Pediatric board review/certified fixed orthodontic courses by Indian dental academy

Pediatric Board ReviewPediatric Board Review
2006-20072006-2007
Session One: July 24, 2006Session One: July 24, 2006
Session Two: August 24, 2006Session Two: August 24, 2006
Session Three: September 26, 2006Session Three: September 26, 2006
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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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BibliographyBibliography
 Blueprints in Pediatrics 1998Blueprints in Pediatrics 1998
 Nelson’s Pediatrics 17Nelson’s Pediatrics 17thth
EditionEdition
 PREP Questions 1999-2006PREP Questions 1999-2006
 Up To DateUp To Date

Scrabble QuizScrabble Quiz
AEINRSTAEINRST
 This is the most common seven letterThis is the most common seven letter
combination you can have on your rack. Therecombination you can have on your rack. There
are 8 different seven letter words “bingos” thatare 8 different seven letter words “bingos” that
can be spelled from this. Can you name one?can be spelled from this. Can you name one?
– Anestri
– Nastier
– Ratines
– Retains
– Retinas
– Retsina
– Stainer
– Stearin

 There are 101 acceptable two letter wordThere are 101 acceptable two letter word
plays in Scrabble, 16 of which start withplays in Scrabble, 16 of which start with
what letter?what letter?
 AA
 AA, AB, AD, AE, AG, AH, AI, AL, AM, AN,AA, AB, AD, AE, AG, AH, AI, AL, AM, AN,
AR, AS, AT, AW, AX, AYAR, AS, AT, AW, AX, AY

 The word ROOST has 4 anagrams, nameThe word ROOST has 4 anagrams, name
them.them.
– ROOTSROOTS
– ROTOSROTOS
– TOROSTOROS
– TORSOTORSO

Question 1.2000Question 1.2000
 A TRUE statement about the epidemiology ofA TRUE statement about the epidemiology of
measles is thatmeasles is that
– A. In countries with no immunization programs, theA. In countries with no immunization programs, the
peak age of infection is infancypeak age of infection is infancy
– B. In US immunization programs have reduced theB. In US immunization programs have reduced the
incidence of infection by 80%incidence of infection by 80%
– C. Usually spread by direct contact with infectiousC. Usually spread by direct contact with infectious
dropletsdroplets
– D. Patients become contagious when the rashD. Patients become contagious when the rash
appearsappears
– E. Incubation period is 4-5 days from exposure toE. Incubation period is 4-5 days from exposure to
onset of symptomsonset of symptoms
 Answer CAnswer C

Teaching Points 1.2000Teaching Points 1.2000
 MeaslesMeasles
– Cough, coryza (inflammation of nasalCough, coryza (inflammation of nasal
mucosal membranes), fever, conjunctivitis,mucosal membranes), fever, conjunctivitis,
exanthem of red macules and papules andexanthem of red macules and papules and
Koplik spotsKoplik spots
– Young children have OM, pneumonia, croupYoung children have OM, pneumonia, croup
and diarrheaand diarrhea
– Acute encephalitis (1:1000) -->PermanentAcute encephalitis (1:1000) -->Permanent
brain injurybrain injury
– In US death 1-3/1000 due to respiratory ofIn US death 1-3/1000 due to respiratory of
neurologic complicationsneurologic complications

 Transmitted by direct contact with infectiousTransmitted by direct contact with infectious
droplets ordroplets or LESS COMMONLYLESS COMMONLY airborne spreadairborne spread
 Since vaccine use in 1963 there has been aSince vaccine use in 1963 there has been a
99% reduction99% reduction in incidence in USin incidence in US
 Children are contagiousChildren are contagious 4-5 days BEFORE rash4-5 days BEFORE rash
appears to 4 days after appearance of rashappears to 4 days after appearance of rash
 Incubation period is 8-12 days from exposure toIncubation period is 8-12 days from exposure to
onset of symptomsonset of symptoms

Koplik SpotsKoplik Spots
Henry Koplik (U.S. Physician, 1858 to 1927)Henry Koplik (U.S. Physician, 1858 to 1927)

 A previously healthy 2 year old is brought to EDA previously healthy 2 year old is brought to ED
because her mom is unable to awaken her forbecause her mom is unable to awaken her for
45 minutes. She has not been ill. PE reveals an45 minutes. She has not been ill. PE reveals an
afebrile, hypotonic child who withdraws her handafebrile, hypotonic child who withdraws her hand
from painful stimuli but does not spontaneouslyfrom painful stimuli but does not spontaneously
open her eyes. RR is 36/min, BP is 92/64. Whatopen her eyes. RR is 36/min, BP is 92/64. What
is the next best thing to obtain?is the next best thing to obtain?
– A. BUNA. BUN
– B. CXRB. CXR
– C. EKGC. EKG
– D. EEGD. EEG
– E. Toxicology screenE. Toxicology screen
 Answer EAnswer E

 Pneumonic for Causes of AlteredPneumonic for Causes of Altered
Consciousness: “Tips from the Vowels”Consciousness: “Tips from the Vowels”
 T-I-P-S-A-E-I-O-UT-I-P-S-A-E-I-O-U
– Trauma/TumorTrauma/Tumor
– Infection/Inborn Errors/Insulin/hypoglycemiaInfection/Inborn Errors/Insulin/hypoglycemia
– PoisonsPoisons
– ShockShock
– Alcohol/AbuseAlcohol/Abuse
– Epilepsy/EncephalopathyEpilepsy/Encephalopathy
– IntussusceptionIntussusception
– OpiatesOpiates
– UremiaUremia

 You have intubated an 8 month old with sepsis and apneaYou have intubated an 8 month old with sepsis and apnea
with a 4.0 endotracheal tube. Proper placement is confirmedwith a 4.0 endotracheal tube. Proper placement is confirmed
by observing chest rise and auscultating symmetric breathby observing chest rise and auscultating symmetric breath
sounds after bag and mask ventilation. Perfusion is <3sounds after bag and mask ventilation. Perfusion is <3
seconds, and heart rate is 120/minute. Five minutes laterseconds, and heart rate is 120/minute. Five minutes later
the RT tells you the oxygen saturation is 83% and the bloodthe RT tells you the oxygen saturation is 83% and the blood
pressure and pulse are dropping. Breath sounds are absentpressure and pulse are dropping. Breath sounds are absent
on the right and the right chest is hypertympanitic. What ison the right and the right chest is hypertympanitic. What is
the most likely diagnosis?the most likely diagnosis?
– A. Esophageal intubationA. Esophageal intubation
– B. Incorrect ET sizeB. Incorrect ET size
– C. Obstructed ET tubeC. Obstructed ET tube
– D. Right main stem bronchus intubationD. Right main stem bronchus intubation
– E. Right pneumothoraxE. Right pneumothorax
 Answer EAnswer E

 ET Tube Size (mm) = …ET Tube Size (mm) = …
– [16 + Age(yr)]/4[16 + Age(yr)]/4
– Preterm 2.5-3.0Preterm 2.5-3.0
– Term 3.0-3.5Term 3.0-3.5
– Infant 3.5-4.0Infant 3.5-4.0
– 1 year 4.0-4.51 year 4.0-4.5
– 3 year 4.5-5.03 year 4.5-5.0
– *An uncuffed tube should be used in patients…*An uncuffed tube should be used in patients…
 <8 years of age<8 years of age
 Approximate distance of insertion measured at teethApproximate distance of insertion measured at teeth
or lips in cm = …or lips in cm = …
– Internal Diameter X 3Internal Diameter X 3
 Straight blades preferred for neonates and infantsStraight blades preferred for neonates and infants

 Drugs that can be given by ETT after dilution withDrugs that can be given by ETT after dilution with
normal saline to 3-5 ml followed by positivenormal saline to 3-5 ml followed by positive
pressure ventilation…pressure ventilation…
 LANELANE
– LidocaineLidocaine
– AtropineAtropine
 0.02mg/kg IV,IO; 0.02-0.06mg/kg ET0.02mg/kg IV,IO; 0.02-0.06mg/kg ET
 Minimum dose is 1ml (0.1 mg) as it comes 0.1 mg/mlMinimum dose is 1ml (0.1 mg) as it comes 0.1 mg/ml
– Naloxone (Narcan)Naloxone (Narcan)
 0.1 mg/kg/dose IM/ET/IV/IO to maximum 2mg/dose. May repeat0.1 mg/kg/dose IM/ET/IV/IO to maximum 2mg/dose. May repeat
every 2-3 minutesevery 2-3 minutes
– EpinephrineEpinephrine
 0.1ml/kg of 1:1000 (0.1mg/kg) IV, IO, ET in non-neonates0.1ml/kg of 1:1000 (0.1mg/kg) IV, IO, ET in non-neonates
 Use 1:10,000 (0.1-0.3ml/kg for all doses and routes) epinephrineUse 1:10,000 (0.1-0.3ml/kg for all doses and routes) epinephrine
via ETT for neonates only. Use high dose 1:1,000 epinephrine forvia ETT for neonates only. Use high dose 1:1,000 epinephrine for
ETT beyond neonatal periodETT beyond neonatal period

PneumothoraxPneumothorax

 Esophageal intubation essentially ruled outEsophageal intubation essentially ruled out
because of previous presence of rise and fall ofbecause of previous presence of rise and fall of
chest and presence of breath sounds unilaterallychest and presence of breath sounds unilaterally
 However, ET tube could have moved if theyHowever, ET tube could have moved if they
repositioned patient; check depth marker atrepositioned patient; check depth marker at
teeth/lipsteeth/lips
 If ETT tube is too small, air leaking around tubeIf ETT tube is too small, air leaking around tube
can impair efforts to ventilate but an audible aircan impair efforts to ventilate but an audible air
leak generally is heard with each positiveleak generally is heard with each positive
pressure breathpressure breath

 Treatment for tension pneumothoraxTreatment for tension pneumothorax
– Immediate needle decompressionImmediate needle decompression
– Patient supine with head of bed at 30 degreePatient supine with head of bed at 30 degree
– 18-20 gauge over the needle catheter (angiocatheter)18-20 gauge over the needle catheter (angiocatheter)
inserted into the…inserted into the…
 22ndnd
intercostal space just “over the top” (Hey dude, this procedureintercostal space just “over the top” (Hey dude, this procedure
is over the top , man!) of the 3is over the top , man!) of the 3rdrd
rib at the midclavicular linerib at the midclavicular line
– 5-10 ml syringe attached to angiocatheter and aspirated5-10 ml syringe attached to angiocatheter and aspirated
gently as needle is advancedgently as needle is advanced
– Loss of resistance or rush of air apparent as soon asLoss of resistance or rush of air apparent as soon as
pleural space is enteredpleural space is entered
– If pneumothorax is confirmed a one-way drainage deviceIf pneumothorax is confirmed a one-way drainage device
should be attachedshould be attached
– A chest tube should be placed after successful needleA chest tube should be placed after successful needle
decompressiondecompression

Needle DecompressionNeedle Decompression

 A 6 year old boy with severe factor VIII deficiencyA 6 year old boy with severe factor VIII deficiency
hemophilia develops increased swelling of the righthemophilia develops increased swelling of the right
distal forearm. There is not history of trauma. Thedistal forearm. There is not history of trauma. The
peripheral circulation is normal and there is no jointperipheral circulation is normal and there is no joint
involvement. The MOST important complication ofinvolvement. The MOST important complication of
bleeding in this location is:bleeding in this location is:
– A. Blood lossA. Blood loss
– B. Muscular DamageB. Muscular Damage
– C. Neurologic ImpairmentC. Neurologic Impairment
– D. Tendon ShorteningD. Tendon Shortening
– E. Vascular DamageE. Vascular Damage
 Answer CAnswer C

 Children with hemophilia can develop severeChildren with hemophilia can develop severe
peripheral neurologic deficits when hematomasperipheral neurologic deficits when hematomas
compress nerves via compartment syndromecompress nerves via compartment syndrome
 In older children increasing pain out of proportionIn older children increasing pain out of proportion
to size of hematoma, numbness and paresis areto size of hematoma, numbness and paresis are
critical signscritical signs
 Often there is no history of trauma inOften there is no history of trauma in
hemophiliacshemophiliacs
 Significant blood loss seen in hematomas of…Significant blood loss seen in hematomas of…
– Thigh or retroperitoneumThigh or retroperitoneum

 Routine venipuncture is safe as long as it isRoutine venipuncture is safe as long as it is
followed by…followed by…
– 5 minutes of firm finger pressure5 minutes of firm finger pressure
 Femoral or jugular venipuncture or arterialFemoral or jugular venipuncture or arterial
puncture should not be undertaken WITHOUT…puncture should not be undertaken WITHOUT…
– PRIOR FACTOR REPLACEMENTPRIOR FACTOR REPLACEMENT
 What about IM immunizations…What about IM immunizations…
– Ok as long as followed by 5 minutes of firm fingerOk as long as followed by 5 minutes of firm finger
pressurepressure
– Large IM injections should be avoided (Decadron,Large IM injections should be avoided (Decadron,
Rocephin IM etc)Rocephin IM etc)

 Tendon shortening only occurs with…Tendon shortening only occurs with…
– Chronic, sever hemarthrosesChronic, sever hemarthroses
– Limited mobilityLimited mobility
– Nerve damageNerve damage
 Muscular damage is not frequent amongMuscular damage is not frequent among
children with hemophiliachildren with hemophilia

Prepatellar HematomaPrepatellar Hematoma

Hematoma after IM injectionHematoma after IM injection

 An ambulance team brings a 6 year old girl in anAn ambulance team brings a 6 year old girl in an
MVA to the ED. She had been unrestrained in theMVA to the ED. She had been unrestrained in the
back seat. The girl is unresponsive on arrival and isback seat. The girl is unresponsive on arrival and is
bleeding profusely from a scalp wound. Herbleeding profusely from a scalp wound. Her
Glasgow Coma Scale is 3. What is the BEST initialGlasgow Coma Scale is 3. What is the BEST initial
step in evaluation and management?step in evaluation and management?
– A. Control profuse scalp bleedingA. Control profuse scalp bleeding
– B. Establish IV accessB. Establish IV access
– C. Order portable cervical spine radiographsC. Order portable cervical spine radiographs
– D. Remove all clothingD. Remove all clothing
– E. Secure an adequate airwayE. Secure an adequate airway
 Answer E.Answer E.

 Priority during primary surveyPriority during primary survey
– AirwayAirway
 Failure to provideFailure to provide
oxygenated blood to theoxygenated blood to the
brain and other vital organsbrain and other vital organs
is the quickest killer of ais the quickest killer of a
trauma victimtrauma victim
– BreathingBreathing
– CirculationCirculation
– DisabilityDisability
– ExposureExposure
 Any victim of head trauma with aAny victim of head trauma with a
GCS of ___ or less should beGCS of ___ or less should be
intubated immediatelyintubated immediately
– 88
 X-rays for cervical fractures…X-rays for cervical fractures…
– AP, Lateral and odontoid viewsAP, Lateral and odontoid views
Dens of Axis C-2Atlas C-1
Odontoid Viewwww.indiandentalacademy.comwww.indiandentalacademy.com

Glasgow Coma ScalesGlasgow Coma Scales
INFANTS & TODDLERS CHILDREN’S & ADULTS
EYE
OPENING
Spontaneous 4 EYE
OPENING
Spontaneous 4
To Voice 3 To Voice 3
To Pain 2 To Pain 2
None 1 None 1
BEST
VERBAL
RESPONSE
Smiles, Interacts 5 BEST
VERBAL
RESPONSE
Oriented 5
Consolable 4 Confused 4
Cries to Pain 3 Inappropriate Words 3
Moans to Pain 2 Incomprehensible Words 2
None 1 None 1
BEST
MOTOR
RESPONSE
Normal spontaneous movement 6 BEST
MOTOR
RESPONSE
Obeys Commands 6
Localizes Pain 5 Localizes Pain 5
Withdraws to Pain 4 Withdraws (Pain) 4
Abnormal Flexion 3 Flexion (Pain) 3
Abnormal Extension 2 Extension (Pain) 2
None 1 None 1www.indiandentalacademy.comwww.indiandentalacademy.com

 A 2 week old presents with tachypnea, poorA 2 week old presents with tachypnea, poor
perfusion, gallop rhythm, diminished pulses, andperfusion, gallop rhythm, diminished pulses, and
hepatomegaly. ABG shows metabolic acidosis.hepatomegaly. ABG shows metabolic acidosis.
Echocardiography reveals critical AorticEchocardiography reveals critical Aortic
Stenosis. What intervention is most likely toStenosis. What intervention is most likely to
stabilize the infant’s condition?stabilize the infant’s condition?
– A. DobutamineA. Dobutamine
– B. EpinephrineB. Epinephrine
– C. Nitric OxideC. Nitric Oxide
– D. 100% oxygenD. 100% oxygen
– E. Prostaglandin E-1E. Prostaglandin E-1
 Answer E.Answer E.

 Severe CHF and cardiogenic shock inSevere CHF and cardiogenic shock in
neonate, think LEFT SIDED LESIONSneonate, think LEFT SIDED LESIONS
– Hypoplastic left heartHypoplastic left heart
– Critical congenital aortic stenosisCritical congenital aortic stenosis
– Critical neonatal coarctation of aortaCritical neonatal coarctation of aorta
 As ductus arteriosus closes, earlyAs ductus arteriosus closes, early
compensatory RV contribution tocompensatory RV contribution to
systemic blood flow and perfusion tosystemic blood flow and perfusion to
kidneys and other organs is lostkidneys and other organs is lost
rapidly developing severe metabolicrapidly developing severe metabolic
acidosisacidosis  myocardial and organmyocardial and organ
dysfunctiondysfunction
 Therefore, need to keep duct OPENTherefore, need to keep duct OPEN
with PGEwith PGE11 (alprostadil) EVEN TO AN(alprostadil) EVEN TO AN
INFANT 1-2INFANT 1-2 MONTHSMONTHS OF AGEOF AGE

 Inotropic agents such as dobutamine orInotropic agents such as dobutamine or
epinephrine may provide supportive therapy butepinephrine may provide supportive therapy but
will not be lifesavingwill not be lifesaving
 Nitric oxide is a pulmonary dilator used in PPHNitric oxide is a pulmonary dilator used in PPH
of newborn but is contraindicated in obstructiveof newborn but is contraindicated in obstructive
left sided heart lesionsleft sided heart lesions
 Serious hypoxia is NOT a problem for infantsSerious hypoxia is NOT a problem for infants
with obstructive left sided lesionswith obstructive left sided lesions
 Arterial pO2 may be normal initially in a sickArterial pO2 may be normal initially in a sick
neonateneonate
 As PDA is opened the O2 will drop due to rightAs PDA is opened the O2 will drop due to right
ventricular flow to the bodyventricular flow to the body

 Attempts to keep O2 HIGH ARE DETRIMENTAL asAttempts to keep O2 HIGH ARE DETRIMENTAL as
high inspired oxygen levels causes powerfulhigh inspired oxygen levels causes powerful
PULMONARY ARTERIAL DILATION which “steals”PULMONARY ARTERIAL DILATION which “steals”
RV output to the pulmonary arteries and away fromRV output to the pulmonary arteries and away from
the bodythe body
 This “steal” factor NOT o2 induced ductal closure isThis “steal” factor NOT o2 induced ductal closure is
the primary risk associated with use ofthe primary risk associated with use of
supplemental O2 when PGE1 is used to keep ductsupplemental O2 when PGE1 is used to keep duct
openopen
 Some degree of pulmonary hypertension (i.e. small,Some degree of pulmonary hypertension (i.e. small,
tight, non-dilated arteries) is essential to promotetight, non-dilated arteries) is essential to promote
systemic flow to the peripheral circulation via thesystemic flow to the peripheral circulation via the
ductusductus

 Hypoplastic Left HeartHypoplastic Left Heart
– 22ndnd
most common congenitalmost common congenital
cardiac lesion presenting in 1cardiac lesion presenting in 1stst
week of lifeweek of life
– Most common cause of deathMost common cause of death
from CHD in 1from CHD in 1stst
month of lifemonth of life
 What are characteristics?What are characteristics?
– Hypoplasia of left ventricleHypoplasia of left ventricle
– Hypoplasia of aortic rootHypoplasia of aortic root
– Aortic valve atresiaAortic valve atresia
– Critical mitral valve stenosis or atresiaCritical mitral valve stenosis or atresia
 Result is a reduction or eliminationResult is a reduction or elimination
of blood flow through left side ofof blood flow through left side of
heartheart

Hypoplastic Left HeartHypoplastic Left Heart
 Ineffective left side of heartIneffective left side of heart 
obligatory left to right shunt where?obligatory left to right shunt where?
– Atrial levelAtrial level
 And right to left shunting where?And right to left shunting where?
– Ductus arteriosusDuctus arteriosus
 Systemic flow isSystemic flow is completely ductalcompletely ductal
dependentdependent
 How do coronary arteries get fed?How do coronary arteries get fed?
– Retrograde coronary perfusionRetrograde coronary perfusion
 As PDA closes neonates becomeAs PDA closes neonates become
critically illcritically ill  CHF, cyanotic,CHF, cyanotic,
tachycardic, tachypneic, ralestachycardic, tachypneic, rales
(crackles) from pulmonary edema,(crackles) from pulmonary edema,
and hepatomegaly; poor peripheraland hepatomegaly; poor peripheral
pulses with vasoconstrictedpulses with vasoconstricted
extremities.extremities.

 Cardiac ExamCardiac Exam
– Loud S2 (Marks beginningLoud S2 (Marks beginning
of diastole and is due toof diastole and is due to
closure of semilunarclosure of semilunar
valves; primarily pulmonicvalves; primarily pulmonic
valve slamming againstvalve slamming against
increased blood volumeincreased blood volume
and pressure)and pressure)
– S3 (Early diastoleS3 (Early diastole
corresponds with end ofcorresponds with end of
first phase of rapidfirst phase of rapid
ventricular filling from atriaventricular filling from atria
and can be normal inand can be normal in
children and young adults)children and young adults)

 Treatment:Treatment:
– PGEPGE11 (alprostadil) immediately to maintain ductal(alprostadil) immediately to maintain ductal
dependent systemic blood flowdependent systemic blood flow
– Cardiac transplantation in the newborn period isCardiac transplantation in the newborn period is
primary treatment for HLHSprimary treatment for HLHS
 Scarcity of newborn organs available for transplantationScarcity of newborn organs available for transplantation
 Life-long need for anti-rejection therapyLife-long need for anti-rejection therapy
 Average life span of the transplanted heart is limitedAverage life span of the transplanted heart is limited
(currently less than 15 years).(currently less than 15 years).
– Most common treatment for HLHS is palliativeMost common treatment for HLHS is palliative
"staged reconstruction""staged reconstruction"

– 1. Norwood operation: performed 11. Norwood operation: performed 1stst
weekweek
 RV becomes the systemic or main ventricleRV becomes the systemic or main ventricle
pumping to the body.pumping to the body.
 ““Neoaorta” is made from part of the pulmonaryNeoaorta” is made from part of the pulmonary
artery and the original, tiny aorta, is enlarged toartery and the original, tiny aorta, is enlarged to
provide blood flow to the body.provide blood flow to the body.
 To provide blood flow to lungs, a small tube graft isTo provide blood flow to lungs, a small tube graft is
placed either from the left subclavian or leftplaced either from the left subclavian or left
innominate artery to the lung vessels (modifiedinnominate artery to the lung vessels (modified
Blalock-Taussig shunt: or from the RV to the lungBlalock-Taussig shunt: or from the RV to the lung
vessels (Sano modification).vessels (Sano modification).

– 2. Bi-directional Glenn procedure2. Bi-directional Glenn procedure
 3 to 6 months of age3 to 6 months of age
 SVC is taken off the heart and sewn directly to theSVC is taken off the heart and sewn directly to the
pulmonary arterypulmonary artery
– 3. Fontan operation3. Fontan operation
 2 or 3 years of age2 or 3 years of age
 IVC is connected directly the blood from theIVC is connected directly the blood from the
pulmonary arteriespulmonary arteries

 During a routine visit, a 14 year old overweightDuring a routine visit, a 14 year old overweight
patient tells you he watches more than 25 hours ofpatient tells you he watches more than 25 hours of
TV per week. What is the most appropriate advice?TV per week. What is the most appropriate advice?
– A. Parents should limit TV to no more than 2 hours/dayA. Parents should limit TV to no more than 2 hours/day
– B. TV commercials have little impact on selection of toysB. TV commercials have little impact on selection of toys
and foodand food
– C. Average adolescent spends 15 hours/week watchingC. Average adolescent spends 15 hours/week watching
TVTV
– D. Unclear relationship between TV viewing and risk ofD. Unclear relationship between TV viewing and risk of
obesityobesity
– E. No relationship between TV viewing and snackingE. No relationship between TV viewing and snacking
 ANSWER AANSWER A

 Children 2-11 22 h/weekChildren 2-11 22 h/week
 Adolescents 12-17 20 h/weekAdolescents 12-17 20 h/week
 Age 18, adolescent will have seen 200,000 violentAge 18, adolescent will have seen 200,000 violent
acts and 18,000 murders on TVacts and 18,000 murders on TV
 Encourage parents to “co-view” programs withEncourage parents to “co-view” programs with
childrenchildren
 Saturday morning commercials; 50% food, 33%Saturday morning commercials; 50% food, 33%
toystoys
 20 best selling toys are from TV shows based on20 best selling toys are from TV shows based on
the toysthe toys
 Increased TV viewing significant factor leading toIncreased TV viewing significant factor leading to
obesityobesity
 Increased TV viewing = increased snackingIncreased TV viewing = increased snacking

Deep Thoughts from RyanDeep Thoughts from Ryan
 ““Dad, how long doesDad, how long does
it take a booger toit take a booger to
form?”form?”
 Booger: Dried nasalBooger: Dried nasal
mucus; bogie inmucus; bogie in
EnglandEngland
 Medical Term:Medical Term:
– RhinolithsRhinoliths

 A male infant born at 36 weeks gestation had a leftA male infant born at 36 weeks gestation had a left
testicle palpable in the inguinal canal. At 12 monthstesticle palpable in the inguinal canal. At 12 months
of age, the left testicle has failed to descend into theof age, the left testicle has failed to descend into the
scrotum. What is most appropriate care for thisscrotum. What is most appropriate care for this
infant?infant?
– A. Observation until 2 years of ageA. Observation until 2 years of age
– B. OrchiopexyB. Orchiopexy
– C. Radionuclide scan of left testicleC. Radionuclide scan of left testicle
– D. Treatment with human chorionic gonadotropinD. Treatment with human chorionic gonadotropin
– E. Treatment with testosteroneE. Treatment with testosterone
 ANSWER BANSWER B

 What percent of preterm male infants have anWhat percent of preterm male infants have an
undescended testisundescended testis
– 30%30%
 Spontaneous descent into scrotum occurs…Spontaneous descent into scrotum occurs…
– over next 3-6 monthsover next 3-6 months
 What is the most reliable method to localize theWhat is the most reliable method to localize the
undescended testis?undescended testis?
– LaparoscopyLaparoscopy
 Orchiopexy, a surgery which places the testis intoOrchiopexy, a surgery which places the testis into
the scrotum is indicated for a testis that fails tothe scrotum is indicated for a testis that fails to
descend by…descend by…
– 6 months of age and is performed at 9-12 months of age6 months of age and is performed at 9-12 months of age

 At 6-12 months of age histological changesAt 6-12 months of age histological changes
representing degeneration of the seminiferousrepresenting degeneration of the seminiferous
tubules occurstubules occurs decrease in quality and quantitydecrease in quality and quantity
of spermatogenesisof spermatogenesis which is progressivewhich is progressive
 The longer the testis remains in its improperThe longer the testis remains in its improper
location the greater the fertility impairmentlocation the greater the fertility impairment
 What percent of all testicular tumors occur inWhat percent of all testicular tumors occur in
patients with an undescended testiclepatients with an undescended testicle
– 10%10%
 Orchiopexy improves fertility but DOES NOTOrchiopexy improves fertility but DOES NOT
change malignancy riskchange malignancy risk

 Relocated testis has aRelocated testis has a 35-48 times35-48 times greatergreater
risk of malignancy than normal testisrisk of malignancy than normal testis
 Does the normal testis also have anDoes the normal testis also have an
increased risk?increased risk?
– YES, just not as highYES, just not as high
 Counsel parents to:Counsel parents to:
– Seek immediate attention for acute testicularSeek immediate attention for acute testicular
pain due to risk of torsionpain due to risk of torsion
– Perform monthly examination of both testesPerform monthly examination of both testes

 Retractile testiclesRetractile testicles
– Bilateral mostlyBilateral mostly
– Found in children >1 year of age, 5-6 yearFound in children >1 year of age, 5-6 year
olds strong reflexolds strong reflex
– Due to strong cremasteric reflexDue to strong cremasteric reflex
– ““Milk them” into scrotumMilk them” into scrotum
– Warm room, frog leg position can makeWarm room, frog leg position can make
examination easierexamination easier

 A newborn female has an open neural tubeA newborn female has an open neural tube
defect, low set ears, VSD, and rib anddefect, low set ears, VSD, and rib and
vertebral column malformations. Which ofvertebral column malformations. Which of
the following MATERNAL conditions wasthe following MATERNAL conditions was
most likely present during pregnancy?most likely present during pregnancy?
 A. AlcoholismA. Alcoholism
 B. Diabetes mellitusB. Diabetes mellitus
 C. HypothyroidismC. Hypothyroidism
 D. Iodine deficiencyD. Iodine deficiency
 E. SyphilisE. Syphilis
– ANSWER: BANSWER: Bwww.indiandentalacademy.comwww.indiandentalacademy.com

 Early prenatal deficits: malformations (3 foldEarly prenatal deficits: malformations (3 fold
increase), growth deficiency, stillbirthincrease), growth deficiency, stillbirth
 The worse the diabetic control the moreThe worse the diabetic control the more
severe the defectssevere the defects
 Cardiac: VSD, TGA, dextrocardiaCardiac: VSD, TGA, dextrocardia
 CNS: Anencephaly,CNS: Anencephaly, holoprosencephalyholoprosencephaly ,,
spina bifida, hydrocephalus,spina bifida, hydrocephalus, caudalcaudal
regression syndromeregression syndrome
 Rib defectsRib defects

 Infants present with macrosomia due toInfants present with macrosomia due to
hyperinsulinemia and excessive glucosehyperinsulinemia and excessive glucose
availabilityavailability
 Both linear growth and weight are affectedBoth linear growth and weight are affected
 If mom has severe vascular disease, canIf mom has severe vascular disease, can
result in IUGRresult in IUGR
 Additional complications: Hyperbilirubinemia,Additional complications: Hyperbilirubinemia,
hypoglycemia, vascular thromboses,hypoglycemia, vascular thromboses,
respiratory distress, birth injury due torespiratory distress, birth injury due to
macrosomiamacrosomia

HoloprosencephalyHoloprosencephaly
 Caused by a failure of theCaused by a failure of the
embryo's forebrain to divide toembryo's forebrain to divide to
form bilateral cerebralform bilateral cerebral
hemispheres causing defects inhemispheres causing defects in
face development face and inface development face and in
brain structure and function.brain structure and function.
 The "alobar" form ofThe "alobar" form of
holoprosencephaly is shown hereholoprosencephaly is shown here
in which there is a single largein which there is a single large
ventricle, because there is noventricle, because there is no
attempt to form separate cerebralattempt to form separate cerebral
hemispheres.hemispheres.
 May be associated with trisomy 13May be associated with trisomy 13
and rarely in association withand rarely in association with
maternal diabetes mellitus.maternal diabetes mellitus.

Spina BifidaSpina Bifida

 Fetal alcohol syndromeFetal alcohol syndrome
– What is the most common teratogen to which fetusesWhat is the most common teratogen to which fetuses
are exposed?are exposed?
 AlcoholAlcohol
– Which U.S. population has the highest incidence ofWhich U.S. population has the highest incidence of
children with FAS?children with FAS?
 Native AmericansNative Americans
– What is the incidence in U.S. (excluding NativeWhat is the incidence in U.S. (excluding Native
Americans)Americans)
 1:10001:1000
– Affects 40% of children in women who drink moreAffects 40% of children in women who drink more
than 4-6 drinks per daythan 4-6 drinks per day

Fetal Alcohol SyndromeFetal Alcohol Syndrome

Epicanthal FoldsEpicanthal Folds

 MaternalMaternal
hypothyroidism hashypothyroidism has
little effect on fetuslittle effect on fetus
which produces itswhich produces its
own thyroid hormoneown thyroid hormone
 Women withWomen with
untreateduntreated
hypothyroidism alsohypothyroidism also
give birth togive birth to
NORMAL babiesNORMAL babies

 Maternal iodine deficiency (rare in developedMaternal iodine deficiency (rare in developed
countries)countries)  fetal deficiencyfetal deficiency
– GoiterGoiter
– Mental retardationMental retardation
– Slightly increased head size due to…Slightly increased head size due to…
 Myxedema [“hard” edema due to increased mucinsMyxedema [“hard” edema due to increased mucins
(proteoglycans) in the fluid] of subcutaneous tissues of(proteoglycans) in the fluid] of subcutaneous tissues of
the brain}the brain}
– Hyperbilirubinemia due to…Hyperbilirubinemia due to…
 Delayed maturation of glucuronide conjugationDelayed maturation of glucuronide conjugation
– Feeding difficulties (choking spells, lack ofFeeding difficulties (choking spells, lack of
interest, somnolence, sluggishness)interest, somnolence, sluggishness)www.indiandentalacademy.comwww.indiandentalacademy.com

– Respiratory difficulties due to…Respiratory difficulties due to…
 Large tongue, apneic episodes, noisy respirations, nasalLarge tongue, apneic episodes, noisy respirations, nasal
obstructionobstruction
– Retarded bone growthRetarded bone growth
– ConstipationConstipation
– Umbilical hernia with large abdomenUmbilical hernia with large abdomen
– Hypothermia and cold and mottled skinHypothermia and cold and mottled skin
– Slow pulseSlow pulse
– Genital and extremity edemaGenital and extremity edema
– Pericardial effusion, murmur, cardiomegalyPericardial effusion, murmur, cardiomegaly
 Prompt treatment with iodine necessary toPrompt treatment with iodine necessary to
prevent mental retardationprevent mental retardation

 Maternal syphilisMaternal syphilis
– Fetus affected by…Fetus affected by…
 Transplacental transmissionTransplacental transmission Treponema pallidumTreponema pallidum
– Syphilis in untreated women can be transmitted toSyphilis in untreated women can be transmitted to
fetus at any time, fetal transfer most common duringfetus at any time, fetal transfer most common during
11stst
year of maternal infectionyear of maternal infection
– 2/3 of live-born neonates with congenital syphilis are2/3 of live-born neonates with congenital syphilis are
asymptomatic at birth.asymptomatic at birth.
– Overt infection can manifest in the fetus, the newborn,Overt infection can manifest in the fetus, the newborn,
or later in childhood.or later in childhood.
– Clinical manifestations after birth are dividedClinical manifestations after birth are divided
arbitrarily into early ( 2 years of age) and late (>2arbitrarily into early ( 2 years of age) and late (>2
years of age)years of age)

 Fetal manifestations of SyphilisFetal manifestations of Syphilis
– StillbirthStillbirth
– Neonatal deathNeonatal death
– Overt infection at birth, such as hydropsOvert infection at birth, such as hydrops
fetalis (abnormal accumulation serous fluid infetalis (abnormal accumulation serous fluid in
fetal tissues)fetal tissues)
– Intrauterine death in 25% of affected infants,Intrauterine death in 25% of affected infants,
with perinatal mortality in an additional 25-with perinatal mortality in an additional 25-
30%, if untreated30%, if untreated

 Early congenital manifestations ofEarly congenital manifestations of
SyphilisSyphilis
– Quite variable, appear within the first 5 weeks of lifeQuite variable, appear within the first 5 weeks of life
– Cutaneous lesions frequently occur on the palms andCutaneous lesions frequently occur on the palms and
soles; if ulcerative in nature, they are highlysoles; if ulcerative in nature, they are highly
contagiouscontagious
– HepatosplenomegalyHepatosplenomegaly
– JaundiceJaundice
– AnemiaAnemia
– Snuffles (obstructed nasal respiration in newborn)Snuffles (obstructed nasal respiration in newborn)
– Metaphyseal dystrophy and periostitis often are notedMetaphyseal dystrophy and periostitis often are noted
on radiographs at birthon radiographs at birth

 Late congenital manifestationsLate congenital manifestations
– Develop from scarring related to earlyDevelop from scarring related to early
infection but can be prevented by treatment ofinfection but can be prevented by treatment of
the infant within the first three months of birththe infant within the first three months of birth
– Late findings include frontal bossing, shortLate findings include frontal bossing, short
maxilla, high palatal arch, Hutchinson triadmaxilla, high palatal arch, Hutchinson triad
(Hutchinson teeth [blunted upper incisors],(Hutchinson teeth [blunted upper incisors],
interstitial keratitis, and eighth nerveinterstitial keratitis, and eighth nerve
deafness), saddle nose, and perioral fissuresdeafness), saddle nose, and perioral fissures
(rhagades)(rhagades)

Saddle Nose
deformity in
congenital syphilis

Hutchinson TeethHutchinson Teeth

 A 5 year old male is hospitalized in January withA 5 year old male is hospitalized in January with
fever and seizures. LP reveals clear CSF with 47fever and seizures. LP reveals clear CSF with 47
WBCs/mmWBCs/mm33
all of which are lymphocytes. On PEall of which are lymphocytes. On PE
he appears obtunded but arouses with painfulhe appears obtunded but arouses with painful
stimuli. Neurologic exam reveals no focal findings.stimuli. Neurologic exam reveals no focal findings.
Which diagnostic test is most likely to reveal thisWhich diagnostic test is most likely to reveal this
child’s illness?child’s illness?
– A. Bacterial culture of CSFA. Bacterial culture of CSF
– B. PCR test of CSF for HSVB. PCR test of CSF for HSV
– C.C. Streptococcus pneumoniaeStreptococcus pneumoniae bacterial antigen test ofbacterial antigen test of
CSFCSF
– D. Viral culture of CSFD. Viral culture of CSF
– E. Viral culture of nasopharyngeal and rectal swabsE. Viral culture of nasopharyngeal and rectal swabs
 ANSWER BANSWER B

Learning Points 10.2000Learning Points 10.2000
 Exam findings are consistent with encephalitisExam findings are consistent with encephalitis
 CSF findings are consistent with a viral etiologyCSF findings are consistent with a viral etiology
 Most likely cause is a sporadic case of herpesMost likely cause is a sporadic case of herpes
simplex virussimplex virus
 Viral cultures of CSF for HSV are RARELYViral cultures of CSF for HSV are RARELY
positive beyond neonatal periodpositive beyond neonatal period
 HSV is not found in cultures of sites outside theHSV is not found in cultures of sites outside the
CNSCNS

Learning Points 10.2000Learning Points 10.2000
 What is the treatment of choice for herpesWhat is the treatment of choice for herpes
encephalitis in a child?encephalitis in a child?
– IV Acyclovir 10 mg/kg/dose q8 for 14-21 daysIV Acyclovir 10 mg/kg/dose q8 for 14-21 days
 What is the treatment of choice forWhat is the treatment of choice for
neonatal herpes encephalitis?neonatal herpes encephalitis?
– IV Acyclovir 20 mg/kg/dose q8 for 14-21 daysIV Acyclovir 20 mg/kg/dose q8 for 14-21 days

 An 18 year old girl presents for a RV. ExamAn 18 year old girl presents for a RV. Exam
reveals tanner stage 5 breasts with 2x2 cmreveals tanner stage 5 breasts with 2x2 cm
nontender, smooth, mobile mass in left breast. Itnontender, smooth, mobile mass in left breast. It
is located at the upper outer quadrant. Theis located at the upper outer quadrant. The
overlying skin is normal and there is no historyoverlying skin is normal and there is no history
of nipple discharge. Family history is negative forof nipple discharge. Family history is negative for
breast cancer. What is the most appropriate nextbreast cancer. What is the most appropriate next
step in evaluation of this breast mass?step in evaluation of this breast mass?
– A. Excisional biopsyA. Excisional biopsy
– B. Fine-needle biopsyB. Fine-needle biopsy
– C. MammographyC. Mammography
– D. Reassurance and reevaluation in 4-6 monthsD. Reassurance and reevaluation in 4-6 months
– E. Referral for surgical consultationE. Referral for surgical consultation
 ANSWER DANSWER D

 What is the diagnosis?What is the diagnosis?
– FibroadenomaFibroadenoma
 Fibroadenomas are most common breastFibroadenomas are most common breast
lesion in an adolescent femalelesion in an adolescent female
 Differential diagnosis breast masses:Differential diagnosis breast masses:
– Fibrocystic changesFibrocystic changes
– CystsCysts
– AbscessesAbscesses
– Rarely, malignancyRarely, malignancy

 Without family history of breast cancer in a 1Without family history of breast cancer in a 1stst
or 2or 2ndnd
degreedegree
relative, primary breast cancer is extremely rare inrelative, primary breast cancer is extremely rare in
adolescentsadolescents
 Fewer than 1/1,000 of adolescent breast masses areFewer than 1/1,000 of adolescent breast masses are
malignantmalignant
 Metastatic lesions from…Metastatic lesions from…
– Rhabdomyosarcoma, neuroblastoma, and lymphoma can occur, butRhabdomyosarcoma, neuroblastoma, and lymphoma can occur, but
rare.rare.
 If anxiety high can begin with what test…If anxiety high can begin with what test…
– Ultrasound to differentiate between cystic and solid massesUltrasound to differentiate between cystic and solid masses
 FNA or biopsy can be done in adolescent with unusually largeFNA or biopsy can be done in adolescent with unusually large
or atypical mass or who is highly anxious about malignantor atypical mass or who is highly anxious about malignant
potentialpotential
 Mammography never is indicated fir evaluation of a breastMammography never is indicated fir evaluation of a breast
mass in teenagers because the dense breast tissue makesmass in teenagers because the dense breast tissue makes
study difficult to interpretstudy difficult to interpret

 A 15 year old girl complains of dysuria andA 15 year old girl complains of dysuria and
abdominal pain for 2 days. She denies nausea,abdominal pain for 2 days. She denies nausea,
vomiting, flank pain and vaginal discharge.vomiting, flank pain and vaginal discharge.
Menarche occurred to years ago and mensesMenarche occurred to years ago and menses
have been irregular. PE reveals SMR stage 4have been irregular. PE reveals SMR stage 4
genitalia, mild suprapubic tenderness, andgenitalia, mild suprapubic tenderness, and
otherwise normal findings. What is the mostotherwise normal findings. What is the most
likely diagnosis?likely diagnosis?
– A. Bacterial vaginosisA. Bacterial vaginosis
– B. Candidal vulvovaginitisB. Candidal vulvovaginitis
– C.C. ChlamydiaChlamydia urethritisurethritis
– D. Pelvic inflammatory diseaseD. Pelvic inflammatory disease
– E. Urinary tract infectionE. Urinary tract infection
 ANSWER E.ANSWER E.

 Bacterial vaginosisBacterial vaginosis
– Grayish discharge with pH >4.5Grayish discharge with pH >4.5
– Saline wet mount reveals >20% clue cells and an absenceSaline wet mount reveals >20% clue cells and an absence
of lactobacilliof lactobacilli
– An isolatedAn isolated Gardenerella vaginalisGardenerella vaginalis infection does notinfection does not
cause dysuria and lower abdominal paincause dysuria and lower abdominal pain
 Candidal vaginosisCandidal vaginosis
– Whitish dischargeWhitish discharge
 Chlamydia trachomatisChlamydia trachomatis
– Causes dysuria if urethra involvedCauses dysuria if urethra involved
– No abdominal pain UNLESS PID presentNo abdominal pain UNLESS PID present
– PID symptoms: lower abdominal pain, cervical motionPID symptoms: lower abdominal pain, cervical motion
tenderness, adnexal tenderness; fever, vomiting, diarrhea,tenderness, adnexal tenderness; fever, vomiting, diarrhea,
irregular vaginal bleeding, increased vaginal dischargeirregular vaginal bleeding, increased vaginal discharge

Clue CellsClue Cells
 Vaginal epithelial cells that appear
fuzzy without distinct edges under
a microscope due to being coated
with G. vaginalis
 Clue cells flake off of the walls of
the vagina and are found in
vaginal smear.
 Chemicals released by the
bacteria that cause bacterial
vaginosis (BV) may damage
vaginal wall cells, causing them to
flake off in greater numbers than
usual.
 When bacterial vaginosis is
present, more than 20% of the
sample vaginal epithelial cells are
clue cells.

Clue CellsClue Cells

 A 3 year old girl comes to the ER withA 3 year old girl comes to the ER with
temperature of 103.1temperature of 103.1oo
F and acute onsetF and acute onset
diarrhea. Stool is guaiac positive withdiarrhea. Stool is guaiac positive with
leukocytes. There is no history of foreign travelleukocytes. There is no history of foreign travel
and the child has not received antibioticsand the child has not received antibiotics
recently. What is the most likely organism?recently. What is the most likely organism?
– A.A. Clostridium difficileClostridium difficile
– B.B. Giardia lambliaGiardia lamblia
– C. RotavirusC. Rotavirus
– D.D. Salmonella enteritidisSalmonella enteritidis
– E.E. Vibrio choleraeVibrio cholerae
 ANSWER D.ANSWER D.

 Viral diarrheaViral diarrhea
– Low-grade fever, vomiting, large, loose wateryLow-grade fever, vomiting, large, loose watery
stoolsstools
– Most common cause…Most common cause…
 RotavirusRotavirus
– Season predominance…Season predominance…
 Winter in United StatesWinter in United States

 Bacterial DiarrheaBacterial Diarrhea
– High fevers, small frequent stools with mucous orHigh fevers, small frequent stools with mucous or
bloodblood
– What can happen if you treatWhat can happen if you treat SalmonellaSalmonella infectioninfection
with antibiotics?with antibiotics?
 Prolong the carrier stateProlong the carrier state
– Which organism is seen after antibiotics?Which organism is seen after antibiotics?
 Clostridium difficileClostridium difficile
– What organism is seen after ingestion of seafood orWhat organism is seen after ingestion of seafood or
water?water?
 VibrioVibrio cholerae
– Giardia lambliaGiardia lamblia results in chronic diarrhea withresults in chronic diarrhea with
malabsorptionmalabsorption

 You are evaluating a 4 week old boy for tearing ofYou are evaluating a 4 week old boy for tearing of
the right eye that has worsened over the past week.the right eye that has worsened over the past week.
Physical exam reveals slight tearing but noPhysical exam reveals slight tearing but no
evidence of purulent exudate or conjunctivalevidence of purulent exudate or conjunctival
erythema. All other findings are normal. The MOSTerythema. All other findings are normal. The MOST
appropriate initial management is…appropriate initial management is…
– A. Administration of amoxicillinA. Administration of amoxicillin
– B. Endoscopic dacrocystorhinostomyB. Endoscopic dacrocystorhinostomy
– C. Instillation of silver nitrate in the eyesC. Instillation of silver nitrate in the eyes
– D. Observation with intermittent massage of the ductD. Observation with intermittent massage of the duct
– E. Surgical dilation of the nasolacrimal ductE. Surgical dilation of the nasolacrimal duct
 ANSWER DANSWER D

 Congenital nasolacrimal duct obstruction is mostCongenital nasolacrimal duct obstruction is most
common abnormality of infant lacrimal system, 5%common abnormality of infant lacrimal system, 5%
affectedaffected
 What percent of those affected have bilateralWhat percent of those affected have bilateral
obstruction?obstruction?
– 30%30%
 Obstruction is usually found where?Obstruction is usually found where?
– Distal endDistal end
 Pertinent negatives on examPertinent negatives on exam
– Conjunctival inflammation, photophobia, blepharospasm,Conjunctival inflammation, photophobia, blepharospasm,
corneal cloudingcorneal clouding

A previously health 1-year-old infant who weighs 10 kg presentsA previously health 1-year-old infant who weighs 10 kg presents
to your office with a fever of 39° C (102.2° F). Her mother isto your office with a fever of 39° C (102.2° F). Her mother is
very concerned about the child’s intake and asks for guidancevery concerned about the child’s intake and asks for guidance
regarding caloric requirements during this illness.regarding caloric requirements during this illness.
Of the following, the best estimate of the child’s caloricOf the following, the best estimate of the child’s caloric
requirements at this time isrequirements at this time is
A.A.500 kcal/d plus 500 kcal due to the fever500 kcal/d plus 500 kcal due to the fever
B.B.1,000 kcal/d plus 250 kcal due to the fever1,000 kcal/d plus 250 kcal due to the fever
C.C.1,500 kcal/d1,500 kcal/d
D.D.1,500 kcal/d plus 250 kcal due to the fever1,500 kcal/d plus 250 kcal due to the fever
E.E.2,000 kcal/d2,000 kcal/d
Answer: BAnswer: Bwww.indiandentalacademy.comwww.indiandentalacademy.com

Question (68.1999)Question (68.1999)
 What is the most effective indicator of whether aWhat is the most effective indicator of whether a
child is getting enough calories?child is getting enough calories?
– Growth ChartGrowth Chart
 Name 5 factors that affect a child’s energy (calorie)Name 5 factors that affect a child’s energy (calorie)
requirements.requirements.
– Basal metabolism calories (Maintenance at rest andBasal metabolism calories (Maintenance at rest and
fasting)fasting)
– Growing caloriesGrowing calories
– Exercise caloriesExercise calories
– Eating caloriesEating calories
– Hypermetabolic states et al (See Table)Hypermetabolic states et al (See Table)

Calculation of CaloricCalculation of Caloric
Requirements Based on BodyRequirements Based on Body
Weight (68.1999)Weight (68.1999)
Body WeightBody Weight Caloric RequirementCaloric Requirement
≤≤ 10 kg10 kg 100 kcal/kg100 kcal/kg
11 to 20 kg11 to 20 kg 1,000 kcal + 501,000 kcal + 50
kcal/kg for each kgkcal/kg for each kg
above 10 kgabove 10 kg
≥≥ 20 kg20 kg 1,500 kcal + 201,500 kcal + 20
kcal/kg for each kgkcal/kg for each kg
above 20 kgabove 20 kgwww.indiandentalacademy.comwww.indiandentalacademy.com

Calculating Energy Lost in FeverCalculating Energy Lost in Fever
(68.1999)(68.1999)
 FormulaFormula
– For each degree above 37For each degree above 37oo
C, multiply by 12%C, multiply by 12%
of maintenance requirements per degree. Thenof maintenance requirements per degree. Then
add to original maintenance requirements foradd to original maintenance requirements for
total energy needs.total energy needs.
– Example: 10 kg infant with 39Example: 10 kg infant with 39oo
C temperature.C temperature.
Calculate total caloric requirements.Calculate total caloric requirements.
 10 kg X 100kcal/kg= 1,000 kcal maintenance needs10 kg X 100kcal/kg= 1,000 kcal maintenance needs
 22oo
X 0.12(1,000kcal) = 240 kcalX 0.12(1,000kcal) = 240 kcal
 Total Needs = 1,240 kcalTotal Needs = 1,240 kcal

Question 69Question 69
A 5-year-old boy is brought to the emergency department afterA 5-year-old boy is brought to the emergency department after
having been struck by an automobile. Physical examination revealshaving been struck by an automobile. Physical examination reveals
facial abrasions, abdominal tenderness, and gross blood at thefacial abrasions, abdominal tenderness, and gross blood at the
urethral meatus. Pelvic radiography reveals a left-sided fracture ofurethral meatus. Pelvic radiography reveals a left-sided fracture of
the superior pubic rami.the superior pubic rami.
Of the following, the best procedure for INITIAL evaluation of theOf the following, the best procedure for INITIAL evaluation of the
urinary tract in this patient isurinary tract in this patient is
A.A.Bladder catheterization via the urethraBladder catheterization via the urethra
B.B.Computed tomography of the abdomenComputed tomography of the abdomen
C.C.Intravenous pyelographyIntravenous pyelography
D.D.Renal untrasonographyRenal untrasonography
E.E.Retrograde urethrographyRetrograde urethrography
Answer: EAnswer: Ewww.indiandentalacademy.comwww.indiandentalacademy.com

Additional Caloric Requirements in SelectedAdditional Caloric Requirements in Selected
Medical and Surgical Conditions (68.1999)Medical and Surgical Conditions (68.1999)
ConditionCondition Maximum Amount ofMaximum Amount of
Additional CaloriesAdditional Calories
RequiredRequired
Hypermetabolic stateHypermetabolic state
due to recent surgerydue to recent surgery
20%20%
Multiple traumaMultiple trauma 25%25%
Severe infectionSevere infection 50%50%
Third-degree burnsThird-degree burns
(<20% of body)(<20% of body)
100%100%
UncomplicatedUncomplicated
starvationstarvation
50%50%

Question (69.1999)Question (69.1999)
 In children who sustain multiple injuries in aIn children who sustain multiple injuries in a
vehicular crash what are the top two “systems”vehicular crash what are the top two “systems”
that are involved?that are involved?
– Central Nervous System #1Central Nervous System #1
– Genitourinary System #2Genitourinary System #2
 Blood at tip of penis suggests urethral injury.Blood at tip of penis suggests urethral injury.
 Injury to the prostatomembranous portion ofInjury to the prostatomembranous portion of
urethra associated with pelvic fracture is mosturethra associated with pelvic fracture is most
common.common.
 Isolated urethral injury in female isIsolated urethral injury in female is
UNCOMMON.UNCOMMON.

Answer Explanations (69.1999)Answer Explanations (69.1999)
 Retrograde urethrography (E.) -CatheterRetrograde urethrography (E.) -Catheter
placed just inside urethral meatus and dyeplaced just inside urethral meatus and dye
insertedinserted
 Routine catheterization (A.) isRoutine catheterization (A.) is
contraindicated with blood at urethralcontraindicated with blood at urethral
meatus because…meatus because…
– Procedure might convert a PARTIAL TEAR ofProcedure might convert a PARTIAL TEAR of
meatus into a COMPLETE TRANSECTIONmeatus into a COMPLETE TRANSECTION

Answer Explanations (69.1999)Answer Explanations (69.1999)
 Abdominal CT would be helpful for…Abdominal CT would be helpful for…
– Evaluating intrabdominal injuriesEvaluating intrabdominal injuries
 Splenic injurySplenic injury
 Liver injuryLiver injury
 Renal injuryRenal injury
 Intravenous pyelography and Renal USIntravenous pyelography and Renal US
will evaluate renal pathology but notwill evaluate renal pathology but not
evaluate suspected urethral injuriesevaluate suspected urethral injuries

Apgar ScoreApgar Score
(Virginia Apgar 1953)(Virginia Apgar 1953)
Component ofComponent of
Apgar ScoreApgar Score
Score (Check at 1 and 5 minutes)Score (Check at 1 and 5 minutes)
00 11 22
Heart RateHeart Rate NoneNone <100<100
beats/minbeats/min
>100>100
beats/minbeats/min
RespiratoryRespiratory
EffortEffort
NoneNone Weak cryWeak cry Lusty cryLusty cry
Muscle ToneMuscle Tone LimpLimp Some flexionSome flexion Well flexedWell flexed
ReflexReflex
IrratibilityIrratibility
No responseNo response Some motionSome motion VigorousVigorous
responseresponse
ColorColor Uniformly BlueUniformly Blue AcrocyanosisAcrocyanosis CompletelyCompletely
pinkpink

You are attending the emergency delivery by cesarean section of aYou are attending the emergency delivery by cesarean section of a
primiparous woman. The gestation was complicated by pregnancy-primiparous woman. The gestation was complicated by pregnancy-
induced hypertension. Deep variable fetal heart rate decelerationsinduced hypertension. Deep variable fetal heart rate decelerations
were noted during labor. At delivery, the infant is acrocyanotic withwere noted during labor. At delivery, the infant is acrocyanotic with
poor tone; spontaneous movement and minimal respiratory effort arepoor tone; spontaneous movement and minimal respiratory effort are
present.present.
Of the following, your INITIAL management is toOf the following, your INITIAL management is to
A.A.Ascertain the heart rate and assign a 1-minute Apgar scoreAscertain the heart rate and assign a 1-minute Apgar score
B.B.Begin tactile stimulation and provide blow-blow oxygenBegin tactile stimulation and provide blow-blow oxygen
supplementationsupplementation
C.C.Dry all skin surfaces and clear the oropharynxDry all skin surfaces and clear the oropharynx
D.D.Initiate bag-mask ventilationInitiate bag-mask ventilation
E.E.Insert an umbilical catheter and administer naloxoneInsert an umbilical catheter and administer naloxone
Answer: CAnswer: Cwww.indiandentalacademy.comwww.indiandentalacademy.com

Learning Points (70.1999)Learning Points (70.1999)
 The body and head of an infant areThe body and head of an infant are
immediately dried with a prewarmed towelimmediately dried with a prewarmed towel
to remove…to remove…
– Amniotic fluidAmniotic fluid
 And to prevent…And to prevent…
– Evaporative heat loss which could lead toEvaporative heat loss which could lead to
hypothermiahypothermia
 Also provides gentle stimulation to infantAlso provides gentle stimulation to infant

 When suctioning, mouth or nose first and why?When suctioning, mouth or nose first and why?
– Mouth to ensure nothing in oropharynx that could beMouth to ensure nothing in oropharynx that could be
aspirated as we are dealing with obligate noseaspirated as we are dealing with obligate nose
breathersbreathers
 Suctioning also provides tactile stimulationSuctioning also provides tactile stimulation
 Score of 7 or more indicates…Score of 7 or more indicates…
– WELL NEWBORNWELL NEWBORN  ROUTINE CARE ANDROUTINE CARE AND
OBSERVATIONOBSERVATION
 Score of 4-6 indicates…Score of 4-6 indicates…
– MILD TO MODERATE DEPRESSION, NEED MOREMILD TO MODERATE DEPRESSION, NEED MORE
INTERVENTION (Blowby, stimulation etc.)INTERVENTION (Blowby, stimulation etc.)
 Score 3 or less…Score 3 or less…
– SEVERE DEPRESSION, NEED TO INTUBATE, CVSEVERE DEPRESSION, NEED TO INTUBATE, CV
SUPPORT, BAG-MASK VENTILATIONSUPPORT, BAG-MASK VENTILATIONwww.indiandentalacademy.comwww.indiandentalacademy.com

 When do you keep on taking ApgarWhen do you keep on taking Apgar
scores?scores?
– When 5 minute is 6 or lessWhen 5 minute is 6 or less
 Additional scores should be assignedAdditional scores should be assigned
every 5 minutes for up to 20 minutes orevery 5 minutes for up to 20 minutes or
until two consecutive scores of 7+ areuntil two consecutive scores of 7+ are
obtainedobtained

A 1-year-old boy has been treated with a low-phenylalanine diet forA 1-year-old boy has been treated with a low-phenylalanine diet for
the past year after having been identified in infancy as havingthe past year after having been identified in infancy as having
phenylketonuria. Despite appropriate dietary restriction ofphenylketonuria. Despite appropriate dietary restriction of
phenylalanine, he has developed neurologic symptoms.phenylalanine, he has developed neurologic symptoms.
Of the following, this child is MOST likely to be deficient inOf the following, this child is MOST likely to be deficient in
A.A.BiotinBiotin
B.B.CobalaminCobalamin
C.C.CarnitineCarnitine
D.D.TegrahydrobiopterinTegrahydrobiopterin
E.E.ThiamineThiamine
Answer: DAnswer: D

 PKU diagnosed by hyperphenylalaninemia inPKU diagnosed by hyperphenylalaninemia in
blood sample taken at 48 hours of ageblood sample taken at 48 hours of age
 Two types:Two types:
– Classical PKU has deficiency inClassical PKU has deficiency in phenylalaninephenylalanine
hydroxylasehydroxylase
– Deficiency of enzyme cofactor tetrahydrobiopterinDeficiency of enzyme cofactor tetrahydrobiopterin
(1-3% patients with hyperphenylalaninemia)(1-3% patients with hyperphenylalaninemia)
 Involved in hydroxylation reactions for tryptophan andInvolved in hydroxylation reactions for tryptophan and
tyrosinetyrosine  OH-tryptophan and L-DOPAOH-tryptophan and L-DOPA
(Neurotransmitters)(Neurotransmitters)
 Thus, phenylalanine restriction by itself in presence ofThus, phenylalanine restriction by itself in presence of
cofactor deficiency WILL NOT prevent neurologicalcofactor deficiency WILL NOT prevent neurological
damagedamage

 How do you diagnose tetrahydrobiopterinHow do you diagnose tetrahydrobiopterin
deficiency?deficiency?
– Caused by recycling or synthesis defectsCaused by recycling or synthesis defects
– Measure pterin metabolites found in urineMeasure pterin metabolites found in urine
– Can also diagnose by a reduction inCan also diagnose by a reduction in
phenylalanine after IV or oral load ofphenylalanine after IV or oral load of
tetrahydrobiopterintetrahydrobiopterin

 How do you treat tetrahydrobiopterinHow do you treat tetrahydrobiopterin
deficiency?deficiency?
– Administer tetrahydrobiopterinAdminister tetrahydrobiopterin
– Replace dopamine and serotonin asReplace dopamine and serotonin as
tetrahydrobiopterin poorly penetrates braintetrahydrobiopterin poorly penetrates brain
where neurotransmitters are formedwhere neurotransmitters are formed
 Also remember there are a smallAlso remember there are a small
percentage of infants born with transientpercentage of infants born with transient
hyperphenylalaninemia which has nohyperphenylalaninemia which has no
clinical consequenceclinical consequence

 Cobalamin is coenzyme foir methmalonyl CoACobalamin is coenzyme foir methmalonyl CoA
mutase whose deficiency results in…mutase whose deficiency results in…
– Methylmalonic aciduriaMethylmalonic aciduria
 Carnitine used for transport of medium and longCarnitine used for transport of medium and long
chain fatty acids across mitochondriachain fatty acids across mitochondria
– Carnitine deficient patients have muscle weaknessCarnitine deficient patients have muscle weakness
 Thiamine deficiency results in…Thiamine deficiency results in…
– Beri beriBeri beri
 Biotin is cofactor for carboxylases thatBiotin is cofactor for carboxylases that
catabolize branched chain amino acids involvedcatabolize branched chain amino acids involved
in fatty acid synthesisin fatty acid synthesis

A 22-month-old girls is nonverbal. She sat alone at 7 months andA 22-month-old girls is nonverbal. She sat alone at 7 months and
walked by 13 months, but now exhibits a wide-based stance, nowalked by 13 months, but now exhibits a wide-based stance, no
longer ambulates, and will not pick up or manipulate toys. Findingslonger ambulates, and will not pick up or manipulate toys. Findings
include: height and weight at the 50include: height and weight at the 50thth
percentile; headpercentile; head
circumference below the 5circumference below the 5thth
percentile, with no increase over thepercentile, with no increase over the
past 8 months; normal fundi, and no organomegaly.past 8 months; normal fundi, and no organomegaly.
Of the following, the MOST likely diagnosis isOf the following, the MOST likely diagnosis is
A.A.AdrenoleukodystrophyAdrenoleukodystrophy
B.B.Cerebral palsyCerebral palsy
C.C.GMGM22 gangliosidosis (Tay-Sachs disease)gangliosidosis (Tay-Sachs disease)
D.D.HypothroidismHypothroidism
E.E.Rett syndromeRett syndrome
Answer: EAnswer: E

 Developmental DelayDevelopmental Delay
– RegressionRegression
– PlateauPlateau
– ProgressionProgression
 Good somatic growth but no head growthGood somatic growth but no head growth
in 8 months known as…in 8 months known as…
– Acquired microcephalyAcquired microcephaly
 Lost purposeful hand use when picking upLost purposeful hand use when picking up
objects known as…objects known as…
– DyspraxiaDyspraxia

 Rett syndrome (SSSH I don’t have Rett syndrome)Rett syndrome (SSSH I don’t have Rett syndrome)
– Neurodegenerative disorderNeurodegenerative disorder
– Females only (male fetuses die in utero)Females only (male fetuses die in utero)
– 1:10,0001:10,000
– X-linked dominantX-linked dominant
– SeizuresSeizures
– SpasticitySpasticity
– ScoliosisScoliosis
– Hand-wringingHand-wringing
– Become severe spastic quadriplegicsBecome severe spastic quadriplegics

 AdrenoleukodystrophyAdrenoleukodystrophy
– Proxisomal disorder only found in malesProxisomal disorder only found in males
– Defect in acyl CoA synthetase in peroxisomesDefect in acyl CoA synthetase in peroxisomes
– Cerebral form (50%),Cerebral form (50%),
adrenomyeloneuropathy (25%), isolatedadrenomyeloneuropathy (25%), isolated
Addison disease or symptomatic (25%)Addison disease or symptomatic (25%)
– Progressive demyelination of brainProgressive demyelination of brain 
 Dementia, Blindness, Deafness, Decorticate stateDementia, Blindness, Deafness, Decorticate state
– Adrenal insufficiencyAdrenal insufficiency

 Tay-SachsTay-Sachs
– Rapidly progressive neurodegenerative disorder due toRapidly progressive neurodegenerative disorder due to
lysosomal storage disorder (GM2, gangliosidosis)lysosomal storage disorder (GM2, gangliosidosis)
caused by deficiency in …caused by deficiency in …
 Beta-hexosaminidase A enzymeBeta-hexosaminidase A enzyme
– Onset before 9 monthsOnset before 9 months
– Hypotonic, never walk, increased startle responseHypotonic, never walk, increased startle response
– Fundoscopic exam reveals…Fundoscopic exam reveals…
 Cherry red spotCherry red spot
– What populations has this been found more frequentlyWhat populations has this been found more frequently
in?in?
 Ashkenazi JewsAshkenazi Jews
 French CanadiansFrench Canadians

 Congenital hypothyroidismCongenital hypothyroidism
– High likelihood for normal development ifHigh likelihood for normal development if
treatment started before 3 months of agetreatment started before 3 months of age
– Can make up some developmental milestonesCan make up some developmental milestones
if treatment begun before 6 months of ageif treatment begun before 6 months of age
– Can see polyneurpathies and muscleCan see polyneurpathies and muscle
weaknessweakness

 Cerebral Palsy: What are 4 types?Cerebral Palsy: What are 4 types?
– SpasticSpastic
– DyskineticDyskinetic
– AtaxicAtaxic
– HypotonicHypotonic
 Must have impaired motor control to makeMust have impaired motor control to make
this diagnosisthis diagnosis

A 10-year-old boy who has hereditary spherocytosis has developedA 10-year-old boy who has hereditary spherocytosis has developed
increasing fatigue and pallor over the past 5 days, and hisincreasing fatigue and pallor over the past 5 days, and his
hemoglobin concentration, which usually ranges between 10 andhemoglobin concentration, which usually ranges between 10 and
11g/dL, now is 5.9g/dL.11g/dL, now is 5.9g/dL.
Of the following, the MOST likely etiology of this decrease inOf the following, the MOST likely etiology of this decrease in
hemoglobin ishemoglobin is
A.A.Aplastic crisisAplastic crisis
B.B.Folic acid deficiencyFolic acid deficiency
C.C.Hyperhemolytic crisisHyperhemolytic crisis
D.D.Iron-deficiency anemiaIron-deficiency anemia
E.E.Splenic sequestrationSplenic sequestration
Answer: AAnswer: A

 Aplastic crisis is the most common cause of severeAplastic crisis is the most common cause of severe
anemia in children with hereditary spherocytosisanemia in children with hereditary spherocytosis
(HS)(HS)
 What is the most common cause of such a crisis?What is the most common cause of such a crisis?
– Parvovirus B19Parvovirus B19 erythema infectiosum (fever, chills,erythema infectiosum (fever, chills,
lethargy, nausea, vomiting, abdominal pain, respiratorylethargy, nausea, vomiting, abdominal pain, respiratory
symptoms, myalgias, arthralgias, “slapped cheek” rash)symptoms, myalgias, arthralgias, “slapped cheek” rash)
– Parvovirus selectively attacks erythroid precursor cellsParvovirus selectively attacks erythroid precursor cells
inhibiting their growthinhibiting their growth  decreased reticulocytes anddecreased reticulocytes and
bilirubin as number of RBCs destroyed decreases dailybilirubin as number of RBCs destroyed decreases daily

 How long does the crisis typically last?How long does the crisis typically last?
– 10-14 days10-14 days
 Are WBCs and platelets affected as well?Are WBCs and platelets affected as well?
– Yes they can but it is usually much milderYes they can but it is usually much milder
 When do you know someone is recovering fromWhen do you know someone is recovering from
a lab standpoint?a lab standpoint?
– Presence of a reticulocytosisPresence of a reticulocytosis
 * Parvovirus infection in first half of pregnancy in* Parvovirus infection in first half of pregnancy in
patient with HS may cause fetal loss due topatient with HS may cause fetal loss due to
severe anemiasevere anemia

 What percentage of kids with HS haveWhat percentage of kids with HS have
mild or no anemia?mild or no anemia?
– 90%90%
 How long is the life span of a RBC in aHow long is the life span of a RBC in a
patient with HS?patient with HS?
– 30 days30 days
 With this short of a lifespan hw does theWith this short of a lifespan hw does the
body keep up?body keep up?
– Enhanced erythropoiesisEnhanced erythropoiesis

 Folic acid and iron deficiency may exacerbateFolic acid and iron deficiency may exacerbate
the anemia but this is a gradual decline inthe anemia but this is a gradual decline in
hemoglobinhemoglobin
 Hyperhemolytic crisis without aplasia occurs inHyperhemolytic crisis without aplasia occurs in
HS in children less than 6 years who have viralHS in children less than 6 years who have viral
syndromessyndromes
– Mild and transient increases in bilirubin,Mild and transient increases in bilirubin,
splenomegaly, anemia, reticulocytosissplenomegaly, anemia, reticulocytosis
 Splenic sequestration is typical of sickle cellSplenic sequestration is typical of sickle cell
disease and is a minor component of hemolyticdisease and is a minor component of hemolytic
crisis associated with spherocytosiscrisis associated with spherocytosis

An 18-day-old term infant develops fever, lethargy, and focalAn 18-day-old term infant develops fever, lethargy, and focal
seizures. Findings include: an ill-appearing infant withoutseizures. Findings include: an ill-appearing infant without
exanthem, hepatomegaly, or jaundice. Analysis of cerebrospinalexanthem, hepatomegaly, or jaundice. Analysis of cerebrospinal
fluid reveals white blood cells, 115/mmfluid reveals white blood cells, 115/mm33
; 45% neutrophils; 55%; 45% neutrophils; 55%
lymphocytes; red blood cells, 40/mmlymphocytes; red blood cells, 40/mm33
; glucose, 45 mg/dL; protien; glucose, 45 mg/dL; protien
200 mg/dL; and negative Gram stain.200 mg/dL; and negative Gram stain.
In addition to ampicillin and cefotaxime, the MOST appropriateIn addition to ampicillin and cefotaxime, the MOST appropriate
treatment to begin at this time istreatment to begin at this time is
A.A.AcyclovirAcyclovir
B.B.Amphotericin BAmphotericin B
C.C.DexamethasoneDexamethasone
D.D.MetronidazoleMetronidazole
E.E.vancomycinvancomycin
Answer: AAnswer: Awww.indiandentalacademy.comwww.indiandentalacademy.com

 HSV is transmitted during delivery via contact withHSV is transmitted during delivery via contact with
maternal secretionsmaternal secretions
 Only 5% of adults in US have a history of genital herpesOnly 5% of adults in US have a history of genital herpes
 20-25% are actively infected with HSV-220-25% are actively infected with HSV-2
 What is the risk of an HSV infection in an infant bornWhat is the risk of an HSV infection in an infant born
vaginally to a mother who has a 1vaginally to a mother who has a 1stst
or primary genitalor primary genital
infection?infection?
– 33-50%33-50%
 What is the risk in a mom with recurrent HSV?What is the risk in a mom with recurrent HSV?
– 3-5%3-5%
 MOST HSV-INFECTED INFANTS ARE BORN TOMOST HSV-INFECTED INFANTS ARE BORN TO
WOMEN WITH NO HISTORY OF GENITAL HERPESWOMEN WITH NO HISTORY OF GENITAL HERPES
AND NO SIGNS OF INFECTION DURINGAND NO SIGNS OF INFECTION DURING
PREGNANCY OR AT DELIVERYPREGNANCY OR AT DELIVERY

 HSV in newbornHSV in newborn
– Generalized systemic infection involving liverGeneralized systemic infection involving liver
and CNS in 25% casesand CNS in 25% cases
– Localized CNS disease 35%Localized CNS disease 35%
– Localized to skin, eyes, mouth 40%Localized to skin, eyes, mouth 40%
– UP TO 33% OF INFANTS WITHUP TO 33% OF INFANTS WITH
DISSEMINATED OR LOCALIZED CNSDISSEMINATED OR LOCALIZED CNS
DISEASE WILL HAVEDISEASE WILL HAVE NONO SKIN, EYES ORSKIN, EYES OR
MOUTH INVOLVEMENTMOUTH INVOLVEMENT

 Disseminated HSV diseaseDisseminated HSV disease
– 11stst
week of lifeweek of life
– Liver and adrenals primarily involvedLiver and adrenals primarily involved
– Irritability, seizures, respiratory distress,Irritability, seizures, respiratory distress,
jaundice, vesicular rash, shockjaundice, vesicular rash, shock
– What is the mortality rate even with treatment?What is the mortality rate even with treatment?
 50-60%50-60%
– What are the two most common causes ofWhat are the two most common causes of
death in disseminated HSV?death in disseminated HSV?
 HSV pneumonitisHSV pneumonitis
 Disseminated intravascular coagulopathyDisseminated intravascular coagulopathy

A 10-year-old girl has complained of intermittent left lowerA 10-year-old girl has complained of intermittent left lower
abdominal pain for 2 days. Previous evaluations, including aabdominal pain for 2 days. Previous evaluations, including a
thorough physical examination, urinalysis, and complete bloodthorough physical examination, urinalysis, and complete blood
count, have not revealed the cause. Tonight she is complaining ofcount, have not revealed the cause. Tonight she is complaining of
pain in the lower left abdomen that radiates into her left leg. Therepain in the lower left abdomen that radiates into her left leg. There
is no history of fever, vomiting, or diarrhea.is no history of fever, vomiting, or diarrhea.
The MOST likely cause of this girl’s pain isThe MOST likely cause of this girl’s pain is
A.A.AppendicitisAppendicitis
B.B.IntussusceptionIntussusception
C.C.Malrotation of the intestineMalrotation of the intestine
D.D.NephrolithiasisNephrolithiasis
E.E.Ovarian torsionOvarian torsion
Answer: EAnswer: E

 Ovarian torsion pain: sharp lower abdominal pain radiatingOvarian torsion pain: sharp lower abdominal pain radiating
to ipsilateral extremity, occasional vomitingto ipsilateral extremity, occasional vomiting
 US can assess ovariesUS can assess ovaries
 Surgical exploration to confirm diagnosis and preventSurgical exploration to confirm diagnosis and prevent
ovarian necrosis (and R/O appendicitis if not already done)ovarian necrosis (and R/O appendicitis if not already done)
 Left sided pain with appendicitis rare but seenLeft sided pain with appendicitis rare but seen
 What is pain on right with palpation of the left called?What is pain on right with palpation of the left called?
– Rovsing’s SignRovsing’s Sign
 What is the obturator sign?What is the obturator sign?
– Pain on internal rotation of the right hip, seen with pelvic appendixPain on internal rotation of the right hip, seen with pelvic appendix
 What is the iliopsoas sign?What is the iliopsoas sign?
– Pain on right hip extension, often seen with retrocecal appendixPain on right hip extension, often seen with retrocecal appendix

 Wrong age for intussusception (around 2 yearsWrong age for intussusception (around 2 years
of age)of age)
 Irritability, colicky abdominal pain, emesisIrritability, colicky abdominal pain, emesis
 Impaired venous returnImpaired venous return  bowel edemabowel edema 
ischemiaischemia  necrosisnecrosis  perforationperforation
 Rectal bleeding seen in what percentage ofRectal bleeding seen in what percentage of
kids?kids?
– 80%; in “currant jelly” form (blood plus mucous)80%; in “currant jelly” form (blood plus mucous)
 Most common location?Most common location?
– IleocolicIleocolic
 Tubular mass palpable in what percentage ofTubular mass palpable in what percentage of
kids?kids?
– 80%80%

 Lead point should be sought out in neonates and childrenLead point should be sought out in neonates and children
older than 5. Name lead points.older than 5. Name lead points.
– Meckel’s diverticulumMeckel’s diverticulum
– Intestinal polypIntestinal polyp
– LymphomaLymphoma
– Foreign bodyForeign body
 KUB: Paucity gas in RLQ or evidence of obstruction with airKUB: Paucity gas in RLQ or evidence of obstruction with air
fluid levelsfluid levels
 Gastrograffin enema shows coiled-spring appearance toGastrograffin enema shows coiled-spring appearance to
bowel which is diagnostic, and may treat as well 75% casesbowel which is diagnostic, and may treat as well 75% cases
 IVFs with NSIVFs with NS
 Laporotomy with direct reduction if enema unsuccessful orLaporotomy with direct reduction if enema unsuccessful or
peritoneal signs present and enema contraindicated due toperitoneal signs present and enema contraindicated due to
concern of perforationconcern of perforation
 Immediate recurrence rate 15%Immediate recurrence rate 15%

A 13-year-old boy has a congested, itchy, and runny noseA 13-year-old boy has a congested, itchy, and runny nose
accompanied by itchy eyes. These symptoms usually occur in theaccompanied by itchy eyes. These symptoms usually occur in the
fall, are unresponsive to over-the-counter decongestants, and hisfall, are unresponsive to over-the-counter decongestants, and his
father has the same problems. Physical examination reveals pale,father has the same problems. Physical examination reveals pale,
boggy nasal turbinates; clear nasal discharge; and dark circlesboggy nasal turbinates; clear nasal discharge; and dark circles
under his eyes.under his eyes.
These findings are MOST consistent withThese findings are MOST consistent with
A.A.Allergic rhinitisAllergic rhinitis
B.B.Infectious rhinitisInfectious rhinitis
C.C.Nonallergic rhinitis with eosinophiliaNonallergic rhinitis with eosinophilia
D.D.Rhinitis medicamentosaRhinitis medicamentosa
E.E.Vasomotor rhinitisVasomotor rhinitis
Answer: AAnswer: A

 Perennial rhinitis (year round)Perennial rhinitis (year round)
– Pets, dust mites, molds, cockroachesPets, dust mites, molds, cockroaches
 Vasomotor rhinitisVasomotor rhinitis
– Diagnosis of exclusion, chronic blockage orDiagnosis of exclusion, chronic blockage or
hypersecretion but negative skin tests and normalhypersecretion but negative skin tests and normal
paranasal sinus imagingparanasal sinus imaging
 Infectious rhinitisInfectious rhinitis
– Mucopurulent discharge, sneezing, limited pruritusMucopurulent discharge, sneezing, limited pruritus
 Rhinitis medicamentosaRhinitis medicamentosa
– Overuse topical decongestantsOveruse topical decongestants
 Nonallergic rhinitis with eosinophiliaNonallergic rhinitis with eosinophilia
– Diagnosis of exclusion, negative skin tests, nasalDiagnosis of exclusion, negative skin tests, nasal
smear positive for eosinophilssmear positive for eosinophils

Pale turbinatesPale turbinates
http://www.entusa.com/Nasal%20Photos/Chronic_Allergic_Rhinitis_15.jpghttp://www.entusa.com/Nasal%20Photos/Chronic_Allergic_Rhinitis_15.jpg

A 5-month-old child is brought to the emergency department by herA 5-month-old child is brought to the emergency department by her
mother because she has been “crying a lot” for the past 24 hours.mother because she has been “crying a lot” for the past 24 hours.
The mother denies any history of fever, trauma, or illness. PhysicalThe mother denies any history of fever, trauma, or illness. Physical
examination reveals a lethargic toddler who is very irritable whenexamination reveals a lethargic toddler who is very irritable when
examined and who has mild tachycardia, scattered bruises over theexamined and who has mild tachycardia, scattered bruises over the
chest, and ecchymosis behind the left ear.chest, and ecchymosis behind the left ear.
The MOST appropriate management is toThe MOST appropriate management is to
A.A.Administer intravenous naloxoneAdminister intravenous naloxone
B.B.Administer a 20 mL/kg bolus of intravenous normal salineAdminister a 20 mL/kg bolus of intravenous normal saline
C.C.Obtain an abdominal radiographObtain an abdominal radiograph
D.D.Obtain a complete blood count and blood culture and administerObtain a complete blood count and blood culture and administer
intravenous ceftriaxoneintravenous ceftriaxone
E.E.Obtain a computed tomographic scan of the head and a skeletalObtain a computed tomographic scan of the head and a skeletal
survey.survey.
Answer: EAnswer: E

 Child abuse red flagsChild abuse red flags
– Inconsistent historyInconsistent history
– History not compatible with injuryHistory not compatible with injury
 Ecchymosis behind left ear is called…Ecchymosis behind left ear is called…
– Battle signBattle sign
 What does this indicate?What does this indicate?
– Basilar skull fractureBasilar skull fracture
 CSF leakage from nose or ear, periorbitalCSF leakage from nose or ear, periorbital
ecchymosis (Raccoon Sign), blood behind theecchymosis (Raccoon Sign), blood behind the
eat drum (hemotympanum) are also signs ofeat drum (hemotympanum) are also signs of
basal skull fracturebasal skull fracture

Battle SignBattle Sign
www.aic.cuhk.edu.hk/web8/Battlewww.aic.cuhk.edu.hk/web8/Battle

Periorbital EcchymosisPeriorbital Ecchymosis
(Raccoon Eyes)(Raccoon Eyes)
www.indianpediatrics.net/sep2005/sep-949.HTMwww.indianpediatrics.net/sep2005/sep-949.HTM
 15 month old with stage IV metastatic15 month old with stage IV metastatic
neuroblastoma and involvement ofneuroblastoma and involvement of
the periorbital tissues and resultantthe periorbital tissues and resultant
proptosis and orbital ecchymosisproptosis and orbital ecchymosis
 Orbital metastases found in up toOrbital metastases found in up to
20% of children with stage IV20% of children with stage IV
neuroblastoma.neuroblastoma.
 Raccoon eyes appearanceRaccoon eyes appearance
associated with neuroblastoma isassociated with neuroblastoma is
probably related to obstruction of theprobably related to obstruction of the
palpebral vessels by tumor tissue inpalpebral vessels by tumor tissue in
and around the orbit.and around the orbit.
 Differential diagnoses for periorbitalDifferential diagnoses for periorbital
edema and ecchymosisedema and ecchymosis
– Child abuse or traumaChild abuse or trauma
– Infection of the soft tissues associatedInfection of the soft tissues associated
with a spreading dental infectionwith a spreading dental infection
– Allergic reactionAllergic reaction
– MyxoedemaMyxoedema
– LymphomaLymphoma
– HaemophiliaHaemophilia

HemotympanumHemotympanum
me.hawkelibrary.com/hemotympanum/26_Mme.hawkelibrary.com/hemotympanum/26_M

An important component of the diagnostic assessment forAn important component of the diagnostic assessment for
any child suspected of having attention deficit hyperactivityany child suspected of having attention deficit hyperactivity
disorder (ADHD) is the use of standardized behavior ratingdisorder (ADHD) is the use of standardized behavior rating
scales. Of the following, the BEST reason to usescales. Of the following, the BEST reason to use
standardized behavior rating scales is that theystandardized behavior rating scales is that they
A.A.Are specific for diagnosing ADHDAre specific for diagnosing ADHD
B.B.Assist in monitoring treatmentAssist in monitoring treatment
C.C.Can be completed after a single classroom observationCan be completed after a single classroom observation
D.D.Determine initial medication dosageDetermine initial medication dosage
E.E.Predict response to medicationPredict response to medication
Answer: BAnswer: B

A 14-year-old boy who has allergic rhinitis reports that heA 14-year-old boy who has allergic rhinitis reports that he
frequently develops coughing and wheezing after aboutfrequently develops coughing and wheezing after about
minutes of playing soccer. These symptoms improve afterminutes of playing soccer. These symptoms improve after
resting for 30 minutes. Of the following, the drug that will giveresting for 30 minutes. Of the following, the drug that will give
the BEST response in this patient if administered just prior tothe BEST response in this patient if administered just prior to
exercise isexercise is
A.A.Inhaled betaInhaled beta22-agonist-agonist
B.B.Inhaled corticosteroidInhaled corticosteroid
C.C.Oral betaOral beta22-agonist-agonist
D.D.Oral corticosteroidOral corticosteroid
E.E.Oral theophyllineOral theophylline
Answer: AAnswer: A

 Exercise Induced AsthmaExercise Induced Asthma
– Bronchoconstriction during exerciseBronchoconstriction during exercise
– Typically within 15 minutesTypically within 15 minutes
– Can occur during cool down as a lat-phaseCan occur during cool down as a lat-phase
response up to 4-12 hours laterresponse up to 4-12 hours later
– Cough, wheeze, SOB, dizzy, stomach painCough, wheeze, SOB, dizzy, stomach pain
– Occurs 80% patients with asthmaOccurs 80% patients with asthma
– Occurs 50% patients with allergic rhinitisOccurs 50% patients with allergic rhinitis

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