NBME Pediatrics Form 3 - Answers & Explanations

Updated: Feb 25, 2020

1) Clostridium difficile

• Always consider Pseudomembranous colitis in a child with fever + bloody diarrhea who took antibiotics within the last 21 days

C.diff can also present with prolonged watery diarrhea

• Although clinical manifestations of Shigella can include fever and bloody diarrhea, this is mainly due to Shigella dysenteriae 1 or Shigella flexneri. Shigella sonnei presents as more of a watery diarrhea. There is also no mention of daycare, travel or immigration from a developing country, making C.diff colitis more likely

2) Cefotaxime • 3rd generation cephalosporins are 1st line for UTI in children

3) Extracardiac left-to-right shunt • PDA = extracardiac left to right blood shunting

4) Pertussis

• Paroxysmal phase: cough with inspiratory “whoop”, posttussive emesis

Dx: Pertussis culture or PCR

Tx: Macrolides

5) Posterior urethral valves

• Most common cause of urinary tract obstruction in newborn boys

6) Thrombocytopenia from platelet sequestration • Hemangioma, thrombocytopenia, and consumptive coagulopathy = Kasabach-Merritt syndrome (infrequent but fatal complication of rapidly growing vascular lesion in infants)

7) Cl 84, K 2.8, pH 7.50 • Hypokalemic hypochloremic metabolic alkalosis due to vomiting

8) Intravenous administration of dopamine

• “Cold septic shock” = septic shock that turned into cardiogenic shock (myocardial dysfunction from inflammatory cytokines)

• Dopamine → ↑ CO (inotropic), ↑ renal blood flow

• Patient is already receiving fluids and is still hypotonic (more IV fluids wouldn’t help)

9) Testing for Chlamydia trachomatis and Neisseria gonorrhoeae

• All patients below 25 years old that are sexually active should be screen for both chlamydia and gonorrhea

10) Intussusception • Sudden, intermittent abdominal pain • Most common cause of intestinal obstruction in children age 3-36 months

11) Physiologic jaundice • Presents on day 2-4 of life • Mothers blood group is B (rules out ABO hemolytic disease) • Mother is Rh ⊕ (rules out Rh hemolytic disease)

12) Trichophyton tonsurans • Tinea capitis (most common in African American children)

• Tx: oral griseofulvin or terbinafine

13) Impaired T-lymphocyte function • Recurring viral/fungal infections are due to T-cell dysfunction/absence

14) Trisomy 18 • Edward syndrome (trisomy 18) = prominent occiput, micrognathia, clenched fists with overlapping fingers, rocker bottom feet

15) Ventricular septal defect • VSD causes shunting of blood from left to right → ↑ blood in pulmonary circulation → ↑ blood in left atrium (LA) → enlargement of LA

16) Iron

• Hypochromic microcytic anemia

• Cow’s milk has low iron content and bioavailability - children shouldn’t be given cow’s milk until 12 months of age

17) Bronchiectasis

• Right middle lobe syndrome (chronic right middle lobe collapse, usually associated with bronchiectasis)

• Medication didn’t relieve symptoms ≠ asthma

18) Insertion of a nasogastric tube

• Polyhydramnios with excess oral secretions and coughing (most prominent after the first feed) = esophageal atresia (with distal TEF)

• Nasogastric tube will fail to pass into the stomach

19) Intravenous administration of 20 mL/kg of 0.9% saline

High-flow 0.9% normal salines initially recommended; add dextrose 5% when serum glucose is ≤ 200

• Add IV potassium if serum potassium ≤ 5.2

20) Ultrasonography of the abdomen

• WAGR syndrome: Wilms tumor, Aniridia (absence of iris), Genitourinary malformation, mental Retardation/intellectual disability

• Wilms tumor doesn’t cross midline (vs Neuroblastoma which crosses midline)

21) LarynxStridor = upper airway obstruction

22) Thyroid-stimulating

• Hypothyroidism → ↑ TSH release (in an attempt to stimulate the thyroid gland)

• DM1 is associated with Hypothyroidism (HLA DR3)

23) Malignant pleural effusion

• Bloody effusion = malignancy, TB or traumatic effusion

• Superior mediastinal mass (possible malignancy) → SVC syndrome (JVD, upper extremity and facial edema)

• If tumor presses on trachea → wheezing and ↑ work of breathing

24) Neuroblastoma

• Crosses midline with CT calcification

• Metastasis to skin → wrist swelling

25) Ultrasonography of the abdomen • Pyloric stenosis • Dx: thickened pylorus on abdominal U/S

26) A • Benign intracranial HTN (pseudotumor cerebri) • Risk factors: female gender, tetracycline, obesity, vitamin A excess

27) Growing pains • Pain that is worse at night and resolves by the morning • Affects bilateral lower extremities • No systemic symptoms with normal physical exam and activity

28) Septic arthritis • Acute onset fever and joint pain, fatigue, refusal to bear weight due to pain

• Erythema, warmth and swelling of the joint • Pain with active and passive ROM • If it were transient synovitis, the patient would be able to bear weight

29) Fundoplication

• Procedure used to treat severe GERD

• Fundus wrapped around backside of esophagus to anchor lower esophagus below diaphragm

30) Measurement of serum C1 esterase inhibitor concentration • Hereditary angioedema - may cause GI tract edema in addition to typical subcutaneous edema → abdominal pain and diarrhea

31) Failure of normal bowel rotation

• Congenital malformation of the midgut with volvulus → abnormal position of small intestine with formation of fibrous bands → obstruction and constriction of blood flow

• Presents in neonate with bilious vomiting and abdominal distention

• Dx: upper GI series showing “corkscrew” pattern; ligament of Treitz on the right side

of abdomen

• Untreated volvulus can progress to bowel ischemia and perforation (surgical emergency)

32) Oral ibuprofen • Dx: Transient synovitis (most common cause of hip pain in children)

• Tx: Rest and NSAIDs (Ibuprofen), follow up in 1 week

33) Reassurance • Absence of 2° pubertal development is normal in girls ≤ 14, and boys ≤ 15

34) Antigen-antibody immune complex • Post-streptococcal glomerulonephritis (type III HSR = antibody immune complex deposition)

35) Sodium nitroprusside • Newer guidelines suggest IV labetalol or nicardipine rather that either hydralazine

(long onset of action, overshoot hypotension) or sodium nitroprusside (cyanide toxicity)

36) Drain cleaner