Respiratory System, Set 1 Question 1. A 3-yr-old boy is undergoing mechanical ventilation 12 hr after repair of an atrial septal defect.

Opioids and benzodiazepines are being used for analgesia and sedation. The mandatory ventilatory rate has been decreased from 20 to 10 breaths min in preparation for removal of the endotracheal tube. The arterial !O2 is 120 mm "g and the arterial !#O2 is $% mm "g. The arterial p" is $.13. The child has no spontaneous respirations. Auscultation of the chest demonstrates that the breath sounds are slightly reduced on the left side. Occasional crac&les can be heard over both bases. The most li&ely reason for this child's acidosis is( a) !ulmonary edema b) !neumonia c) #ardiogenic shoc& d) )espiratory depression e) !neumothora* d)Explanation: As a result of sedation and analgesia+ he is hypoventilating+ ,hich is manifested by an acute respiratory acidosis and hypercarbia.O*ygenation may not be affected if he is breathing enriched o*ygen.The reduced breath sounds and crac&les could be due to atelectasis. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 2. A 3-mo-old infant is brought to the emergency room because of lethargy and poor feeding. .he appears pale. Other findings include subcostal retractions and use ofthe abdominal muscles during e*piration. "er breathing rate is 30 min. 1reath sounds are decreased bilaterally. .he has a prolonged e*piratory phase. /o ,heezing or crac&les are audible.An abnormality in ,hich of the follo,ing components of the respiratory system is most li&ely to be involved in the genesis of these manifestations2 a) Alveolar surfactant b) 3ung interstitium c) 4ntrathoracic air,ays d) 5iaphragm e) 6edullary respiratory neurons c)Explanation: Air,ay edema or inflammation ,ill produce this constellation of findings.7ith smaller air,ay involvement+ this patient may eventually demonstrate ,heezing. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 3. 7hich of the follo,ing functional findings is most li&ely in a 12-yr-old girl ,ho has developed acute rheumatic carditis ,ith severe mitral insufficiency2 a) 4ncreased pea& e*piratory flo, b) 4ncreased vital capacity c) 4ncreased residual volume d) 5ecreased functional residual capacity e) 4ncreased #O diffusion capacity

d)Explanation: #ardiac failure produces interstitial and alveolar edema+ ,hich ,ill reduce the 8)#. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 4. A 2-,&-old infant begins to e*perience episodes of acute respiratory distress after undergoing repair of esophageal atresia. The episodes appear to be triggered by crying. The infant becomes agitated and demonstrates decreased breath sounds bilaterally+ ,ith the development of cyanosis and bradycardia. !hysical e*amination conducted ,hen he is calm reveals mild subcostal retractions ,ith a respiratory rate of 9% breaths min+ bilateral rhonchi+ and a prolonged e*piratory phase.7hich of the follo,ing is most li&ely to be the cause of the respiratory distress episodes2 a) !atent ductus arteriosus b) )ecurrent laryngeal nerve in:ury c) #hoanal atresia d) !ulmonary hypertension e) Tracheomalacia e)Explanation: Tracheomalacia is ;uite common after repair of esophageal atresia.7ea&ness of both the e*trathoracic and intrathoracic trachea can produce episodes of cyanosis and respiratory distress often triggered by crying+ an*iety+ or pain.-.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 5. 4ntercostal retractions are caused by( a) 5irect traction applied by the diaphragm on the ribs b) #ontraction of the internal intercostal muscles c) #ontraction of the e*ternal intercostal muscles d) 5ecreased pleural pressure e) )ecruitment of the scalene and sternocleidomastoid muscles d)Explanation: 7hen the compliance of the chest is greater than the negative intrathoracic pressure generated during inspiration+ retractions ,ill develop.The intercostal space is even more compliant than the chest ,all. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 6. A 1-mo-old infant is breathing supplemental o*ygen from a hood at a measured concentration of 9%< after developing respiratory distress. A !O2 of =0 mm "g+ a !#O2 of %0 mm "g+ and a p" of $.30 are measured in a blood sample obtained from the left radial artery. 7hich of the follo,ing interpretations is most consistent ,ith these findings2 a) The blood sample is venous b) The infant has a right-to-left shunt via the ductus arteriosus c) O*ygen diffusion across the alveolar-capillary membrane is impaired d) The patient is hypoventilating e) The blood gas anomalies are caused by ventilation-perfusion ine;uality

e)Explanation: The patient has both hypercarbia and hypo*ia.Assuming the 84O2 in the hood is 9%<+ one ,ould e*pect a !aO2 much higher than =0 mm"g.The most common cause of hypo*ia in children ,ith acute respiratory disorders is a ventilation perfusion mismatch. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 7. A premature infant is undergoing mechanical ventilation for respiratory distress syndrome. !ea& inspiratory pressure is 32 cm "2O+ positive end-e*piratory pressure -!>>!0 is % cm "2O+ and ventilatory rate is 30 breaths min. The infant has decreased peripheral perfusion+ manifested as a prolonged capillary refill time and ,ea& arterial pulses. The central venous pressure measured at the right atrium ,ith an umbilical venous catheter is 2 mm "g -or appro*imately 3 cm "2O0. Arterial !O2 is ?0 mm "g+ and arterial !#O2 is 3? mm "g.7hich of the follo,ing measures is most li&ely to result in an improvement in this infant's perfusion2 a) )educe !>>! to 3 cm "2O b) )educe pea& inspiratory pressure to 2? cm "2O c) )educe ventilatory rate to 2= breaths min d) Administer 10 m3 &g of normal saline e) 1egin an infusion of dopamine at % @g &g min d)Explanation: The !aO2 and !#O2 are ;uite appropriate and in the target range for appropriate therapy.!oor peripheral perfusion and ,ea& pulses -and presumably lo, blood pressure0 in this setting should respond to e*pansion of the intravascular volume ,ith normal saline.The poor perfusion may have preceded the initiation of !>>!+ but may have also been e*acerbated by the !>>!. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 8. A %-mo-old infant develops signs of respiratory distress after coughing and sneezing for 3 days. "e has mar&ed subcostal and intercostal retractions and a respiratory rate of ?0 breaths min. 1reath sounds are mar&edly diminished on both sides. 5iffuse crac&les can be heard bilaterally. There is no stridor. Arterial o*ygen saturation in 100< o*ygen by non-rebreather mas& is ?0<. The s&in is pale and peripheral arterial pulses are ,ea&.7hich of the follo,ing is the most appropriate immediate course of action2 a) Administration of corticosteroids b) 4ntubation of the trachea and mechanical ventilation c) .ampling of arterial blood and measurement of arterial p" and blood gases d) Administration of normal saline e) Administration of diuretics b)Explanation: This child is in respiratory failure.An arterial blood gas determination may be helpful+ but persistent hypo*ia -?0< saturation on pulse o*imetry0 ,hile the patient is on 100< 84O2 is an indication for intubation and

mechanical ventilation.#!A! may be tried under very controlled circumstances but rarely avoids intubation.-.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Auestion B. A 1=-yr-old boy ,ho has been diagnosed ,ith a yet uncharacterized form of muscular dystrophy develops increased somnolence. "e responds only to painful stimuli. "is respiratory rate is 90 breaths min. "is arterial o*ygen saturation in room air is ?$<. After administration of supplemental o*ygen+ the arterial !O2 is 1%0 mm "g+ the arterial !#O2 is $0 mm "g+ and the arterial p" is $.30. 7hich of the follo,ing statements defines this situation most accurately2 a) 5ecreased hypo*ic drive after correction of the hypo*emia has resulted in acute hypercapnia b) !ulmonary hypertension caused by chronic hypo*emia has produced increased ventilation-perfusion ine;uality c) )enal tubular compensation of prolonged hypercapnia has resulted in an elevation of serum bicarbonate levels d) The patient has become dehydrated e) A fi*ed intrapulmonary right-to-left shunt is responsible for the limited response to administration of o*ygen c)Explanation: O,ing to poor ventilatory muscular effort+ the patient has been hypoventilating for a long enough time to allo, renal tubular reabsorption of bicarbonate to compensate for the prolonged hypercarbia -respiratory acidosis0.#ompensation cannot totally correct the p" to normal.4f the drive for ventilation ,as inhibited by the hypero*ia+ the !#O2 ,ould be even higher and the p" lo,er. -.ee #hapter 3%$ in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 10. A 9-mo-old African-American infant ,as found unresponsive in his crib by his mother in the early morning and could not be resuscitated. "e had been placed for sleep on his bac& but ,as found on his stomach. At a ,ell-child e*amination the previous day+ he had been found to be in good health and received his routine immunizations. "e ,as born at 3= ,& of gestation and ,eighed 2+920 g. "is medical history ,as other,ise unremar&able. After a thorough scene investigation+ autopsy+ and revie, of the medical history+ the cause of death ,as determined to be sudden infant death syndrome -.45.0. 7hich of the follo,ing factors has not been found to be associated ,ith greater ris& of .45.2 a) !rematurity b) 6ovement to a prone position after having been placed supine to sleep c) 4mmunizations d) African-American heritage e) 3o, birth ,eight c)Explanation: 6ultiple studies have loo&ed at the potential associations bet,een immunizations and .45../one has ever demonstrated a relationship ,ith .45.. -.ee #hapter 3=0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 11.

4n the clinical scenario described in Question 10+ ,hich of the follo,ing physiologic abnormalities is most li&ely to be related to the child's sudden+ une*pected death due to .45.2 a) 4ncreased susceptibility to bacterial infection b) !rolonged A-T interval c) 6edium-chain fatty acid metabolic abnormality d) Arousal responsiveness from sleep e) 1rainstem autonomic control of heart rate and blood pressure d)Explanation: Arousal responsiveness from sleep is thought to be the most common mechanism for .45..This together ,ith rebreathing in the prone position may e*plain many cases. 1 has been associated ,ith .45. but is uncommon. # has also been associated ,ith .45. but its incidence is un&no,n.1oth 1 and # should be suspected ,hen more than one case of .45. occurs in a family or if there are nonhealthy affected family members.-.ee #hapter 3=0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 12. Of the follo,ing+ the strongest ris& factor associated ,ith .45. is( a) .mo&ing by the mother in the prenatal period b) .mo&ing by the father in the prenatal period c) >*posure of the infant to environmental tobacco smo&e after he or she is born d) .mo&ing by the mother prenatally only in association ,ith alcohol use e) There is no association bet,een smo&ing and .45. a)Explanation: This is the epidemiologically correct ans,er.Although # is also important+ the prenatal e*posure is more dominant. -.ee #hapter 3=0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 13. All of the follo,ing measures are recommended by the American Academy of !ediatrics to reduce the ris& of .45. e*cept( a) !lacing babies on their bac& to sleep b) Avoiding ,aterbeds+ sofas and other soft surfaces for sleep c) Avoiding overheating during sleep d) Csing a pacifier if the infant is not breast feeding e) Avoiding pillo,s in the infant's sleep environment d)Explanation: !acifier use is interesting+ as some believe that it reduces the ris& of .45..4t is controversial and is not consistently agreed on as a protective factor and is not recommended by the AA!.-.ee #hapter 3=0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 14. All of the follo,ing statements are true e*cept( a) 6ost episodes of acute pharyngotonsillitis are viral b) )apid enlargement of one tonsil is typical of pharyngotonsillitis

c) 7ith cryptic tonsillitis+ a fre;uent clinical presentation is halitosis+ chronic sore throat+ or a history of e*pelling foul-tasting and foul-smelling cheesy lumps d) 4n many children+ the diagnosis of air,ay obstruction is made by history and physical e*amination e) Tonsillectomy alone is usually performed for recurrent or chronic pharyngotonsillitis b)Explanation: >nlargement of one tonsil+ ,hich occurs acutely+ is typical of a peritonsillar abscess and not routine pharyngotonsillitis.!eritonsillar abscesses may obstruct the air,ay and are treated ,ith intravenous antibiotics -penicillin is OD0 and incision and drainage or aspiration.-.ee #hapter 3=? in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 15. 7hich of the follo,ing is not an indication for adenoidectomy alone2 a) #hronic nasal infection -chronic adenoiditis0 b) #hronic sinus infections that have failed medical management c) )ecurrent bouts of acute otitis media d) )ecurrent otorrhea in children ,ith tympanostomy tubes e) )ecurrent pharyngotonsillitis e)Explanation: 4n this situation tonsillectomy alone is effective treatment.-.ee #hapter 3=? in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 16. A $-yr-old African-American boy is brought to your office by his parents+ ,ho describe loud snoring+ difficulty breathing+ and obstructed breathing at night. "is teacher has complained that he seems inattentive and hyperactive+ but his parents thin& he is :ust a Ehigh-energyE child. The father is obese and on #!A! for obstructive sleep apnea+ and his 164 is 20 &g m2. 8indings on physical e*amination are completely unremar&able e*cept for 2F tonsillar hypertrophy and some mouth breathing.7hat is the most appropriate ne*t step in diagnosis2 a) /europsychological testing b) 3ateral soft tissue radiograph of the nec& c) #T study of the upper air,ay d) 5iagnostic testing for obstructive sleep apnea e) >#G and echocardiogram d)Explanation: Although all of these are useful+ at some point it is most ,ise to perform dynamic testing for obstructive sleep apnea in a sleep laboratory.-.ee #hapter 3=B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 17. A 10-yr-old African-American boy is referred to you by the school psychologist for medical management of suspected A5"5 because of inattention+ behavior problems+ and poor school performance. "e goes to bed at 10(30 !.6. and falls asleep immediately. "is brother ,ill no longer share a room ,ith him because of loud

snoring. 4t is difficult for his parents to ,a&e him for school in the morning at $(00 A.6. "e reports that he struggles to stay a,a&e and pay attention during the day. "e usually naps for 1-2 hr after school+ but not in school. On the ,ee&ends+ he stays up until midnight and sleeps until B(00 A.6. "e denies sudden losses of muscle tone+ dreaming during the day+ or sleep paralysis. 8indings on physical e*amination are remar&able for a 164 of 30 &g m2 and 3F tonsillar hypertrophy. 7hich of the follo,ing is the most li&ely diagnosis2 a) 4nsufficient sleep b) 5elayed sleep phase syndrome c) Obstructive sleep apnea syndrome d) /arcolepsy e) 4diopathic hypersomnia c)Explanation: "is snoring+ 164+ and tonsillar hypertrophy strongly suggest obstructive sleep apnea.4t ,ould be interesting if in addition to snoring the family noted pauses bet,een his noisy sleep-related breathing.-.ee #hapter 3=B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 18. Hou receive a follo,-up note from your community cardiology colleague that a mutual patient+ a $-yr-old boy ,ith trisomy 21+ has ne, findings of pulmonary hypertension. The child had a I.5 that spontaneously closed by age 2 yr. "is room air pulse o*imetry value is B?<. The second heart sound is loud and the intensity of the !2 component is increased. >#G sho,s normal sinus rhythm and right ventricular hypertrophy. >chocardiogram sho,s normal intracardiac anatomy ,ith no evidence of a !5A+ but there is mild tricuspid regurgitation ,ith an increased :et velocity across the tricuspid valve. The heart size ,as normal on *-ray study. Hour colleague is planning a cardiac catheterization to assess the nature and severity of the pulmonary hypertension. "e also orders thyroid function studies.Hou see the child in your office for a pre-catheterization general health assessment. The child+ ,ho is usually very cooperative+ is sleepy and irritable. Hou note prominent mouth breathing+ 3F tonsillar hypertrophy+ and a prominent pectus deformity.7hat is the most appropriate ne*t step in management2 a) #hec& pre-catheterization hemoglobin level+ hematocrit+ electrolytes+ and clotting factors b) )e;uest diagnostic studies for obstructive sleep apnea c) Order a lateral soft tissue radiograph of the nec& d) Order an 6)4 study of the upper air,ay e) .tart the child on steroids to shrin& the enlarged tonsils b)Explanation: #hildren ,ith trisomy 21 have an increased ris& for obstructive sleep apnea.4n this case+ the pulmonary hypertension is not due to cardiac problems but is most li&ely to be due to prolonged hypo*ia and hypercarbia during sleep.-.ee #hapter 3=2 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 19. /osebleeds are commonly associated ,ith all of the follo,ing e*cept( a) 5igital trauma

b) c) d) e)

6enstruation 8amily history of epista*is .inus infections 5ry ,inter air

b)Explanation: The five most common causes of epista*is are on your hand -the fingersJ0.6enstruation-related epista*is is e*tremely uncommon. 7ith severe recurrent non-infection-related epista*is+ the child may have a coagulopathy such as von 7illebrand disease.-.ee #hapter 3=2 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 20. /osebleeds in children most commonly arise from a) Turbinates b) /asopharyn* c) !osterior septum d) Diesselbach's ple*us -anterior septum0 e) 6a*illary sinus d)Explanation: This is an easily reachable area that is easily irritated by pic&ing or inflammation.-.ee #hapter 3=2 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 21. 7hen a dis& battery is seen as a foreign body in the nose of a child+ ,hich of the follo,ing is the most important consideration in management2 a) The patient should be referred electively to a specialist for removal b) 4t may lea& and cause local tissue damage c) The parents should remove it immediately d) /ose drops should be given until it can be removed e) )emoval may be simply done in the office b)Explanation: These are particularly dangerous because of the ris& of a chemical burn or pressure necrosis in a small space and because attempts to remove them could actually push them from the anterior space to the more distal posterior space.4mmediate removal is indicated.-.ee #hapter 3=2 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 22. /asal polyps in children are( a) /ever found to arise in the ethmoid sinus b) #ommon in infancy c) .een only in children ,ith cystic fibrosis d) Associated ,ith allergic rhinitis e) "ard to distinguish from nasal turbinates

d)Explanation: Although cystic fibrosis is a common cause of nasal polyps+ especially in children younger than 12 yr+ it is also seen ,ith other conditions such as allergies.-.ee #hapter 3=3 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 23. The paranasal sinuses in children( a) Are all present at birth b) 5evelop during the teenage years c) Gro, and develop during the first seven years of life d) >asily visualized on plain radiographs e) Are unli&ely to be infected before the age of 12 yr c)Explanation: .ome sinuses are present at birth+ ,hereas others develop after birth.Aeration as seen on *-ray may occur after sinus formation.-.ee #hapter 3=% in /elson Te*tboo& of !ediatrics+ 1$th ed.0 -----------------------------------------------------------------------------Question 24. An 1?-mo-old girl has a 2-day history of rhinorrhea+ pharyngitis+ and lo,-grade fever. 5uring the night+ she ,a&es ,ith a bar&y cough+ hoarseness+ and inspiratory stridor. 7hich of the follo,ing is the most li&ely etiologic agent2 a) 4nfluenza virus type A b) )espiratory syncytial virus c) !arainfluenza virus d) Adenovirus e) 6ycoplasma pneumoniae c)Explanation: This is the classic presentation of croup.4nvolvement of the vocal cords -laryngitis in adults0 is most often due to parainfluenza virus but may also be due to any of these pathogens.-.ee #hapter 3$1 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Respiratory System, Set 2 Question 1. A 2-yr-old boy is presented to the emergency department at 3 A.6. ,ith a chief complaint of fever and cough. "is respiratory rate is 3= min+ his temperature is 3Bo#+ and his pulse o*imetry reading is B=<. On physical e*amination he has a bar&y cough and stridor only ,ith crying. "e is ,ell hydrated+ able to drin&+ and consolable. 7hat is the appropriate ne*t step in patient management2 a) /asal ,ashing for influenza virus and respiratory syncytial virus b) 3ateral radiograph of the nec& c) /ebulized racemic epinephrine d) #omplete blood count and blood culture e) 5ose of de*amethasone e)Explanation: 4n this patient ,ith croup and manifesting stridor only ,ith crying+ de*amethasone is indicated.4f there ,ere stridor at rest+ racemic epinephrine

and de*amethasone ,ould be indicated. -.ee #hapter 3$1 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 2. Hou are the pediatric consultant for a community emergency department. The department's physician calls to as& advice about a 3-yr-old boy ,ith fever and a cough. "e thin&s the patient has croup but is also concerned about epiglottitis. 7hich of the follo,ing physical findings is most helpful in attempting to differentiate croup from epiglottitis2 a) 8ever b) 1ar&y cough c) .tridor d) 5rooling e) )espiratory distress b)Explanation: 4n an unimmunized child+ epiglottitis usually manifests ,ith high fever+ to*icity+ air hunger+ and drooling but ,ithout a bar&ing cough.>piglottitis is uncommon in children immunized against ". influenzae type b+ and if it occurs+ it does so in unimmunized children or those ,ith an unusual bacterial etiology. -.ee #hapter 3$0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 3. Hou are a primary pediatrician in an office ,here a third-year medical student is doing her cler&ship. Hou have :ust seen the fifth patient that day ,ith a classic clinical presentation for croup( bar&y cough+ fever+ and stridor ,hen agitated. Hou once again prescribe de*amethasone. The third-year medical student as&s about the data for the use of steroids in croup. 7hich of the follo,ing has not been demonstrated in studies of the use of steroids in croup2 a) .horter hospitalization b) 5ecreased need for subse;uent medical interventions c) Oral de*amethasone is as effective as intramuscular administration d) 5ecreased need for o*ygen e) )educed hospitalization d)Explanation: 5e*amethasone has been ;uite effective in the management of children ,ith mild to moderate croup.4ts efficacy in reducing the need for o*ygen in more severely affected children has not been demonstrated.-.ee #hapter 3$1 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 4. A 9-yr-old boy presents ,ith sore throat and fever of sudden onset. "e has difficulty s,allo,ing and his breathing is labored. "e is drooling and sitting upright and leaning for,ard in a tripod position. 7hat is the appropriate ne*t step in patient management2 a) #omplete blood count and blood culture follo,ed by immediate prophylactic intravenous antibiotics b) 3ateral radiograph of the nec& c) 5ose of oral de*amethasone d) 5irect laryngoscopy in the operating room

e)

#omplete physical e*amination including inspection of the oral cavity

d)Explanation: This is the classic presentation for epiglottitis. Although this disorder is uncommon in the era of immunization against ". influenzae type b+ physicians must be a,are of this dangerous disease ,ith its re;uirement for immediate air,ay protection.-.ee #hapter 3$1 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 5. A 2-yr-old girl had an upper respiratory tract infection appro*imately %-$ days ago. .he had a lo,-grade fever+ cough+ and rhinorrhea. .he did not re;uire any medical intervention. .he appeared to be improvingK no,+ ho,ever+ she has a high fever and brassy cough. On physical e*amination she is to*ic-appearing ,ith a fever of 3B.?o#. .he can lie flatK she does not drool and has no dysphagia+ but does have some evidence of respiratory distress ,ith increased ,or& of breathing and retractions. On auscultation her lungs are clear bilaterally. 7hich of the follo,ing is the most appropriate antibiotic for this condition2 a) >rythromycin b) #iproflo*acin c) Ampicillin d) Gentamicin e) /afcillin e)Explanation: This child has bacterial tracheitis as a complication of a previous viral respiratory tract infection.The most li&ely bacterial organism is .taphylococcus aureus+ although other organisms may be responsible..ome physicians might use ceftria*one to cover these pathogens.-.ee #hapter 3$1 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 6. A 2L-yr-old girl has had symptoms of an upper respiratory infection for 1 ,ee&. Over the past 29 hours+ fever and tachypnea developed+ ,ith ,orsening cough and increased ,or& of breathing. .he has a temperature of 3B.1o #+ a respiratory rate of 90 min+ and mild to moderate intercostal retractions. O*ygen saturation is B9-B%<. "er e*amination reveals diffuse ,heezing+ inspiratory rhonchi+ and crac&les in the right anterolateral chest. #hest film sho,s a shaggy right heart border+ generalized hyperinflation+ and peribronchial cuffing. 7hite blood cell count is 1?+000 mm3,ith $0< granulocytes.Of the follo,ing+ ,hich is the most appropriate ne*t step in diagnosis2 a) .putum culture b) 3ung puncture c) 1lood culture d) Iiral culture e) #old agglutinins titer c)Explanation: The child has bacterial pneumonia.A child this young usually does not produce sputum or re;uire a lung puncture.A blood culture is ;uite

appropriate.Iiral !#) assay may be better than a viral culture. -.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 7. Outpatient management of the patient described in Question 30 is considered in vie, of the patient's clinical status. #linical features suggest a bacterial pneumonia. 7hich of the follo,ing is the most appropriate treatment option2 a) !enicillin !O b) #efi*ime !O c) >rythromycin !O d) #ephale*in !O e) Amo*icillin !O e)Explanation: "igh-dose oral amo*icillin ,ill be effective against most pneumococci.7ith highly resistant pneumococci+ treatment ,ith intravenous vancomycin is necessary.-.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 8. A previously healthy 12-yr-old boy presents ,ith upper respiratory symptoms of ? days' duration+ ,ith ,orsening cough and fever. The season is autumn. >*amination reveals a temperature of 3BM#+ a respiratory rate of 29 min+ and inspiratory crac&les in both lung fields. O*ygen saturation is B3-B9<. #hest film sho,s scattered infiltrates in multiple lung fields+ more focal consolidation in the right lo,er lobe+ and blunting of the right costophrenic angle. 7hite blood cell count is 11+000 mm3 ,ith a normal differential.7hich of the follo,ing is the most appropriate ne*t step in diagnosis2 a) .putum culture b) Tuberculin s&in testing c) Throat culture d) #old agglutinins titer e) >rythrocyte sedimentation rate d)Explanation: 4t is li&ely that this patient has 6ycoplasma pneumonia.6ore effective diagnostic tests include 6ycoplasma !#) and 4g6 assays.-.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Auestion B. 7hich of the follo,ing is the most appropriate ne*t step in the management of the patient described in Question 322 a) >rythromycin !O b) Amo*icillin !O c) /o antibiotic therapy d) #eftria*one 46 e) #efuro*ime 4I

a)Explanation: >rythromycin or azithromycin is ;uite effective in improving the clinical course of 6ycoplasma pneumonia. -.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 10. A 9-yr-old boy has had rhinorrhea and cough for 9 days+ ,ith fever+ ,orsening cough+ and chest discomfort over the past 2 days. "is temperature is 90.1o#+ respiratory rate is 2? min+ and o*ygen saturation is ??<. >*amination reveals splinting+ decreased breath sounds+ and dullness to percussion over the right posterior chest+ ,ith crac&les heard over the right upper posterior chest. "is ,hite blood cell count is 30+000 mm3 ,ith a predominance of granulocytes. #hest film sho,s opacification of the right hemithora*. A right lateral decubitus film of the chest reveals significant pleural fluid.7hich of the follo,ing is the most appropriate ne*t step in diagnosis and management2 a) Tube thoracostomy drainage b) 1ronchoscopy c) .putum culture d) /asopharyngeal s,abs for viral antigens e) #old agglutinins titer a)Explanation: Thoracentesis is of value both as a diagnostic aid and as a therapeutic procedure.This patient obviously had a symptomatic effusion and improved dramatically after ,ithdra,al of $00 m3 of cloudy fluid.-.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 11. Gram stain of the pleural fluid from the patient described in Question 34 reveals gram-positive cocci in clusters.7hich of the follo,ing is the most appropriate treatment2 a) Ampicillin 4I b) #efuro*ime 4I c) >rythromycin 4I d) >rythromycin and ampicillin 4I e) #efota*ime and vancomycin 4I

e)Explanation: The child probably has pneumococcal pneumonia.4t could be pneumonia due to .. aureus+ but there are no pneumatoceles.The pneumococcus is becoming resistant to penicillins and even to cephalosporins.4f it is a life-threatening illness+ vancomycin should be added. -.ee #hapter 3$B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 12. A $-yr-old child ,ith a 3-yr history of cough+ intermittent ,heezing+ and poor gro,th has t,o s,eat chloride values of 3= and 91 m>; liter. Additional diagnostic testing to rule out cystic fibrosis should include( a) #T imaging of the chest b) /asal potential difference measurement

c) d) e)

8at balance measurement -$2-hr stool collection0 5/A analysis for the N8%0? mutation .,eat chloride analysis in siblings

b)Explanation: This is a useful test that has abnormal results in #8. Today's 5/A testing for the many -in the hundreds0 of mutations in the #8T) gene is available and is of great value in e;uivocal test results.-.ee #hapter 902 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 13. A 12-yr-old child ,ith confirmed cystic fibrosis has e*perienced cramping abdominal pain intermittently for the past ? days. The pain is diffuse and unrelated to eating and is not attended by guarding or rebound. The patient denies emesis or diarrhea. The most li&ely cause of the abdominal pain is( a) 4ntussusception b) !eritonitis c) !ancreatitis d) 5istal intestinal obstruction syndrome -54O.0 e) #holecystitis d)Explanation: 54O.+ also called meconium ileus e;uivalent+ is an obstruction due to impacted stool.4f the patient has been receiving high-dose pancreatic enzymes+ a fibrosing colonopathy must also be considered. -.ee #hapter 902 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 14. A ne,born infant fails to pass meconium for the first 9? hr. Abdominal distention and emesis have occurred overnight. The ne*t diagnostic steps ,ould include( a) .,eat chloride assay b) Genotyping the child for #8 c) #ontrast imaging of the lo,er gastrointestinal tract d) 6anometry e) .erum immunoreactive trypsin assay c)Explanation: The e*amination ,ill loo& for a meconium plug or a small left colon -,hich suggests pro*imal intestinal obstruction as in atresias0.4n both e*amples+ #8 must be considered.4f "irschsprung disease is considered+ a suction biopsy should also be performed.-.ee #hapter 902 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 15. A 3.%-&g male infant born at term after an uncomplicated pregnancy and delivery develops respiratory distress shortly after birth and re;uires mechanical ventilation. The chest radiograph reveals a normal cardiothymic silhouette but a diffuse groundglass appearance to the lung fields. .urfactant replacement fails to improve gas e*change. Over the first ,ee& of life+ the hypo*emia ,orsens. )esults of routine cultures and echocardiographic findings are negative. A term female sibling died at 1

mo of age ,ith Erespiratory distress.E7hich of the follo,ing is the most li&ely diagnosis2 a) Total anomalous pulmonary venous return b) 6econium aspiration c) /eonatal pulmonary alveolar proteinosis d) 5isseminated herpes simple* infection e) 6edium-chain acyl-dehydrogenase deficiency c)Explanation: )5. in a term infant not responding to surfactant replacement therapy is most li&ely to represent neonatal pulmonary alveolar proteinosis.-.ee #hapter 3?B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 16. 7hich of the follo,ing laboratory evaluations should be obtained in the case in Question 3B2 a) 1lood and tracheal cultures for virus and yeast b) )epeat echocardiogram c) )83! analysis of the .!-1 gene d) )83! analysis of the 6#A5 gene e) Crine organic acid screen c)Explanation: /eonatal alveolar proteinosis is due to a genetic mutation causing a deficiency of surfactant protein 1.-.ee #hapter 3?B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 17. 4f the laboratory analysis confirms .!-1 deficiency+ ,hat is the most appropriate ne*t step in management of the patient described in Question 3B2 a) Obtain a lung biopsy b) 1egin inhaled nitric o*ide c) 5iscuss lung transplantation ,ith the family d) Administer surfactant e) 1egin corticosteroids c)Explanation: >#6O is a temporizing bridge to lung transplantation+ ,hich potentially can cure this disorder. -.ee #hapter 3?B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 18. A 3.2-&g full-term female infant is delivered by vaginal delivery. .he is initially cyanotic and is in significant respiratory distress. Auscultation of the chest reveals diminished breath sounds in the left hemithora* and a scaphoid abdomen. After bag and mas& ventilation+ an endotracheal tube is placed. The point of ma*imal impulse -!640 is shifted to the right side of the chest.The most important initial intervention is( a) 4mmediate bronchoscopy b) !lacement of a nasogastric tube

c) d) e)

A chest radiograph to assess placement of endotracheal tube 4mmediate surgery Administration of epinephrine

b)Explanation: This patient potentially has a diaphragmatic hernia and needs gas to be removed or prevented from entering the bo,el+ ,hich acts as a space-occupying lesion in the chest.-.ee #hapter 3$0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 19. A 19-yr-old boy ,ith a pectus e*cavatum deformity presents for evaluation. "e denies any e*ercise intolerance or cough but does e*perience intermittent ,heezing on e*ertion. "e states he is not concerned about ho, his chest appears. !hysical e*amination reveals a mild pectus deformity.7hich of the follo,ing abnormalities on diagnostic ,or&-up suggests the need for surgical correction2 a) 8>I1 8I# ratio of 0.=0 on spirometry b) A 7olff-!ar&inson-7hite pattern on >#G c) 3o, ventilatory reserves during a ma*imal e*ercise test d) A total lung capacity of ?0< of predicted e) A pea& ,or& capacity of =0< of predicted e)Explanation: 6any children ,ith a pectus e*cavatum do not need surgery according to results of ,or& capacity studies.-.ee #hapter 910 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 20. A 1%-yr-old boy ,ith thoracic scoliosis undergoes evaluation for surgery. "istory is unremar&able+ and findings on physical e*amination are normal e*cept for a mild thoracic scoliosis. A #obb angle of 2% degrees is noted on the chest radiograph. "is vital capacity is ?0< of predicted+ and his e*ercise tolerance is minimally reduced.7hat is the most appropriate ne*t step in treatment of this patient2 a) )epeat assessment in = mo b) )eassurance that surgery ,ill not be re;uired c) .pinal fusion surgery d) 1one density assessment -5>A scan0 e) !hysical therapy to correct scoliosis a)Explanation: 5epending on ,here he is in his puberty gro,th spurt+ the curve may not change+ or if he continues to gro,+ the curve may ,orsen.-.ee #hapter 910 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 21. A $L-yr-old girl presents ,ith a history of lo,-grade fever+ nonproductive cough+ and mild dyspnea. After treatment ,ith an oral antibiotic+ the child began to sho, some signs of improvement. "o,ever+ the child subse;uently e*perienced increasing dyspnea+ a productive cough+ and ,heezing. A chest radiograph demonstrates hyperlucency. .pirometry sho,s a severe obstructive pattern.The most li&ely diagnosis is(

a) b) c) d0 e)

!ulmonary alveolar microlithiasis 7ilson-6i&ity syndrome 8ollicular bronchitis 1ronchiolitis obliterans !ostviral syndrome

d)Explanation: 1ronchiolitis obliterans may follo, a viral bronchitis or pneumonia.6easles virus and adenovirus may be potential agents.-.ee #hapter 3$? in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 22. A 3-yr-old boy has been coughing daily for 2 mo. The cough is nonproductive and occurs during sleep in the early morning hours as ,ell as during the day+ particularly ,hen the child is active. On physical e*amination both height and ,eight are in the %0-$%th percentile+ and chest e*amination is unremar&able. There is no evidence of digital clubbing. A chest roentgenogram is interpreted as normal. The diagnostic procedure most li&ely to ascertain the cause is( a) .putum cytology and culture b) .,eat chloride testing c) 1ronchoscopy d) #omplete blood count e) Trial of bronchodilator therapy e)Explanation: This is a common pattern seen in some children ,ith asthma.1ronchitis in children is often an incorrect diagnosis+ as many children are later found to have asthma.-.ee #hapter 3$= in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 23. A previously healthy 2-yr-old girl is given oral antibiotic therapy for a cough+ fever+ and patchy consolidation of the right lo,er lobe. /o crac&les are heard on chest auscultation. The fever abates+ the cough improves+ but a follo,-up chest film at ? ,& demonstrates even more dense consolidation involving the right lo,er lobe. /e*t steps in the evaluation should include( a) 1ronchoscopy b) 1acterial culture of the nasopharyn* c) 1arium esophagram d) Allergy s&in testing e) 3ung biopsy a)Explanation: This child could have many problems such as a foreign body+ but the clinical picture is highly suggestive of a se;uestration.4f a pulmonary se;uestration is found+ 5oppler flo, studies of the artery supplying the se;uestration ,ill sho, the artery coming from the aorta.-.ee #hapter 3$0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 24.

8or the mechanically ventilated child+ ,hich medical condition is most often associated ,ith successful ,ean off all ventilatory support2 a) #entral hypoventilation b) 1ronchopulmonary dysplasia c) .pinal muscular atrophy d) /one of the above b)Explanation: #hildren ,ith 1!5 usually are successfully ,eaned.The others in choices A and # often become dependent on their ventilator.-.ee #hapter 911 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Respiratory System, Set 3 Question 1. All of the follo,ing may present a barrier to home discharge on a ventilator e*cept( a) 3ac& of appropriate housing b) 3ac& of committed caregivers c) 3ac& of private insurance d) 3ac& of telephone c)Explanation: #ommunication and being able to provide constant care are &eys to home ventilator management.4nsurance status could be private or public.-.ee #hapter 911 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 2. A 2-yr-old boy undergoing outpatient surgery for tonsillectomy vomits ,hile recovering from general anesthesia in the postoperative recovery area. 7ithin 1-2 min he develops tachypnea+ chest retractions+ and hypo*emia. 7hich of the follo,ing is the most li&ely e*planation for these findings2 a) Acute blood loss from postoperative bleeding b) Anesthetic reaction c) 1acterial infection and to*in release d) Acute air,ay obstruction from aspirated material e) Atelectasis d)Explanation: Acutely after an aspiration there is a mechanical obstruction ,ith irritation+ ,hich can cause bronchospasm.3ater a chemical pneumonia and possibly bacterial infection may supervene.-.ee #hapter 3?0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 3. Of the follo,ing diagnostic tests+ the most sensitive for detecting recurrent air,ay aspiration is( a) Cpper gastrointestinal series b) 6odified barium s,allo, ,ith video fluoroscopy

c) d) e)

A gastroesophageal radionuclide scintiscan #hest #T scan 1ronchoscopy

b)Explanation: This dynamic study ,ill often demonstrate aspiration during s,allo,ing but may not sho, aspiration from emesis or reflu*.-.ee #hapter 3?0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 4. A 9-,&-old healthy-appearing term infant is evaluated in the office for stridor+ ,hich has persisted since birth. The noisy breathing is accompanied by moderate signs of inspiratory obstruction including suprasternal and subcostal retractions. "e feeds ade;uately and is gaining ,eight but fre;uently spits up. The most li&ely cause of his symptoms is( a) Tracheomalacia b) Iascular ring c0 3aryngomalacia d) Tonsil and adenoid hypertrophy e) .ubglottic hemangioma c)Explanation: 3aryngomalacia is common and often produces noisy breathing that ,orsens ,ith viral upper respiratory tract infections or in the supine position.-.ee #hapter 3$0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 6. The most common bronchial foreign body is( a) )a, carrot fragments b) !opcorn c) /ut fragments+ particularly peanuts d) /ails e) #oins c)Explanation: Anything small enough can get into the bronchus.E.mallE is relative to the size of the bronchus and is thus age dependent./uts+ sunflo,er seeds+ and the li&e should not be given to small children.-.ee #hapter 3$2 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 7. A =-mo-old boy presents ,ith biphasic stridor and a recent episode of croup. "e has had minimal response to bronchodilator therapy. "is past history reveals that he ,as a premature infant ,ho ,as intubated and ventilated for = ,&. The most li&ely cause of his respiratory distress is( a) Ac;uired subglottic stenosis b) Iascular ring c) Iiral laryngotracheobronchitis d) )eactive air,ays disease chronic lung disease e) )eflu* laryngitis

a)Explanation: .ubglottic stenosis may be congenital or ac;uired.5irect laryngoscopy ,ill confirm the diagnosis.-.ee #hapter 3$3 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 8. A 9-yr-old boy ,ith a history of tracheoesophageal fistula -T>80 repair at birth is evaluated for a chronic cough. The cough has persisted since he ,as discharged from the hospital after his T>8 repair. The cough is dry and bar&ing and occasionally associated ,ith e*piratory ,heezing. The most li&ely cause of the chronic cough is( a) #ough-variant asthma b) .inusitis c) Tracheomalacia d) Gastroesophageal reflu* e) .ubglottic stenosis c)Explanation: Tracheomalacia is very common after a T>8 repair..ome patients also develop reactive air,ays and reflu*.-.ee #hapter 3$0 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 10. The initial management of a hemodynamically stable 2-mo-old infant ,ith supraventricular tachycardia should include( a) Iagal stimulation b) #ardioversion c) 5efibrillation d) 5igitalization e) 4ntravenous verapamil a)Explanation: 4n infants+ the vagal maneuver of choice is placing a plastic bag containing iced saline completely over the nose and mouth. 4f this is unsuccessful+ intravenous adenosine is the ne*t step. Iagotonic maneuvers in older children include doing a Ialsalva maneuver+ straining+ breath holding+ s;uatting+ drin&ing iced ,ater+ coughing+ vomiting+ and gagging. -.ee #hapter 92? in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 11. 5isorders associated ,ith complete heart bloc& include all of the follo,ing e*cept( a) 6aternal systemic lupus erythematosus b) Dearns-.ayre syndrome c) )heumatoid arthritis d) #ardiac rhabdomyoma e) >ndocarditis c)Explanation: )heumatoid arthritis primarily involves the pericardium and not the conduction system. Another cause of complete heart bloc& is in:ury to the

conduction system during reparative surgery for congenital heart disorders. -.ee #hapter 92? in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 12. A previously healthy $-yr-old girl has a 3-,& history of fever+ myalgias+ and a positive blood culture for .taphylococcus aureus. The past medical history is negative including a normal camp physical e*amination = mo ago+ ,hich did not reveal any heart murmur. After repeating a blood culture+ the ne*t step in her evaluation should be( a) #hest radiograph b) #omplete blood count c) >chocardiogram d) 1one scan e) 5ental clinic appointment c)Explanation: This patient has bacterial endocarditis of a previously normal valve. .. aureus is a common pathogen producing endocarditis of a native valve. The duration of the illness is too long for a simple viral illness+ and in the absence of bone or soft tissue findings+ any person ,ith a positive blood culture for .. aureus should be considered as having endocarditis until proven other,ise. -.ee #hapter 92B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 13. 6a:or findings in the 5u&e criteria for the diagnosis of endocarditis include all of the follo,ing e*cept( a) T,o separate positive blood cultures for common bacteria b) 4ntracardiac mass on a valve seen ,ith echocardiography c) 5ehiscence of a prostatic valve d) Osler nodes e) 6ore than t,o positive blood cultures for unusual bacteria d)Explanation: 4mmune comple* phenomena and embolic events are minor criteria. T,o ma:or or one ma:or and 3-% minor criteria suggest definite endocarditis. -.ee #hapter 92B in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 14. An ?-yr-old boy presents ,ith fever of 2 ,ee&s' duration+ shortness of breath+ an&le edema+ intermittent painful s,elling of the ,rists+ elbo,s+ and &nees unrelated to edema+ and a ne, systolic murmur. One month ago he had a sore throat that lasted for % days+ ,hich resolved spontaneously. The most li&ely diagnosis is( a) >ndocarditis b) )heumatoid arthritis c) 6eningococcal sepsis d) Glomerulonephritis e) )heumatic fever

e)Explanation: The sore throat represented an untreated episode of group A streptococcal pharyngitis. )heumatic fever presents acutely as a migrating polyarthritis+ pancarditis -valves+ myocardium+ pericardium0+ and erythema marginatum -not in this patient0. 5elayed or chronic manifestations include chorea or subcutaneous nodules. These all represent ma:or criteria for the diagnosis+ but documentation of a previous streptococcal infection is also re;uired. -.ee #hapter 930 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 15. A 3-mo-old female infant has a history of poor feeding+ shortness of breath during feedings+ failure to thrive+ and chronic cough. !hysical e*amination reveals tachycardia and a gallop rhythm but no murmur. There is hepatomegaly but no cyanosis. A chest radiograph reveals cardiomegaly. The most appropriate diagnostic test is( a) >chocardiogram b) >lectrocardiogram c) 1lood culture d) .erum amino acids e) Crine p" a)Explanation: The differential diagnosis includes myocarditis+ cardiomyopathies+ anomalous coronary arteries+ and arteriovenous malformations in the liver or brain. The echocardiogram reveals poor contractibility and a dilated cardiomyopathy. -.ee #hapter 931 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 16. After further evaluation and treatment for heart failure+ the child described in Question 15 should also be started on( a) .elenium b) Iitamin 11 c) Thyroid hormone d) #arnitine e) /one of the above d)Explanation: Although deficiencies of all of these nutrients -or hormone0 may produce heart failure+ the clinical picture and history are not compatible ,ith A-#. 6any believe that all infants ,ith cardiomyopathy should receive a trial of carnitine after being evaluated for metabolic inborn errors of metabolism associated ,ith cardiomyopathy. -.ee #hapter 931 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 17. A 20-day-old previously ,ell full-term infant is presented ,ith fever+ tachypnea+ tachycardia of severity out of proportion to the fever+ a gallop rhythm+ and hepatomegaly. 4mportant steps in the evaluation of this neonate include all of the follo,ing e*cept( a) "ead ultrasonography b) >chocardiography c) Iiral cultures and !#) assay

d) e) f)

>#G 3iver function tests 1lood culture

a)Explanation: This neonate has a febrile illness ,ith heart failure. -.ee #hapter 931 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 18. The echocardiogram for the patient in Question 17 reveals myocarditis+ and the viral cultures reveal an enterovirus. 4n addition to medications to treat the heart failure+ ,hich additional therapy is no, indicated2 a) "eart transplantation b) !leconaril c) )ibavirin d) 4ntravenous immunoglobulins e) Oseltamivir b)Explanation: !leconaril is a potent antiviral agent that is very effective against enteroviruses. 4t is the agent of choice for treatment of severe enteroviral infections. -.ee #hapter 931 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 19. A 1-day-old infant is noted to be cyanotic. !hysical e*amination reveals a grade 2-3 = systolic murmur and a single loud second heart sound. The chest radiograph reveals a normal-sized heart and decreased pulmonary vascular mar&ings. The electrocardiogram ->#G0 reveals left ventricular dominance. The ne*t step in the management of this neonate is to administer( a) .odium bicarbonate b) 6orphine c) !rostaglandin >1 d) 5igo*in e) !ositive pressure ventilation c)Explanation: The murmur may represent a patent ductus arteriosus -!5A0. 4f the !5A closes+ mar&ed cyanosis ,ould supervene+ resulting in acidosis+ shoc&+ and death. !rostaglandin >1 -!G>10 maintains patency of the ductus arterious bet,een the pulmonary artery and the aorta. -.ee #hapter 923 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 20. The most li&ely diagnosis for the patient described in Question 19 is( a) !ersistent pulmonary hypertension b) Transposition of the great arteries c) Truncus arteriosus d) !ulmonary atresia e) Total anomalous venous return

d)Explanation: !ulmonary atresia is manifested by a small right ventricle+ decreased pulmonary vascular mar&ings+ early and mar&ed cyanosis ,ithout heart failure+ and ductal dependence to maintain some pulmonary blood flo,. -.ee #hapter 923 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 21. An 1?-mo-old child is noted to assume a s;uatting position fre;uently during playtime at the daycare center. The mother also notices occasional episodes of perioral cyanosis during some of these s;uatting periods. The day of admission+ the child becomes restless+ hyperpneic+ and deeply cyanotic. 7ithin 10 min+ the child becomes unresponsive. The most li&ely underlying lesion is( a) #ardiomyopathy b) Anomalous coronary artery c) Tetralogy of 8allot d) #onstipation e) 1reath-holding spell c)Explanation: The child described has tetralogy of 8allot ,ith e*ercise-induced cyanosis. The more serious episode is a cyanotic+ blue+ or EtetE spell and may be due to decreased systemic vascular resistance+ increased pulmonary artery pressure+ or right ventricular outflo, tract obstruction. The murmur of tetralogy -the pulmonary stenosis0 often disappears or lessens during a spell. -.ee #hapter 923 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 ----------------------------------------------------------------------------Question 22. Therapy of a EblueE or EtetE spell could include all of the follo,ing e*cept( a) >pinephrine b) Dnee-chest position c) O*ygen d) 6orphine e) .odium bicarbonate f) !henylephrine a)Explanation: >pinephrine is potentially dangerous because it may e*acerbate inotropy and contractile forces+ ,hich may obstruct the right ventricular infundibulum. 4ndeed+ propranolol has been used to treat EtetE spells. -.ee #hapter 923 in /elson Te*tboo& of !ediatrics+ 1$th ed.0 -----------------------------------------------------------------------------