ASIPP Pediatric Questions

Question 1

1664. 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

Answer 1

1664. 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

Question 2

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)

Answer 2

1665. Answer: B

Source: Goodwin J, Board Review 2005

Question 3

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

Answer 3

1666. Answer: C

Source: Goodwin J, Board Review 2005

Question 4

1667. Which of the following fracture types is more suspicious
of child abuse?
A. Epiphyseal
B. Diaphyseal
C. Growth plate
D. Metaphyseal
E. Torus

Answer 4

1667. 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

Question 5

1668. The most common malignant bone tumor in children is
A. Osteosarcoma
B. Ewing’s sarcoma
C. Neuroblastoma
D. Wilm’s tumor
E. Leukemia

Answer 5

1668. 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

Question 6

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

Answer 6

1669. 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

Question 7

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

Answer 7

1670. 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

Question 8

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

Answer 8

1671. Answer: D
      Source: Raj P, Pain medicine - A comprehensive Review -
      Second Edition

Question 9

1672. 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

Answer 9

1672. Answer: B
      Explanation:
      Reference: Behrman, 16/e, pp 16, 1829. McMillan, 3/e, p
1673. 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

Question 10

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

Answer 10

1673. 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

Question 11

1674. 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%

Answer 11

1674. 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

Question 12

1675. The most common benign pediatric pain syndrome is
A. Headache
B. Chest pain
C. Limb pain
D. Back pain
E. Abdominal pain

Answer 12

1675. Answer: A
      Explanation:
      headache
      Source: Boswell MV, Board Review 2004

Question 13

1676. 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

Answer 13

1676. 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

Question 14

1677. 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

Answer 14

1677. 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.

Question 15

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

Answer 15

1678. Answer: A
      Explanation:
      0.4 mg/kg/hr
      Source: Boswell MV, Board Review 2004

Question 16

1679. 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

Answer 16

1679. 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

Question 17

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

Answer 17

1680. Answer: B

Source: Raj, Pain Review 2nd Edition

Question 18

1681. 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

Answer 18

1681. 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

Question 19

1682. 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

Answer 19

1682. 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

Question 20

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

Answer 20

1683. 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.

Question 21

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

Answer 21

1684. 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

Question 22

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

Answer 22

1685. 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

Question 23

1686. 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

Answer 23

1686. 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.

Question 24

1687. 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

Answer 24

1687. 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

Question 25

1688. 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

Answer 25

1688. Answer: A Explanation: Reference: Behrman, 16/e, pp 2075-2076, 2080-2082, 2106. 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

Question 26

1689. 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

Answer 26

1689. 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

Question 27

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

Answer 27

1690. 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.

Question 28

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

Answer 28

1691. 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

Question 29

``` 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 ```

Answer 29

``` 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.) ```

Question 30

1693. 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

Answer 30

1693. 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

Question 31

1694. 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

Answer 31

1694. 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

Question 32

1695. 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

Answer 32

1695. 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

Question 33

1696. 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

Answer 33

1696. 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

Question 34

``` 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 ```

Answer 34

1697. 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

Question 35

1698. Concerning sickle cell disease which of the following is or are true? 1. About 25% of children with an average of 3 vaso-occlusive crises a yea are addicted to opioid medication 2. 1 in 25 African Americans will develop sickle cell disease 3. Bone marrow transplantation is no longer considered a viable option due to an unacceptable infection rate with HIV 4. Hydroxyurea increases the proportion of HBF in the blood, minimizing the percentage of cells that can ‘sickle’

Answer 35

1698. Answer: D | Source: Goodwin J, Board Review 2005

Question 36

1699. Compared to the adult, which of the following correctly characterize morphine pharmacokinetics in the neonate? 1. Free fraction is greater 2. Clearance is increased 3. Conjugation is decreased 4. Half life is shortened

Answer 36

1699. Answer: B (1 & 3) | Source: Boswell MV, Board Review 2004

Question 37

1700. Advantages of acetaminophen over aspirin when used as an analgesic in children include 1. lack of gastric irritation 2. no association with Reye syndrome 3. lack of platelet dysfunction 4. complete absorption when administered rectally

Answer 37

1700. 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

Question 38

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

Answer 38

1701. Answer: E | Source: Goodwin J, Board Review 2005

Question 39

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

Answer 39

1702. Answer: B | Source: Goodwin J, Board Review 2005

Question 40

1703. Neonates are susceptible to respiratory suppression with opioids because of 1. Decreased protein binding 2. Increased blood brain barrier permeability 3. Reduced GFR 4. Immature hepatic enzymes

Answer 40

1703. Answer: E | Source: Goodwin J, Board Review 2005

Question 41

1704. In the pediatric population the most pain causing problem in oncology is 1. Osteosarcomas 2. End stage lymphoblastic leukemia 3. Meningiomas 4. Diagnostic Procedures and Treatment Protocols

Answer 41

1704. Answer: D | Source: Goodwin J, Board Review 2005

Question 42

1705. Compared to the adult, which of the following correctly characterize morphine pharmacokinetics in the neonate? 1. Blood levels are lower 2. Clearance is increased 3. Conjugation is increased 4. Half life is prolonged

Answer 42

1705. Answer: D (4 Only)

Question 43

1706. In the newborn 1. Albumin levels are lower than in the adult 2. Local anesthetics are less protein bound 3. Drugs have decrease affi nity for fetal protein 4. Drug free fractions are increased

Answer 43

1706. Answer: E (All)

Question 44

1707. The use of regional anesthesia in premature infants less than 60 weeks of postconceptual age has been advocated to reduce 1. retinopathy of prematurity 2. intracranial hemorrhage 3. stress reaction to surgery 4. postoperative apnea

Answer 44

1707. 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.

Question 45

``` 1708.Which of the following are potential adverse effect associated with salicylate therapy: 1. Hypotension 2. Bronchial hyperactivity 3. Macular degeneration 4. Hyperglycemia ```

Answer 45

1708. Answer: A (1, 2, & 3) | Source: Jackson KC. Board Review 2003

Question 46

1709. Where “fi rst and Worst” Headaches are concerned in children 1. A SAH is more likely to result from a AVM bleed than from an aneurysm 2. Upper respiratory infections with fever is the most common cause 3. New onset migraine is the second most common cause 4. Viral meningitis can present without a fever, stiff neck and a normal neuro exam

Answer 46

1709. Answer: E | Source: Goodwin J, Board Review 2005

Question 47

1710. Which of the following is true? 1. Paraffi n is a good heating method in patients with rheumatoid arthritis 2. Whirpool therapy is useful to patients with metastatic bone disease 3. Patients with diabetic foot neuropathy should use heat lamps for pain relief 4. Hot packs may be routinely applied for over an hour

Answer 47

1710. 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

Question 48

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

Answer 48

1711. 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

Question 49

1712. Transcutaneous electrical stimulation 1. Is based on the gate theory of pain 2. Mechanistically activates large diameter afferent fi bers, in order to suppress afferent small fi ber input into the spinal cord 3. High intensity, low frequency stimulation is thought to work via a naloxone reversible mechanism 4. Low frequency, high pulse duration cause strong muscle contractions

Answer 49

1712. 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

Question 50

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

Answer 50

1713. Answer: E (All) Source: Raj P, Pain medicine - A comprehensive Review - Second Edition

Question 51

1714. Pain assessment scales for children that employ faces are 1. McGrath’s 2. CHEOPS 3. Oucher 4. DC Children’s

Answer 51

1714. Answer: B (1 & 3) | Source: Boswell MV, Board Review 2004

Question 52

1715. Which of the following are true? NMDA receptors in the neonate and newborn are 1. Widely expressed in the nervous system 2. Play a role in synaptic reorganization 3. Are important in neuronal development 4. Provide fast pain processing

Answer 52

1715. 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

Question 53

1716. Which of the following are true? 1. Full term infants habituate to repeated stimuli 2. Premature infants demonstrate sensitization to noxious stimuli 3. Neonates have well developed nociceptive afferent system 4. Newborns are more sensitive to painful stimuli than adults

Answer 53

1716. Answer: E (All)

Question 54

``` 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 ```

Answer 54

1717. Answer: E (All) Source: Raj P, Pain medicine - A comprehensive Review - Second Edition

Question 55

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

Answer 55

1718. Answer: E (All) | Source: Boswell MV, Board Review 2004

Question 56

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

Answer 56

1719. 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.

Question 57

1720. Gastrointestinal absorption of drugs in infants may vary from adults because in infants 1. Gastric mucosa is less developed than adults 2. Emptying requires 6-8 hours 3. Gastric acid production is less than adults 4. Gastric emptying is biphasic

Answer 57

1720. Answer: A (1, 2, & 3 )

Question 58

1721. True statements regarding pain assessment in nonverbal children include 1. neurophysiologic elements involved in pain perception are present in preterm infants 2. undesirable physiologic responses can be caused by pain in neonates 3. hormonal-metabolic responses to noxious stimuli are present in preterm infants 4. neonates experience pain

Answer 58

1721. 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

Question 59

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

Answer 59

``` 1722. Answer: E Explanation: All of the above are contraindications to heat therapy, including scar tissue Source: Shah RV, Board Review 2006 ```

Question 60

``` 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 ```

Answer 60

1723. Answer: C (2 & 4) | Source: Boswell MV, Board Review 2004

Question 61

1724. Down’s syndrome is associated with 1. a high incidence of congenital heart defects 2. upper and lower airway abnormalities 3. cervical neck instability 4. sensitivity to atropine

Answer 61

1724. 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.

Question 62

``` 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 ```

Answer 62

``` 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 ```

Question 63

1726. True statements regarding the use of IV-PCA in children include 1. it is safe and effective 2. its use may be restricted by inability to activate the pump 3. it can be used in children age 7 and older 4. it is a universal therapy for postoperative pain control in children

Answer 63

1726. 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

Question 64

1727. The Children’s Hospital of Eastern Ontario (CHEOPS) pain assessment tool 1. Incorporates face pictures 2. May not be useful for postoperative pain 3. Was designed for children 4. Measures six items

Answer 64

1727. Answer: C (2 & 4)

Question 65

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

Answer 65

1728. 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

Question 66

``` 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 ```

Answer 66

1729. Answer: C (2 & 4)