NBME CMS Peds 21-30

Volume Overload

• Immune complex glomerulonephritis (e.g., PSGN) leads to sodium and water retention.
• Signs include facial/leg edema, decreased urine output, hypertension, hematuria, proteinuria, and RBC casts.
• Periorbital edema and cola-colored urine post-strep infection indicate hypertension due to salt and fluid retention.

Catecholamine Excess

• Pheochromocytoma causes adrenergic symptoms such as episodic headache, palpitations, sweating, and hypertensive crises.
• There is no proteinuria or edema.

Idiopathic Hypertension

• Primary hypertension is a diagnosis of exclusion.
• There are no nephritic signs or preceding illness.

Mineralocorticoid Excess

• Conn syndrome (aldosterone excess) presents with hypertension, hypokalemia, and metabolic alkalosis.
• It is not nephritic and would not present with RBC casts or proteinuria.

Stimulation of Parasympathetic System

• Parasympathetic overactivity is not a cause of hypertension.
• Hypertension is due to the sympathetic or renin-angiotensin-aldosterone system (RAAS).
• Parasympathetic stimulation typically leads to decreased heart rate and blood pressure.

Volunteering at a Skilled Nursing Care Facility

• This is a high TB risk due to prolonged close contact with elderly/crowded populations.
• Skilled nursing facilities are congregate settings with increased TB transmission risk.
• A 17 mm PPD result is significant (>15 mm PPD), even without symptoms.

Overseas Travel (to Ireland)

• Brief travel to non-endemic areas does not significantly increase TB risk.
• TB risk is elevated in sub-Saharan Africa, India, and Southeast Asia, but not Ireland.

Participation in High School Events

• Normal adolescent activities are not crowded enough to substantially increase TB risk.
• This is in contrast to prisons or shelters, which are high-risk settings.

Raising Livestock

• This poses a risk for zoonotic infections like Q fever or anthrax, not tuberculosis.
• Mycobacterium tuberculosis is transmitted from human to human.

Sexual Activity

• Sexual activity is not relevant to respiratory spread and is not a TB risk factor.

Smoking Marijuana

• Occasional marijuana use does not significantly increase TB risk unless chronic pulmonary disease is present.

Constitutional Growth Delay

• This is a normal variant involving being a "late bloomer."
• Features include a short but healthy teen, parents of normal height, and Tanner stage 2 at age 15.
• Bone age is less than chronological age, puberty is late, and normal final height is achieved.

Adrenal Insufficiency

• Signs include fatigue, hypotension, decreased appetite, hyperpigmentation, and salt-wasting.
• Low cortisol ± aldosterone leads to weight loss, nausea, and early pubic hair.

Familial Short Stature

• This includes short parents, normal bone age, and normal puberty.
• Consistent short stature with bone age equaling chronological age is typical.
• Tall parents would rule this out.

Growth Hormone Deficiency

• There is severe growth failure, delayed bone age, and crossing down percentiles.
• Short stature is accompanied by decelerating growth velocity.

Insufficient Caloric Intake

• Decreased weight leads to decreased height, often associated with eating disorders.
• Signs include weight loss, low BMI, and signs of malnutrition like dry skin, lanugo, and fatigue.

Monthly Infusion of Immune Globulin

• BTK gene defect leads to no mature B cells and decreased levels of all Ig types.
• This is indicated for a male infant with recurrent sinopulmonary infections, low IgG/IgA/IgM, and normal lymphocytes.
• Treatment involves lifelong IVIG to replace missing antibodies.

Amoxicillin Prophylaxis

• This can prevent infections but does not treat the underlying immune defect.
• It is used in cardiac or splenic patients, not primary immunodeficiencies.

Granulocyte Colony-Stimulating Factor Therapy

• Used for neutropenia (e.g., chemo patients).
• It stimulates granulocyte production, not B cells or Igs.
• Normal neutrophil count indicates it is not needed.

Oral Prednisone Therapy

• Causes immunosuppression and is used for autoimmune/inflammatory conditions.
• It would worsen infection risk.

Splenectomy

• Splenectomy increases infection risk and is used in hereditary spherocytosis or trauma.
• It is contraindicated unless clearly indicated.

Retinoblastoma

• RB1 mutation leads to retinal tumor, causing a white reflex and may present with exotropia.
• Infant with new-onset eye wandering (strabismus), leukocoria, and appearing well.
• This is the most common ocular tumor in kids with treatment including chemo/enucleation.

Acquired Exotropia

• Outward eye deviation secondary to vision loss, not a primary diagnosis.
• It does not cause leukocoria.

Chronic Endophthalmitis

• Painful red eye after surgery or hematogenous infection.
• Ill-appearing infant with conjunctival injection, but not leukocoria.

Congenital Glaucoma

• Presents at birth or early infancy and does not cause leukocoria.
• Includes epiphora (tearing), photophobia, blepharospasm, and large cloudy cornea.

Familial Cataract

• Leukocoria at birth, not after normal prior development.
• There is bilateral or unilateral lens opacity, often from birth, but not progressive strabismus.

Transient Tachypnea of the Newborn

• Delayed clearance of fetal lung fluid leads to hypoxia and tachypnea.
• Common in C-section babies.
• CXR shows fluid in fissures and hyperinflated lungs, resolving in 24–48 hours.
• Tachypnea and oxygen saturation of 88%.

Aspiration Pneumonia

• Inflammatory response with patchy infiltrates and coarse breath sounds.
• Associated with meconium, poor tone, and abnormal delivery.

Bacterial Pneumonia

• Infection-related distress that may occur with prolonged rupture of membranes is indicated.
• Fever, leukocytosis, and new infiltrates are present.

Bronchopulmonary Dysplasia

• Chronic lung disease from alveolar damage.
• Occurs in preterm infants with prolonged oxygen or ventilation.

Idiopathic Pulmonary Fibrosis

• Rare in infants.
• Characterized by a restrictive lung pattern and honeycombing.

Pulmonary Hemorrhage

• Often seen in preterms with surfactant therapy.
• Sudden decompensation and bloody secretions are indicative.

Respiratory Distress Syndrome of the Newborn

• Surfactant deficiency leads to atelectasis and grunting.
• Premature infant with ground-glass CXR.
• This baby is late preterm (38 weeks) with hyperinflation, not collapse.

Lyme Disease

• Early localized Borrelia burgdorferi leads to erythema migrans and flu-like symptoms.
• Expanding erythematous rash with central clearing (“bull's eye”), mild fever, endemic area.
• Treat with doxycycline (amoxicillin in young children).

Atopic Dermatitis

• Chronic, not acutely expanding; pruritic, not tender.
• Dry, itchy, scaly rash in flexural areas with a history of allergies/asthma.

Cellulitis

• Warm, red, painful, rapidly spreading skin infection.
• There is no central clearing and is typically not ring-shaped.

Folliculitis

• Follicle-centered pustules on hair-bearing areas.
• Folliculitis is not a large expanding plaque.

Herpes Simplex / Herpes Zoster

• Painful grouped vesicles on an erythematous base
• Not ring-shaped or slowly expanding.

Impetigo

• Honey-colored crusts usually on the face.
• Not associated with systemic symptoms or central clearing.

Juvenile Melanoma

• Rare in kids and is not an expanding rash.
• Asymmetry, irregular borders, diameter >6 mm.

Kawasaki Disease

• No systemic inflammation or mucosal involvement.
• Fever ≥5 days + mucocutaneous signs (conjunctivitis, rash, extremity changes).

Neurofibromatosis

• Genetic, not an infectious rash.
• Café-au-lait macules, axillary freckling, neurofibromas are present.

Nevus Flammeus (Port-Wine Stain)

• Present from birth and is non-expanding.
• Congenital flat vascular patch.

Poison Ivy Dermatitis

• Not a target lesion.
• Linear vesicles from urushiol exposure.

Endoscopic Examination of the Airway

• Foreign body aspiration leads to partial obstruction → air trapping.
• Sudden-onset wheezing, unilateral hyperinflation, poor response to bronchodilators.
• Rigid bronchoscopy is diagnostic and therapeutic.

Chest Percussion and Physiotherapy

• Helps mobilize secretions, not obstruction.
• Used in chronic mucus clearance (e.g., CF, bronchiectasis).
• Not effective for solid foreign bodies.

Oral Amoxicillin

• Bacterial infection (otitis, pneumonia) with fever, productive cough.
• Subacute onset, consolidation on CXR.

Oral Corticosteroids

• Ineffective if bronchodilators don’t help, which suggests it’s not asthma.
• Moderate to severe asthma or croup.
• Decreases airway inflammation and is used with albuterol.

Subcutaneous (or IM) Epinephrine

• Used for diffuse airway obstruction, not unilateral.
• Anaphylaxis: sudden wheeze + hypotension + rash + stridor.
• Bronchodilation + vasoconstriction.

Recommend a Diet Diary with Calorie Counts

• Inadequate caloric intake is the most common cause.
• A first-line step is to assess intake before labs or imaging.
• To be done if drop in weight percentile only, otherwise well-appearing.

Reevaluate Weight in 1 Week

• Delays intervention and monitoring only works after an intervention is started.
• Rechecking without change is not enough.

Test Stool for Reducing Substances/Fecal Fat

• Not first-line in asymptomatic child.
• For chronic diarrhea, steatorrhea, or failure after dietary intervention.
• Used to assess malabsorption.

Admit to Hospital

• Only for severe failure to thrive (FTT) or an unsafe environment.
• Reserved for serious concerns such as neglect, organic disease, or dehydration.
• Not necessary in a stable, thriving child.

Abdominal X-Ray

• Not part of the initial FTT workup and is not needed if there are no GI symptoms.
• Used for obstruction, distention, or constipation.

Adenoidectomy and Tonsillectomy

• OSA leads to airway obstruction and cor pulmonale.
• Indicated by snoring, mouth breathing, adenoidal/tonsillar hypertrophy, and RVH.
• First-line treatment for OSA in children.

Digoxin and Diuretics

• Symptom control only and does not fix the cause of OSA.
• Used for heart failure, improves contractility, and reduces preload.

Pulmonary Vasodilator Therapy

• Not helpful when pulmonary hypertension is secondary to OSA.
• Used in primary pulmonary hypertension, it directly lowers pulmonary vascular resistance (PVR).

Pulmonary Artery Banding

• Irrelevant here; there is no congenital defect.
• Used in congenital heart disease (e.g., transposition) to train the LV to pump against systemic pressure.

Repair of Tricuspid Regurgitation

• Fix the underlying OSA first, as it is not a valve problem.
• Mild TR is secondary to RV dilation from PH.
• The valve issue is secondary, not primary.