Download Pedia exam (I included the side notes when available and added

Pedia exam
(I included the side notes when available and added some of my own where sinipag ako (mostly from Nelson’s, WHO integrated
management of childhood illnesses handout)
1.
Enumerate the components of a complete pediatric history and give brief descriptions of each (10pts)
Gen data – basic info
Chief complaint – reason for consult, preferably limited to 1 sign/symptom
HPI – events leading to consult; if with pain  PQRST, (+) meds – name, dose, frequency, duration, pertinent (+), (-)
ROS – other complaints per organ system
PMH – previous hospitalizations, surgery, accidents, injuries, past/other existing diseases, include drug reactions, allergies
FMH – illness in the family/relatives (e.g. congenital anomalies, drug reactions, allergies)
B&MH – prenatal, perinatal and postnatal events; maternal illnsesses/exposure during pregnancy, trauma
DevHx – 4 domains: gross motor (reflexes, cephalocaudal pattern of development), fine motor (hands and fingers, good pincer grasp
and voluntary release, proximo-distal pattern), language (receptive – alert, recognizes mother, turns to voice, understands ‘no,’
plays games; expressive – cry, coo, laugh, babble, words, phrases, sentences), cognitive – sensorimotor development, object
permanence)
NutHx – +/- breast feeding, bottle feeding, onset of solid feeding, preferences, usual diet
ImmHx – vaccines given, including booster shots and dates for each
P/SH – living conditions, family stressors
HEADSSS for adolescents – home, education, activities, drugs, sexuality, suicide, safety; include employment, goals, screen for
depression
Case 1 (for numbers 2-5): a 3-month-old male, weighing 4 kg and measuring 50cm, went to the OPD for poor feeding.
2.
If his birth weight was 3.2 kg, what is his expected weight?
a. 4.0 kg
b. 4.5 kg
c. 5.0 kg*
d. 5.5 kg
 For < 6mos, wt (g) = age (mos) x 600 + BW
3.
If his birth length was 45 cm, what is his expected height?
a. 54 cm*
b. 55 cm
c. 56 cm
d. 57 cm
 0-3 mos, + 9cm; 3-6 mos, + 8cm, 6-9mos, +5cm, 9-12 mos, +3 cm
4.
If his birth head circumference was 35 cm, what would be his expected head circumference?
a. 35 cm
b. 36 cm
c. 37 cm
d. 38 cm*
 For 1st 4 mos, + ½ inch per month;
5.
According to the waterlowe classification, what is the patient’s nutritional assessment if his ideal weight for actual length is 5.0
kg?
a. Normal
b. Mild stunting, mild wasting
c. Mild stunting, moderate wasting*
d. Moderate stunting, moderate wasting
 For stunting: none >95, mild 90-95, moderate 85-95, severe <85; for wasting: none > 90, mild 81-90, moderate 71-80,
severe <70. Values are percentages of actual length/height over expected length/height for stunting, or percentages of
actual weight over expected weight-for-height for wasting
Case 2 (for numbers 6-10): a 14-week-old baby was brought to the OPD for a well-baby check-up.
6.
At this age, according to the EPI, what immunizations should the patient have received in the past?
a. BCG, OPV 1, DPT 1, Hepa B1
b. BCG, OPV 1, DPT 1, Hepa B2
c. BCG, OPV 2, DPT 2, Hepa B1
d. BCG, OPV 2, DPT 2, Hepa B2*
 Sched for vaccines: BCG – birth, booster at school entry; OPV and DPV – 6, 10, 14 weeks; Hepa B – 0, 1, 6 months;
measles 9 months
7.
What immunizations are due for this visit?
a. OPV 2, DPT 2, Hepa B2
b. OPV 3, DPT 3, Hepa B2
c. OPV 2, DPT 2
d. OPV 3, DPT 3*
8.
General contraindications for vaccinations include the following, EXCEPT:
a. Anaphylactiv reaction to a previous dose of the same vaccine
b. Anaphylactic reaction to a vaccine constituent
c. Presence of a moderate or severe illness, regardless of the presence or absence of fever*
d. None of the above
 Contraindications – immunocompromised (may not give live vaccines), prolonged steroid use; severe illness –
precaution only
9.
True or false*: Restarting the immunization series or giving additional doses is indicated when the intervals between the vaccine
doses exceed those that are recommended.
10. True* or false: Most vaccines can be given simultaneously, without impairment of effectiveness or safety, especially for
inadequately immunized children, to ensure timely completion of the recommended schedule.
11. A developmentally normal child who can be pulled to sit with no head lag is at what age?
a. 4 weeks
b. 8 weeks
c. 12 weeks
d. 16 weeks*
Commonly used milestones in pedia exams (taken from table 10-3, 10-4, 11-1 of Nelson’s, so ages may be different):
Gross motor
Good head control – 2 months
Pull to sit, no head lag – 4 mos
Sits without support – 6 months
Walks alone – 12 months
Runs – 16 months
Jumps – 24 months
Stands on one foot – 36 months
Hops on one foot – 48 months
Skips – 60 months
Fine motor
Grasps rattle – 3½ months
Reaches for objects – 4 months
Transfers objects – 5½ months
Thumb-finger grasp – 8 months
Scribbles – 13 months
Imitates horizontal stroke – 24 mo
Copies circle – 36 months
Copies cross & square – 48 mos
Draws triangle – 60 months
Communication and language
Social smile – 2 months
Monosyllabic babble – 6 months
Inhibits to ‘no,’ follows one-step
command w/gesture – 7 mos
First real word – 12 months
Puts 3 words together – 24 mos
Knows full name – 30 months
Knows age and sex – 36 months
Tells a story – 48 months
Cognitive
Stares where object disappeared –
2 months
Stares at own hand – 4 months
Object permanence – 8 months
Pretend play with doll – 17 mos
Helps to undress – 24 months
Helps dress, washes hands – 36mo
Goes to toilet alone, plays with
several children – 48 months
12. A developmentally normal child who is just able to sit without support, transfer objects from hand to hand, and speak in a
monosyllabic babble is probably at what age?
a. 4 months
b. 6 months*
c. 8 months (smiley answer)
d. 10 months
13. A developmentally normal child who just hops on one foot, copies a cross and square, tells a story, and goes to the toilet alone
is probably at what age?
a. 24 months
b. 36 months
c. 48 months*
d. 60 months
Case 3 (for numbers 14-15): a 9-year-old female sought consult at the adolescent clinic for headaches. As part of your complete
physical examination, you note that her pubic hair is sparse, straight and lightly pigmented, and that her breasts are elevated in
small mound.
Girls
SMR
1
2
Pubic hair
Preadolescent
Sparse, straight, light
3
Dark, beginning to curl
4
5
Coarse, curly
Adult
Breasts
Preadolescent
Elevated as small mound
Breast and areola
enlarged
Areola forms 2o mound
Adult
Pubic hair
Preadolescent
Scanty, long, light
Boys
Penis
Preadolescent
Slight enlargement
Testes
Preadolescent
Enlarged scrotum, pink
Dark, beginning to curl
Longer
Larger
Coarse, curly
Adult
Larger
Adult
Scrotum dark
Adult
14. What is the patient’s tanner staging?
a. SMR stage 0
b. SMR stage 1
c. SMR stage 2*
d. SMR stage 3
15. The most rapid increase in height for girls is found in which tanner stage?
a. SMR stage 0
b. SMR stage 1
c. SMR stage 2
d. SMR stage 3*
 Growth spurt – 11.5 years, SMR 2-3
Case 4 (for numbers 16-17): a 7-year-old male came at the OPD with a history of perianal pruritus. As part of your complete PE, you
note that he still has no pubic hair.
16. What is the patient’s tanner staging?
a. SMR stage 0
b. SMR stage 1*
c. SMR stage 2
d. SMR stage 3
17. The most rapid increase in height in boys is found in which tanner stage?
a. SMR stage 0
b. SMR stage 1
c. SMR stage 2
d. SMR stage 3
 Growth spurt – 13.5 years, SMR 3-4
Case 5 (for numbers 18-19): baby boy Hans was delivered via emergency CS at 42 weeks gestational age after decelerations in
cardiac activity were noted. There was note of thickly meconunium-stained fluid. The patient was hypotonic, gasping, and
bradycardic with a HR of 50s.
18. The next appropriate step is to
a. Stimulate the patient
b. Administer epinephrine
c. Provide positive-pressure bag-and-mask ventilation
d. Intubate the trachea and provide negative pressure suction*
19. After resuscitation, the patient is prepared for ICU admission. You will highly consider the following differentials EXCEPT:
a. Hyaline membrane disease*
b. Neonatal sepsis
c. Neonatal pneumonia
d. Meconium aspiration syndrome
 HMD usually in preterms; MAS almost never in preterms
Case 6 (for numbers 20-24): baby girl Abby was born via SVD at 37 weeks gestational age. After initial resuscitation, at 1 minute, the
patient was noted to have a pink body, but with cyanotic extremities, HR of 120s, slight flexion of extremities, and was crying,
especially after suctioning.
20. What is the patient’s apgar score?
a. 7
b. 8*
c. 9
d. 10
 APGAR – heart rate (<60, >60, >100), respiratory effort (none, slow and irregular, good or crying), reflex irritability
(none, grimace, cough or sneeze), tone (limp, some flexion, active movement), color (blue or pale, acrocyanotic,
completely pink). 1-minute apgar signals need for immediate resuscitation; 5-, 10-, 20-minute apgar indicates the
probability of successfully resusciting the baby. The apgar score was not designed to predict neurologic outcome.
21. The 1-minute apgar score predicts:
a. The need for immediate resuscitation*
b. The probability of successfully resuscitating the infant
c. The neurologic outcome of the infant after resuscitation
d. All of the above
22. After 5 minutes of continued resuscitation, the patient had spontaneous movement of all her extremities, but remained
acrocyanotic. What is the patient’s apgar score?
a. 7
b. 8
c. 9*
d. 10
23. The 5-minute apgar score predicts:
a. The need for immediate resuscitation
b. The probability of successfully resuscitating the infant*
c. The neurologic outcome of the infant after resuscitation (smiley answer)
d. All of the above
24. Newborn care for this patient would include the following, EXCEPT:
a. Vitamin K 1mg IM
b. Ophthalmic pointment OU
c. Aseptic cord care
d. None of the above*
25. Jaundice is most likely physiologic in a term infant in which of the following situations?
a. Jaundice at 12 hours of life
b. Serum bilirubin level increasing less than 5mg/dL/24 hours in the first 2-4 days*
c. Direct serum bilirubin > 1mg/dL
d. Jaundice at 12 days of age
 More likely physiologic if term, after 2nd DOL, increases <5mg/dL/24 hours, direct <1.5mg/dL, resolves in <10 days
26. A neonate developed yellowish discoloration of the skin at 2 weeks of age. Your differentials, EXCEPT:
a. Breast milk jaundice
b. Breastfeeding jaundice*
c. Biliary atresia
d. Hepatitis
27. A purely breastfed neonate was seen at the OPD for yellowish discoloration of the skin. The patient was other well. The
primary consideration was breast milk jaundice. The most appropriate thing to do is:
a. Advise the mother to discontinue breastfeeding for 1-2 days*
b. Advise the mother to increase frequency of breastfeeding to > 10/24 hours
c. Send the patient to PER for admission and laboratory work-up
d. Give the patient Phenobarbital
Case 7 (for numbers 28-30): a 6-month-old male was brought to the PER for diarrhea of 1 day’s duration with stools characterized as
watery, yellowish, non-bloody and non-foul-smelling. On PE, the patient was noted to be restless and irritable and very thirsty. He
had sunken eyeballs, dry oral mucosa and fair skin turgor.
28. Based on the WHO recommendations, what is the patient’s hydration status?
a. No signs of dehydration
b. Some dehydration*
c. Severe dehydration
 Severe (two or more of the following): lethargic or unconscious, sunken eyes, not able to drink or drinking poorly, skin
pinch goes back very slowly. Some (two or more of the following): restless or irritable, sunken eyes, drinks eagerly or is
thirsty, skin pinch goes back slowly.
29. If you are to hydrate this patient orally, how much ORS should you give in the first 4 hours?
a. 200-400mL
b. 400-600mL*
c. 600-800mL
d. 800-1200mL
 The approximate amount of ORS required is 75cc/kg for the 1 st 4 hours. Otherwise, may use age: up to 4 months –
200-450cc, 4–12 months – 450-800 cc, 12 months up to 2 years – 800-960 cc, 2-5 years – 960-1600 cc.
30. After hydration, the child improves. You decide to send the patient home with following instructions, EXCEPT:
a. Give the child more fluids than usual
b. Continue to feed the child
c. Seek consult if there are signs of dehydration or other problems
d. None of the above*
 4 rules of home treatment – give extra fluid, give zinc (ages 2-5 years), continue feeding, know when to return
Case 8 (for numbers 31-33): a 10-month-old male was rushed to the PER for generalized tonic-clonic seizures lasting for about 2
minutes associated with a fever of 39oC. History revealed that the patient has been febrile for the last 3 days, associated with cough,
colds and decreased feeding. On PE, T=38.3 oC, HR 140, RR 30, breath sounds were clear, and no neurologic deficits were noted. The
patient’s father had episodes of febrile seizures as a child.
31. Characteristics of simple febrile seizures include the following, EXCEPT:
a. It is age-dependent and rarely occurs before 9 months or after 5 yers of age
b. Usually associated with a core temperature that increases rapidly to 390C or greater
c. Usually generalized tonic-clonic in character, lasting for a few seconds up to 10 minutes
d. Repeated convulsions may occur within the same day*
 Nelson’s section 586.1 provides a concise reading on febrile seizures that provides the answers for questions 31-33
32. Differentials for the underlying infection include the following, EXCEPT:
a. Sepsis
b. Bacterial meningitis
c. Viral encephalitis*
d. None of the above
33. Febrile seizures are treated by the following, EXCEPT:
a. Control of fever
b. Treatment of underlying infection
c. Initiation of prophylactic anticonvulsants*
d. None of the above
Case 9 (for numbers 34-35): a 3-year-old male was brought to the PER triage for dypnea. He had a 2-day history of cough,
productive of yellowish phlegm, associated with low-grade fever. No medication has been given. On PE, the patient was noted to
have an RR of 56, T 37.9OC, subcostal retractions, and harsh breath sounds but with no alar flaring, wheezing or cyanosis.
34. According to the ARI protocol, what does this patient have?
a. Viral upper respiratory tract pneumonia
b. Pneumonia
c. Severe pneumonia*
d. Very severe illness
 Cough/colds: RR < 50 (or <40 if older than 1 year); pneumonia: tachypnea; severe pneumonia: tachypnea plus chest
indrawing; severe pneumonia: tachypnea plus chest indrawing plus cyanosis/failure to feed or drink
35. What is the next appropriate thing to do?
a. Advise to increase fluid intake and send the patient home
b. Start amoxicillin at 50 mkday and sent the patient home with instructions for follow-up
c. Admit the patient and start pen G IV at 100,000 mkday*
d. Admit the patient and do tracheal intubation
 Cough/colds: follow-up in 5 days if not improving; pneumonia – give oral antibiotics for 3 days; severe pneumonia –
give first dose antibiotic and refer to hospital
Case 10 (for numbers 36-39): an 18-month-old female is noted to assume a squatting position frequently while playing. The mother
also noted occasional episodes of perioral cyanosis during the squatting episodes. Three days PTA, the child developed cough
productive of yellowish phlegm. On the day of admission, the child became restless, tachypnic, and deeply cyanotic. Within 10
minutes, the child becomes unresponsive
36. What is a valuable diagnostic test to differentiate a pulmonary disease from a cyanotic congenital heart disease?
a. Chest x-ray
b. Pulse oximetry
c. Hyperoxia test*
d. ABG
 Performed by taking ABG at FiO2 100% for at least 20-30 minutes. If PO2 < 150mmHg, congenital cyanotic heart
disease; if > 150mmHg, pulmonary disease
37. What is the most likely underlying lesion?
a. Cardiomyopathy
b. Tertralogy of fallot*
c. Aspiration pneumonia
d. Cystic fibrosis
38. What finding is expected in the chest xray?
a. Multichamber enlargement
b. Boot-shaped heart*
c. Pneumonic infiltrates on the right upper lung field
d. Egg on a string sign
39. While blood was being extracted from the patient, she became dyspnic and deeply cyanotic and again became unresponsive.
Management will include the following, EXCEPT:
a. Knee-chest position
b. Oxygen
c. Epinephrine*
d. Morphine
 During tet spells, calm patient  knee-chest position  O2  subcutaneous morphine  NaHCO3 if acidotic
Case 11 (for umbers 40-43): a 7-year-old male diagnosed with tetralogy of fallot came to the PER with increase sleeping time,
headache, and vomiting of 2 days’ duration. He had a 1-month history of low-grade fever. On PE, the patient was drowsy but
arousable, with bacterial papilledema, weakness of the right upper and lower extremities, and (+) Babinski reflex on the right.
40. What will you consider?
a. Brain abscess*
b. Cardiovascular accident, infarct
c. TB meningitis
d. Space-occupying lesion
e. All of the above
 Common TOF complications – Cerebral thromboses (<2 years of age, reason for doing phlebotomy), brain abscess (> 2
years of age), bacterial endocarditis, heart failure
41. The following laboratory work-up should be done on admission, EXCEPT:
a. CBC
b. BUN, Ccrea
c. Lumbar tap*
d. Cranial CT scan
 Don’t know why. Probably to check for contraindications to lumbar tap first?
42. What is/are the drugs of choice for a brain abscess?
a. Pen G
b. Chloramphenicol
c. Both*
d. Neither
 Initial therapy for a brain abscess resulting from a congenital cyanotic lesion is penicillin and metronidazole
43. What are the CT scan findings in TB meningitis?
a. Hydrocephalus
b. Basal enhancement
c. Arteritis/infarction
d. All of the above*
 TB meningitis: CSF findings – leukocytes from 10-500, lymphocyte predominance, glucose low, protein high; CT/MRI
findings – basilar enhancement, communicating hydrocephalus with signs of cerebral edema or focal ischemia
Case 12 (for numbers 44-45): an 8-year-old female came to the PER triage with slight dyspnea, nausea, and pruritic wheals all over
her body. The mother reveals that the patient had no known food allergies, but had developed the symptoms about 30 minutes
after intake of canned nuts. Both parents were asthmatic. On PE, the patient had HR 120s, RR 30, BP 90/50, and wheals all over her
body. There was wheezing on auscultation.
44. What is your diagnosis?
a. Allergic reaction
b. Anaphylactoid reaction
c. Anaphylactic reaction*
d. Adverse reaction
45. What is the next appropriate thing to do?
a. Send the patient to AMBU
b. Admit the patient and give diphenhydramine IM immediately
c. Admit the patient and give epinephyrine IM immediately*
d. Admit the patient and secure airway by tracheal intubation
 Epinephrine was probably chosen due to hypotension (90/50); other times, may give diphenhydramine
Case 13 (for numbers 46-48): a 10-year-old male was seen at the OPD for on-and-off cough of 3 months’ duration. This was
associated with loss of appetite, weight loss, and intermittent low-grade fever. His father was reportedly diagnosed to have a ‘spot
in the lung’ for which he was give 3 types of medications which he took for 3 months. On PE, the child was poorly nourished, had
stable vital signs, matted cervical lymphadenopathy, and clear breath sounds.
46. What class would the patient fall under if PPD turns out to be positive?
a. I
c. III
b. II
d. IV
 I – exposure, II – infection (I + positive PPD), III – disease (II + signs/symptoms/labs), IV – recurrence
47. The following are true about purified protein derivate (PPD) EXCEPT:
a. 0.1mL is given intradermally, for a wheal 6-10mm
b. The induration, not the erythema, should be measured perpendicular to the long axis of the forearm
c. The lesion should be measured 48-72 hours after administration
d. A lesion measuring 10mm is a positive result*
 Cutoff for positive value differs depending on local prevalence, patient exposure to TB
48. What treatment regimen will you start for this patient?
a. 2 HRZ OD then 4 HR OD*
b. 2 HRZ OD then 10 HR OD
c. 2 HRZ +E/S then 4 HR + E/S OD
d. 2 HRZ + E/S then 10 HR + E/S OD
 Just regular PTB so no need for extended second phase; also, no oral streptomycin
Case 14 (for numbers 49-52): an 11-year-old female was admitted at the PGH for nose bleeding. She had a 5-day-history of
moderate-to-high-grade fever associated with headache and vague abdominal pain. She had no vomiting, diarrhea or petechiae. On
PE, HR 110, RR 24, BP 90/60, T 38.5OC, clear breath sounds, and no abdominal mass. Tourniquet test was positive.
49. What will you consider?
a. Typhoid fever
b. Dengue hemorrhagic fever
c. Fever of unknown origin
d. A and B*
50. What sample will you send for culture studies to confirm typhoid fever?
a. Blood*
b. Urine
c. Stool
d. A and B
 Blood cultures often positive early in disease, whereas urine ad stool are positive after 1st week; may also do bone
marrow cultures when blood cultures are negative
51. If this was dengue hemorrhagic fever, what stage will the patient fall under?
a. I
c. III
b. II*
d. IV
 I – only fever, II – I + tourniquet test, III – II + bleeding / lab findings, IV – III + shock
52. The following are laboratory findings seen in DHF EXCEPT:
a. Thrombocytopenia
b. Hemoconcentration
c. Prolonged PT/PTT
d. None of the above*
 Lab findings: hemoconcentration with an increase of >20% in hematocrit, thrombocytopenia, prolonged bleeding time,
moderately decreased prothrombin level that is seldom <40% of control, hypoalbuminemia. Roentgenograms of the
chest reveal pleural effusions (left > right) in nearly all patients.
Case 15 (for numbers 53-57): a 13-year-old male was brought to the OPD for a 1-week history of cough, productive of whitish
phlegm, associated with dyspnea, bipedal edema, palpitation, easy fatigability, orthopnea, and migratory knee joint pains. As a
younger child the patient experienced recurrent sore throats. On PE, the patient had HR 140, RR 30, BP 100/70, T 37.5oC, neck vein
engorgement, a swollen and tender right knee, and bipedal edema. Upon auscultation there was note of rales on bilateral lung
fields, a grade 3/6 holosystolic murmur, heard best at the apex and with radiation to the axilla, and a regular albeit increased heart
rate.
53. What will you consider?
a. Rheumatic fever
b. Rheumatic heart disease
c. Pneumonia
d. All of the above*
 Jones criteria or RF: evidence of infection (culture or antibodies) plus 2 major or 1 major and 2 minor criteria; major
(migratory polyarthritis, carditis, chorea, erythema marginatum, subcutaneous nodules), minor (arthralgia, fever,
elevated CRP/ESR, prolonged PR interval on ECG)
54. What laboratory work-up will you request for?
a. CXR, 12L ECG
b. CXR, 13L ECG, 2D echo
c. CXR, 13L ECG, 2D echo, ASO, ESR, CRP
d. CXR, 13L ECG, 2D echo, ASO, ESR, CRP, blood CS*
 Checking for all criteria
55. What is the organism responsible for RF?
a. Streptococcus A*
b. Streptococcus B
c. Streptococcus C
d. Streptococcus D
 GABHS, actually
56. What is the most common valvular lesion in RHD?
a. Mitral stenosis
b. Mitral regurgitation*
c. Aortic stenosis
d. Aortic regurgitation
57. Management of this patient will include the following, EXCEPT:
a. Fluids and salt restriction
b. Diuretics
c. Inotropes*
d. Antibiotics
e. None of the above
(for the renal questions, tinamad na ako magresearch, hehe. Iexplain niyo na lang sa akin, please)
58. The triad of edema, hypoalbuminemia, and proteinuria constitutes what disease?
a. Nephritic syndrome*
b. Acute glomerulonephritis
c. Nephritic-nephrotic syndrome
d. UTI
59. The triad of edema, hypertension and hematuria constitutes what disease?
a. Nephritic syndrome
b. Acute glomerulonephritis*
c. Nephritic-nephrotic syndrome
d. UTI
60. What is/are the most common cause/s of nephritic syndrome?
a. IgA nephropathy
b. Post-infectious glomerulonephritis
c. Minimal change disease*
d. A and B
61. What is/are the most common cause/s of AGN?
a. IgA nephropathy
b. Post-infectious glomerulonephritis*
c. Minimal change disease
d. A and B
62. What is the most common organism responsible for post-infections GN?
a. Group A β-hemolytic streptococcus*
b. Group B α-hemolytic streptococcus
c. Group A α-hemolytic streptococcus
d. Group B β-hemolytic streptococcus
63. Management of nephritic syndrome includes:
a. Fluid restriction
b. Diuretics
c. Steroids
d. Antibiotics*
64. Management of AGN includes the following, EXCEPT:
a. Fluid restriction
b. Diuretics
c. Steroids*
d. Antibiotics
65. Bonus – draw a self portrait (6 pts)