GI/Nutrition Flashcards
List 2 indications that paediatricians should consider recommending probiotics for.
- Prevent antibiotic-associated diarrhea
- Shorten duration of acute infectious viral diarrhea
- Prevent necrotizing enterocolitis
- Decrease symptoms of colic (decreased daily crying time)
- Decrease some symptoms of IBS
Identify 2 functions of the colonic bacteria
- Contribute to the gut’s barrier function (↑mucin secretion, ↓gut permeability, modulate immune function)
- Metabolize malabsorbed carbohydrates into SCFAs = fuel for enterocytes
- Acidify colonic content
- ↑water absorption
Name the vitamin absorption, function, deficiency and toxicities.
Vitamin A, D, E, K, B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pyridoxine), B7 (biotin), B9 (folic acid), B12 (cyanocobalamin), C
Vitamin
Absorption
Function
Deficiency
Toxicity
Serum measure
Vitamin A
(retinol/ B-carotene)
Small bowel
Vision
Epithelium
Night blind
Keratomalacia
Bitot spots
Xerophthalmia
Hepatotoxicity
Hyperlipidemia
Alopecia
Ataxia
Cheilitis
HA/ IIH
Retinol
Retinol binding protein
Vitamin D
(cholecalciferol)
Small bowel
Skin
Regulate
Ca and PO4
Rickets
Hypocalcemia
HypoPO4
Hypercalcemia
Worsened milk-alkali syndrome
25-OH vit D
PTH
Vitamin E
Small bowel
Cell membrane antioxidant
Prolonged INR
abN bone dev
Coagulopathy
Hemorrhage
Alpha-tocopherol
Vitamin K
(phytonadione)
Small bowel
Activates clotting factors
Prolonged INR
Hemolysis
INR (for factors 2, 7, 9, 10)
Vitamin B1
(thiamine)
Jejunum
ATP synthesis
Pyruvate dehydrogenase cofactor
Refeeding and alcoholism
Wernicke enceph
Dry beriberi (dilated cardiomyopathy, Korsakoff psychosis)
none
Erythrocyte transketolase activity
Vitamin B2
(riboflavin)
Small bowel
Macronutrient metabolism
Iron absorption
Angular stomatitis
Cheilosis
Glossitis
Seb dermatitis
none
Erythrocyte glutathione reductase activity
Vitamin B3
(niacin)
Stomach
Small bowel
Precursor of NAD+/NADP+
DNA repair
Hormone synth
Pellagra (dermatitis, diarrhea, dementia, death)
Vasodilation
Pruritis
Myopathy
Headache
Urine niacin-methylated metabolites
Vitamin B6
(pyridoxine)
Jejunum
Hb synth
Nerve cell fxn
Glucose hemostasis
Dermatitis
Glossitis
Seizures
Anemia
Ataxia
Sensory neuropathy
Pyridoxal phosphate
Vitamin B7
(biotin)
Small bowel
Coenzyme
Dermatitis
Alopecia
Ataxia
Seizures
None
Biotin level
Vitamin B9
(folic acid)
Small bowel
DNA synth/repair
RBC prod
Neural tube formation
Neural tube defects
Anemia
Growth delay
Diarrhea
weakness
Rare
Folate level
Vitamin B12
(cyanocobalamin)
TI
Needs intrinsic factor
Hb synthesis
Macro anemia
Weakness
Paresthesia
(risk pernicious anemia if crohns, gastritis, bariatric surgery, TI Surg)
None
B12 levels
Methylmalonic acid
Homocysteine
Vitamin C
(ascorbic acid)
Ileum
Collagen synth
(wound healing)
Scurvy (anemia, gingival bleeding, perifollicular hemorrhage, poor wound healing)
Rare
(avoid supp if renal failure, iron overload, warfarin)
Ascorbic acid
What are causes of Protein Losing Enteropathy?
What are the symptoms?
How to diagnose?
- PLE = Abnormal protein loss from GI tract
- Causes:
- Abnormal protein leakage across the gut
- Ie. mucosal erosion, gut inflammation
- Decreased protein uptake by lymphatic system
- Ie. Post-Fontan
- Lymphatic obstruction
- Ie. Intestinal lymphangiectasia
- Metabolic
- Ex. congenital disorders of glycosylation
- Abnormal protein leakage across the gut
- Causes:
- Symptoms:
- Diarrhea: fat and/or carbohydrate malabsorption
- Edema: dependent, extremity, facial
- Pleural or pericardial effusion
- Diagnosis:
- Labs
- Low serum proteins (albumin, A1AT, ceruloplasmin, transferrin)
- Malabsorption of fat-soluble vitamins (ADEK)
- Hypogammaglobulinemia (IgA, IgG, IgM)
- Lymphocytopenia
- Normal UA (no urine protein loss)
- Normal liver function (ie. not low production b/c liver disease)
- Diagnostic:
- 24hr collection = elevated stool a1-antitrypsin or fecal calprotectin
- Small bowel contrast study
- “Stacked coins”—thickened or edematous folds
- Endoscopy for mucosal inflammation
- Labs
What is the presentation and management of H pylori?
- Most common cause of gastritis (50% of population)
- Risk factors:
- Developing countries, crowded living, no running water, low SES
- Colonizes stomach and has T cell response with bacteria that release urease
- Leads to epithelial damage and inflam
- Presentation
- Peptic ulcer disease, iron deficiency anemia, reflux
- Diagnosis:
- Gold standard = endoscopy with biopsy
- Nodularity in stomach with cobblestone appearance
- Urea breath test
- Stool antigen
- Gold standard = endoscopy with biopsy
- Treatment:
- Triple therapy = amoxicillin + clarithromycin + PPI x 14 days
(Picture of gastroschisis) Which of the following anomalies is associated with this condition: a. Intestinal atresia b. Renal anomaly c. Cardiac anomaly
a. Intestinal atresia Right of umbilicus - defect in abdominal wall (vs omphalocele which herniate abdominal contents in sac through umbilicus) -1/10 babies have intestinal atresia (omphalocele has cardiac, renal, neural tube defects, genetic associations)
(AXR with a large bubble of stomach gas and a second bubble of gas to the left of this, no gas distally) a. What is this XR sign called? b. What diagnosis is this consistent with? c. What syndrome is often associated with this diagnosis? d. What specific heart lesion are babies with this syndrome at risk for?
a. What is this XR sign called? double bubble b. What diagnosis is this consistent with? congenital duodenal atresia c. What syndrome is often associated with this diagnosis? Trisomy 21 d. What specific heart lesion are babies with this syndrome at risk for? AV canal defects
A 16 year old female presents with decreased appetite and weight loss. There is a height-weight discrepancy. She has an anal fissure. What is the most appropriate investigation: a. UGI and small bowel follow through b. psychiatry consult c. barium enema
a. UGI and small bowel follow through - now probably more likely to do MRE if available - chronic anal fissures are associated with Crohn’s - UGI can show aphthous ulcers, strictures, fistulae
5 yo with cough and fever. Crackles on the RLL. CXR shows either diaphragmatic eventration vs hernia. What is the best next test for diagnosis? a. Diaphragm fluoroscopy b. Ultrasound c. Exploratory laparotomy d. MRI
b. Ultrasound U/S can help differentiate CDH from diaphragmatic eventration (weakness of diaphragm, but not a hole in diaphragm - can be acquired from phrenic nerve injury or congenital); on U/S see paradoxical movement of hemidiaphragm in eventration
13 year old with early morning throat pain. Parents comment that she has bad breath. What would you do: A) upper GI B) Abdo u/s C) CXR D) pH probe
D) pH probe - best option of these to assess for GERD
An 8 month old child is admitted for viral gastroenteritis. The child has intermittent episodes of screaming and vomiting. On examination the child is pale and lethargic. Which of the following examinations is most useful in diagnosis of this patient: a. AXR b. Serum lactate c. Air enema
c. Air enema - diagnostic and curative for intussusception; air preferred to saline/contrast as lower risk of perforation
A 6 year old boy tells his mother that he has swallowed a nickel. You do an abdominal XR and see a round radioopaque round object in the stomach. What is your management: a. Observation b. Upper endoscopy and removal c. Cathartics
a. Observation - once in stomach, 95% of FBs pass spontaneously - take the batteries and sharp objects out of trachea stat, otherwise can observe x24h for passage into stomach
Child with Foreign body in the esophagus. List 3 indications for removal
Battery Sharp object blunt object not passing into stomach in 24h meat not passing into stomach in 12h 70% esophageal FBs remain trapped
Best test of hepatic synthetic function? a. AST b. ALT c. INR d. Alk Phos e. GGT
c. INR assessment of liver synthetic function: increased PTT, INR that does not correct with vitamin K
Confirmation of milk intolerance a. D-xylose b. jejunal biopsy c. milk RAST test d. serum IgE e. milk challenge
e. milk challenge - gold standard for CMPI a. D-xylose - test for malabsortion b. jejunal biopsy - test for lactase deficiency c. milk RAST test - aka specific IgE test - use in suspicion of IgE mediated CMPI d. serum IgE - not useful
A child presents with watery diarrhea. Stool reducing substances will NOT be positive with which of the following: a. glucose b. sucrose c. fructose d. lactose e. galactose
b. sucrose - acidic stool with 2+ reducing substances suggests carbohydrate malabsorption - reducing substances include all in question plus pentose but NOT sucrose - basic concept: you need an enzyme to convert disaccharides to monosaccharides (the small intestine can only absorb monos, not disaccharides); SO if you don’t have this enzyme you have a bunch of disacchs which end up in the colon. In the colon they get converted to methane and organic acids (reducing substances) which cause osmotic diarrhea
What 4 screening tests would you order in a child with suspected celiac disease?
- anti-TTG IgA antibodies (can be unreliable in < 2 y.o. because relative IgA deficiency) - IgA level (if low, TTG can be falsely negative) - CBC, B12, iron studies Consider: - IgG anti-deamidated gliadin peptide antibodies (useful if IgA deficient) - if TTG antibodies are positive but <10x the ULN, should have upper GI scope - if >10x ULN should have anti-endomesial antibody testing (EMA)
Kid with CP presents with difficulties swallowing. She is tolerating her GT feeds but has difficulty managing her oral secretions. Of note, she got Botox injections to her legs last week. On exam, she has oral secretions and her legs feel less hypertonic. What do you do: a. pH probe b. do a swallow study c. observe in hospital
ANSWER: c. observe in hospital (assuming due to botox) b. do a swallow study (can esp if you think achalasia) Botox can cause systemic effects beyond just local injection, including dysphagia
Newborn post repair for TEF with esophageal atresia, persistent respiratory distress. 3 possible diagnoses
- tracheomalacia (almost always associated with TEF) - refistulization - GERD - cardiac anomaly (VACTERL)
A 1 month old has progressive non-bilious vomiting. On exam, there is a small palpable olive in the RUQ. What would be the most likely lab abnormality? a. metabolic acidosis b. respiratory acidosis c. hypokalemia d. alkalotic urine e. hypernatremia
c. hypokalemia Pyloric stenosis Hypochloremic, hypokalemia metabolic alkalosis - puke out HCl, Na and K; RAAS kicks in and preserves Na at expense of K
What is true about intussusception? a) Meckel’s diverticulum is the most common lead point b) 75% of cases are idiopathic c) most patients present with red currant jelly stools
ANSWER: b) 75% of cases are idiopathic - most UTD version of Nelson’s says 90% idiopathic c) most patients present with red currant jelly stools - blood is usually passed in the first 12 hours, though sometimes not for 1-2 days (normal stools are often still passed in the first few hours of symptoms)
Infant has problem of vomiting with feeds and chronically wheezy. Upper GI shows indentation of upper esophagus. What are two diagnoses you consider (2)?
Ddx of wheeze, vomiting and indentation of esophagus: - vascular ring - pulmonary artery sling
2 indications for fundoplication in 6 mo child with GERD.
- refractory esophagitis - strictures - chronic pulmonary disease
Mother has two month old child who is fed 6-8 0z of formula every 6 to 8 hours. The baby spits up with feeding and is irritable. What are four recommendations to help alleviate this problem without medication?
- reduce volume of feeding 2. increase frequency of feeding 3. feed baby in more upright position 4. take breaks during feed to burp baby to allow for pacing 5. keep baby upright for 30 minutes after feed, and position prone or upright when awake
Pyloric stenosis: lyte abN a. Hyperkalemia b. Metabolic acidosis c. Hypochloremia d. Hyponatremia
c. Hypochloremia Hypochloremia, hypokalemia metabolic alkalosis
Kid vomiting recurrently, missing lots of school, mom has headaches. Most likely cause? a. abdominal migraines b. benign paroxysal vertigo c. separation anxiety
a. abdominal migraines
8 month male, quadriplegic, has GER treated with ranitidine. FTT. NG placed, starting to grow, doing well with NG. Next to consider? a) g-tube b) J-tube c) pH probe d) G-tube + nissen fundoplication
a) g-tube GT indications include FTT, severe GERD, neurologic impairment.
3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do: 1. Give hydrochloric acid IV 2. OR immediately 3. Give large amounts of chloride IV 4. Give 5mmol/kg of KCl IV bolus 5. Give ascorbic acid IV
- Give large amounts of chloride IV Correct alkalosis pre-OR to prevent post-op apnea (compensate for metabolic alkalosis by not breathing)
Oral rehydration in kid with mod dehydration a) 100cc/kg over 4h b) 50cc/kg over 4h c) NS bolus 20cc/kg
a) 100cc/kg over 4h - Mild 50cc/kg over 4 hours or Moderate 100cc/kg over 4 hours, 5-10cc at a time - severe- bolus then ORT
days post scoliosis surgery. Presents with bilious vx. Etiology? a. SMA syndrome b. Small bowel adhesions c. Pancreatitis
a. SMA syndrome Superior mesenteric artery syndrome - compression of duodenum by SMA against aorta
Child with CP and GERD. Name 2 tests to confirm this diagnosis. Name 4 severe complications of GERD.
- Tests to confirm: pH monitoring - intraluminal impedence - ?trial of PPIs and evaluate for symptom response 2. Complications: - Barrett’s esophagus - strictures - aspiration pneumonia - laryngeal edema/granulomas
A 14 year old black male with one year history of intermittent abdominal pain and some diarrhea. a. unlikely a primary lactase deficiency b. if reducing substances are negative then a disaccharidase deficiency is ruled out c. try avoiding milk d. do a breath hydrogen test e. do a hemoglobin electrophoresis
ANSWER: c. try avoiding milk a. primary lactase deficiency includes congenital and non-persistence of lactase enzyme (most common cause - 85% of black adults have this) d. could also do a breath hydrogen test, but not considered necessary for diagnosing lactose intolerance
Why do you treat Salmonella bacteremia in a 2 month old child? a) To eliminate the carrier state b) To decrease the duration of symptoms c) To prevent meningitis d) To eliminate shedding from the GI tract
c) To prevent meningitis Salmonella gastro (not bacteremia) does not need to be treated and is poorly responsive to treatment since the infection is in the enterocytes and antibiotics cannot act on it (also abx prolong excretion/shedding, do not shorten duration of sx and can create chronic carrier state). ABC for immunocompromised and babies <3 months only
A 12 yo girl presents with >5 days of fever, unwell. Hepatomegaly. HR 85 despite the temperature of 39.5, BP normal. CBC und urine tests normal. Blood culture shows gram negative bacilli. What is the cause? a) pyelonephritis b) ovarian torsion c) typhoid fever
c) typhoid fever - salmonella enterica typhi
A previously well 13-month-old presents with generalized puffiness and lethargy. Urine is negative for protein & blood. Albumin is 13. Initial treatment would include: a. steroids b. IV albumin c. Protein hydrolysate formula d. Lactose free formula
c. Protein hydrolysate formula (ddx of protein losing enteropathy is milk protein allergy)
Shwachman-Diamond Syndrome baby. Which vitamin level would be normal? a. Vit A b. Vit e c. Vit B12 d. Vit D
c. Vit B12 - abnormalities: cytopenias (esp neutropenia), exocrine pancreas dysfunction (do not absorb fat soluble vitamins), bony (short stature, metaphyseal dysostosis, dental anomalies)
A 3 mos girl BW SGA at 2200g at GA38, now wt 10th, ht 25th, HC 50 th. Which is true? 1. 2 yr for catch up growth in IUGR 2. f/u in 6 mos no nutritional intervention 3. need w/u for organic FTT 4. increase dietary protein 5. if not at 50 th %ile by 6 months then needs work up for organic FTT
- 2 yr for catch up growth in IUGR
2 year old M suspected of having Celiac disease. What is the most definitive test? a) Jejunal Bx b) Anti-gliadin Ab’s c) Anti tissue transglutaminase Ab’s d) Gluten free diet
a) Jejunal Bx
a 6 mo baby with FTT is very irritable. Was breastfed initially and solids were introduced at 4 months of age. What is the likely diagnosis? a) Celiac disease b) CF c) Cow’s milk allergy
a) Celiac disease
Child with FTT, abd distention, wasted limbs and buttocks, irritable. Diagnosed with Celiac disease. List 4 other causes of small intestinal flat villi besides celiac dz.
- giardiasis - bacterial overgrowth - crohn’s - HIV enteropathy - lymphoma
Name 3 atypical presentations of celiac disease. List 2 conditions that are associated with celiac disease.
- dermatitis herpetiformis - iron deficiency anemia, unresponsive to iron supplements - osteoporosis 2. T1DM hypothyroidism T21, Williams, Turners
Baby with delayed meconium passage, abdo distension and calcifications on AXR a) Hirschprungs b) CF c) duodenal atresia
b) CF - meconium peritonitis: intrauterine rupture of bowel leads to peritoneal calcifications
A 6 year old boy presents to your office with a history of diarrhea and periorbital edema. He is found to have an albumin of 24 (or 12). Name 4 diagnoses on your differential.
- IBD - CMPA/FPIES - giardiasis - celiac disease
A mother brings in her 13-month-old child because he seems to have been getting a diaper rash and diarrhea with the introduction of new foods over the past couple months. 1. arrange for skin testing and RAST 2. carbohydrate intolerance is a common cause 3. it is due to sensitization to cow’s milk protein 4. citrus fruits and tomatoes can cause this via an immune-mediated mechanism 5. if mucous is not present in the stool then it cannot be an immune problem
- carbohydrate intolerance is a common cause - Loose watery diarrhea, flatulence, abdominal distention and pain · With onset of new foods (fruits)
12 month old child who has passed 3 soft red stools in the past 12 hours. He is asymptomatic. The same thing happened 4 months ago but resolved. His Hb is now 70. Investigation? a. Upper endoscopy b. UGI series c. Nuclear med scan for ectopic gastric tissue
c. Nuclear med scan for ectopic gastric tissue - Meckels diverticulum causes 50% of lower GI bleeds in kids under 2 - presents with painless rectal bleeding
2-week old child with a 1 week history of stool mixed with blood in an infant? Bottlefeeding well, passed stool in first 24 hours. Most likely dx? a. anal fissure b. cow milk protein allergy enterocolitis c. Meckel’s diverticulum
b. cow milk protein allergy enterocolitis - would say fissure most likely, but ongoing x1 week and to have fissure start at only 1 week of life seems unusual
A 2 yo is in the ER with bright red rectal bleeding. He is pale-looking but otherwise well. He does not appear to be in any discomfort. On rectal exam, you find blood mixed with stool on your glove. Hemoglobin is normal. What is the most likely diagnosis? a) ulcerative colitis b) Meckel’s diverticulum c) Anal fissures d) Bleed from peptic ulcer
b) Meckel’s diverticulum
2 week old girl with rectal bleeding. HR 220, BP 60/35, abdomen tense and sensitive. What is the next step in your diagnostic approach: 1. Call general surgery 2. Abdominal ultrasound 3. IV antibiotics 4. Abdominal x-ray 5. Barium swallow with small bowel follow through
- Abdominal x-ray
1 mo old baby with blood mixed in with his stool. Cause? a . Anal fissure b. Cows milk allergy c. Colitis d. Mat blood
a . Anal fissure Anal fissure is most common cause of rectal bleeding in kids under age 1; second most common is cow’s milk allergy
What are 2 surgical complications of HSP
- intussusception 2. intestinal perforation
3 month old boy comes in for routine newborn care. The mother describes symptoms of URTI and mentions that when he has coughed on two recent occasions, she has noticed a swelling protruding from his anus [picture of rectal prolapse]. List the most likely underlying etiology.
- most cases are idiopathic - onset between 1-5 years of age and resolves by 3-5 years of age - ix: rule out CF and sacral nerve root lesions
An 8 month old baby presents with an abdominal mass, thrombocytopenia, systolic murmur and a murmur over the liver. Ultrasound shows a 3 cm mass in the liver. What would you do? a) DIC work-up b) Bone marrow c) Pulmonary imaging d) Liver function tests
a) DIC work-up - in Kasabach Merritt get rapidly enlarging hemangioma, TCP, hypofibrinogen/coagulopathy - clotting cascade gets activated within vasculature of hemangioma
Neonate, now two weeks old, with abdominal mass palpable. Has a history of umbilical catheterization. What is the cause of hepatosplenomegaly? a) Portal vein thrombosis b) Infection
a) Portal vein thrombosis
2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause? 1. hepatic hemangioma 2. portal vein thrombosis 3. hereditary spherocytosis 4. congenital CMV 5. fungal infection
- portal vein thrombosis
Child with abdo pain, periumbilical, nonradiating. Physical exam normal. Ht and wt on 25%ile. a. chronic constipation b. IBD c. nonfunctional abdo pain d. lactose intolerance e. UTI
a. chronic constipation - this is most likely functional abdominal pain, but picked constipation since that’s not a choice *note - ado pain in any location aside from periumbilical is suggestive of potential serious etiology
A 5-month-old is brought to the ER because of intermittent abdominal pain for the past 5 weeks. The pain occurs several times daily, during which he screams and extends his arms and legs up simultaneously. The episodes last only seconds, and afterwards he returns to normal. His mother also feels that he has not been himself for the past month and that he doesn’t smile as easily. a) colic b) constipation c) epilepsy d) intermittent intussusception e) reflux esophagitis
c) epilepsy concern for infantile spasms - flexion or extension of trunk or extremities sustained for 1-2 seconds; and developmental regression - classic age of onset is 4 months
6 year old boy presents with severe abdominal pain and vomiting. On examination his abdomen is tender and he is tense and guarding. What three things do you do for management (3)?
Management of acute abdominal pain and vomiting - NPO - NG inserted to decompress stomach/gut - Surgical consult - IV fluids - Analgesia
Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash. What is his diagnosis?
HSP: palpable purpura in context of normal platelets plus one of abdo pain, arthritis, IgA deposition on biopsy, renal involvement (hematuria, proteinuria, RBC casts)
Kid with abdominal migraine. Family history of migraines. What are two periodic syndromes associated with migraine development as an adult.
- cyclic vomiting 2. abdominal migraine 3. recurrent abdominal pain 4. recurrent vomiting
A 13 year old girl is seen with abdominal pain of 24 hour duration that she now rates as an 8/10. She has a fever. On examination she has a diffusely tender abdomen and is guarding. You call general surgery to consult. In the meantime, what is your priority in management: a. Blood C&S and antibiotics b. IV fluids and analgesia c. IV fluids and CT abd
b. IV fluids and analgesia
14 yo black boy with one year history of post-prandial intermittent abdominal pains. Normal stools. No bloating. No vomiting. What test do you do? 1. hemoglobin electrophoresis 2. Hydrogen breath test 3. Gastroscopy with biopsy 4. UGI/SBFT 5. Abdo ultrasound
- Hydrogen breath test
Sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain. Hb 79 (prev 89), AST and ALT slightly elevated. Unconjugated bilirubin is increased. What is the most likely diagnosis? a. fitz hugh Curtis b. cholecystitis c. hepatitis C d. HIV e. vasoocclusive disease of the liver
ANSWER: a.fitz hugh Curtis (+ sexually active and pain + perihepatitis with right shoulder + AST/ALT are normal or mildly elevated) b.cholecystitis (unconjugated bili does not fit (in keeping with hemolysis), expect to have conjugated bili up, +/- fever and mild AST/ALT could fit.) - possible though c. hepatitis C d.HIV e)vasoocclusive disease of the liver
Sickle cell girl who is obese, RUQ pain, increased liver enzymes, had been treated and recovers from the event. What do you recommend? a. cholecystectomy b. low-fat diet c. ursodiol
a. cholecystectomy
1 m baby irritable, not feeding well, vomited once, distended abdomen. On exam VSS except mild tachycardia. There is a mass in the right scrotal, firm and non reducible. Does not transilluminate. What is the next step? a. Ultrasound b. Urgent surgical consultation c. Nuclear scan d. Testicular Doppler
b. Urgent surgical consultation
A 10 yo boy has headache, abdominal pain and lethargy anytime of the day. He has missed 30 days of school in 4 months. He has: a) migraines b) school phobia c) Brain tumour
b) school phobia
A 6 year old boy with severe abdo pain 8/10, febrile, tachycardic at 160. Abdomen is rigid. As you call surgeons, what do you do? a) Culture and start antibiotics b) Bolus with normal saline and give morphine for analgesia c) Bolus with normal saline and arrange for urgent CT
b) Bolus with normal saline and give morphine for analgesia Fluid resuscitation immediately (this patient is in shock), then culture and antibiotics
Lebanese girl with abdominal pain and fever for one day, recurrent episodes. During an episode you do some labs and find increased ESR, increased CRP and decreased albumin. What is a likely diagnosis? a) paroxysmal nocturnal hemoglobinuria b) familial mediterranean fever
b) familial mediterranean fever 1-3 days every 4-8 weeks
What is the most specific test for pancreatitis: 1. Amylase 2. Lipase 3. Abdo U/S 4. Abdo CT scan 5. AXR
- Lipase Dx of pancreatitis is lipase >3x ULN
Kid with peptic ulcer. His treatment would likely include a. amoxil +clarithro + PPI b.clinda and clarithro c. flagyl and tobra
a. amoxil +clarithro + PPI other tx options: ▪ Amox + Metronidazole + PPI ▪ Clarithromycin + Metronidazole + PPI
A 10 month old child presents to your emergency department with a history of intermittent irritability and vomiting interspersed with periods of looking relatively well. The episodes are coming closer and closer together in time. You diagnose intussusception. What are 3 contraindications to air enema? What are 2 situations in which air enema is unlikely to work?
- What are 3 contraindications to air enema? Refractory shock Necrosis/Perforation Peritonitis 2. What are 2 situations in which air enema is unlikely to work? Multiple recurrences ileoileal intussusception known lead point
Patients with inflammatory bowel disease lose weight due to: a) inadequate nutrient intake b) increased metabolic demands c) malabsorption d) drug-nutrient interactions
a) inadequate nutrient intake - patients develop food avoidance because eating causes pain and diarrhea; also pro inflammatory cytokines cause anorexia
Teenager presents with 3 year chronic history of intermittent abdominal pain and bloody stools and also arthritis. His height and weight are less than the 5%. What is his diagnosis? What are two skin complications from his disease?
- IBD - most likely Crohn’s (more likely to present with FTT) 2. erythema nodosum, psoriasis, pyoderma gangrenosum
Teenager with weight loss and perianal abscess. a.) Dx? b.) Child had perianal abscess. Management x2 lines.
a. IBD (more likely Crohn’s as perianal disease more common in Crohn’s than UC) b. good perianal hygiene, antibiotics, treatment of underlying condition, topical tacrolimus (may be helpful in IBD)
Teenage girl with a history of ulcerative colitis, status post total colectomy. Had a “J- pouch” and an anal pull-through ostomy that was later removed. Did have an ileostomy, but that was closed following an end-to-end anastomosis. Now she presents with a 5-day history of bloody diarrhea 8 times per day. Stool cultures are all negative. What is the diagnosis? What 1 treatment would be the best?
- pouchitis 2. treatment: oral metronidazole or ciprofloxacin
Kid with Crohn’s. Stomach aches in morning, gone in afternoon. Crohn’s is under control. Missed 30 days of school in past two months. 3 points to management.
- reassurance of family that CD is under control and review of symptoms that would indicate a flare - parents should avoid reinforcing symptoms that result in secondary gain - patient should return to school and regular activities - cognitive behavioural therapy may be beneficial
Crohns patient who has failed prednisone management. Started on azathioprine. Comes back 2 weeks later. Abdominal pain, periumbical. Vomiting. Give 2 most likely causes.
Medication related: - known side effects of this medication - hepatitis - pancreatitis Crohn’s related: - stricture - intra-abdominal abscess
Boy has had inflamed, ulcerated lips and gums. (Picture shown). Which of the following conditions is this more likely to be seen with? a. Chronic mycoplasma infection b. IBD c. Eosinophilic gastritis d.Contact dermatitis
b. IBD
5 yo with bloody stools. Hyperpigmented lesions on lip and mucosa. Diagnosed with intussusception. What is underlying cause? a. HSP b. Peutz-Jehgers c. Langerhans histiocytosis
b. Peutz-Jehgers - Type of Inherited Colorectal Cancer Syndrome - Key: mucocutaneous pigmentation + extensive GI hamartomas polyposis
Kid with crohn’s on sulfasalazine and has hairless patch with slight scale. a. alopecia areata b. trichotillomania c. tinea capitus
a. alopecia areata -AI disorder, seen in IBD; treated with steroids, methotrexate or sulfasalazine
14 yo boy with R lower quadrant abdo pain, wt loss and diarrhea. RLQ mass palpable and anal fissure noted. What is the most likely diagnosis? List 2 diagnostic tests to confirm diagnosis. List 3 acute complications of this disease.
- Dx: Crohn’s 2. Ix: Upper endoscopy and colonoscopy with biopsy + UGI with SBFT or MRE 3. thrombosis/stroke, perianal fissure and fistula, bowel perforation, bowel obstruction
A 16 year old boy with a known diagnosis of ulcerative colitis comes to see you in your office with his mother. He and his mother have been doing some research and are concerned about the risk of adenocarcinoma in UC. Name 2 risk factors for adenocarcinoma in the setting of a diagnosis of UC.
- Pancolitis 2. Primary sclerosing cholangitis
2 life threatening complications of ulcerative colitis
- toxic megacolon 2. bowel perforation 3. adenocarcinoma
1 year old with rectal abscess. Mgmt? a. Systemic abx b. Excision by surgery c. I and D
c. I and D (note: can just do nothing) - healthy infant - can just watch and wait; sitz baths, pain management
Which is most characteristic of encopresis: a. usually in morning b. dilated bowel c. mostly in preschool children d. stool softeners often cure the problem
b. dilated bowel
3 month old boy with constipation since birth, FTT, mildly distended abdomen and no stool on rectal examination. What would be the most appropriate next test: a. rectal biopsy b. TSH c. Sweat chloride d. follow up in 6 months
a. rectal biopsy True constipation in the neonatal period is most likely secondary to Hirschsprung disease, intestinal pseudoobstruction, or hypothyroidism
A child is referred for refractory encopresis. Spine exam and DTR’s are normal. The rectal ampulla is dilated with lots of stool. How should he now be treated: a) fecal emollient b) peristaltic agent c) high fibre diet d) bowel washouts e) encourage regular exercise
d) bowel washouts fecal emollient (laxatives that incorporate more water and fat into the stool and make it pass through easier - examples include docusate) b) peristaltic agent (act on the intestinal mucosa or nerve plexus and stimulate peristalsis - examples include senna and bisacodyl)
False negatives for sweat chloride a. hypoalbuminemia b. hyponatremia c. hypercalcemia
a. hypoalbuminemia
Girl with rectal prolapse x 2 reduced easily in the ER. What do you do? a. reassure mom b. observe and follow in 3 months c. sweat chloride d. barium enema
c. sweat chloride
What is most useful intervention in treating encopresis? a) pharmacologic b) behavioural c) pharmacologic and behavioural d) biofeedback
c) pharmacologic and behavioural
A 3-week-old infant has jaundice. BW 3250g, now 3490g. Breastfeeding well. Hemoglobin 127, bilirubin 270, Coombs negative. What should be done: a. stop breastfeeding and start formula feeding b. come back in 1 week for reassessment c. do further tests including liver enzymes d. refer to a gastroenterologist
b. come back in 1 week for reassessment Breast milk jaundice
A 3 week old who is brought to the office because mother thinks he is too yellow. Breastfed. Otherwise well. Total bili is 180. Direct is 8. What do you do? A) septic workup B) investigate for blood group incompatibility reassure mother that condition may last for 4-12 weeks investigate for metabolic disease
B) investigate for blood group incompatibility
You are called from a family doctor about a 5 day old jaundiced baby. Well looking. Total bili is 355. He is breastfed. What do you recommend: A) septic work up B) investigate for a metabolic disease C) coombs test and hg D) start phototherapy E) follow up in 1 week
C) coombs test and hg
A newborn infant was an unconjugated bilirubin of 310 at 72 hours of age. Breastfeeding is improving. Looks well, has lost 8% of birthweight. What should be done: a) stop breastfeeding and start phototherapy b) stop breastfeeding and repeat bilirubin q4h to decide on phototherapy c) continue breastfeeding, start phototherapy, and check for ABO incompatibility d) start phototherapy and work-up for metabolic disease e) recommend exchange transfusion as bilirubin level is likely to be in exchange range in 12 hours
c) continue breastfeeding, start phototherapy, and check for ABO incompatibility
Unconjugated hyperbilirubinemia can be caused by all EXCEPT: a) decreased conjugation b) increased uptake by hepatocytes c) increased excretion d) increased enterohepatic circulation e) increased breakdown of hemoglobin
c) increased excretion
A sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain. Hbg 79 (prev 89), AST and ALT slightly elevated. Unconjugated bilirubin is increased. What is the most likely diagnosis? a) Fitz-Hugh-Curtis b) cholecystitis c) hepatitis C d) HIV e) vaso-occlusive disease of the liver
a) Fitz-Hugh-Curtis b) cholecystitis Depends on additional info in prompt, but one of these 2
3 week old child breastfeeding and growing well, jaundiced now. Mom is O and baby is A+. What is the cause? a. ABO incompatibility b. breastmilk jaundice c. hypothyroidism
b. breastmilk jaundice
2 month old M with poor growth, jaundice and conjugated hyperbilirubinemia. Best initial imaging study. a. CT abdo b. MRI c. U/S w doppler flow studies d. Nuclear med biliary excretion scan
c. U/S w doppler flow studies
What is the most common presentation of alpha 1 antitrypsin in children? a) Jaundice b) Emphysema c) Bronchiectasis d) Cirrhosis e) Pneumothorax
a) Jaundice Presents with GI issues in kids, lung issues don’t manifest until late teens/adulthood
Description of kid with alagille (butterfly vtb, heart murmur, cholestatic jaundice at 2 weeks of life), eyes show a) chorioretinitis b) posterior embryotoxon c) cataract d) glaucoma
b) posterior embryotoxon (film/membrane around eye)
A photograph is shown of Kayser-Fleischer rings in a 14-year-old boy. What should be evaluated in this patient: a) liver function b) renal function c) blood triglyceride levels d) skeletal abnormalities e) joint abnormalities
a) liver function Wilson’s disease - degenerative changes in the brain, liver disease, and Kayser-Fleischer rings in the cornea
Child with fulminant liver failure. Three reasons for encephalopathy
- increased serum levels of ammonia - presence of false neurotransmitters (competitive inhibition from false NT that are created by a.a. metabolism) - increased GABA receptor activity - increased circulating levels of endogenous benzodiazepine-like compounds
What is true regarding extrahepatic portal hypertension: a) associated with hepatomegaly b) associated with splenomegaly c) liver transaminases will be abnormal d) most common cause is splenic vein thrombosis
b) associated with splenomegaly Causes ▪ Extrahepatic ● Portal Vein Obstruction ● Omphalitis with vein infection ● UVC- thrombosis ● Peritonitis/ Appendicitis ● IBD ● Splenic vein thrombosis ▪ Intrahepatic ● Cirrhosis ● Hepatitis ● Fibrosis ● Malignancy ● Granulomatous
You are admitting a child to hospital with newly diagnosed liver failure. You are concerned about the possibility of portal hypertension. Name 2 features on physical examination that suggest portal hypertension.
▪ Anorectal varices ▪ Caput Medusa ▪ Splenomegaly
A 13 y.o. with mild jaundice and fatigue. Lab results: AST=222; ALT=150 (increased); Bilirubin 35/20; alpha-1-antitrypsin=2.5 g/l (normal); hepatitis B surface antigen negative; hepatitis C IgM negative. The most likely diagnosis: a. autoimmune hepatitis b. hepatitis C c. Wilson’s disease d. sclerosing cholangitis e. alpha-1-antitrypsin disease
a. autoimmune hepatitis - insidious onset - fatigue, malaise, anorexia - aminotransferases often range from 100-300 (but can be over 1000 in symptomatic patients) - bili can be normal or elevated - ALP and GGT normal to slightly increased - low albumin - prolonged PTT, INR - normochromic, normocytic anemia, leukopenia and TCP
A child has resolving viral hepatitis. AST and ALT have normalized. Bilirubin is still elevated. Which of the following is best to monitor serially: a. GGT b. INR c. Albumin d. ALP
b. INR - INR most useful test for liver synthetic function; focus of monitoring in hepatitis is for liver injury (altered synthetic function is most important indicator of liver injury) - rapidly falling AST/ALT but rising GGT and bill can be poor prognosis - fall in AST/ALT usually falls behind fall in bilirubin
Child with increased unconjugated bili, increase conjugated bili, increased ALT, AST. Normal alpha- 1 antitrypsin, 1:512 anti-smooth muscle ab. Most likely dx? a. Gilberts b. Alpha 1 antitrypsin c. PSC d. Autoimmune
d. Autoimmune ( associated with anti-smooth muscle antibody ) - work-up should include: o R/O viral serologies, alpha1 antitrypsin and wilsons, celiac, IBD, PSC (MR choliangiography)
A 15 year old with h. pylori. You should treat with: A) h2 blocker B) amox, clarithro and proton pump inhibitor C) clarithro and h2 blocker D) amox and proton pump inhibitor
B) amox, clarithro and proton pump inhibitor - treatment: eradication is necessary even in asymptomatic patients - amox, clarithro and PPI - amox, flagyl and PPI - clarithro, flagyl and PPI - antibiotics are taken for 14 days, PPI for 1 month
Competitive sports and nutrition in pediatrics - which is true? 1. give high carbo drinks 2. give protein supplements 3. provide a well balanced diet 4. give Calcium and vit D supplements 5. change child’s diet according to the sport in which they’re involved.
- provide a well balanced diet
28 wk prem now 28 days old and on oxygen for CLD. On 150 cc/kg/d EBM by gavage, also on Fe, aldactazide, vit E and fluticasone. Calculate the caloric intake, what should his caloric intake be? What 2 ways do you recommend optimizing nutrition.
- 150ml/kg/day x 1 ounce/30 mls = 5 ounces/kg/day x 20kcal/1 ounce = 100kcal/kg/day - energy requirements for growth in BPD patients are 130-150kcal/kg/day - can use fortified human milk or fortified preterm formula to increase caloric density as high as 30kcal/ounce - diuretics in patients with BPD cause loss of Na, K, Cl and Ca in the urine - recommend supplementation with KCl and NaCl to maintain normal levels - ensure normocalcemia to prevent osteopenia of prematurity
You work north of 55 th parallel. What do you counsel mothers regarding vit D in an 8 month old bottle fed baby? a. 400 units all year long b. 400 units in winter c. 800 units all year long d. No supplementation necessary
b. 400 units in winter (assume already getting 400IU for Vit D fortified formula, so need to top up to 800 in winter
A mother comes in with her newborn baby and tells you that she lives out in the country where they have well water. What should she do about vitamins and fluoride? What do you tell her about each (be specific) (2)
Vitamins- supplement with Vit D 400IU if breastfeeding (no need if formula) - If the fluoride concentration in the well water is <0.3ppm then starting at 6 months of age teeth should be brushed twice daily; if this does not happen then supplemental fluoride should be given (best preparations have topical effect - mouthwash, lozenges or drops (dilute drops in water before squirting on teeth))
Phytoestrogens in soy contraindicated for: a) all males b) immune deficiency c) galactosemia d) congenital hypothyroidism
d) congenital hypothyroidism -soy can interfere with uptake of thyroid hormone and prolongs increase in TSH Note: galactosemia is the only condition in which soy formula is indicated
The best form of nutrition for an infant with short gut syndrome: a. breast milk b. long-term total parenteral nutrition c. elemental formula with MCT d. soy formula with MCT e. whey hydrolysate formula
a. breast milk Breast Milk (optimal macronutrient composition and trophic factors to foster adaptation, immunoglobulins to enhance barrier function, hypoallergenic, low osmotic load) ▪ Extensively hydrolyzed with MCT-enriched formula is also good if no EBM
An otherwise well 6-month-old presents with a one month history of passing small hard stools once per week. She is exclusively breast-fed. Appropriate management would include: a. careful use of laxatives b. enema c. change to lactose free formula d. introduce solids e. change to iron free formula
a. careful use of laxatives
A 1 week old breastfed baby comes into your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with the Vitamin K injection at birth or with the newborn screen. The anus appears normal and there is no evidence of a fissure. List the most likely cause of the blood in the stool.
- milk protein allergy/intolerance note: swallowed maternal blood common, but does not usually present with BRBPR
A 3-week-old infant is going to be formula-fed, and you suggest an iron-fortified formula. The mother asks you what problems she should expect. How do you counsel her: a. colic b. constipation c. black stool d. no problems
d. no problems *key is that there is no evidence that iron fortified formula causes constipation, colic, GI cramping, fussiness or reflux
Absolute contraindications of breastfeeding for the infant. a. Hep B b. Bilateral mastitis c. Active TB
c. Active TB Active TB contraindication until completed 2 weeks of treatment
Describe 3 maternal infections that represent absolute contraindications to breast-feeding.
- active untreated TB until completed 2 weeks of treatment - can give EBM, just don’t breastfeed - untreated maternal brucellosis - HIV - human T-cell lymphotrophic virus type I and II
A new mother is hoping to breastfeed. She has been on paroxetine for her depression and was recently started on propranolol for her hypertension. Which of the following is true: a. Neither of these medications is a contra-indication to breast-feeding b. The propranolol should be changed to another anti-hypertensive before breast-feeding c. The paroxetine should be discontinued before breast-feeding
a. Neither of these medications is a contra-indication to breast-feeding -may be excreted in breast milk but no evidence that the presence of these medications will cause harm to baby Some contraindications to BF: ● High dose metronidazole (d/c for 12-24h to allow excretion of dose) ▪ Mothers on cytotoxic chemo ▪ Radioactive isotopes or radiation therapy ▪ Infants w/ classic galactosemia (need soy formula)
Which of the following is true regarding iron supplementation in a preterm infant who is breast-fed: a. do not use iron as it interferes with absorption of iron in breastmilk b. start iron supplementation at one month of age c. start only if on a non-iron fortified supplemental formula
b. start iron supplementation at one month of age - supplement from 1 month until 12 months
Contraindication to breastfeeding: a. vegan mother b. erythromycin c. prednisone d. alcohol e. active tuberculosis
e. active tuberculosis - no BF until 2 weeks of treatment completed; can still give EBM - re vegan diet: not a problem but mom may need supplementation (B12, Vit D, Fe) - if mom’s levels are fine then it’s all good
At a routine well-baby visit, a mother tells you that she has been mixing honey into her baby’s formula to make it more sweet. You advise her that her child: a. does not need the excess calories b. is at risk for Clostridium botulinum c. is at risk for E. coli d. is at increased risk for allergies e. is at increased risk for dental caries
b. is at risk for Clostridium botulinum - no honey until 1 year of age - immature digestive system cannot get rid of spores from c botulinum - once 1 year old, able to get rid of them so risk decreased
A vegan mother comes to you and is hoping to breastfeed her baby. Which of the following vitamins do recommend supplementation with: a. iron b. vitamin B12 c. vitamin C d. folate
b. vitamin B12
What nutrient is vegan diet deficient in?
Vitamin B12
What nutritional deficiency is a 12 year old vegan child at risk for?
B12 deficiency
A 13-month-old child on a vegetarian diet is at risk for which deficiency: a. vitamin C b. calcium c. folate d. zinc e. iron
e. iron
Breastfed 7 month old babe of a vegan mom. Thriving. What do you supplement baby with? a. Vitamin B12 b. Folic acid c. calcium d. iron
a. Vitamin B12 CPS statement does recommend supplementing baby with B12 - 0.4mcg/kg/day
Mom feeding goat’s milk to a 2 month old baby. What do you need to supplement with? a. Ca b. Fe c. Folate d. multivitamin
c. Folate
Child with short gut. Which is the best form of feeding? a. elemental formula with MCT b. soy formula with MCT c. TPN d. lactose free formula e. gluten free diet
a. elemental formula with MCT *remember if it’s an option, breast milk is the most ideal form of feeding
Neonate on TPN. List four things that will increase his incidence of cholestasis.
- lower birthweight (especially <1000g) - longer duration of therapy (especially >2 weeks) - complicated medical course (e.g. resp distress, hypoxia, acidosis, NEC, sepsis) - short bowel syndrome
TPN – list four metabolic complications
- hypertriglyceridemia - cholestasis - hyperglycemia - hypokalemia
A 1 mo baby with FTT and diarrhea. WBC 5 x10 9 (80% neutrophils, 10% lymphocytes, 6% basophils, 4% eosinophils). a.) What does this make you think of? (i.e. interpret the labs) b.) List 2 causes
a.) What does this make you think of? - neutrophil predominance and borderline low WBC count are suspicious for bacterial infection; borderline high eosinophils; low lymphocytes - immunodeficiency b.) List 2 causes - HIV - lymphopenia - SCID - lymphopenia - UTI - parasitic infection
27 mos female, bone age is 17 mos, short stature. Ht and wt graphs provided show N bw and length and a gradual fall to below the 3 rd percentile for wt A) constitutional B) familial short stature C) hCG deficiency D) malnutrition
D) malnutrition Normal at birth -> then weight drop off -> assume that ht drop off with malnutrition causing bone age delay. Constitutional wouldn’t cause wt drop; familial short stature wouldn’t either.
14 mos male, FTT, vomiting, met acidosis, pH 7.31, bicarb 14, K 3.5, Na140, Cl 118, urine pH 6.3 a. distal RTA b. Bartters c. organic acidopathy d. nutrit. deprivation
Interpretation = Non anion gap metabolic acidosis with alkalotic urine. a. distal RTA -kidneys pushing out less H+ so urine is alkalotic (pH>5.5) -Bartter get hypoK metabolic alkalosis and dysmorphic - organic acidopathy: high AG metabolic acidosis
Changing to the WHO growth will result in what when looking at the growth of breast fed babies?
WHO charts are based on breast fed babies so they will look normal; formula fed babies will look FTT in the first 6 months because formula fed babies grow slower than BF babies in the first 6 months, and then catch up after (CDC curves were based on North American babies who are more likely to be formula fed)
3yo only gained 2 kg last year a. reassure b. consult dietician for intake c. malabsorption work-up
a. reassure Increases of approximately 2 kg (4-5 lb) in weight and 7-8 cm (2-3 in) in height per year (from age 2 years until puberty)
A 13 year old girl comes to you with a BMI of 31. Which of the following is she at risk for? a. type 2 diabetes mellitus b. delayed onset of menarche c. AVN of the femoral head d. Pancreatitis
a. type 2 diabetes mellitus
You are counseling the mother of a child who is significantly overweight about her child’s diet and exercise habits. a. What BMI is considered overweight for a child? b. What BMI is considered obese for a child?
a. overweight: BMI 85-95th percentile b. obese: BMI >95th percentile
Features of childhood obesity include all EXCEPT: a. 50% chance of being obese if one parent is obese, 80% if both parents are obese b. premorbid psychological problems predate the onset of obesity c. increased incidence in lower socioeconomic class d. associated with decreased exercise
b. premorbid psychological problems predate the onset of obesity - lower SES associated with obesity in developed countries, but failure to thrive in developing countries; high SES in developing countries is associated with obesity (if you’re rich in a poor country you’re fat; if you’re poor in a rich country you’re fat)
Adopted kid from caribbean with edema, abdominal distention, yellow tinged rusty hair. What is the most likely? a. Kwashiorkor b. Marasmus c. B1 deficiency d. B6 deficiency e. zinc deficiency f. nephrotic syndrome
a. Kwashiorkor (protein deficiency) *marasmus get severe wasting with scaphoid abdomen *B1 deficiency (thiamine) - leads to beriberi (peripheral neuropathy) *B6 = pyridoxine - goat milk deficient in B6 - seizures, FTT
Mom brings 10mo son from another country. Worried re: malnutrition. Baby has thick costochondral junctions. a) Diagnosis? b) List 2 physical findings that would support the diagnosis
a) Diagnosis: Vitamin D deficiency rickets b) List 2 physical findings: 1. frontal bossing 2. protruding abdomen 3. FTT 4. enlargement of wrists or ankles
Breastfed baby, presents with rash around his orifices. Also has glossitis, stomatitis, corneal dystrophy. What is the cause? a. Vitamin C deficiency b. Vitamin A deficiency c. Vitamin B12 deficiency d. Zinc deficiency
d. Zinc deficiency - zinc in breast milk sufficient until 7 months of age, then infants need to get it from solid food diet - this could specifically be acrodermatitis enteropathica - AR disorder with zinc deficiency - get findings in question
All are features of iron deficiency anemia EXCEPT: a. Pica b. Koilonychia c. cheilitis d. mild scleral icterus e. psychomotor retardation
d. mild scleral icterus - would be more in hemolytic b. Koilonychia = spoon nails c. cheilitis (angular cheilitis= inflammation at corners of mouth) e. psychomotor retardation (yes - delayed psychomotor development, irreversible behavioural and IQ deficiency)
Some vitamins are stored in large amounts and there may be no biochemical or clinical evidence of deficiency for many months. Which of the following vitamins behaves as such: a. Thiamine (B1) b. vitamin C c. vitamin B12 d. riboflavin (B2) e. folate
c. vitamin B12 - A, D and B12 store in large amounts in liver
The reason maxeran (metaclopramide) is not used commonly is: a. side effects b. cost c. interactions with other drugs
a. side effects increased risk in younger patients of dystonic reactions/extrapyramidal symptoms
Fat absorption in childhood: a. fats are exclusively digested by pancreatic lipase b. medium-chain triglycerides require solubilization c. triglycerides require tryptic predigestion d. triglycerides require hydrolysis to free fatty acids e. lipolysis is enhanced by gastric acid
d. triglycerides require hydrolysis to free fatty acids o almost all dietary fat absorbed IN PROXIMAL JEJUNUM
