2029. Rudolph, 21/e, pp
2274-2276.
In contrast to adults, children with migraine
most often have “common” migraine: bifrontal headache
without an aura or diffuse throbbing headache of only a
few hours’ duration. As with adults, the headaches can be
terminated with vomiting or sleep. Family history is
frequently positive. Association with attention defi cit
hyperactive disorder is not common, but a relationship with seizure disorder can be seen.
Source: Yetman and Hormann
19
Q
- Pain assessment and measurement in children between
the ages of 2 and 7 years is best evaluated by
A. visual analogue scale rating
B. body movements and facial expressions
C. self-report
D. Oucher scale (faces scale)
E. All of the above
A
- Answer: D
Explanation:
(Ferrante, pp 487-488.)
Children between the ages of 2
and 7 years lack abstract thinking and the verbal skills
necessary to express their feelings of pain. Therefore,
nonverbal techniques are used to assess the intensity of
their pain. A practical, reliable, and easy-to-apply bedside
guide is a faces scale, such as the Oucher scale.
Source: Kahn and Desio
20
Q
1683.All the following statements concerning the fetal
hematologic system are true EXCEPT
A. physiologic anemia occurs at 1 month of age
B. fetal hemoglobin has P-50 of 19mmHg compared with
26mmHg for adult hemoglobin
C. fetal hemoglobin has a greater affi nity for O2, and this
manifests as decreased O2 delivery to the periphery
compared with adult hemoglobin
D. the decreased P-50 of fetal hemoglobin causes a shift to
the left of the oxygen dissociation curve
E. decreased release of oxygen by fetal hemoglobin is offset
by increased oxygen delivery provided by elevated hemoglobin
concentrations in neonates
A
- Answer: A
Explanation:
(Stoelting, Anesthesia and Co-Existing Disease, 3/e. p
583.)
There are differences between fetal hemoglobin and adult
hemoglobin that infl uence O2 transport and delivery. Fetal
hemoglobin has a greater affi nity for oxygen, which results
in a lower P-50 (19 mmHg) and causes a shift to the left
of the O2 dissociation curve. For these reasons, there is
decreased release of O2 to the periphery. However, there is
a greater amount of fetal hemoglobin, and this offsets the
increased affi nity by increasing delivery of O2. Physiologic
anemia occurs at about 2 to 3 months of age, when
production of adult hemoglobin begin in earnest.
Source: Curry S.
21
Q
1684.A previously healthy 7-year-old child suddenly complains
of a headache and falls to the fl oor. When examined in the
emergency room, he is lethargic and has a left central
facial weakness and left hemiparesis with conjugate
ocular deviation to the right. The most likely diagnosis is
A. Hemiplegic migraine
B. Supratentorial tumor
C. Todd’s paralysis
D. Acute subdural hematoma
E. Acute infantile hemiplegia
A
- Answer: E
Explanation:
Reference: Behrman, 16/e, pp 1854-1855. McMillan, 3/e,
pp 614-615, 1929,1931-1933. Rudolph, 21/e, pp 2246-
2248, 2257-2258, 2261, 2274-2275.
The abrupt onset of a hemisyndrome, especially with the
eyes looking away from the paralyzed side, strongly
indicates a diagnosis of acute infantile hemiplegia. Most
frequently, this represents a thromboembolic occlusion of
the middle cerebral artery or one of its major branches.
Hemiplegic migraine commonly occurs in children with a
history of migraine headaches. Todd’s paralysis follows
after a focal or Jacksonian seizure and generally does not
last more than 24 to 48 h. The clinical onset of
supratentorial brain tumor is subacute, with repeated
headaches and gradually developing weakness. A history
of trauma usually precedes the signs of an acute subdural
hematoma. Clinical signs of other diseases can appear
fairly rapidly, but not often with the abruptness of
occlusive vascular disease.
Source: Yetman and Hormann
22
Q
1685. Which of the following is a more common form of pain in children? A. Migraine headache B. Abdominal pain C. Chest pain D. Limb pain E. Back pain
A
- Answer: B
Explanation:
Abdominal pain is the second most common type of
benign
pain in children. Overall, headache is more common
(tension). Migraine headache occurs in about 5% of
children.
Source: Boswell MV, Board Review 2004
23
Q
- A 16-year old high school student was running track
and developed sudden pain in the leg with tenderness on
palpation and tingling. Subsequently, pain increased in
intensity with ankle swelling and erythema. MRI showed
no evidence of fracture but edema of muscles in the lower
leg was observed. The most likely diagnosis is:
A. Complex regional pain syndrome
B. Tarsal tunnel syndrome
C. Peroneal tenosynovitis
D. Compartment syndrome
E. Achilles tendonitis
A
- Answer: C
Explanation:
The sudden onset with exercise, swelling and tingling
suggest compartment syndrome. All the conditions may
cause leg and ankle pain. Different Achilles affl ictions
present with distinctive clinical features. Achilles tendon
tears can be sustained during a traumatic incident and can
mimic other tendonopathies. Tarsal tunnel syndrome
involves the motor and sensory branches of the tibial
nerve (L4 to S3) as it travels deep to the fl exor
retinaculum. Ischemia to the tibial nerve occurs after
fracture of the medial malleolus, calcaneus, or
sustentaculum tali. Continued distally, a “joggers’ foot” is
typically associated with medial plantar nerve entrapment
due to hyperpronation (eccentric loading) in long distance
runners. Impression occurs at the abductor hallucis
insertion with the patient complaining of symptoms from
the medial longitudinal arc to the toes during and after
exercise.
With the chronic compartment syndrome, the changes are
reversible and the involved muscles may be completely
normal between episodes. The patient’s initial complaint
includes a deep ankle pain over the anterolateral
compartments of the leg during or after a relatively long
period of exercise; the pain disappears with cessation of
activity. Symptoms often interfere enough to cause the
athlete to either rest or reduce the intensity of the activity,
and the symptoms may be reproduced by either
dorsifl exion or plantarfl exion of the foot. Patients with
recurrent exertion compartment syndrome are at risk for
developing peroneal muscle herniations at the fascial
tunnel in the anterolateral distal leg. This tunnel serves as
a hiatus and source of intercompartment relief of pressure
buildup.
In acute compartment syndrome, continued, mounting
pressure causes pain out of proportion, pulselessness, and
dramatic pain on passive stretching of the muscle in the
involved compartment; this causes irreversible tissue
necrosis.
Exertional compartment syndromes are often exerciseinduced,
and typically occur either chronically in well
trained athletes or acutely in individuals preforming
unaccustomed exercises, such as marching or prolonged
running. A compartment syndrome occurs when
increased pressure within a limited space comprises the
circulation to the contents of that space, resulting in
reduction of muscle and nerve profusion. In both traumatic and exercise-induced compartment syndromes,
the muscles
within the compartment enlarge with lactate and cause a
reduction in blood fl ow to the relatively small anterior and
lateral crural compartments. Muscle bulk increases by
20% after exercise. This is not to be confused with
anterior shin splint syndrome, which shows no pressure
elevation with the anterolateral compartment of the leg.
Individual variation in the relationship of muscle bulk to
the compartment volume may account for the
susceptibility of certain persons to exercise-induced
compartment syndrome. Even though the
pathophysiology of both forms of compartment syndrome
are essentially the same, the end result of the acute form
differs from that of the chronic. In both conditions,
ischemia resulting from abnormal pressure causes pain.
24
Q
- A 7 -year-old boy presents with a I-year history of pain
of the left anterior thigh. He has no history of trauma.
On physical examination, he has limited hip motion,
especially with abduction and internal rotation. A slight
limp is noticeable with ambulation. Pain is brought on by
activity and improves with rest. Which of the following is
the most likely diagnosis?
A. Osteochondrosis
B. Osgood-Schlatter disease
C. Muscular dystrophy
D. Rickets
E. juvenile rheumatoid arthritis
A
- Answer: A
Explanation:
A. Osteochondrosis is an uncommon disorder that affects
boys more than girls between the ages of 2 and 12.
* The hallmark is avascular necrosis of the capital femoral
epiphysis, which has the potential to regenerate new bone.
- Consequently, children with osteochondrosis are of
short stature and present with a painless limp.
B. Osgood-schlatter disease occurs in adolescence and is
usually self-limiting.
- It is due to patellar tendon stress, which causes pain in
the region of the tibial tuberosity especially when the
patient extends the knee against resistance.
C. Muscular dystrophy is characterized by progressive
weakness and muscle atrophy.
D. Rickets is attributed to vitamin D defi ciency and is
manifested by bowing of the long bones, enlargement of
the epiphyses of the long bones, delayed closure of the
fontanels, and enlargement of the costochondral junctions
of the ribs (rachitic rosary).
E. Juvenile rheumatoid arthritis is an infl ammatory
disorder that begins in childhood and may produce
extraarticular symptoms, including iridocyclitis, fever,
rash, anemia, and pericarditis.
Source: Seidel
25
Q
- A 16-year-old basketball player complains of pain in
his knees. A physical examination reveals, in addition to
tenderness, a swollen and prominent tibial tuberosity.
Radiographs of the area are unremarkable. The most likely diagnosis is
A. Osgood-Schlatter disease
B. Popliteal cyst
C. Slipped capital femoral epiphysis
D. Osteochondrosis
E. Gonococcal arthritis
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 2075-2076, 2080-2082, - McMillan, 3/e, pp 749, 2109-2110. Rudolph, 21/e,
pp 2432, 2437-2438.
This history is typical of Osgood-Schlatter disease.
Microfractures in the area of the insertion of the patellar
tendon into the tibial tubercle are common in athletic
adolescents. Swelling, tenderness, and an increase in size of
the tibial tuberosity are found. Radiographs can be
necessary to rule out other conditions. Treatment consists
of rest.
Osteochondrosis is avascular necrosis of the femoral head.
This condition usually produces mild or intermittent pain
in the anterior thigh but can also present as a painless
limp.
Gonococcal arthritis, although common in this age range,
is uncommon in this anatomic site. More signifi cant
systemic signs and symptoms, including chills, fever,
migratory polyarthralgias, and rash, are commonly seen.
Slipped capital femoral epiphysis is usually seen in a
younger, more obese child (mean age about 10 years) or in
a thinner, older child who has just undergone a rapid
growth spurt. Paid upon movement of the hip is
diagnostic.
Popliteal cysts are found on the posterior aspect of the
knee.
Source: Yetman and Hormann
26
Q
- A 3-year-old boy’s parents complain that their child has
diffi culty walking. The child rolled, sat, and fi rst stood at
essentially normal ages and fi rst walked at 13 months of
age. Over the past several months, the family has noticed
an increased inward curvature of the lower spine as he
walks and that his gait has become more “waddling” in
nature. On examination, you confi rm these fi ndings and
also notice that he has enlargement of his calves. This
child most likely has
A. Occult spina bifi da
B. Muscular dystrophy
C. Brain tumor
D. Guillain-Barre syndrome
E. Botulism
A
- Answer: B
Explanation:
Reference: Behrman, 16/e, pp 1873-1877. McMillan, 3/e,
pp 1972-1976. Rudolph, 21/e, pp 2289-2293.
The most common form of muscular dystrophy is
Duchenne muscular dystrophy. It is inherited as an Xlinked
recessive trait. Male infants are rarely diagnosed at
birth or early infancy since they often reach gross
milestone at the expected age. Soon after beginning to
walk, however, the features of this disease become more
evident. While these children walk at the appropriate age,
the hip girdle weakness is seen by age 2. Increased lordosis
when standing is evidence of gluteal weakness. Gower sign
(use of the hands to “climb up” the legs in order to assume
the upright position) is seen by 3 to 5 years of age, as is
the
hip waddle gait. Ambulation ability remains through
about 7 to 12 years, after which use of a wheelchair is
common. Associated features include mental impairment
and cardiomyopathy. Death due to respiratory failure,
heart
failure, pneumonia, or aspiration is common by 18 years
of age.
Source: Yetman and Hormann
27
Q
1690.Normal fetal circulation is characterized by all the
following EXCEPT
A. high pulmonary vascular resistance
B. low systemic vascular resistance
C. right-to-left shunting of blood through the foramen
ovale
D. right-to-left shunting of blood through a ventricular
septal defect (VSD) that closes functionally soon after
delivery
E. right-to-left shunting of blood via the ducts arteriosus
A
- Answer: D
Explanation:
Stoelting, Anesthesia and Co-Existing Disease, 3/e. pp 37-
38, 581-582.)
A ventricular septal defect (VSD) is not a normal
component of the fetal circulation pattern. VSDs
constitute
approximately 28 percent of congenital cardiac anomalies, and they are more common in premature infants. Twentyeight
percent of VSDs are small and will close
spontaneously. The symptoms of a large VSD include
tachypnea, tachycardia, failure to thrive, recurrent
pulmonary infections, and ultimately congestive heart
failure. If medical management is unsuccessful, surgical
treatment, which depends on the type of VSD, is
considered.
Source: Curry S.
28
Q
1691.Your 18-year-old college freshman reports of fever,
muscular pain (especially neck), headache, and malaise.
He describes the area from the back of his mandible
toward the mastoid space as being full and tender and
that his earlobe on the affected side appears to be sticking
upward and outward. Drinking sour liquids causes
much pain in the affected area. You quickly retrieve his
immunization card and suddenly realize that he has
failed to get vaccinated for
A. Mumps
B. Varicella
C. Rubella
D. Measles
E. Herpangina
A
- Answer: A
Explanation:
Reference: Behrman, 16/e, pp 817-820, 946-955, 961-962,
973-977. McMillan 3/e, pp 704, 1127-1130, 1134-1142.
Rudolph, 21/e, pp 1042-1045, 1053-1058, 1075-1079,
1223.
In addition to the fi ndings described, mumps typically
swells to the opposite side in a day or so after symptoms
appear on the fi rst side. Other fi ndings include redness
and swelling at the opening of Stensen’s duct, edema and
swelling in the pharynx, and displacement of the uvula on
the affected side. A rash would not be expected. Measles
presents in a child with a several day history of malaise,
fever, cough, coryza, and conjunctivitis followed by the
typical, widespread, erythematous, maculopapular rash.
Koplik spots, white pinpoint lesions on a bright red buccal
mucosa often in the area opposite his lower molars,
appear transiently and are pathognomonic. Symptoms of
rubella, usually a mild disease, include diffuse
maculopapular rash that lasts for 3 days, marked
enlargement of the posterior cervical and occipital lymph
nodes, low-grade fever, mild sore throat, and, occasionally
, conjunctivitis, arthralgia, or arthritis. Signs and
symptoms of varicella include a prodrome of fever,
anorexia, headache, and mild abdominal pain, followed 24
to 48 h later by the typical clear, fl uid fi lled vesicles
(dewdrop on a rose petal). The rash of varicella typically
starts on the scalp, face, or trunk. The lesions are pruritic
and appear in crops over the next several days, with old
lesions crusting over as new lesions develop. Herpangina
causes sudden (usually high) fever, headache, backache,
and, frequently, vomiting. Oral lesions are vesicles or ulcers
usually found on the anterior tonsillar pillars, but can
occur nearly anywhere in the mouth. They are caused by
an enterovirus for which vaccination is not available.
Source: Yetman and Hormann
29
Q
1692. The glomerular fi ltration rate reaches that of the adult by age A. 1 month B. 6 month C. 1 year D. 18 months E. 2 years
A
1692. Answer: C Explanation: (Miller, 4/e. pp 2469-2470.) By age 1 year glomerular fi ltration reaches the adult rate. Source: (Miller, 4/e. pp 2469-2470.)
30
Q
- The analogue chromatic continuous scale (ACCS) allows
a child to rate his or her pain according to
A. numbers
B. faces
C. color
D. words
E. pictures
A
- Answer: C
Explanation:
(Ferrante, p 488.)
Pain ratings can be reliably assessed
using an analogue chromatic continuous scale (ACCS),
which allows grading of a child’s pain into a numeric
value. The ACCS consists of a slide rule with graduated
shades of red. The brightness of the color represents the
intensity of pain. The child is asked to rate his or her pain
by moving a sliding line indicator onto the appropriate
color.
Source: Kahn and Desio
31
Q
- The following statements about thermoregulation in the
neonate are all true EXCEPT
A. neonates have a larger body surface area compared with
body weight than do adults
B. neonates have mature central thermoregulatory control
C. neonates have a specialized ability to produce heat
D. neonates have a very thin layer of subcutaneous fat
E. neonates cannot shiver to produce heat
A
- Answer: B
Explanation:
(Stoelting, Anesthesia and Co-Existing Disease, 3/e. pp
583-584.)
Neonates are particularly prone to hypothermia in the
operating room as their central thermoregulatory controls
are immature. They have a large ratio of body surface are
to body weight and lose heat more quickly than adults do.
Neonates also have less insulating subcutaneous fat than
do adults. Infants do not shiver to produce heat. Heat is
generated from the metabolism of the brown fat they
possess. Methods to prevent heat loss in neonates include
increasing the operating room temperature, warming
fl uids, heating and humidifying gases, covering exposed
body surfaces, and using radiant-heat tables in the
operating room.
Source: Curry S
32
Q
- Which of the following statements pertaining to control
of ventilation in neonates is true?
A. Hypoxia leads to sustained hyperventilation
B. Hypercarbia leads to sustained hyperventilation
C. The ventilatory response to hypercarbia in newborns is
mature at birth
D. With both hypoxia and hypercarbia, newborns respond
initially by hyperventilating but then start to hypoventilate
E. None of the above
A
- Answer: D
Explanation:
(Stoelting, Anesthesia and Co-Existing Disease, 3/e. pp
579-580.)
Control of ventilation in premature infants and neonates
is immature. When neonates are subjected to hypoxia or
hypercarbia, for 1 to 2 min, there is hyperventilation. After
this time, the neonate will hypoventilate and may even
become apneic. High levels of carbon dioxide may be a
respiratory depressant in neonates. Respiratory
depressants will act synergistically with the immature
response to ventilation. It must also be remembered that
oxygen consumption and carbon dioxide production in a
neonate are double those in an adult.
Source: Curry S
33
Q
- About 12 days after a mild upper respiratory infection,
a 12-year-old boy complains of weakness in his lower
extremities. Over several days, the weakness progresses
to include his trunk. On physical examination, he has the
weakness described and no lower extremity deep tendon
refl exes, muscle atrophy, or pain. Spinal fl uid studies
are notable for elevated protein only. The most likely
diagnosis in this patient is
A. Bell’s palsy
B. Muscular dystrophy
C. Guillain-Barre syndrome
D. Charcot-Marie-Tooth disease
E. Werdnig-Hoffmann disease
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, pp 1892-1893. McMillan, 3/e,
pp 1959-1965, 1972-1976. Rudolph, 21/e, pp 2281-2283.
The paralysis of Guillain-Barre occurs about 10 days after
a nonspecifi c viral illness. Weakness is gradual over days
or weeks, beginning in the lower extremities and
progressing toward the trunk. Later, the upper limbs and
the bulbar muscles can become involved. Involvement of
the respiratory muscles is life threatening. The syndrome seems to be caused by a demyelination in the motor and,
occasionally, the sensory nerves. Measurement of spinal
fl uid protein is helpful in the diagnosis; protein levels are
increased to more than twice normal, while glucose and
cell counts are normal. Hospitalization for observation is
indicated. Treatment can consist of intravenous
immunoglobulin, steroids, or plasmapheresis. Recovery is
not always complete. Bell palsy usually follows a mild
upper respiratory infection, resulting in the rapid
development of weakness of the entire side of the face.
Muscular dystrophy encompasses a number of entities that
include weakness over months. Charcot-Marie-Tooth
disease has a clinical onset including peroneal and intrinsic
foot muscle atrophy, later extending to the intrinsic hand
muscles and proximal legs. Werdnig-Hoffmann disease is
an anterior horn disorder that presents either in utereo (in
about one-third of cases) or by the fi rst 6 months of life
with hypotonia, weakness, and delayed developmental
motor milestones.
Source: Yetman and Hormann
34
Q
1697.The following idiopathic scoliosis would be most commonly found in girls age range: A. Birth to 3 years B. 4 to 10 years C. 11 to 18 years D. 19 to 25 years E. >25 years
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, pp 2083-2084. McMillan, 3/e,
pp 2117-2121. Rudolph, 21/e, pp 2000-2001.
The most common form of scoliosis is idiopathic
scoliosis. Three age ranges of idiopathic scoliosis exist:
infantile (which presents at birth to 3 years of age),
juvenile (presenting at 4 to 10 years age), and adolescent
(the most common form, accounting for 80% of cases and
presenting from 11 years and older). To diagnose this
condition, the back is viewed from behind, with the
patient in the standing position. The waist, shoulders, and
pelvis should be symmetric. The spine is examined for
symmetry or deformity. The patient is then asked to bring
the palms together in the front and bend at the waist.
Viewing the patient from behind will allow for
identifi cation of any humps, valleys, or other deformities
of the spine. Identifi ed abnormalities can be confi rmed
radiographically. Premenarchal girls with a curvature of
the spine of more than 20° on radiographs need close
follow-up every 4 to 6 months because the risk of
progression is high.
Source: Yetman and Hormann
35
Q
- Concerning sickle cell disease which of the following is
or are true? - About 25% of children with an average of 3 vaso-occlusive
crises a yea are addicted to opioid medication - 1 in 25 African Americans will develop sickle cell disease
- Bone marrow transplantation is no longer considered a
viable option due to an unacceptable infection rate with
HIV - Hydroxyurea increases the proportion of HBF in the
blood, minimizing the percentage of cells that can
‘sickle’
A
- Answer: D
Source: Goodwin J, Board Review 2005
36
Q
- Compared to the adult, which of the following correctly
characterize morphine pharmacokinetics in the neonate? - Free fraction is greater
- Clearance is increased
- Conjugation is decreased
- Half life is shortened
A
- Answer: B (1 & 3)
Source: Boswell MV, Board Review 2004
37
Q
- Advantages of acetaminophen over aspirin when used as
an analgesic in children include - lack of gastric irritation
- no association with Reye syndrome
- lack of platelet dysfunction
- complete absorption when administered rectally
A
- Answer: A (1, 2, & 3)
Explanation:
(Ferrante, p 490.)
Acetaminophen is widely used as an
analgesic in children of all ages. It is not associated with
Reye syndrome, as is aspirin. Other advantages over
aspirin include lack of gastric irritation, lack of platelet dysfunction, and lack of cross-sensitivity to aspirin.
Hypersensitivity is rare. A higher dose is recommended
for rectal use (15 to 20 mg/kg). Absorption of
acetaminophen is incomplete and unreliable when the
drug is administered rectally.
Source: Kahn and Desio
38
Q
1701.Regarding complex regional pain syndrome, which of the
following are true?
1. In children the female to male ratio is 4:1
2. In adults the female to male ratio is 1:1
3. In children the lower extremities are most often affected
4. In adults, the upper extremities are most often affected
A
- Answer: E
Source: Goodwin J, Board Review 2005
39
Q
1702.The main differences between adult and pediatric
migraine headaches are
1. In children, the headache is usually bilateral
2. Ophthalmoplegic migraine is the most common pediatric
migraine variant
3. . In children a migraines range from 1-48 hours in duration
where in adults the range is 4-72 hours
4. Basilar migraine is the least common (but most dangerous)
pediatric migraine variant
A
- Answer: B
Source: Goodwin J, Board Review 2005
40
Q
- Neonates are susceptible to respiratory suppression with
opioids because of - Decreased protein binding
- Increased blood brain barrier permeability
- Reduced GFR
- Immature hepatic enzymes
A
- Answer: E
Source: Goodwin J, Board Review 2005
41
Q
- In the pediatric population the most pain causing
problem in oncology is - Osteosarcomas
- End stage lymphoblastic leukemia
- Meningiomas
- Diagnostic Procedures and Treatment Protocols
A
- Answer: D
Source: Goodwin J, Board Review 2005
42
Q
- Compared to the adult, which of the following correctly
characterize morphine pharmacokinetics in the neonate? - Blood levels are lower
- Clearance is increased
- Conjugation is increased
- Half life is prolonged
A
- Answer: D (4 Only)
43
Q
- In the newborn
- Albumin levels are lower than in the adult
- Local anesthetics are less protein bound
- Drugs have decrease affi nity for fetal protein
- Drug free fractions are increased
A
- Answer: E (All)
44
Q
- The use of regional anesthesia in premature infants less
than 60 weeks of postconceptual age has been advocated
to reduce - retinopathy of prematurity
- intracranial hemorrhage
- stress reaction to surgery
- postoperative apnea
A
- Answer: D (4 Only)
Explanation:
(Miller, 4/e. pp 2119-2120)
Although the use of regional anesthesia has been
advocated to reduce the incidence of postoperative apnea
in premature infants less than 60 weeks of
postconceptional age, unequivocal data based on
prospective, randomized, blinded studies are still lacking.
Source: Curry S.
45
Q
1708.Which of the following are potential adverse effect associated with salicylate therapy: 1. Hypotension 2. Bronchial hyperactivity 3. Macular degeneration 4. Hyperglycemia
A
- Answer: A (1, 2, & 3)
Source: Jackson KC. Board Review 2003
46
Q
- Where “fi rst and Worst” Headaches are concerned in
children - A SAH is more likely to result from a AVM bleed than
from an aneurysm - Upper respiratory infections with fever is the most
common cause - New onset migraine is the second most common cause
- Viral meningitis can present without a fever, stiff neck
and a normal neuro exam
A
- Answer: E
Source: Goodwin J, Board Review 2005
47
Q
- Which of the following is true?
- Paraffi n is a good heating method in patients with rheumatoid
arthritis - Whirpool therapy is useful to patients with metastatic
bone disease - Patients with diabetic foot neuropathy should use heat
lamps for pain relief - Hot packs may be routinely applied for over an hour
A
- Answer: A
Explanation:
In a study of rheumatoid arthritis patients, statistically
signifi cant improvements in ROM and grip function were
noted after paraffi n treatment in conjunction with active
ROM exercises.
After 20 minutes, the temperature of the underlying tissue
is elevated 2°C at 1 cm and 1°C at a depth of 2 cm.
Prolonged exposure to hot packs may cause burns.
Temperatures above 50 degrees C may cause injury.
Patients with diabetic neuropathy may be relatively
insensate, which is a contraindication to heat therapy.
Malignancy is a contraindication to hydrotherapy.
Source: Shah RV, Board Review 2006
48
Q
1711.True statements regarding the use of opioids for pain
management in children include the following :
1. Minor side effects occur more commonly in children
than adults
2. The incidence of respiratory depression is directly related
to dose
3. Meperidine is preferred over morphine
4. Tolerance is an uncommon clinical problem in children
A
- Answer: C (2 & 4)
Explanation:
(Ferrante, pp 491-492.)
Meperidine is not routinely used
in infants and children because of prolonged elimination
half-life in neonates (6 to 39 h) and because repeated
administration may lead to an accumulation of the
normeperidine metabolite, which may produce CNS
excitation and seizures. The incidence of respiratory
depression with mu agonists is directly related to the dose.
Minor opioid side effects (e.g., nausea and vomiting)
occur no more frequently in children than in adults.
Tolerance is an uncommon clinical problem in children
when opioids are used in appropriate doses for short
periods of time.
Source: Kahn and Desio
49
Q
- Transcutaneous electrical stimulation
- Is based on the gate theory of pain
- Mechanistically activates large diameter afferent fi bers,
in order to suppress afferent small fi ber input into the spinal cord - High intensity, low frequency stimulation is thought to
work via a naloxone reversible mechanism - Low frequency, high pulse duration cause strong muscle
contractions
A
- Answer: E
Explanation:
The gate control theory explains the mechanisms of pain
relief associated with TENS treatment for many
conditions. Simply stated, this theory proposed the
existence of a gating mechanism in the dorsal horns of the
spinal cord, where there is an interaction between the
small-diameter, unmyelinated C fi bers, which mediate the
transmission of pain, and the larger-diameter, myelinated
A fi bers, which mediate sensation of light touch and
pressure.
High-intensity, low-frequency stimulation (frequently
referred to as “acupuncture-like TENS”) also appears to
offer pain relief, the effects of which can be reversed with
naloxone, an opiate antagonis
Central to the discussion of the rationale of TENS therapy
are its various stimulation parameters. Low-frequency and
high-pulse [width] energy cause strong, rhythmic muscle
contractions.
Source: Shah RV, Board Review 2006
50
Q
1713.The faces pain diagrams are appropriate for use with
which of the following types of patients?
1. The elderly
2. Children
3. Individuals with mental retardation
4. Postoperative patients on a ventilator
A
- Answer: E (All)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
51
Q
- Pain assessment scales for children that employ faces are
- McGrath’s
- CHEOPS
- Oucher
- DC Children’s
A
- Answer: B (1 & 3)
Source: Boswell MV, Board Review 2004
52
Q
- Which of the following are true? NMDA receptors in the
neonate and newborn are - Widely expressed in the nervous system
- Play a role in synaptic reorganization
- Are important in neuronal development
- Provide fast pain processing
A
- Answer: A (1,2, & 3)
Explanation:
NMDA receptors provide slow pain processing; AMPA
receptors provide fast response to painful stimuli
Source: Boswell MV, Board Review 2004
53
Q
- Which of the following are true?
- Full term infants habituate to repeated stimuli
- Premature infants demonstrate sensitization to noxious
stimuli - Neonates have well developed nociceptive afferent
system - Newborns are more sensitive to painful stimuli than
adults
A
- Answer: E (All)
54
Q
1717. Which of the following groups of patients are at risk for inadequate measurement? 1. Elderly 2. Pediatric 3. Burn patients 4. Low back pain patients
A
- Answer: E (All)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
55
Q
1718.Which of the following are true regarding migraine
headaches in children?
1. Migraine without aura more frequent than with aura
2. Prevalence of migraine is about 5% of children
3. Frequency about the same in boys and girls
4. Abdominal pain may be symptom
A
- Answer: E (All)
Source: Boswell MV, Board Review 2004
56
Q
1719.True statements concerning fl uid and electrolyte
management in pediatric patients include which of the
following?
1. Because of the greater hypoxic damage associated with
high blood glucose levels and the infrequent occurrence
of hypoglycemia in newborns, administration of a dextrose
containing solution is not recommended
2. During the fi rst days of life, term newborns need a
larger volume of maintenance fl uid per kilogram of
body weight than do older children
3. Replacement fl uid for defi cit and third-space loss should be hypotonic given the inability of young infants to
handle an excess sodium load
4. To minimize dehydration, restriction of fl uids in a neonate
should be less than 2 to 4 h
A
- Answer: D (4 Only)
Explanation:
(Miller, 4/e. pp 2108-2109, 2112-2113.)
The greater hypoxic damage associated with high blood
glucose levels has been shown only in animal studies.
Hypoglycemia in newborns is a real concern. Therefore,
administration of a dextrose containing solution is
recommended, but blood glucose levels should be
monitored to prevent hyperglycemia. Term newborns do
have a large ratio of body surface area to weight and a
higher metabolic demand. Their maintenance fluid
requirement, however, is usually lower during the first
days of life because of their inability to excrete excess
water. Replacement fluid for deficit and third-space loss
should be an isotonic solution because of the inability of
young infants to handle and eliminate excess free water
load; they are better able to handle an excess sodium load.
Source: Curry S.
57
Q
- Gastrointestinal absorption of drugs in infants may vary
from adults because in infants - Gastric mucosa is less developed than adults
- Emptying requires 6-8 hours
- Gastric acid production is less than adults
- Gastric emptying is biphasic
A
- Answer: A (1, 2, & 3 )
58
Q
- True statements regarding pain assessment in nonverbal
children include - neurophysiologic elements involved in pain perception
are present in preterm infants - undesirable physiologic responses can be caused by pain
in neonates - hormonal-metabolic responses to noxious stimuli are
present in preterm infants - neonates experience pain
A
- Answer: E (All)
Explanation:
(Ferrante, pp 486-487.)
Available data indicate that the
neurophysiologic and neurochemical components
necessary for the transduction, transmission, modulation,
and perception of nociception are present in term and
preterm infants. The hormonal-metabolic responses to
noxious stimuli are also intact. Similarly, undesirable
physiologic responses can be provoked by pain. Term and
preterm infants can undergo substantial changes in
hemodynamics, oxygen saturation, and intracranial
pressure in response to noxious surgical stimuli. Thus, in
contrast to previously held beliefs, the evidence suggests
that neonates experience pain and should be treated for it.
Source: Kahn and Desio
59
Q
1722.In which of the following situations should heat be
avoided
1. Tissues with inadequate vascular supply
2. Acute injury
3. Bleeding disorders
4. Regions of severely insensate tissue
A
1722. Answer: E Explanation: All of the above are contraindications to heat therapy, including scar tissue Source: Shah RV, Board Review 2006
60
Q
1723.The Children’s Hospital of Eastern Ontario (CHEOPS) pain assessment tool 1. Designed for postoperative pain 2. Was designed for neonates 3. Incorporates face pictures 4. Measures six items
A
- Answer: C (2 & 4)
Source: Boswell MV, Board Review 2004
61
Q
- Down’s syndrome is associated with
- a high incidence of congenital heart defects
- upper and lower airway abnormalities
- cervical neck instability
- sensitivity to atropine
A
- Answer: A (1, 2, & 3)
Explanation:
(Miller, 4/e. pp 968-969.)
Patients with Down’s syndrome (trisomy 21) have a high
incidence of congenital heart defects. They frequently also
have upper and lower airway abnormalities. In addition,
they may have atlanto-occipital instability (C1-C2). The
previously reported sensitivity to atropine has been
disproved.
Source: Curry S.
62
Q
1725.Which of the following is (are) characterize common migraine headache in children 1. Without aura 2. Usually unilateral 3. Abdominal pain common 4. Tinnitus and vertigo
A
1725. Answer: B (1 & 3) Explanation: Common migraine is without aura by defi nition, and is more often bilateral than in adults. Source: Boswell MV, Board Review 2004
63
Q
- True statements regarding the use of IV-PCA in children
include - it is safe and effective
- its use may be restricted by inability to activate the
pump - it can be used in children age 7 and older
- it is a universal therapy for postoperative pain control
in children
A
- Answer: A (1, 2, & 3)
Explanation:
(Ferrante, pp 496-497.)
IV-PCA appears to be safe and
effective in children and is frequently preferred by nursing
staff, parents, and particularly adolescent patients.
However, there are a small number of older children and
adolescents who may not wish to be bothered with selfmedication.
They may feel indifferent and even dissatisfi ed
with PCA and would rather receive analgesics by
traditional methods. Therefore, PCA is not a universal
therapy for postoperative pain control. IV-PCA can be
used in children as young as 7 years of age. However, it
may be restricted by age, developmental understanding of
the purpose of PCA, and inability to activate the pump in
the presence of muscular weakness or immobilization.
Source: Kahn and Desio
64
Q
- The Children’s Hospital of Eastern Ontario (CHEOPS)
pain assessment tool - Incorporates face pictures
- May not be useful for postoperative pain
- Was designed for children
- Measures six items
A
- Answer: C (2 & 4)
65
Q
1728.Which of the following medication regimens would be
appropriate for use in ventilated patient in an intensive
care unit?
1. Intravenous morphine and diazepam
2. Epidural morphine and local anesthetic with intravenous
diazepam
3. Intravenous fentanyl and midazolam
4. Epidural local anesthetic alone
A
- Answer: A (1, 2, & 3)
Explanation:
(Shoemaker, pp 796-799.)
Ventilated patients in an intensive care setting require
analgesia as well as sedation to alleviate anxiety and
promote sleep. Intravenous opioids and benzodiazepines
administered by infusion and supplemented with boluses
as needed are quite effective. Epidural analgesia should be
supplemented with intravenous benzodiazepines or other
sedating medications that will provide anxiolysis and
promote sleep.
Source: Kahn and Desio
66
Q
1729.Drug kinetics may be altered in infants, with infants having 1. Decreased total body water 2. Larger volumes of distribution 3. Smaller extracellular fl uid space 4. Lower peak blood levels
A
- Answer: C (2 & 4)
