Section 6: Pediatrics 2

Question 1

List the effects of the following drugs on the neonate

1. Anesthetics
2. Barbiturates
3. Mgnesium sulfate
4. Phenobarbital
5. Sulfonamides

Answer 1

1. Respiratory depression, CNS depression
2. Respiratory depression, CNS depression
3. Respiratory depression
4. Vitamine K deficiency
5. Displaces bilirubin from albumin

Question 2

List the effects of the following drugs on the neonate

1. NSAIDs
2. ACE inhibitors
3. Isotretinoin
4. Phenytoin
5. Diethylstilbestrol (DES)

Answer 2

1. Premature closure of the ductus arteriosus
2. Craniofacial abnormalities
3. Facial and ear anormalies, congenital heart disease
4. Hypoplastic nails, typical facies, IUGR
5. Vaginal adenocarcinomas

Question 3

List the effects of the following drugs on the neonate

1. Tetracycline
2. Lithium
3. Warfarin
4. Valproate/Carbamazepine

Answer 3

1. Enamel hypoplasia, discolored teeth
2. Ebstein’s anomaly
3. Facial dysmorphism and chondrodysplasia
4. Mental retardation, neural tube defects

Question 4

1. At what age does birth weight normally doubles?
2. At what age does birth weight normally triples?

Answer 4

1. At 6 months
2. At 12 months (1 year)

Question 5

True or False:

Height percentile at 2 years of age normally correlates with final adult height percentile

Answer 5

True

Question 6

Best indicators for:

1. Acute malnutrition
2. Underweight and overweight

Answer 6

1. Weight/height < 5 percentile
2. BMI

Question 7

True or False:

1. Skeletal maturity is related to sexual maturity
2. Psychosocial deprivation is the most common cause of failure to thrive in all age groups
3. All cases of underfeeding must be reported to child protective services (CPS)
4. Work up is mandatory for any child who has crossed 2 major growth percentile

Answer 7

1. True. It is less related to chronological age
2. True
3. True
4. True

Question 8

List the advantages of breastfeeding

Answer 8

1. Passive transfer of T-cell immunity
   
   • Decreased risk of allergies and gastrointestinal and respiratory infections
2. Psychological/emotional
   
   • Maternal-infant bonding

Question 9

List the contraindications to breastfeeding

Answer 9

HIV

CMV

HSV lesions on breast

HBV until infant has recieved HBV vaccine

Acute maternal disease if absent in infant (e.g., tuberculosis, sepsis)

Breast cancer

Substance abuse

Drugs

Question 10

List the drugs for which there is absolute contraindications to breastfeeding

Answer 10

Antineoplastics

Iodine/mercurials

Lithium

Chloramphenicol

Nicotine

Alcohol

Question 11

List the drugs for which there is relative contraindications to breastfeeding

Answer 11

Neuroleptics

Sedatives

Metronidazole

Tetracycline

Sulfonamides

Steroids

Question 12

1. List the newborn reflexes present at birth
2. When do they disappear?
3. The parachute reflex is extension of the arms when fall is stimulated. When does it appear and disappear?

Answer 12

1. Newborn reflexes at birth:
   
   • Moro
   • Grasp
   • Rooting
   • Tonic neck
   • Placing
2. 4 to 6 months
3. Appears at 6 to 8 months and persists

Question 13

List the developmental milestones at:

1. 9 months
2. 12 months
3. 15 months

Answer 13

1. 9 months:
   
   • Pincer grasp
   • Creeps and crawls
   • Knows own name
2. 12 months:
   
   • Cruises
   • Says one or more words
   • Plays ball
3. 15 months
   
   • Builds 3-cube tower
   • Walks alone
   • Makes lines and scribbles

Question 14

List the developmental milestones at:

1. 18 months
2. 24 months

Answer 14

1. 18 months:
   
   • Builds 4-cube tower
   • Walks down stairs
   • Says 10 words
   • Feeds self
2. 24 months:
   
   • Builds 7-cube tower
   • Runs well
   • Goes up and down stairs
   • Jumps with 2 feet
   • Thread shoelaces
   • Handles spoon
   • Says 2-3 sentences

Question 15

List the developmental milestones at:

1. 36 months
2. 48 months

Answer 15

1. 36 months
   
   • Walks downstairs in alternating feet
   • Rides tricycle
   • Knows age and sex
   • Understands taking turns
2. 48 months
   
   • Hops on one foot
   • Throws ball overhead
   • Tell stories
   • Participate in group play

Question 16

True or False:

The following are contraindications to breastfeeding

1. A reaction to a previous DPT of temperature <105^oF, redness, soreness, and swelling
2. A mild, acute illness in an otherwise well child
3. A concurrent antimicrobial therapy
4. A family history of seizures or sudden infant death syndrome

Answer 16

1. False
2. False
3. False
4. False

Question 17

True or False:

The following vaccines are contraindicated in the presence of egg allergy

1. MMR
2. Influenza
3. Yellow fever

Answer 17

1. False
2. True
3. True

Question 18

1. Which vaccine is given at birth?
2. Which vaccine is given at 1 or 2 months?
3. List the vaccines that are given at 2 months
4. List the vaccines that are given at 4 months
5. List the vaccines that are given at 6 months

Answer 18

1. Hep B vaccine
2. Hep B vaccine
3. 2 months vaccines
   
   • Hep B
   • Rotavirus (Rota)
   • Diphtheria, tetanus, pertusis (DTaP)
   • Haemophilus influenzae type B (HiB)
   • Pneumococcal (PCV)
   • Inactivated poliovirus (IPV)
4. As in (3) above except for Hep B
5. As in 3 above except that Hep B and IPV may be given anytime between 6 and 18 months

Question 19

1. When is influenza vaccine given?
2. When is MMR given routinely?
3. When is Varicella vaccine given routinely?
4. When is Hep A vaccine given

Answer 19

1. Yearly from 6 months
2. At 12 to 15 months and at 4 to 6 years
3. At 12 to 15 months and at 4 to 6 years
4. From 12 to 23 months: 2 doses

Question 20

Active immunization schedule after exposure to

1. Measles
   
   • For those < 6 months
   • Between 6 months to 12 months
   • For those greater than 12 months
   • For pregnant or immunocompromised persons
2. Varicella
   
   • For susceptible children and household contacts
   • Susceptible pregnant women, newborns whose mothers had chicken pox within 5 days before delivery to 48 hours after delivery

Answer 20

1. Measles
   
   • 0-6 months: Ig
   • 6-12 months: Ig plus vaccine
   • >12 months: Vaccine only within 72 hours of exposure
   • Pregnant or immunocompromized: Ig only
2. Varicella
   
   • Susceptible children and household contacts: VZIG and vaccine
   • Susceptible pregnant women, newborns whose mothers had chicken pox within 5 days before delivery to 48 hours after delivery: VZIG

Question 21

Active immunization schedule after exposure to

1. Hepatitis B
2. Hepatitis A
3. Mumps and Rubella

Answer 21

1. Ig plus vaccine; repeat vaccine at 1 month and 6 months
2. For children > 2 years only: Ig plus vaccine
3. No postexposure protection available

Question 22

True or False:

1. HiB conjugated vaccine covers nontypeable Haemophilus
2. HiB conjugated vaccine is not given after 5 years
3. Invasive Haemophilus influenzae infection confers immunity
4. Varicella has been associated with development of herpes zoster
5. Meningococcal conjugate vaccine is indicated for all college freshmen living in dormitories

Answer 22

1. False
2. True
3. False. Patient still requires vaccines if < 5 years
4. True
5. True

Question 23

Indications for hospitalization in child abuse

Answer 23

• Medical condition requires
• Diagnosis is unclear
• There is no alternative safe place

Question 24

A 2-year-old child is brought in for a severe cough, fever, and runny nose. The cough sounds like a bark and she is in obvious respiratory distress. Upon physical examination, she refuses to lie flat. CXR shows a positive steeple sign. What is the most appropriate next step in management?
a. Intubate

b. Racemic epinephrine
c. Empiric antibiotics
d. Acetaminophen
e. CT neck

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 435). Kaplan Medical Test Prep. Kindle Edition.

Answer 24

B. This child presents with classic signs of croup, an inflammation that is quite literally choking off the upper airway. The seallike barking cough with URI-like symptoms gives it away. This is a medical emergency. To prevent asphyxiation and probable tracheostomy, administer racemic epinephrine to decrease swelling. Do not waste time with radiology. There is no medical evidence suggesting that intubation, antibiotics, or antipyretics decrease mortality.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 435). Kaplan Medical Test Prep. Kindle Edition.

Question 25

State (1) the diagnosis, (2) causative organism, (3) diagnostic tests, (4) outline the management including emergency measures, and (5) complications/prognosis of the following presentation: * Age: 3 momths to 5 years * Sore throat * Coryza * Hoarseness * Deep barking cough * Inspiratory stridor * Tachypnea * Symptoms are worse at night or when lying flat

Answer 25

1. Croup 2. Parainfluenza 1 or 3; Influenza A or B 3. Neck X-ray (NOT needed for diagnosis) 4. Mgt: * Humified oxygen * Nebulized epinephrine and corticpsteroids * N/B: *_antitussives, decongestants, sedatives, or antibiotics are NOT used in the management of Croup_* 5. Spontaneous resolution in 1 week; Always suspect diagnosis of epiglottitis

Question 26

State (1) the diagnosis, (2) causative organism(s), (3) diagnostic tests, (4) outline the management including emergency measures, and (5) complications/prognosis of the following presentation: * Sudden onset of muffled voice * Drooling * Dysphagia * High fever * Inspiratory stridor * Preference for tripod position * Refusal to lie flat * Toxic appearance

Answer 26

1. Epiglottitis 2. H.influenzae type B (now less common); Strep pyogenes; Strep pneumoniae; Staph aureus; Mycoplasma 3. Neck X-ray (thumb-print sign); Blood cultures; Nasopharyngoscopy in the OR; Epiglottic swab culture. *_Diagnostic workup is after stabilization as this is a medical emergency_* 4. Mgt: * Transfer to hospital/OR * Consult ENT and anesthesia * Intubate * Give antibiotics (ceftriaxone) and steroids * Give rifampin to all close contacts 5. Airway obstruction and death

Question 27

State (1) the diagnosis, (2) causative organism(s), (3) diagnostic tests, (4) outline the management including emergency measures, and (5) complications/prognosis of the following presentation: * Age: \< 3 years * Brassy cough * High fever * Resp distress * Usually preceded by a viral URTI * NO drooling; NO dysphagia

Answer 27

1. Bacterial tracheitis 2. S. aureus 3. Diagnosis based on clinical evidence and laryngoscopy * CXR shows subglottic narrowing plus ragged tracheal air column * Blood cultures * Throat cultures 4. Antistaphylococcal antibiotics; May require intubation if severe 5. Airway obstruction

Question 28

A 4-year-old child is brought in because of extreme irritability and refusal to eat. He refuses to lean back, speaks in muffled words, looks extremely ill, and is drooling. CXR shows a positive thumbprint sign. What is the most appropriate next step in management? a. Intubate b. Racemic epinephrine c. Empiric antibiotics d. Physical examination e. CT neck Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 436). Kaplan Medical Test Prep. Kindle Edition.

Answer 28

**A**. This child presents with classic signs of epiglottitis, the truest medical emergency in pediatrics. He must be intubated at once. Do not waste time with anything else, including a full examination, as his airway may close off any minute. Purists even say to avoid startling the child. This case mentions a thumbprint sign to aid your studies, but CXR is rarely done with such a convincing presentation. The remaining choices are not indicated until airway management is conducted. **Remember your ABCs**. Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 436). Kaplan Medical Test Prep. Kindle Edition.

Question 29

Epiglottitis can be differentiated from Croup by the absence of barking cough in the former

Answer 29

True

Question 30

State the most common sites of airway obstruction in 1. Children \> 1 year 2. Children \< 1 year

Answer 30

1. Larynx 2. Trachea or right main bronchus

Question 31

When is a murmur in the exam innocent?

Answer 31

* When there is fever, infection or anxiety * It is systolic * When it is \< grade 2/6

Question 32

True or False: Antibiotic therapy should be started at the same time as workup for congenital heart disease (CHD)

Answer 32

**True**. This is becuse sepsis and CHD present very similarly

Question 33

CHD 1. Best initial tests 2. Most accurate test 3. List the conditions with increased vascular markings on CXR

Answer 33

1. CXR and ECG 2. Echocardiography 3. Increased vascular markings * Transposition of the great arteries (TGA) * Hypoplastic left heart syndrome * Truncus arteriosus

Question 34

Conditions that require antibiotics prior to dental procedures

Answer 34

1. Prosthetic valves 2. Previous endocarditis 3. CHD (unrepaired or repaired with persistent defect) 4. Cardiac transplantation patients with cardiac valve abnormalities

Question 35

True or False Consider renal cuases of HTN in EVERY pediatric patient presenting with hypertension

Answer 35

True

Question 36

List the screening tests for HTN in children

Answer 36

* CBC * Urinalysis * Urine culture * Electrolytes * Glucose * BUN * Creatinine * Calcium * Uric acid * Lipid panel (for essential HTN and positive family hx)

Question 37

List the Meckel’s Diverticulum Rule of 2s Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 426). Kaplan Medical Test Prep. Kindle Edition.

Answer 37

* Affects 2% of population * Occurs 2 feet from the ileocecal valve * Affects 2 types of ectopic tissue (gastric and pancreatic) * Male patients 2 times more affected * Patient \< age 2 * Only 2% of patients symptomatic * About 2 inches long Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 426). Kaplan Medical Test Prep. Kindle Edition.

Question 38

List the Meckel’s Diverticulum Rule of 2s

Answer 38

* Affects 2% of population * Occurs 2 feet from the ileocecal valve * Affects 2 types of ectopic tissue (gastric and pancreatic) * Male patients 2 times more affected * Patient \< age 2 * Only 2% of patients symptomatic * About 2 inches long Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 426). Kaplan Medical Test Prep. Kindle Edition.

Question 39

Indications for hydroxyureas in sickle cell anemia

Answer 39

* =\> 3 crises per year * Symptomatic anemia * Life-threatening complications

Question 40

List the routine care for sickle cell anemia patients

Answer 40

1. **Penicillin prophylaxis** * Begins at 2 months until 5 years of age 2. **Immunizations** * Regular immunizations * Pneumococcal at 2 months * Influenza vaccine at 6 months then yearly * Meningococcal at 2 years 3. **Daily folate supplementation**

Question 41

What is the age of the child with the following developmental milestones? * Walks downstairs in alternating feet * Rides tricycle * Knows age and sex * Understands taking turns

Answer 41

36 months (3 years)

Question 42

What is the age of the child with the following developmental milestones? * Hops on one foot * Throws ball overhead * Tell stories * Participate in group play

Answer 42

48 months (4 years)

Question 43

What is the age of the child with the following developmental milestones? * Pincer grasp * Creeps and crawls * Knows own name

Answer 43

9 months

Question 44

What is the age of the child with the following developmental milestones? * Cruises * Says one or more words * Plays ball

Answer 44

12 months

Question 45

What is the age of the child with the following developmental milestones? * Builds 3-cube tower * Walks alone * Makes lines and scribbles

Answer 45

15 months

Question 46

What is the age of the child with the following developmental milestones? * Builds 4-cube tower * Walks down stairs * Says 10 words * Feeds self

Answer 46

18 months

Question 47

What is the age of the child with the following developmental milestones? * Builds 7-cube tower * Runs well * Goes up and down stairs * Jumps with 2 feet * Thread shoelaces * Handles spoon * Says 2-3 sentences

Answer 47

24 months

Question 48

Management for lead poisoning 1. Blood lead level \<= 10ug/dL 2. Blood lead level between 10 and 14 ug/dL 3. Blood lead level \> 15 ug/dL 4. Blood lead level bwtween 15 and 19 ug/dL 5. Blood lead level bwtween 20 and 44 ug/dL 6. Blood lead level bwtween 45 and 70 ug/dL 7. Blood lead level \> 70ug/dL

Answer 48

1. Acceptable level 2. Repeat blood test in 3 months 3. Evaluation of the source, education, and a health department referral 4. Repeat blood test in 2 months 5. Repeat blood test in 1 week 6. Chelation therapy with one oral drug, succimer and repeat blood test in 1 month 7. Hospitalize patient, and treat with 2 chelation drugs, dimercaprol (BAL) and calcium EDTA