Download MARCH 2006 Friend asks you to make a medical certificate stating

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