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MARCH 2006 1. Friend asks you to make a medical certificate stating that he was sick even when he had another reason for his absence: Explain to him you cannot make him one 2. A 4-year old with sinusitis; x-ray done will not show which sinus: Frontal Both the ethmoidal and maxillary sinuses are present at birth, but only the ethmoidal sinuses are pneumatized ( Fig. 377-1 ). The maxillary sinuses are not pneumatized until 4 yr of age. The sphenoidal sinuses are present by 5 yr of age, whereas the frontal sinuses begin development at age 7–8 yr and are not completely developed until adolescence. 3. U/L ratio of 1.1 at approximately what age? 5 y/o The ratio of upper body segment divided by lower body segment (U/L ratio) equals approximately 1.7 at birth, 1.3 at 3 yr of age, and 1.0 after 7 yr of age. Higher U/L ratios are characteristic of short-limb dwarfism or bone disorders, such as rickets. 4. 11 months old, expected number of teeth? 5 Number of teeth= Age in mos - 6 5. Weight for age is a good measure of: Acute Undernutrition Weight for height below the 5th percentile remains the single best growth chart indicator of acute undernutrition. A BMI less than the 5th percentile also indicates that a child is underweight. Brief periods of weight loss or poor weight gain are usually rapidly corrected and do not permanently affect size. Children who have been chronically malnourished may be short as well as thin, so that their weight-for-height curves may appear relatively normal. Chronic, severe undernutrition in infancy may depress head growth, an ominous predictor of later cognitive disability. (P. 72) Despite the need for additional approaches, a number of anthropometric indices have been used successfully for many years to estimate the prevalence of undernutrition among preschool-aged children. These include height-for-age, weight-for-age, and weight-for-height. The 1st is an index of the cumulative effects of undernutrition during the life of the child, the 2nd reflects the combined effects of both recent and longer-term levels of nutrition, and the last reflects recent nutritional experiences. Values <80–90% of expected are considered abnormally low. 6. Best measure of adiposity: BMI Although widely accepted as the best clinical measure of under- and overweight, BMI may not provide an accurate index of adiposity, because it does not differentiate lean tissue and bone from fat. Measurement of the triceps, subscapular, and suprailiac skinfold thickness can be used to estimate adiposity; considerable experience is needed for accuracy. The American Academy of Pediatrics Nutrition Handbook, 5th edition, questions the use of fat folds to estimate total body fat, noting that the method has not been validated in young children and that basic assumptions of the method, that subcutaneous fat is a marker of total fat and that measured sites represent average skin fat thickness, are not true. 7. Denver II is used for what age group: 0-6 8. Disadvantage of Newborn Behavioral Assessment Scale (NBAS): requires extensive training for an examiner to reach proficiency since it provides a FORMAL MEASURE of an infant’s neurodevelopmental competencies, including state control, autonomic reactivity, reflexes, habituation and orientation toward auditory and visual stimuli. So cguro dapat alam mo lahat yan para magawa mo siya! (P. 42) 9. Pubic hair coarse,curly; large glans; dark scrotum: Tanner stage? SMR 4 10. Vit A excess: Alopecia and papilledema 11. 12. 13. 14. 15. Toxicity can be induced in adults and children with chronic daily intakes of 15,000 μg and 6,000 μg, respectively. Symptoms subside rapidly on withdrawal of the vitamin. Signs of subacute or chronic toxicity may include headache; vomiting; anorexia; dry, itchy desquamating skin; seborrheic cutaneous lesions; fissuring at the corners of the mouth; alopecia and/or coarsening of the hair; bone abnormalities; swelling of the bones; enlargement of the liver and spleen; diplopia; increased intracranial pressure; irritability; stupor; limited motion; and dryness of the mucous membranes. In addition, desquamation of the palms and the soles of the feet is common. Radiographs show hyperostosis affecting several long bones, especially in the middle of the shafts. Serum levels of vitamin A are elevated. Hypercalcemia and/or liver cirrhosis may be present. Xeropthalmia,conjunctivitis; blurred vision, photophobia: VIT A DEFICIENCY Patient with Dermatitis, edema: Kwasiorkor Edematous SCU (kwashiorkor) may initially present as vague manifestations that include lethargy, apathy, and/or irritability. When advanced, there is lack of growth, lack of stamina, loss of muscle tissue, increased susceptibility to infections, vomiting, diarrhea, anorexia, flabby subcutaneous tissues, and edema. The edema usually develops early and may mask the failure to gain weight. It is often present in internal organs before it is recognized in the face and limbs. Liver enlargement may occur early or late in the course of disease. Dermatitis is common, with darkening of the skin in irritated areas, but in contrast to pellagra, not in areas exposed to sunlight. Depigmentation may occur after desquamation in these areas, or it may be generalized. The hair is sparse and thin, and in dark-haired children, it may become streaky red or gray. Breastfeeding mother diagnosed with hyperthyroidism and started on Methimazole. What advice would you give regarding the feeding of her baby? P. 682, Drugs and breastfeeding. Methimazole is contraindicated in breastfeeding In the 1st yr of life, breastfed infants plot higher for weight on the growth curve compared to formula fed infants during the: 1st 6 mos Compared with current standards, an exclusively breast-fed infant would be expected to plot higher for weight in the 1st 6 mo, but relatively lower in the 2nd half of the 1st year (P.70) Most common type of dehydration associated with diarrhea: Isotonic In approximately 70–80% of patients, the losses of water and sodium are proportionate, with isotonic dehydration developing. Hyponatremic dehydration is seen in approximately 10–15% of all patients with diarrhea. It occurs when large amounts of electrolytes, especially sodium, are lost in the stool out of proportion to fluid losses. It occurs more frequently with bacillary dysentery or cholera. Hyponatremia may develop or worsen if there is a considerable oral intake of low-electrolyte or electrolyte-free fluids during diarrhea . Disproportionately large net losses of water compared with losses of electrolytes result in hypernatremic dehydration. It is seen in 10–20% of patients with diarrhea and may occur during the course of diarrhea when oral homemade electrolyte solutions with high concentrations of salt are administered or when infants are fed boiled skim milk, which produces a high renal solute load and increased urinary water losses. Hypernatremia secondary to water loss and not sodium retention: Diabetes Insipidus, p. 273 Table on Causes of Hypernatremia SIADH-Hyponatremia Cerebral Salt Wasting-Hyponatremia Diuretics- causes Hypokalemia CLINICAL PARAMETER SIADH CEREBRAL SALT WASTING CENTRAL DI Serum sodium Low Low High Urine output Normal or low High High Urine sodium High Low Very high Intravascular volume status Normal or high Low Low Serum uric acid Low Normal or high High Vasopressin level High Low Low 16. Most common complication of TPN: Most important problem is SEPSIS in central vein infusion. (?) Answer: elevated liver enzymes 17. Normal Serum osmalarity: 285-295, p. 269 18. Normal Anion gap acidosis: Diarrhea Table-Causes of Metabolic Acidosis, p298 NORMAL ANION GAP Diarrhea Renal tubular acidosis (RTA) Distal (type I) RTA (MIM 179800/602722/267300)[*] Proximal (type II) RTA (MIM 604278)[†] Hyperkalemic (type IV) RTA (MIM 201910/264350/177735/145260)[‡] Urinary tract diversions Posthypocapnia Ammonium chloride intake INCREASED ANION GAP Lactic acidosis Tissue hypoxia (shock, hypoxemia, severe anemia) Liver failure Malignancy Intestinal bacterial overgrowth Inborn errors of metabolism Medications (nucleoside analogues, metformin) Ketoacidosis Diabetic ketoacidosis Starvation ketoacidosis Alcoholic ketoacidosis Kidney failure Poisoning Ethylene glycol Methanol Salicylate Toluene Paraldehyde Inborn errors of metabolism 19. GCS score requiring intubation: < 8 Patients with a GCS score of 8 or less may require aggressive management, including mechanical ventilation and intracranial pressure monitoring. (p394) 20. Ratio of chest compressions to respirations for CPR in a child: 5:1 Chest Compression: Ventilation Relationships Compression rate NEONATE 1–8 YR 120 At least 100 100 Compression-ventilation ratio[*] 3 : 1 Pulse check[‡] 5:1 Umbilical artery Brachial >8 YR 15 : 2[†] Carotid 21. Most common chromosomal abnormality: Trisomy, p. 507. 22. In MSUD, which amino acid is decreased: ALANINE Decarboxylation of leucine, isoleucine, and valine is accomplished by a complex enzyme system (branched-chain α-ketoacid dehydrogenase) using thiamine pyrophosphate (vitamin B 1) as a coenzyme. This mitochondrial enzyme consists of four subunits: E 1α, E1β, E2, and E3. The E3 subunit is shared with two other dehydrogenases in the body, namely pyruvate dehydrogenase and α-ketoglutarate dehydrogenase. Deficiency of this enzyme system causes MSUD 23. Inborn error of metabolism with rotting fish odor of urine: Trimethylaminuria INBORN ERROR OF METABOLISM URINE ODOR Glutaric acidemia (type II) Sweaty feet, acrid Hawkinsinuria Swimming pool Isovaleric acidemia Sweaty feet, acrid Maple syrup urine disease Maple syrup Hypermethioninemia Boiled cabbage Multiple carboxylase deficiency Tomcat urine Oasthouse urine disease Hops-like Phenylketonuria Mousey or musty Trimethylaminuria Rotting fish Tyrosinemia Boiled cabbage, rancid butter 24. Best indicator of maturity in a term infant: 25. Meconium stained tracheal suctioning done, suddenly presented with cyanosis, decreased breath sounds: Pneumothorax TABLE 410-1 -- Causes of Pneumothorax in Children SPONTANEOUS Primary idiopathic—usually resulting from ruptured subpleural Secondary blebs Congenital lung disease Congenital cystic adenomatoid malformation Bronchogenic cysts Pulmonary hypoplasia Conditions associated with increased intrathoracic pressure Asthma Bronchiolitis Air-block syndrome in neonates Cystic fibrosis Airway foreign body Infection Pneumatocele Lung abscess Bronchopleural fistula Diffuse lung disease Langerhans cell histiocytosis Tuberous sclerosis Marfan syndrome Ehlers-Danlos syndrome Metastatic neoplasm—usually osteosarcoma (rare) TRAUMATIC Noniatrogenic Penetrating trauma Blunt trauma Loud music (air pressure) Iatrogenic Thoracotomy Thoracoscopy, thoracentesis Tracheostomy Tube or needle puncture Mechanical ventilation onset is usually abrupt, and the severity of symptoms depends on the extent of the lung collapse and on the amount of pre-existing lung disease. Pneumothorax may cause pain, dyspnea, and cyanosis. There is respiratory distress, retractions, and markedly decreased breath sounds over the involved lung. (p.1836) Although PPHN can also present with cyanosis, infants become ill in the delivery room or within the 1 st 12 hrs of life. (P.744) 26. Why IVH in the germinal matrix: The area is highly vascular with little tissue support. Immature blood vessels in this highly vascular region of the brain combined with poor tissue vascular support predispose premature infants to hemorrhage p. 715 27. Most common cause of seizure in an infant: HIE, p. 2471 28. Lab results in a plethoric newborn important: HCT 0.78. p. 773. Severe complications include seizures, stroke, pulmonary hypertension, necrotizing enterocolitis, renal vein thrombosis, and renal failure. Many affected infants are asymptomatic. Hyperviscosity is present in most infants with central Hct values of 65% or higher and accounts for the symptoms of polycythemia. 29. Why PIP is increased in HMD: goals of mechanical ventilation are to improve oxygenation and elimination of carbon dioxide without causing pulmonary barotrauma or oxygen toxicity. Acceptable ranges of blood gas values, after balancing the risks of hypoxia and acidosis against those of mechanical ventilation, vary between institutions and range between a PaO2 of 50–70 mm Hg, a PaCO2 of 45–65 mm Hg, and a pH of 7.20–7.35. During mechanical ventilation, oxygenation is improved by increasing either the FIO2 or the mean airway pressure. The latter can be increased by increasing the peak inspiratory pressure, gas flow, the inspiratory: expiratory ratio, or PEEP. Excessive PEEP may impede venous return, thereby reducing cardiac output and decreasing oxygen delivery despite improvement in Pa O2. PEEP levels of 4–6 cm H2O are usually safe and effective. Carbon dioxide elimination is achieved by increasing the peak inspiratory pressure (tidal volume) or the rate of the ventilator 30. Cause of seizure in a preeclamptic mother: Hypocalcemia secondary to hypermagnesemia. P. 287, P.778. Clinically significant hypermagnesemia is almost always secondary to excessive intake. It is unusual, except in neonates born to mothers who are receiving intravenous magnesium for preeclampsia or eclampsia 31. Allergy test that detects allergen specific IgE in the serum: RAST The presence of IgE specific for a particular allergen can be documented in vivo by skin testing or in vitro by the measurement of allergen-specific IgE levels in the serum . The most widely employed test for documenting the presence of allergen-specific IgE in the serum is the radioallergosorbent test (RAST), with allergens of an individual allergen extract bound to a solid phase support. P. 940 Allergen skin testing is the primary in vivo procedure for the diagnosis of allergic disease. Mast cells with allergen-specific IgE antibodies attached to high-affinity receptors on their surface reside in the skin of allergic patients. The introduction of minute amounts of an allergen to which the patient is allergic into the skin results in cross linking by the allergen of allergen-specific IgE antibodies on the mast cell surface, thereby triggering mast cell activation. 32. Most common cause of mortality in 1st 10 days of Kawasaki disease: Myocarditis The acute febrile phase, which usually lasts 1–2 wk, is characterized by fever and the other acute signs of illness. The dominant cardiac manifestation is myocarditis. In addition, a macrophage activation syndrome may rarely be evident . The subacute phase begins when fever and other acute signs have abated, but irritability, anorexia, and conjunctival injection may persist. The subacute phase is associated with desquamation, thrombocytosis, the development of coronary aneurysms, and the highest risk of sudden death in those who have developed aneurysms. This phase generally lasts until about the 4th wk. The 33. 34. 35. 36. 37. 38. convalescent phase begins when all clinical signs of illness have disappeared and continues until the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) return to normal, ≈6–8 wk after the onset of illness. P. 1038 Livedo reticularis, a lacelike bluish or erythematous discoloration is seen in: SLE JDM: rash often has onset in sun-exposed areas and develops as the first symptom in 50% of cases, and concomitantly with weakness in 25% of cases. The characteristic periorbital violaceous erythema (heliotrope) may cross the bridge of the nose, in a masklike distribution, and involve the ears as well. Edema may be limited to the periorbital area, or generalized, and may involve the scalp with inflammation sufficient to result in partial baldness. The rash is often florid and is usually palpable over joints, especially the metacarpal phalangeal, intercarpal phalangeal (Gottron papules), knees, elbows, and medial malleoli of the ankles . Cutaneous involvement can spread to the extensor surfaces of the extremities, the torso in a shawl-like distribution, and be generalized involving the trunk and buttocks PAN: Vasculitis affecting the skin may be manifested by purpura, edema, and linear erythema with palpable, painful nodules along the course of affected arteries. In cutaneous PAN, the findings are limited to the skin JRA: It is characterized by a quotidian fever with temperatures to ≥39°C, sometimes followed by mildly hypothermic temperatures for ≥2 wk. Each febrile episode is frequently accompanied by a characteristic faint, erythematous, macular rash; these evanescent salmon-colored lesions may be linear or circular, from 2–5 mm in size, and are often distributed in groups with a linear distribution most commonly over the trunk and proximal extremities ( Fig. 154-8 ). This rash is not pruritic. Its most diagnostic feature is its transient nature, with a group of lesions usually lasting <1 hr. The Koebner phenomenon, which is cutaneous hypersensitivity to superficial trauma resulting in a localized recurrence of the rash, is suggestive, but not diagnostic, of systemic-onset disease. Heat, such as a warm bath, also evokes a reappearance of the rash. Arthritis, hepatosplenomegaly, high grade fever and rash: JRA Systemic-onset disease is characterized by arthritis and prominent visceral involvement that includes hepatosplenomegaly, lymphadenopathy, and serositis, such as a pericardial effusion. It is characterized by a quotidian fever with temperatures to ≥39°C, sometimes followed by mildly hypothermic temperatures for ≥2 wk. P.1002 SLE- (-) hepatosplenomegaly Kawasaki- (-) hepatosplenomegaly Rash on an infant’s perineal are with satellite lesion: Candida Adolescent female with exposure to mother with TB,has signs and sxs of TB, CXR(+) cavitary lesions: 2HREZ, 4HR Patient has TB Disease. TB Concensus Most common complication of MUMPS: Meningoencephalitis The most common complications of mumps are meningitis, with or without encephalitis, and gonadal involvement. Uncommon complications include conjunctivitis, optic neuritis, pneumonia, nephritis, pancreatitis, and thrombocytopenia.p1343 Complication of varicella that invades subcutaneous layer of the skin: necrotizing fascitis Varicella is a well-described risk factor for serious invasive infections caused by group A streptococcus, which can have a fatal outcome. The more invasive infections, such as varicella gangrenosa, bacterial sepsis, pneumonia, arthritis, osteomyelitis, cellulitis, and necrotizing fasciitis, account for much of the morbidity and mortality of varicella in otherwise healthy children Bullous impetigo, SSSS: Staph aureus Nonbullous impetigo, Erysipelas: Grp A strp skin infections 39. Erythema on cheeks and neck: strep infection rash appears within 24–48 hr after onset of symptoms, although it may appear with the 1st signs of illness. It often begins around the neck and spreads over the trunk and extremities. It is a diffuse, finely papular, erythematous eruption producing a bright red discoloration of the skin, which blanches on pressure. It is often more intense along the creases of the elbows, axillae, and groin. The skin has a goosepimple appearance and feels rough. The face is usually spared, although the cheeks may be erythematous with pallor around the mouth. After 3–4 days, the rash begins to fade and is followed by desquamation, 1st on the face, progressing downward, and often resembling that seen subsequent to a mild sunburn staph aureus- Staphylococcus is an important cause of pyogenic skin infections, including impetigo contagiosa, ecthyma, bullous impetigo, folliculitis, hydradenitis, furuncles, carbuncles, staphylococcal scalded skin syndrome, and a syndrome resembling the rash of scarlet fever. Infection may also complicate wounds or occur as superinfection of other noninfectious skin disease (eczema) 40. A 5 y/o came in for vomiting after the px went on a picnic. She ate spaghetti, cupcakes, salad. The patient’s mother claim that all the food except the cupcakes were prepared at home. The px’s mother did not refrigerate the anymore since the weather was cool. 8-12 hrs hx of eating cupcakes with butter icing, (+) vomiting. What did the px have? staph aureus Food poisoning may be caused by ingestion of preformed enterotoxins produced by staphylococci in contaminated foods. Approximately 2–7 hr after ingestion of the toxin, sudden, severe vomiting begins. Watery diarrhea may develop, but fever is absent or low. Cholera- more of diarrhea, (-) hx of eating anything Salmonella- high grade fever, gen myalgia, abdominal pain, hepatosplenomegaly, abdominal pain, diarrhea. Vomiting may be present but not a common clinical feature 41. Dx of Leptospirosis: MAT-microscopic agglutination test,p.1272. Dark field microscopy: syphilis 42. Postexposure vaccination not effective in: Mumps Measles: The vaccine is effective in prevention or modification of measles if given within 72 hr of exposure. Immune globulin may be given up to 6 days following exposure to prevent or modify infection. Varicella: Vaccine given to normal children within 3–5 days after exposure (as soon as possible is preferred) is effective in preventing or modifying varicella, especially in a household setting where exposure is very likely to result in infection. Varicella vaccine is now recommended for postexposure use, for outbreak control. 43. Infant with high grade fever and colds. Upon defervescence of fever, rose-colored rah appeared: Roseala Infantum Roseola is a mild febrile, exanthematous illness occurring almost exclusively during infancy.Occasionally, the fever may gradually diminish over 24–36 hours (“lysis”). A rash appears within 12–24 hr of fever resolution. In many cases, the rash develops during defervescence or within a few hours of fever resolution. Measles: After an incubation period of 8–12 days, the prodromal phase begins with a mild fever followed by the onset of conjunctivitis with photophobia, coryza, a prominent cough and increasing fever. Symptoms increase in intensity for 2–4 days until the 1st day of the rash. The rash begins around the forehead (around the hairline), behind the ears, and on the upper neck as a red maculopapular eruption. It then spreads downward to the torso and extremities, reaching the palms and soles in up to 50% of cases. RASH APPEARDS AT THE HEIGHT OF THE FEVER Rubella: most common in preschool-aged and school-aged children. In children, the 1st manifestation of rubella is usually the rash, which is variable and not distinctive. It begins on the face and neck as small, irregular pink macules that coalesce, and it spreads centrifugally to involve the torso and extremities, where it tends to occur as discrete macules 44. Drug if given with EBV infxn causes a non-IgE mediated rash: Amoxicillin Rashes are usually maculopapular and have been reported in 3–15% of patients. Up to 80% of patients with infectious mononucleosis experience “ampicillin rash” if treated with ampicillin or amoxicillin 45. Mother had varicella 24 hrs before delivery. Baby will develop: disseminated varicella Infants whose mothers develop varicella in the period from 5 days prior to delivery to 2 days afterward are at high risk for severe varicella. The infant acquires the infection transplacentally as a result of maternal viremia, which may occur up to 48 hr prior to the maternal rash. Depending on when virus crosses the placenta, the infant's rash may occur toward the end of the 1st week to the early part of the 2nd week of life. Because the mother has not yet developed a significant antibody response, the infant receives a large dose of virus without the moderating effect of maternal anti-VZV antibody. If the mother develops varicella more than 5 days prior to delivery, she still may pass virus to the soon-to-be-born child, but infection is attenuated due to transmission of maternal antibody across the placenta 46. Typhoid fever on the 1st 5 days of illness: CBC and blood culture mainstay of the diagnosis of typhoid fever is a positive culture from the blood or another anatomic site. Results of blood cultures are positive in 40–60% of the patients seen early in the course of the disease, and stool and urine cultures become positive after the 1st wk. The stool culture result is also occasionally positive during the incubation period. 47. Multiple mouth ulcers with fever: Herpetic Ginigivostomatitis extremely painful condition with sudden onset, pain in the mouth, drooling, refusal to eat or drink, and fever of up to 40.0–40.6°C. The gums become markedly swollen, and vesicles may develop throughout the oral cavity, including on the gums, lips, tongue, palate, tonsils, and pharynx herpangina: characterized by sudden onset of fever, sore throat, dysphagia, and lesions in the posterior pharynx. Temperatures can range from normal to 41°C (106°F); fever tends to be greater in younger patients. Headache and backache may occur in older children, and vomiting and abdominal pain occur in 25%. Characteristic lesions, present on the anterior tonsillar pillars, soft palate, uvula, tonsils, posterior pharyngeal wall, and, occasionally, the posterior buccal surfaces, are discrete 1–2 mm vesicles and ulcers that enlarge over 2–3 days to 3–4 mm and are surrounded by erythematous rings that vary in size up to 10 mm. Coxsackie A 48. Malaria chemoprophylaxis given for how long after returning from travel to an endemic area: 4 weeks Chemoprophylaxis is necessary for all visitors to and residents of the tropics who have not lived there since infancy ( Table 285-2 ). Children of nonimmune women should have chemoprophylaxis from birth. Chemoprophylaxis should be started 1–2 wk before entering the endemic area (except for doxycycline administration, which can begin 1–2 days before departure) and continue for at least 4 wk after leaving 49. Case of dengue with petechiae: Stage II I-nonspecific constitutional sx; hemorrhagic mx is a (+) tourniquet test II-spontaneous bleeding in addition to mx of gr 1 pxs usually in the form of skin or other hges (mucocutaneous, GI) III-circulatory failure: rapid, weak pulse, narrow pulse pressure, hypotension, with cold, clammy skin and restlessness IV-profound shock III and IV: constitutes DSS 50. Included in the minor criteria of RF: Arthralgia MAJOR MANIFESTATIONS[*] SUPPORTING EVIDENCE OF ANTECEDENT GROUP A MINOR MANIFESTATIONS STREPTOCOCCAL INFECTION MAJOR MANIFESTATIONS[*] SUPPORTING EVIDENCE OF ANTECEDENT GROUP A MINOR MANIFESTATIONS STREPTOCOCCAL INFECTION Carditis Clinical features: Polyarthritis Arthralgia Fever Erythema marginatum Laboratory features: Subcutaneous nodules Elevated acute phase reactants: Positive throat culture or rapid streptococcal antigen test Elevated or increasing streptococcal antibody titer Erythrocyte sedimentation rate C-reactive protein Prolonged PR interval Chorea 51. Paroxysms of cough followed by vomiting: Pertusis As initial symptoms wane, coughing marks the onset of the paroxysmal stage (2–6 wk). The cough begins as a dry, intermittent, irritative hack and evolves into the inexorable paroxysms that are the hallmark of pertussis. A well-appearing, playful toddler with insignificant provocation suddenly expresses an anxious aura and may clutch a parent or comforting adult before beginning a machine-gun burst of uninterrupted coughs, chin and chest held forward, tongue protruding maximally, eyes bulging and watering, face purple, until coughing ceases and a loud whoop follows as inspired air traverses the still partially closed airway. Post-tussive emesis is common, and exhaustion is universal. 52. Vitamin A for measles: Recommendations for Vitamin A Treatment of Children with Measles INDICATIONS • Children 6 mo to 2 yr of age hospitalized with measles and its complications (e.g., croup, pneumonia, and diarrhea). (Limited data are available about the safety and need for vitamin a supplementation for infants <6 mo of age.) • Children >6 mo of age with measles who are not already receiving vitamin A supplementation and who have any of the following risk factors: • immunodeficiency • clinical evidence of vitamin A deficiency • impaired intestinal absorption • moderate to severe malnutrition • recent immigration from areas where high mortality rates attributed to measles have been observed REGIMEN Parenteral and oral formulations of vitamin A are available in the USA. The recommended dosage, administered as a capsule, is: • Single dose of 200,000 IU orally for children ≥1 yr of age (100,000 IU for children 6 mo to 1 yr of age) • The dose should be repeated the next day and again 4 wk later for children with ophthalmologic evidence of vitamin A deficiency 53. Case of a symptomatic 5 y/o child with TB exposure and Mantoux Test 10 mm: Primary Pulmo TB 54. Vaccine introduced in the past decade that resulted in a dramatic decrease in the prevalence of bacterial infxns in infants and children: HiB 55. Preferred IM injection site for infants: Anterolateral thigh 56. TB complication that takes 20 years: Renal TB,15-20 yrs after primary infxn 57. Maternal measles antibodies wanes after: 4-6 mos 58. Infants born to HBsAg (+) mother: Hep B vaccine shld be given within 12 hours of birth Both HBIG and vaccine should be administered within 12 hr of infant's birth, and within 24 hr of identifiable blood exposure. HBIG can be given up to 14 days after sexual exposure. ∫HBIG dose: 0.5 μL for newborns of HBsAg-positive mothers, and 0.06 μL/kg for all others when recommended. 59. (+) anti-HBS but (-) anti-HBc and (-) HbsAg HAV HBV HCV HDV HEV Acute Anti-HAV IgM (+) Anti-HBc IgM (+) Anti-HCV (+) Anti-HDV IgM (+) Anti-HEV IgM (+) Infection Blood PCR (+)[*] HBsAg (+) HCV RNA (+) Blood PCR (+) Blood PCR (+) Anti-HBs (PCR) HBsAg (+) HBV DNA (+) (PCR) Past infection (recovered) Chronic infection Anti-HAV IgG (+) Anti-HBs (+) N/A Anti-HBs (-) Anti-HCV (-) Anti-HDV IgG (+) Anti-HEV IgG (+) Anti-HBc IgG (+) Blood PCR (-) Blood PCR (-) Anti-HBc IgG (+) Anti-HCV (+) Anti-HDV IgG (+) N/A HBsAg (+) Blood PCR (+) Blood PCR (-) Anti-HBs Blood PCR (-) HBsAg (+) PCR (+) or (-) Vaccine response Anti-HAV IgG (+) Anti-HBs (+) N/A N/A N/A Anti-HBc (-) 60. 3 y/o suddenly screams in pain every 5-10 minutes with a mass in the RUQ: Intussusception typical cases, there is sudden onset, in a previously well child, of severe paroxysmal colicky pain that recurs at frequent intervals and is accompanied by straining efforts with legs and knees flexed and loud cries. The infant may initially be comfortable and play normally between the paroxysms of pain; but if the intussusception is not reduced, the infant becomes progressively weaker and lethargic. At times, the lethargy is out of proportion to the abdominal signs. 61. NB non-bilious vomiting, electrolyte imbalance and a palpable olive-shaped mass at the epigastric area: Pyloric stenosis Duodenal atresia: HALLMARK is bilious vomiting Malrotation: bilious emesis Intussusception: bilious emesis with sausage-shaped mass 62. Most common cause of respirtatory tract infxn in children: RSV 63. Adolecent with asthma, xray has 20% pneumothorax, treatment: Oxygen and thoracotomy A small (<5%) pneumothorax complicating asthma may also resolve spontaneously. Administering 100% oxygen may hasten resolution. If there is >5% collapse or if the pneumothorax is recurrent or under tension, chest tube drainage is necessary. Oxygen and needling: cannot be done since px’s an adolescent already 64. Anatomic location of chest tube placement for pnuemothorax: 4 th-9th ICS LAAL 65. Child with hx of choking, suddenly presents with dyspnea and wheezing: Foreign Body Aspiration Three stages of symptoms may result from aspiration of an object into the airway: 1. Initial event— violent paroxysms of coughing, choking, gagging, and possibly airway obstruction occur immediately when the foreign body is aspirated. 2. Asymptomatic interval— the foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside. This stage is most treacherous and accounts for a large percentage of delayed diagnoses and overlooked foreign bodies. It is during this 2nd stage that the physician may minimize the possibility of a foreign body accident, being reassured by the absence of symptoms that no foreign body is present. 3. Complications— obstruction, erosion, or infection develops to direct attention again to the presence of a foreign body. In this 3rd stage, complications include fever, cough, hemoptysis, pneumonia, and atelectasis 66. Px presents w/ nosiy breathing and wheezes that disappear during sleep: Laryngomalacia: Of congenital laryngeal anomalies in children with stridor, 60% are caused by laryngomalacia, the most common congenital laryngeal anomaly and the most frequent cause of stridor in infants and children. Typically, stridor is inspiratory, low pitched, and exacerbated by any exertion (crying, agitation, feeding), supine position, and viral infections of the upper airway. Stridor results from the collapse of supraglottic structures inward during inspiration. Symptoms usually appear in the first 2 wk of life and increase in severity for up to 6 mo, although gradual improvement can begin at any time. Laryngopharyngeal reflux is commonly associated with laryngomalacia. Bronchomalacia: The dominant finding, low-pitched monophonic wheezing, is most prominent over the central airways. Parents often describe persistent respiratory congestion even in the absence of a viral respiratory infection. When the lesion involves only one main bronchus (more commonly the left), the wheezing is louder on that side 67. Px presents with high-grade fever, cough and colds. Examination of the pharynx revealed displacement of the uvula: Peritonsilar abscess Peritonsillar cellulitis/abscess, which is relatively common compared to the deep neck infections, is caused by bacterial invasion through the capsule of the tonsil, leading to cellulitis and/or abscess formation in the surrounding tissues. The typical patient with a peritonsillar abscess is an adolescent with a recent history of acute pharyngotonsillitis. Clinical manifestations include sore throat, fever, trismus, and dysphagia. Physical examination reveals an asymmetric tonsillar bulge with displacement of the uvula. An asymmetric tonsillar bulge is diagnostic, but it may be poorly visualized because of trismus . 68. Px had fever, sudden onset of respiratory distress with hyperextension of the neck and refusal to feed: Epiglottitis- dramatic, potentially lethal condition is characterized by an acute potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction. The degree of respiratory distress at presentation is variable. The initial lack of respiratory distress can deceive the unwary clinician; respiratory distress can also be the 1st manifestation, however. Often, the otherwise healthy child suddenly develops a sore throat and fever. Within a matter of hours, the patient appears toxic, swallowing is difficult, and breathing is labored. Drooling is usually present and the neck is 69. 70. 71. 72. 73. 74. hyperextended in an attempt to maintain the airway. The child may assume the tripod position, sitting upright and leaning forward with the chin up and mouth open while bracing on the arms. A brief period of air hunger with restlessness may be followed by rapidly increasing cyanosis and coma. Stridor is a late finding and suggests near-complete airway obstruction. Retropharyngeal Abscess- fever, irritability, decreased oral intake, and drooling. Neck stiffness, torticollis, and refusal to move the neck may also be present. Most common CHD in children, not including the newborn period: VSD Case of a px with a harsh systolic murmur at the left lower sterna border, no failure signs. Most likely: Small VSD-Characteristically, a loud, harsh, or blowing holosystolic murmur is present and heard best over the lower left sternal border, and it is frequently accompanied by a thrill Large VSD-holosystolic murmur of a large VSD is generally less harsh than that of a small VSD and more blowing in nature because of the absence of a significant pressure gradient across the defect, with failure signs Secundum ASD-In most patients, the 2nd heart sound is characteristically widely split and fixed in its splitting in all phases of respiration. A systolic ejection murmur is heard; it is medium pitched, without harsh qualities, seldom accompanied by a thrill, and best heard at the left middle and upper sternal border. It is produced by the increased flow across the right ventricular outflow tract into the pulmonary artery, not by low-pressure flow across the ASD. A short, rumbling mid-diastolic murmur produced by the increased volume of blood flow across the tricuspid valve is often audible at the lower left sternal border. PDA-classic continuous murmur is described as being like machinery or rolling thunder in quality. It begins soon after onset of the 1st sound, reaches maximal intensity at the end of systole, and wanes in late diastole. It may be localized to the 2nd left intercostal space or radiate down the left sternal border or to the left clavicle. Child with colds and cough develops fever and dyspnea. PE showed a HR of 170. CXR showed cardiomegaly: Myocarditis initially have fever, severe heart failure, respiratory distress, cyanosis, distant heart sounds, weak pulses, tachycardia out of proportion to the fever, mitral insufficiency caused by dilatation of the valve annulus, a gallop rhythm, acidosis, and shock. Evidence of viral hepatitis, aseptic meningitis, and an associated rash may be present. In the most fulminant form, death may occur within 1–7 days of the onset of symptoms. The chest roentgenogram demonstrates an enormously enlarged heart and pulmonary edema; the electrocardiogram reveals sinus tachycardia, reduced QRS complex voltage, and ST segment and T-wave abnormalities. Arrhythmias may be the first clinical manifestation and, in the presence of fever and a large heart, strongly suggest acute myocarditis. Cyanotic heart disease that squats: TOF Earliest type of valvular involvement in RHD: Mitral Insufficiency-Mitral insufficiency is the result of structural changes that usually include some loss of valvular substance and shortening and thickening of the chordae tendineae. During acute rheumatic fever with severe cardiac involvement, heart failure is caused by a combination of mitral insufficiency coupled with inflammatory disease of the pericardium, myocardium, endocardium, and epicardium. Mitral Stenosis-It takes 10 yr or more for the lesion to become fully established, although the process may occasionally be accelerated. Rheumatic mitral stenosis is seldom encountered before adolescence and is not usually recognized until adult life Presents w/ ‘granulocytic sarcoma’: AML patients with AML may present with any or all of the findings associated with marrow failure in ALL. In addition, patients with AML present with signs and symptoms that are uncommon in ALL, including subcutaneous nodules or “blueberry muffin” lesions, infiltration of the gingiva, signs and laboratory findings of disseminated intravascular coagulation (especially indicative of acute promyelocytic leukemia), and discrete masses, known as chloromas or granulocytic sarcomas. These masses may occur in the absence of apparent bone marrow involvement and typically are associated with the M2 subcategory of AML with a t(8;21) translocation. Chloromas also may be seen in the orbit and epidural space. CNS symptoms are more common in AML than ALL. 75. CBC findings in ITP besides decreased platelets: Normal WBC, Normal Hgb Severe thrombocytopenia (platelet count <20 × 10 9/L) is common, and platelet size is normal or increased, reflective of increased platelet turnover. In acute ITP, the hemoglobin value, white blood cell (WBC) count, and differential count should be normal. Hemoglobin may be decreased if there have been profuse nosebleeds or menorrhagia. Bone marrow examination shows normal granulocytic and erythrocytic series, with characteristically normal or increased numbers of megakaryocytes. Some of the megakaryocytes may appear to be immature and are reflective of increased platelet turnover Thrombotic Thrombocytopenic Purpura-Laboratory findings provide important clues to the diagnosis and show microangiopathic hemolytic anemia characterized by morphologically abnormal RBCs, with schistocytes, spherocytes, helmet cells, and an elevated reticulocyte count in association with thrombocytopenia 77. Most common intracranial tumor in children: Astrocytoma-are a heterogeneous group of pediatric CNS tumors that account for approximately 40% of cases. These tumors occur throughout the CNS Juvenile pilocytic astrocytoma (JPA) is the most common astrocytoma in children, accounting for 20% of all brain tumors Glioblastoma-second most common astrocytoma is fibrillary infiltrating astrocytoma, a group of tumors characterized by a pattern of diffuse infiltration of tumor cells among normal neural tissue and potential for anaplastic progression. Based on their clinicopathologic characteristics, they are grouped as low-grade astrocytomas (WHO grade II), malignant astrocytomas (anaplastic astrocytoma, WHO grade III), and glioblastoma multiforme (GBM, WHO grade IV). Of this group, the fibrillary LGA is the second most common astrocytoma in children, accounting for 15% of brain tumors. Ependymoma-occurring predominantly in childhood and accounting for 10% of childhood tumors. Approximately 70% of ependymomas in childhood occur in the posterior fossa. TABLE 497-2 -- Distribution of Childhood Brain Tumors Based on Histology HISTOLOGY DISTRIBUTION (% OF TOTAL) Medulloblastoma/primitive neuroectodermal tumor 20 Juvenile pilocytic astrocytoma 20 Low-grade astrocytoma 15 High-grade astrocytoma 7 Ependymoma 7 Craniopharyngioma 7 Unclassified primary tumors 7 Choroid plexus tumors, germ cell tumors, oligodendroglioma, meningioma, mixed tumors, pineal parenchymal tumors 1–2 (each histologic group) The Childhood Brain Tumor Consortium reported a slight predominance of infratentorial tumor location (43.2%), followed by the supratentorial location (40.9%), spinal cord (4.9%), and multiple sites (11%). 78. Earliest manifestation of retinoblastoma: Pupillary abnormality Retinoblastoma classically presents with leukocoria, a white pupillary reflex which often is first noticed when a red reflex is not present at routine newborn or well-child examination or in a flash photograph of the child. Strabismus often is the initial presenting complaint. 79. Sunburst appearance on xray: Osteosarcoma TABLE 501-1 -- Comparison of Features of Osteosarcoma and the Ewing Family of Tumors FEATURE OSTEOSARCOMA EWING FAMILY OF TUMORS Age Second decade Second decade Race All races Primarily whites Sex (M : F) 1.5 : 1 1.5 : 1 Cell Spindle cell–producing osteoid Undifferentiated small round cell, probably of neural origin Predisposition Retinoblastoma, Li-Fraumeni syndrome, Paget disease, radiotherapy None known Site Metaphyses of long bones Diaphyses of long bones, flat bones Presentation Local pain and swelling; often, history of injury Local pain and swelling; fever Radiographic findings Sclerotic destruction (less commonly lytic); sunburst pattern Primarily lytic, multilaminar periosteal reaction (“onion skinning”) Differential diagnosis Ewing sarcoma, osteomyelitis Osteomyelitis, eosinophilic granuloma, lymphoma, neuroblastoma, rhabdomyosarcoma Metastasis Lungs, bones Lung, bones Treatment Chemotherapy Chemotherapy Ablative surgery of primary tumor Radiotherapy and/or surgery of primary tumor Without metastases: 70% cured; with metastases at diagnosis, ≤20% survival Without metastases: 60% cured; with metastases at diagnosis, 20–30% survival Outcome 80. Case of oliguria with dark urine: Hemolytic Uremic Syndrome HUS is most common in children younger than 4 yr of age. The onset is usually preceded by a gastroenteritis characterized by fever, vomiting, abdominal pain, and diarrhea that is initially watery but then becomes bloody. Less commonly, patients may present after an upper respiratory tract infection. Sudden onset of pallor, irritability, weakness, lethargy, and oliguria usually occurs 5–10 days after the initial gastrointestinal or respiratory illness 81. What characterizes Gr IV ureteral reflux: Reflux into grossly dilated calyces Grading of vesicoureteral reflux Grade I: reflux into a nondilated ureter Grade II: reflux into the upper collecting system without dilatation Grade III: reflux into dilated ureter and/or blunting of calyceal fornices Grade IV: reflux into a grossly dilated ureter Grade V: massive reflux, with significant ureteral dilatation and tortuosity and loss of the papillary impression 82. Most common enzyme defect in CAH: 21-Hydroxylase deficiency More than 90% of CAH cases are caused by 21-hydroxylase deficiency 83. An excess of growth hormone in a patient with a closed epiphyses will cause: Acromegaly In young persons with open epiphyses, overproduction of GH results in gigantism; in persons with closed epiphyses, the result is acromegaly. 84. Which of the ff is not a cause of macrocephaly: CMV-microcephaly Thalassemia-Features of ineffective erythropoiesis include expanded medullary spaces (with massive expansion of the marrow of the face and skull), extramedullary hematopoiesis, and a huge caloric need Hydrocephalus-ALAM NYO NA YAN! Subdural effusion-The diagnosis of subdural hemorrhage may be delayed until the chronic subdural fluid volume expands and produces megalocephaly, frontal bossing, a bulging fontanel, anemia, and sometimes seizures. 85. Most common cause of viral encephalitis in children: Enterovirus vs Herpes simplex (?) Enteroviruses are the most common cause of viral meningoencephalitis HSV encephalitis is the leading cause of sporadic, nonepidemic encephalitis in children and adults in the USA. It is an acute necrotizing infection generally involving the frontal and/or temporal cortex and the limbic system and, beyon the neonatal period, is almost always caused by HSV-1. 86. Px with increased drowsiness and irritability for 2 weeks. His older sister has chronic cough. CSF showed (+) pellicle formation: TB Meningitis 87. TB Meningitis stage II is characterized by: Cranial Nerve Palsies 1st stage: which typically lasts 1–2 wk, is characterized by nonspecific symptoms, such as fever, headache, irritability, drowsiness, and malaise. Focal neurologic signs are absent, but infants may experience a stagnation or loss of developmental milestones 2nd stage: usually begins more abruptly. The most common features are lethargy, nuchal rigidity, seizures, positive Kernig or Brudzinski signs, hypertonia, vomiting, cranial nerve palsies, and other focal neurologic signs. The accelerating clinical illness usually correlates with the development of hydrocephalus, increased intracranial pressure, and vasculitis. Some children have no evidence of meningeal irritation but may have signs of encephalitis, such as disorientation, movement disorders, or speech impairment 3rd stage: marked by coma, hemiplegia or paraplegia, hypertension, decerebrate posturing, deterioration of vital signs, and eventually death 88. Not considered as neonatal seizure: Absence Focal seizures consist of rhythmic twitching of muscle groups, particularly those of the extremities and face. These seizures are often associated with localized structural lesions as well as with infections and subarachnoid hemorrhage. Multifocal clonic convulsions are similar to focal clonic seizures but differ in that many muscle groups are involved, frequently several simultaneously. Tonic seizures are characterized by rigid posturing of the extremities and trunk and are sometimes associated with fixed deviation of the eyes. Myoclonic seizures are brief focal or generalized jerks of the extremities or body that tend to involve distal muscle groups. Subtle seizures consist of chewing motions, excessive salivation, and alterations in the respiratory rate including apnea, blinking, nystagmus, bicycling or pedaling movements, and changes in color. 89. Not an indication for LP: asymptomatic 2 y/o If any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the cerebrospinal fluid (CSF) is indicated. A lumbar puncture should be strongly considered in children <12 mo of age and considered in those 12–18 mo of age, especially if seizures are complex or sensorium remains clouded after a short postictal period. 90. Seizure w/o loss of consciousness: Simple Partial The distinguishing characteristic of SPS is that the patients remain conscious and may verbalize during the seizure. No postictal phenomenon follows the event. Complex Partial Seizure-may begin with a simple partial seizure with or without an aura, followed by impaired consciousness; conversely, the onset of the CPS may coincide with an altered state of consciousness. Absence-Simple (typical) absence (petit mal) seizures are characterized by a sudden cessation of motor activity or speech with a blank facial expression and flickering of the eyelids. GTC-Patients suddenly lose consciousness and, in some cases, emit a shrill, piercing cry. Their eyes roll back, their entire body musculature undergoes tonic contractions, and they rapidly become cyanotic in association with apnea. The clonic phase of the seizure is heralded by rhythmic clonic contractions alternating with relaxation of all muscle groups. The clonic phase slows toward the end of the seizure, which usually persists for a few minutes, and patients often sigh as the seizure comes to an abrupt stop 91. Drug of choice for seizures in neonates: Phenobarbital Phenobarbital, the drug of choice, is given with an intravenous loading dose (20 mg/kg); additional doses of 5–10 mg/kg (up to 40–50 mg/kg total) may be needed. 92. Prognosis of bacterial meningitis in a 2-month old patient: Guarded with 10-20% developing neurologic sequealae The highest mortality rates are observed with pneumococcal meningitis. Severe neurodevelopmental sequelae may occur in 10–20% of patients recovering from bacterial meningitis, and as many as 50% have some, albeit subtle, neurobehavioral morbidity. The prognosis is poorest among infants younger than 6 mo and in those with high concentrations of bacteria/bacterial products in their CSF. Those with seizures occurring more than 4 days into therapy or with coma or focal neurologic signs on presentation have an increased risk of long-term sequelae. There does not appear to be a correlation between duration of symptoms before diagnosis of meningitis and outcome. 93. Presents with Tredelenburg gait: Poliomyelitis The walking child often presents to the physician after the family has noticed a limp, a waddling gait, or a leg-length discrepancy. The affected side appears shorter than the normal extremity, and the child will toe-walk on the affected side. The Trendelenburg sign is positive in these children, and a Trendelenburg gait is usually observed. As in the younger child, there is limited abduction on the affected side and the knees are at different levels when the hips are flexed (the Galeazzi sign). Excessive lordosis, which develops secondary to altered hip mechanics, is common and is often the presenting complaint. 94. Treatment of choice for scabies in young children: Permethrin Application of permethrin 5% cream (Elimite) or 1% lindane cream or lotion to the entire body from the neck down, with particular attention to intensely involved areas, is standard therapy 95. Px recently diagnosed with PTB and started on triple anti-TB meds and consulted because of seizures. What would u ask in the history: Dose of Isoniazid given Major adverse events include hepatotoxicity in 1% of children and -3% of adults, increasing with age, and dose-related peripheral neuropathy. Pyridoxine can ameliorate the peripheral neuropathy and is indicated for breast-feeding infants and their mothers, children and youth on milk- or meat-deficient diets, pregnant adolescents, and symptomatic HIV-infected children. Minor adverse events include rash, worsening of acne, epigastric pain with occasional nausea/vomiting, decreased vitamin D levels, and dizziness. The liquid formulation of INH is mixed in sorbitol, which often causes diarrhea and stomach upset. Rifampicin-can be associated with adverse events such as transient elevations of liver enzymes, gastrointestinal upset with cramps, nausea, vomiting and anorexia, headache, dizziness, and immunologically mediated fever and flulike symptoms. Thrombocytopenia and hemolytic anemias can also occur. Rifabutin has a similar spectrum of toxicities, except for an increased incidence of rash (4%) and neutropenia (2%). Rifapentine has fewer adverse events but has an association with hyperuricemia and cytopenias, especially lymphopenia and neutropenia. All rifamycins can turn urine and other secretions (tears, saliva, stool, sputum) an orange color, which can stain contact lens. Patients and families should be warned about this common but otherwise innocuous adverse effect 96. Treatment of Ibuprofen overdose: Supportive care Good supportive care is essential in the treatment of acute NSAID overdose or poisoning. There is no specific antidotal therapy for this class of drugs. Emesis is of little benefit, but activated charcoal can be administered 97. Thimerosal-containing vaccines: Mercury Thimerosal is a mercury-containing preservative used in some vaccines. Thimerosal contains 49.6% mercury by weight and is metabolized to ethyl mercury and thiosalicylate Arsenic-Chronic exposure to low levels of arsenic usually is from environmental or occupational sources. Over the course of years, dermatologic lesions develop, including hyperpigmentation, hypopigmentation, hyperkeratoses (especially on the palms and soles), squamous and basal cell carcinomas, and Bowen disease (cutaneous squamous cell carcinoma in situ). Encephalopathy and peripheral neuropathy may be present. Hepatomegaly, hypersplenism, noncirrhotic portal fibrosis, and portal hypertension occur. Blackfoot disease is an obliterative arterial disease of the lower extremities associated with chronic arsenic exposure that has been described in Taiwan. Carcinogenicity of chronic arsenic exposure is reflected in increased rates of cancers of the skin, lung, liver, bladder, and kidney and of angiosarcomas. Lead98. An infant ingested mercury from a broken thermometer. Antidote for mercury poisoning: BAL Dimercaprol, also known as 2,3-dimercaptopropanol or British antilewisite (BAL), is the chelator of choice if a patient cannot tolerate oral therapy EDTA-Lead 99. Paracetamol toxicity treatment: NAC 100.Children are most susceptible to this tool of bioterrorism because of unavailability of a vaccine: Clostridium botulinum The fluoroquinolones and tetracyclines are commonly cited as agents of choice in the treatment and prophylaxis of anthrax, plague, tularemia, brucellosis, and Q fever. Both families often are avoided in children, although the risk of morbidity and mortality from diseases induced by agents of bioterrorism far outweighs the minor risks associated with short-term use of these agents. Ciprofloxacin received, as its first licensed pediatric indication, U.S. Food and Drug Administration (FDA) approval for use in the prophylaxis of anthrax after inhalational exposure (terrorism). Doxycycline is now licensed specifically in children for the same indication. Immunizations potentially useful in preventing biologic agent–induced diseases often are not approved for use in pediatric patients. The currently available anthrax vaccine is licensed only for those between 18–65 yr of age plague vaccine-currently out of production and probably ineffective against inhalational exposures, was approved only for 18–61 yr olds smallpox vaccine-a live vaccine employing vaccinia virus, can cause fetal vaccinia and demise when given to pregnant women. Although licensed vaccines (pre-exposure immunologic measures) exist against anthrax and smallpox, widespread use of either vaccine is likely to be problematic, especially in children. The anthrax vaccine is licensed only for those persons age 18 yr and older and is given as a 6-dose series over 18 mo and requires annual booster doses. These issues, coupled with a limited supply, make civilian employment of the current anthrax vaccine on a large scale unlikely, although a new recombinant anthrax vaccine is in the late stages of development and is being studied as a 3-dose series TABLE 711-2 -- Critical Biologic Agents of Terrorism DISEASE Anthrax (inhalational).[*] CLINICAL FINDINGS INCUBATION ISOLATION PERIOD PRECAUTIONS Febrile prodrome 1–5 d with rapid progression to mediastinal lymphadenitis and mediastinitis, sepsis, shock, and meningitis Standard Patients who are clinically stable after 14 days can be switched to a single oral agent (ciprofloxacin or doxycycline) to complete a 60-day course.[†] INITIAL TREATMENT PROPHYLAXIS [‡] Ciprofloxacin 10–15 mg/kg IV q12h Ciprofloxacin 10–15 mg/kg PO q12h OR OR Doxycycline 2.2 mg/kg IV q12h Doxycycline 2.2 mg/kg PO q12h AND Clindamycin[§] 10– 15 mg/kg IV q8h AND Penicillin G[‖] 400– 600 k U/kg/d IV ÷ q4h Plague (pneumonic) Febrile prodrome with rapid progression to fulminant pneumonia, hemoptysis, sepsis, DIC 2–3 d Droplet (for first 3 d of therapy) Gentamicin 2.5 mg/kg IV q8h Doxycycline 2.2 mg/kg PO q12h OR OR Doxycycline 2.2 mg/kg IV q12h Ciprofloxacin 20 mg/kg PO q12h OR DISEASE CLINICAL FINDINGS INCUBATION ISOLATION PERIOD PRECAUTIONS INITIAL TREATMENT PROPHYLAXIS Ciprofloxacin 15 mg/kg IV q12h Tularemia Pneumonic: Abrupt onset of fever with fulminant pneumonia Typhoidal: Fever, malaise, abdominal pain 2–10 d Standard Same as for plague Same as for plague Smallpox Febrile prodrome with synchronous, centrifugal, vesiculopustular exanthema 7–17 d Airborne (+ contact) Supportive care Botulism Afebrile descending 1–5 d symmetrical flaccid paralysis with cranial nerve palsies Standard Supportive care; None antitoxin (see text) may halt the progression of symptoms but is unlikely to reverse them Viral hemorrhagic fevers Febrile prodrome 4–21 d with rapid progression to shock, purpura, and bleeding diatheses Contact (consider airborne in cases of massive hemorrhage) Supportive care; None ribavirin may be beneficial in select cases Vaccination may be effective if given within the first several days after exposure 101. At what age is the best time to repair a cleft lip? 3 months Surgical closure of a cleft lip is usually performed by 3 mo of age, when the infant has shown satisfactory weight gain and is free of any oral, respiratory, or systemic infection. The initial repair may be revised at 4 or 5 yr of age. Corrective surgery on the nose may be delayed until adolescence. Nasal surgery can also be performed at the time of the lip repair 1 year-In an otherwise healthy child, closure of the palate is usually done before 1 yr of age to enhance normal speech development. God bless us all…….100%! JAU