MCQs in Pediatrics Part IV PDF

MCQ s in Pediatrics PART IV ZUHAIR M. ALMUSAWI MCQs in Pediatrics Part IV ZUHAIR M. ALMUSAWI CABP, IBCLC, FRCP Edin PROFESSOR OF PEDIATRICS COLLEGE OF MEDICINE – UNIVERSITY OF KERBALA CONSULTANT PEDIATRICIAN KARBALA TEACHING HOSPITAL FOR CHIL...

MCQ s in Pediatrics PART IV ZUHAIR M. ALMUSAWI MCQs in Pediatrics Part IV ZUHAIR M. ALMUSAWI CABP, IBCLC, FRCP Edin PROFESSOR OF PEDIATRICS COLLEGE OF MEDICINE – UNIVERSITY OF KERBALA CONSULTANT PEDIATRICIAN KARBALA TEACHING HOSPITAL FOR CHILDREN KARBALA – IRAQ I  CONTRIBUTORS AHMED TAWFIQ; CABP, MRCPCH Consultant Pediatrician Karbala Teaching Hospital for Children/Karbala USAMA AL-JUMAILY; FICMS, ABMS, JBMS Assistant Professor of Pediatrics College of Medicine/University of Kerbala Consultant Pediatric Hemato-Oncologist Imam Hussein Teaching Hospital/Karbala KHALID KHALIL ALAARAJI; CABP, FICMS, DCH Assistant Professor of Pediatrics College of Medicine/University of Kerbala Consultant Pediatrician Karbala Teaching Hospital for Children/Karbala QAHTAN ALOBAIDAY; CABP, FICMS, FICMS (nephro) Consultant Pediatric Nephrologist Karbala Teaching Hospital for Children/Karbala HASANEIN H. GHALI; FICMS, FICMS (hem/onc) Assistant Professor of Pediatrics College of Medicine/University of Baghdad Consultant Pediatric Hemato-Oncologist Children Welfare Teaching Hospital Medical City/Baghdad HAYDER ALMUSAWI; CABP, DCH Pediatrician ALKhidhir General Hospital/ ALMuthanna II AQEEL MAHDI; CABP, FICMS Consultant Pediatrician Karbala Teaching Hospital for Children /Karbala HAIDAR A N ABOOD; MSc, PhD Assistant Professor of Clinical Pharmacology College of Medicine/University of Kerbala Karbala Teaching Hospital for Children/Karbala MARYAM ZUHAIR ALMUSAWI; FICMS Pediatrician Obstetric and Gynecology Teaching Hospital/Karbala MUSTAFA SHIHAB AL-ANBAKI; CABP, DCH Pediatrician Children Welfare Teaching Hospital Medical City/Baghdad III  DEDICATION In the time of COVID-19 pandemic, when the silence and distancing in the globe were accepted as norms; when the great armies became worthless; and when the governments became perturbed; some people accepted the challenge and sacrifice. Those who wear the white coats; started a momentous pivotal battle, and showed great heroism towards this ever-worst crisis in life-time with no much choices. This book was written during the time of social and physical distancing amidst COVID-19 time, where uncertainties lie ahead, waiting for the life to come back to normalcy. To all our colleagues over the world; all medical staff; all those who are working to find a solution, to the souls of our colleagues who sacrificed, to all people who lost their lives; to all families and kids who lost their beloved ones, we dedicate this humble work. A special greeting to the participating authors Dr. Khalid and Dr. Akeel who survived the hard times of COVID19 infection. I.S.B.N. 978-9922-637-61-7 Number of Deposition of This Book at Iraqi House of Books and Documents (Iraqi National Library) 2418/2020 IV  PREFACE William Osler (1849-1919) ‘’To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all’’ This book contains a wealth of data and a myriad of information. It is divided into chapters; each one has two sections; questions and answers. The questions are made with different levels (easy to difficult). All are prepared to test the depth of knowledge and accuracy of practice. The information on most of the questions is made according to the standards of Nelson's textbook of Pediatrics 21st edition. The concept of questions is that; there is one or more keys included in the given question, according to the difficulty of each one. The reader needs to recognize it and choose the answer accordingly. Sometimes more that one correct answer is possible which could be deceptive; the candidate needs to choose the most appropriate one that fits the given scenario. The section of answers usually highlights the important key and the related explained information. It is highly recommended to keep a notebook and a marker pen to dictate and highlight the keys of difficult questions to save time to review them all again. Discussion with colleagues and peer groups is the benchmark for success in reading this work. By the end of reading this book, the author is sure that every student will be assiduous in pointing out every important point in this book. V  CONTENTS Chapter 1 The Field of Pediatrics QUESTIONS……………………………………………………………………………… 1 ANSWERS ……………………………………………………………………………… 6 Chapter 2 Growth, Development, and Behavior QUESTIONS ……………………………………………………………………………… 9 ANSWERS ……………………………………………………………………………… 17 Chapter 3 Behavioral and Psychiatric Disorders QUESTIONS ……………………………………………………………………………… 22 ANSWERS ……………………………………………………………………………… 27 Chapter 4 Learning and Developmental Disorders QUESTIONS ……………………………………………………………………………… 31 ANSWERS ……………………………………………………………………………… 35 Chapter 5 Nutrition QUESTIONS ……………………………………………………………………………… 38 ANSWERS ……………………………………………………………………………… 52 Chapter 6 Fluid and Electrolyte Disorders QUESTIONS ……………………………………………………………………………… 59 ANSWERS ……………………………………………………………………………… 69 Chapter 7 Pediatric Drug Therapy QUESTIONS ……………………………………………………………………………… 76 ANSWERS ……………………………………………………………………………… 103 Chapter 8 Emergency Medicine and Critical Care QUESTIONS ……………………………………………………………………………… 122 ANSWERS ……………………………………………………………………………… 132 Chapter 9 Human Genetics QUESTIONS ……………………………………………………………………………… 139 ANSWERS ……………………………………………………………………………… 147 Chapter 10 Metabolic Disorders QUESTIONS ……………………………………………………………………………… 152 ANSWERS ……………………………………………………………………………… 174 VI Chapter 11 The Fetus and the Neonatal Infant QUESTIONS ……………………………………………………………………………… 183 ANSWERS ……………………………………………………………………………… 210 Chapter 12 Adolescent Medicine QUESTIONS ……………………………………………………………………………… 225 ANSWERS ……………………………………………………………………………… 227 Chapter 13 Immunology QUESTIONS ……………………………………………………………………………… 228 ANSWERS ……………………………………………………………………………… 239 Chapter 14 Allergic Disorders QUESTIONS ……………………………………………………………………………… 244 ANSWERS ……………………………………………………………………………… 254 Chapter 15 Rheumatic Diseases of Childhood QUESTIONS ……………………………………………………………………………… 258 ANSWERS ……………………………………………………………………………… 273 Chapter 16 Infectious Diseases QUESTIONS ……………………………………………………………………………… 281 ANSWERS ……………………………………………………………………………… 336 Chapter 17 The Digestive System QUESTIONS ……………………………………………………………………………… 359 ANSWERS ……………………………………………………………………………… 380 Chapter 18 The Respiratory System QUESTIONS ……………………………………………………………………………… 397 ANSWERS ……………………………………………………………………………… 413 Chapter 19 The Cardiovascular System QUESTIONS ……………………………………………………………………………… 425 ANSWERS ……………………………………………………………………………… 448 Chapter 20 Diseases of the Blood QUESTIONS ……………………………………………………………………………… 462 ANSWERS ……………………………………………………………………………… 487 Chapter 21 Cancer and Benign Tumors QUESTIONS ……………………………………………………………………………… 496 VII ANSWERS ……………………………………………………………………………… 523 Chapter 22 Nephrology QUESTIONS ……………………………………………………………………………… 530 ANSWERS ……………………………………………………………………………… 547 Chapter 23 Urologic Disorders in Infants and Children QUESTIONS ……………………………………………………………………………… 556 ANSWERS ……………………………………………………………………………… 566 Chapter 24 Gynecological Problems of Childhood QUESTIONS ……………………………………………………………………………… 571 ANSWERS ……………………………………………………………………………… 576 Chapter 25 The Endocrine System QUESTIONS ……………………………………………………………………………… 579 ANSWERS ……………………………………………………………………………… 594 Chapter 26 The Nervous System QUESTIONS ……………………………………………………………………………… 601 ANSWERS ……………………………………………………………………………… 629 Chapter 27 Neuromuscular Disorders QUESTIONS ……………………………………………………………………………… 645 ANSWERS ……………………………………………………………………………… 656 Chapter 28 Disorders of the Eye QUESTIONS ……………………………………………………………………………… 662 ANSWERS ……………………………………………………………………………… 671 Chapter 29 The Ear QUESTIONS ……………………………………………………………………………… 677 ANSWERS ……………………………………………………………………………… 682 Chapter 30 The Skin QUESTIONS ……………………………………………………………………………… 685 ANSWERS ……………………………………………………………………………… 713 Chapter 31 Bone and Joint Disorders QUESTIONS ……………………………………………………………………………… 731 ANSWERS ……………………………………………………………………………… 748 Chapter 32 Rehabilitation Medicine VIII QUESTIONS ……………………………………………………………………………… 759 ANSWERS ……………………………………………………………………………… 764 Chapter 33 Environmental Health QUESTIONS ……………………………………………………………………………… 767 ANSWERS ……………………………………………………………………………… 779 Chapter 34 Laboratory Medicine QUESTIONS ……………………………………………………………………………… 788 ANSWERS ……………………………………………………………………………… 791 IX Chapter 1 The Field of Pediatrics Questions ZUHAIR ALMUSAWI 1. What is the leading cause of worldwide under-five mortality rate (U5MR)? A. Preterm birth complications B. Pneumonia C. Perinatal asphyxia D. Diarrheal diseases E. Malaria 2. Which of the following is the MOST common cause of under-5 mortality in developing countries? A. Diarrheal disease B. Pneumonia C. Malaria D. AIDS E. Measles 3. Which of the following countries has the lowest rank of child mortality rate in the world? A. U.S.A. B. United Kingdom C. Cuba D. Czech Republic E. Japan 4. In 2002 an estimated 1.5 million under-5 deaths were caused by vaccine preventable diseases. Which of the following is the top contributor? A. Haemophilus influenzae B (Hib) B. Measles C. Rotavirus D. Pertussis 1  E. Tetanus 5. For which of the following conditions curative treatment is possible but may not succeed? A. Cystic fibrosis B. Severe immunodeficiency C. Chronic respiratory failure D. Muscular dystrophy E. Advanced cancer 6. For which of the following conditions, there is intensive long-term treatment, but premature death is still possible? A. Severe cerebral palsy B. Cystic fibrosis C. Tay-Sachs disease D. Batten disease E. Severe forms of osteogenesis imperfect 7. What is the first line drug used in moderate pain management? A. Short-acting opioid B. Acetaminophen C. Ibuprofen D. Salicylates E. Codeine 8. Which of the following can be used as adjuvant drugs for bone pain? A. Amitriptyline B. Carbamazepine C. Steroids D. Codeine E. Ketamine 9. Which of the following can be used in a 10-old child with life-threatening illness and excessive respiratory secretions? A. Intramuscular hyoscyamine sulfate B. Scopolamine patch C. Intramuscular atropine D. Oral dexamethasone 2  E. Intravenous lorazepam 10. What is the MOST effective antidepressant for children with life-threatening illness and depression? A. Clonidine B. Methylphenidate C. Benzodiazepines D. Nortriptyline E. Methadone 11. What is the MOST common cause of global injury deaths to children, adolescents, and young adults? A. Suicide B. Road traffic injuries C. Drowning D. Fire and burn E. Falls 12. Which of the following age groups is most vulnerable to poisonings? A. Infants B. Toddlers C. Preschool children D. School children E. Adolescents 13. Which of the following is an important precursor of serious school violence? A. Mental health problems B. Racial tensions C. Alcohol use D. poverty E. Bullying 14. Which of the following is a common manifestation of bullying? A. School avoidance B. Academic failure C. Social problems D. Lack of friends E. Suicidal ideation 3 15. A 14-year-old boy may need careful screening for bullying if he is A. quiet B. overly confident C. depressed D. disabled E. obese 16. Pediatricians can counsel parents to help their children avoid exposure to any form of media violence under age of A. 4 years B. 6 years C. 8 years D. 10 years E. 12 years 17. Which of the following is a manifestation of stress reactions in children ≤6 years exposed to war or terrorism? A. Terrified affect B. Truancy C. Somatization D. Depressive affect E. Irrational fear 18. Which type of child abuse is difficult to prove inspite of its extreme harm? A. Physical abuse B. Sexual abuse C. Psychological abuse D. Inadequate healthcare E. Inadequate education 19. What is the most common manifestation of child physical abuse? A. Hair pulling B. Bites C. Burns D. Bruises E. Fractures 20. Which of the following features is suggestive of inflicted bruises? 4  A. Bruising in a toddler B. Bruising of shin C. Bruising of nose D. Patterned bruising E. Multiple bruises of same age 21. Which of the following fractures is MOSTLY inflicted? A. Clavicular B. Femoral C. Supracondylar humeral D. Posterior rib fractures E. Distal extremity 22. A single young mother brought her 8-year-old daughter complaining from genital redness and bleeding for the last 3 days. The mother gives history that her daughter has social withdrawal, fearfulness, and learning difficulties with new-onset bed-wetting. Of the following, the MOST likely cause of the genital complaint is A. urethral prolapse B. vaginal foreign body C. accidental trauma D. sexual abuse E. vaginal tumor 5 Chapter 1 The Field of Pediatrics Answers ZUHAIR ALMUSAWI 1.(A) The leading causes of worldwide U5MR are preterm birth complications, pneumonia, perinatal asphyxia, diarrheal diseases, and malaria. Many of these causes are linked to malnutrition. 2.(A) Causes of under-5 mortality differ greatly between developed and developing nations. In developing countries, 66% of deaths in children 8-12 yr old). 10.(B) Because of its immediate and positive effect on mood, methylphenidate may be an effective antidepressant for children at end of life, when there may not be time for a traditional antidepressant to take effect. 11.(B) 12.(B) Toddlers do not have the judgment to know that medications can be poisonous or that some houseplants are not to be eaten. 13.(E) Bullying and weapon carrying may be important precursors to more serious school violence. 14.(A) Signs of a child being involved in bullying or exposed to school violence include physical complaints such as insomnia, stomachaches, headaches, and new-onset enuresis. Psychological symptoms, such as depression, loneliness, anxiety, and suicidal ideation, may occur. Behavioral changes, such as irritability, poor concentration, school avoidance, and substance abuse, are common. School problems, such as academic failure, social problems, and lack of friends, can also occur. 15.(B) Children who are aggressive, overly confident, lacking in empathy, or having persistent conduct problems may need careful screening. 16.(C) These younger children do not have the capacity to distinguish fantasy from reality. 17.(A) Manifestations of Stress Reactions in Children and Adolescents Exposed to War, Terrorism, and Urban Violence Children ≤6 Yr  Excessive fear of separation  Clinging behavior  Uncontrollable crying or screaming  Freezing (persistent immobility)  Sleep disorders  Terrified affect 7   Regressive behavior  Expressions of helplessness and passivity Children 7-11 Yr  Decline in school performance  Truancy  Sleep disorders  Somatization  Depressive affect  Abnormally aggressive or violent behavior  Irrational fears  Regressive and childish behavior  Expressions of fearfulness, withdrawal, and worry 18.(C) Psychological abuse includes verbal abuse and humiliation and acts that scare or terrorize a child. Although this form of abuse may be extremely harmful to children, resulting in depression, anxiety, poor self-esteem, or lack of empathy, child protective services seldom becomes involved because of the difficulty in proving such allegations. 19.(D) 20.(D) Bruises are the most common manifestation of physical abuse. Features suggestive of inflicted bruises include (1) bruising in a preambulatory infant (occurring in just 2% of infants), (2) bruising of padded and less exposed areas (buttocks, cheeks, ears, genitalia), (3) patterned bruising or burns conforming to shape of an object or ligatures around the wrists, and (4) multiple bruises, especially if clearly of different ages. 21.(D) Clavicular, femoral, supracondylar humeral, and distal extremity fractures in children older than 2 yr are most likely noninflicted unless they are multiple or accompanied by other signs of abuse. 22.(D) 8 Chapter 2 Growth, Development, and Behavior Questions ZUHAIR ALMUSAWI 1. What is the fetal age by which external genitals are distinguishable? A. 8 weeks B. 10 weeks C. 12 weeks D. 14 weeks E. 16 weeks 2. What is the approximate average term newborn weight? A. 3 kg B. 3.2 kg C. 3.4 kg D. 3.5 kg E. 3.75 kg 3. At what age, the baby starts to cruise? A. 4 months B. 7 months C. 10 months D. 12 months E. 15 months 4. What is the approximate age of humerus head appearance? A. At birth B. 3 weeks C. 6 weeks D. 12 weeks E. 6 months 5. At what age, Infants can discriminate rhythmic patterns in native vs non- native language? 9  A. 2 months B. 4 months C. 6 months D. 8 months E. 10 months 6. What is the age of achievement of object permanence (constancy)? A. 4 months B. 7 months C. 9 months D. 12 months E. 15 months 7. Which of the following is of benefit for colic management in a 2-month-old crying infant? A. Simethicone B. Anticholinergic medications C. Fennel extract D. Chiropractic manipulation E. Continuous carrying 8. Ali can sit on small chair; walks up stairs with 1 hand held; makes tower of 4 cubes; and can name pictures. What is the expected age of Ali? A. 12 months B. 15 months C. 18 months D. 24 months E. 30 months 9. Salem runs well, opens doors; climbs on furniture; makes tower of 7 cubes, puts 3 words together; handles spoon well; and helps to undress. What is the expected age of Salem? A. 15 months B. 18 months C. 24 months D. 30 months E. 36months 10 10. Mohammed rides tricycle; stands momentarily on 1 foot; makes tower of 10 cubes; copies circle; knows age and sex; helps in dressing; and washes hands. What is the expected age of Mohammed? A. 18months B. 24 months C. 30 months D. 36 months E. 48months 11. Ali can hop on 1 foot; throws ball overhand; uses scissors to cut out pictures; copies cross and square; draws man with 2-4 parts besides head; tells story; plays with several children; and goes to toilet alone. What is the expected age of Ali? A. 30 months B. 36 months C. 42 months D. 48months E. 60 months 12. Salma can skip; draws triangle from copy; names heavier of 2 weights; names 4 colors; counts 10 pennies correctly; dresses and undresses; and asks questions about meaning of words. What is the expected age of Salma? A. 36 months B. 42 months C. 48months D. 60 months E. 72 months 13. A normal height mother brought her 2-year-old son whose height is 90 cm asking you about the expected adult height of her son, you answer that the approximate adult height is A. 170 cm B. 175 cm C. 180 cm D. 185 cm E. 190 cm 11 14. A 4-year-old child should put in a typical sentence at least A. 2 words B. 3 words C. 4 words D. 5 words E. 6 words 15. Although 5% of preschool children will stutter, it will resolve in 80% of those children by age of A. 6 years B. 7 years C. 8 years D. 9 years E. 10 years 16. The upper-to-lower body segment ratio equals approximately 1.7 at birth, and 1.0 after A. 5 yr B. 7yr C. 9 yr D. 11yr E. 13 yr 17. What is the MOST common cause of delayed teeth eruption? A. Hypothyroidism, B. Hypoparathyroidism C. Familial D. Idiopathic E. Rickets 18. A couple came to you asking about the expected adult height of their 2-year- old daughter, the mother is 63 inches tall and the father is 70 inches tall. Your proper answer will be, the daughter's sex-adjusted midparental height will be A. 56-64 inches B. 58-66 inches C. 60-68 inches D. 62-70 inches E. 64-72 inches 12 19. A couple came to you asking about the expected adult height of their 3- year-old son, the mother is 63 inches tall and the father is 70 inches tall. Your proper answer will be, the son's sex-adjusted midparental height will be A. 62-70 inches B. 63-71 inches C. 64-72 inches D. 65-73 inches E. 66-74 inches 20. A 1-year-old child presents with repetitive, stereotyped, and rhythmic movements in the form of head banging and body rocking. These behaviors typically occur with the transition to sleep at bedtime, but also at nap times and after nighttime arousals. Of the following, the MOST important aspect in management is A. ordering EEG B. ordering MRI brain C. referral to pediatric neurology D. reassurance to the family E. starting antiepileptic drug 21. Which of the following is suggested by poor linear growth in the context of good BMI? A. Malnutrition B. Celiac disease C. Inflammatory bowel disease D. Hypothyroidism E. Renal tubular acidosis 22. In which of the following conditions with short stature, bone age is normal? A. Familial short stature B. Constitutional delay C. Hypothyroidism D. Undernutrition E. Celiac disease 23. Which of the following provide an accurate clinical index of adiposity? A. BMI B. Triceps skinfold thickness 13  C. Hydrodensitometry D. Bioelectrical impedance E. Total body water measurement 24. Which of the following is a cause of early exfoliation of teeth? A. Hypothyroidism B. Hypoparathyroidism C. Gum fibrosis D. Hypophosphatasia E. Crowding of teeth 25. At what age, children do understand that death is irreversible and that it may involve them or their families? A. Children approximately 3 yr old B. Preschool-age children C. Early school-age children D. Children approximately 9 yr E. Pubertal age 26. Which of the following is TRUE regarding sleep duration and sleep patterns in the first 2 months of life? A. Average total sleep 15-18 hr B. Prematures sleep less than full-term infants C. Bottle-fed babies sleep longer than breastfed babies D. Established nocturnal diurnal pattern E. Sleep periods are separated by 2-4 hr awake 27. There is substantial overlap between the clinical impairments associated with obstructive sleep apnea syndrome (OSAS) and the diagnostic criteria for ADHD, including A. Poor concentration B. Increased irritability C. Mood instability D. Low frustration tolerance E. Depression 28. Which of the following can accurately predict which children with snoring have obstructive sleep apnea syndrome? 14  A. Clinical history B. Physical findings C. Overnight polysomnogram D. X-ray of post-nasal space E. MRI of post-nasal space 29. A 12-year-old obese boy presents with loud, frequent, and disruptive snoring; restless sleep; with nocturnal diaphoresis. He is mouth breather, with hyponasal speech, and morning headach. Oropharyngeal examination revealed enlarged tonsils. Of the following, the first-line treatment of this boy is A. watchful waiting B. weight reduction C. positional therapy D. continuous positive airway pressure E. adenotonsillectomy 30. Which of the following parasomnias occur during rapid eye movement sleep? A. Confusional arousals B. Sleep terrors C. Sleep walking D. Night mares E. All the above 31. Which of the following is MOST successful in the management of partial arousal episodes occurring on a nightly basis? A. Parental education B. Reassurance C. Avoidance of caffeine D. Scheduled awakenings E. Benzodiazepines 32. A 13-year-boy has uncomfortable and unpleasant sensations in the legs, in addition to the urge to move the legs on lying in bed to sleep at night or riding in a car for prolonged periods. His parents report that their child is a restless sleeper, moves around, and even falls out of bed during the night. 15 Of the following, the MOST likely diagnosis is A. Leg cramps B. Neuropathy C. Arthritis D. Restless legs syndrome E. Nerve compression (“leg fell asleep”) 16 Chapter 2 Growth, Development, and Behavior Answers ZUHAIR ALMUSAWI 1.(C) By wk 12, the gender of the external genitals becomes clearly distinguishable. 2.(C) The average term newborn weighs approximately 3.4 kg (7.5 lb); boys are slightly heavier than girls. Average weight does vary by ethnicity and socioeconomic status. The average length and head circumference are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. 3.(C) At 10 months, baby can pulls to standing position; “cruises” or walks holding on to furniture. 4.(B) 5.(A) Infants at 2 mo of age can discriminate rhythmic patterns in native vs non- native language. 6.(C) A major milestone is the achievement by 9 mo of object permanence (constancy), the understanding that objects continue to exist, even when not seen. At 4-7 mo of age, infants look down for a yarn ball that has been dropped but quickly give up if it is not seen. With object constancy, older infants persist in searching. They will find objects hidden under a cloth or behind the examiner's back. 7.(C) Gripe water (containing herbal supplements), and fennel extract may have benefit, but the evidence is weak. 8.(C) 18 Months Motor: Runs stiffly; sits on small chair; walks up stairs with 1 hand held; explores drawers and wastebaskets Adaptive: Makes tower of 4 cubes; imitates scribbling; imitates vertical stroke; dumps raisin from bottle Language: 10 words (average); names pictures; identifies 1 or more parts of body Social: Feeds self; seeks help when in trouble; may complain when wet or soiled; kisses parent with pucker 9.(C) 24 Months 17 Motor: Runs well, walks up and down stairs, 1 step at a time; opens doors; climbs on furniture; jumps Adaptive: Makes tower of 7 cubes (6 at 21 mo); scribbles in circular pattern; imitates horizontal stroke; folds paper once imitatively Language: Puts 3 words together (subject, verb, object) Social: Handles spoon well; often tells about immediate experiences; helps to undress; listens to stories when shown pictures. 10.(D) 36 Months Motor: Rides tricycle; stands momentarily on 1 foot Adaptive: Makes tower of 10 cubes; imitates construction of “bridge” of 3 cubes; copies circle; imitates cross Language: Knows age and sex; counts 3 objects correctly; repeats 3 numbers or a sentence of 6 syllables; most of speech intelligible to strangers Social: Plays simple games (in “parallel” with other children); helps in dressing (unbuttons clothing and puts on shoes); washes hands. 11.(D) 48 Months Motor: Hops on 1 foot; throws ball overhand; uses scissors to cut out pictures; climbs well Adaptive: Copies bridge from model; imitates construction of “gate” of 5 cubes; copies cross and square; draws man with 2-4 parts besides head; identifies longer of 2 lines Language: Counts 4 pennies accurately; tells story Social: Plays with several children, with beginning of social interaction and role- playing; goes to toilet alone 12.(D) 60 Months Motor: Skips Adaptive: Draws triangle from copy; names heavier of 2 weights Language: Names 4 colors; repeats sentence of 10 syllables; counts 10 pennies correctly Social: Dresses and undresses; asks questions about meaning of words; engages in domestic role-playing 13.(C) By 24 mo, children are about half their ultimate adult height. Head growth slows slightly, with 85% of adult head circumference achieved by age 2 yr, leaving only an additional 5 cm (2 in) gain over the next few years. 14.(C) As a rule of thumb, between ages 2 and 5 yr, the number of words the child puts in a typical sentence should, at a minimum, equal the child's age (2 by age 2 yr, 3 by age 3 yr, and so on). 18 15.(C) Children with stuttering should be referred for evaluation if it is severe, persistent, or associated with anxiety, or if parental concern is elicited. 16.(B) The U/L ratio equals approximately 1.7 at birth, 1.3 at 3 year, and 1.0 after 7 year. Higher U/L ratios are characteristic of short-limb dwarfism, as occurs with Turner syndrome or bone disorders, whereas lower ratios suggest hypogonadism or Marfan syndrome. 17.(D) Delayed eruption is usually considered when no teeth have erupted by approximately 13 month of age (mean + 3 SD). Common causes include congenital or genetic disorders, endocrine disorders (e.g., hypothyroidism, hypoparathyroidism), familial conditions, and (the most common) idiopathic conditions. Individual teeth may fail to erupt because of mechanical blockage (crowding, gum fibrosis). 18.(C) Boys: [(Maternal height + 5 inches) + Paternal height]/2 Girls: [Maternal height + (Paternal height – 5 inches)]/2 Furthermore, generally 4 inches (2 SD) is applied above and below this value to provide a genetic target height range. For example, if the mother is 63 inches tall and the father 70 inches tall, the daughter's sex-adjusted midparental height is 64 inches ± 4 inches, for a target height range of 60-68 inches. 19.(D) The son of these parents would have a sex-adjusted midparental height of 69 inches, with a range of 65-73 inches. 20.(D) Sleep-related rhythmic movements, including head banging, body rocking, and head rolling, are characterized by repetitive, stereotyped, and rhythmic movements or behaviors that involve large muscle groups. These behaviors typically occur with the transition to sleep at bedtime, but also at nap times and after nighttime arousals. Children typically engage in these behaviors as a means of soothing themselves to (or back to) sleep; these are much more common in the 1st yr of life and usually disappear by preschool age. These behaviors typically occur in normally developing children and in the majority of cases do not indicate some underlying neurologic or psychologic problem. Usually, the most important aspect in management of sleep-related rhythmic movements is reassurance to the family that this behavior is normal, common, benign, and self-limited. 21.(D) Poor linear growth in the setting of decreasing BMI suggests a nutritional or gastrointestinal issue, whereas poor linear growth in the context of good or robust BMI suggests a hormonal condition (hypothyroidism, growth hormone deficiency, cortisol excess). 22.(A) In familial short stature the bone age is normal (comparable to chronological age), whereas constitutional delay, endocrinologic short stature, 19 and undernutrition may be associated with delay in bone age comparable to the height age. 23.(B) Although widely accepted as the best clinical measure of underweight and overweight, BMI may not provide an accurate index of adiposity because it does not differentiate lean tissue and bone from fat. In otherwise a healthy individual, lean body mass is largely represented by BMI at lower percentiles. BMI >80–85% largely reflects increased body fat with a nonlinear relationship between BMI and adiposity. In the setting of chronic illness, increased body fat may be present at low BMI, whereas in athletes, high BMI may reflect increased muscle mass. Measurement of the triceps, subscapular, and suprailiac skinfold thickness have been used to estimate adiposity. Other methods of measuring fat, such as hydrodensitometry, bioelectrical impedance, and total body water measurement, are used in research, but not in clinical evaluation, but whole body dual-energy x-ray absorptiometry (DXA) is beginning to emerge as a tool for measuring body fat and lean body mass. 24.(D) Causes of early exfoliation include hypophosphatasia, histiocytosis X, cyclic neutropenia, leukemia, trauma, and idiopathic factors. 25.(D) Children approximately 9 yr and older do understand that death is irreversible and that it may involve them or their families. These children tend to experience more anxiety, overt symptoms of depression, and somatic complaints than do younger children. 26.(C) Total sleep: 10-19 hr per 24 hr (average, 13-14.5 hr), may be higher in premature babies Bottle-fed babies generally sleep for longer periods (2-5 hr bouts) than breastfed babies (1-3hr). Sleep periods are separated by 1-2 hr awake. No established nocturnal diurnal pattern in 1st few wk; sleep is evenly distributed throughout the day and night, averaging 8.5 hr at night and 5.75 hr during day. 27.(A) There is substantial overlap between the clinical impairments associated with OSAS and the diagnostic criteria for ADHD, including inattention, poor concentration, and distractibility. 28.(C) Because no combination of clinical history and physical findings can accurately predict which children with snoring have OSAS, the gold standard for diagnosing OSAS remains an in-lab overnight polysomnogram (PSG). 20 29.(E) In the majority of cases of pediatric OSAS, adenotonsillectomy is the first- line treatment in any child with significant adenotonsillar hypertrophy, even in the presence of additional risk factors such as obesity. 30.(D) Nightmares, which are much more common than partial arousal parasomnias but are often confused with them, tend to be concentrated in the last third of the night, when REM sleep is most prominent. 31.(D) Scheduled awakenings is a behavioral intervention that involves having the parent wake the child 15-30 min before the time of night that the 1st parasomnia episode occurs and is most likely to be successful in situations where partial arousal episodes occur on a nightly basis. 32.(D) Diagnostic Criteria for Restless Legs Syndrome A. An urge to move legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by the following: 1. The urge to move the legs begins or worsens during periods of rest or inactivity. 2. The urge to move the legs is partially or totally relieved by movement. 3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night. B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months. C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. D. The symptoms in criterion A are not attributable to another mental disorder or medical condition (e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioral condition (e.g., positional discomfort, habitual foot tapping). E. The symptoms are not attributable to the physiological effects of a drug or abuse or medication (e.g., akathisia). 21 Chapter 3 Behavioral and Psychiatric Disorders Questions AHMED TAWFIQ 1. You are evaluating a 10-month-old girl with frequent regurgitation, rechewing of regurgitated material, arching of back, inattentiveness, developmental delay, and failure to gain weight. Taking deep social history reveals baby separation from biological mother because of divorce 3 months ago, and the new care giver is the step mother. Baby was completely well in the first 7 months of life. Of the following, the MOST likely diagnosis is A. GERD B. rumination disorder C. Sandifer syndrome D. pyloric stenosis E. diencephalic tumor 2. A 4-year-old boy presents with history eating of clay, paper, and soap. He is quite intelligent boy with normal anthropometric parameters, he is eating balanced diet. During interview you noticed that the mother is not paying attention to the child bad behaviors. Of the following the MOST likely cause is A. iron deficiency B. autism C. child neglect D. family disorganization E. zinc deficiency 3. Which of the following is representing a tic disorder in childhood? A. thumb sucking B. nail biting C. trichotillomania D. bruxism (teeth grinding) E. head jerking 22 4. What are the MOST common psychiatric disorders of childhood? A. Anxiety disorders B. Tic disorders C. Major depressive disorders D. Eating disorders E. Psychotic disorders 5. A completely well and lacking any history of drug intoxication or trauma, a 4- year-old girl presents with frightening episodes for the last 2 days. She is complaining that a snake is crawling over her and she is trying to remove it. Each episode lasts about 30 minutes. Of the following the MOST likely cause is A. posttraumatic stress disorder B. acute phobic hallucinations C. attention-deficit hyperactivity disorder D. Tourette syndrome E. psychosis 6. An 8-year-old boy referred to psychologist for evaluation because of frequent running away from school. The BEST way for avoidance of such behavior in future is to A. transfer the child to new environment and new school B. teach him in special school C. find a way to make father or mother present during school time D. address the pressure factors and make a plan with parents and school staff E. refer to pediatric psychiatrist 7. A 12-year-old adolescent girl with established diagnosis of anorexia nervosa has started successful inpatient management by interdisciplinary team (dietician, mental health and physician), she showed increased weight of about 1.5 Kg/week. She starts to develop episodes of tachycardia, hypertension, confusion, and seizures. Of the following, the MOST appropriate investigation that helps in management is A. thyroid function test B. cranial CT C. serum phosphorus 23  D. renal function test E. random blood sugar 8. A 15-year-old girl referred from primary health care center for progressive weight loss. During interview, you find her highly obsessed about fatness especially in stomach and thigh areas; she has lanugo hair on her face and upper body, dry skin, some bruising, gooseflesh orange-yellow skin hands. BMI 18 kg/m2, HR 60 bpm, B.P 90/60, and the investigational work up were normal. Of the following, the MOST appropriate plan of management is A. hospital admission with interdisciplinary team management B. referral to mental health service C. reassurance with follow up visits D. primary health care management with interdisciplinary team E. scheduled focused discussion visits to improve body image 9. What is the MOST common cause for complete suicide? A. Family conflicts B. Substance abuse C. Hormonal changes D. Social and media violence E. Preexisting psychiatric illness 10. What is the antidepressant of choice in the treatment of depression in preadolescent period? A. Fluoxetine B. Escitalopram C. Sertraline D. Paroxetine E. Citalopram 11. Separation anxiety disorder SAD can vary in presentation according to the affected age; those between the age of 13-16 years often have A. excessive fear that harm will come to a parent B. physical complaints C. nightmares D. reluctance to sleep alone E. persistent avoidance of being alone 24 12. An 8-year-old girl referred to cardiology clinic because of recurrent attacks of chest pain which occurs almost always at night. During the interview you find a well-dressed and quite intelligent girl who describes the episode as palpitations, sweating, shaking, shortness of breath, dizziness, chest pain, and nausea. She has concern about recurrence of these symptoms and she is afraid from impending death. Of the following, the MOST likely diagnosis is A. panic disorder B. obsessive compulsive disorder C. ischemic heart disease D. separation anxiety disorder E. hyperthyroidism 13. A 3-year-old girl with epilepsy on valproate 30mg/kg/day. She is under treatment for severe empyema with linezolid. She has responded very well initially but on fifth day of antibiotic treatment, she develops severe attack of hyperthermia, agitation, tachycardia, diaphoresis and tremor. Of the following, the MOST likely diagnosis is A. malignant hyperthermia B. central hyperthermia C. neuroleptic malignant syndrome D. serotonin syndrome E. evolving bacterial resistance 14. What is the MOST common dose-dependent side effect of stimulant medications used in ADHD? A. Irritability B. Appetite suppression C. Aggression D. Social withdrawal E. Visual hallucinations 15. Which of the following antidepressants is a selective serotonin reuptake inhibitor SSRI? A. Fluoxetine B. Mirtazapine C. Venlafaxine D. Duloxetine 25  E. Bupropion 16. Which of the following is classified as first generation antipsychotic medication? A. Risperidone B. Olanzapine C. Haloperidol D. Lithium E. Lurasidone 26 Chapter 3 Behavioral and Psychiatric Disorders Answers AHMED TAWFIQ 1.(B) Risk factors for rumination disorder in infants and young children include a disturbed relationship with primary caregivers, lack of an appropriately stimulating environment, neglect, stressful life situations, learned behavior reinforced by pleasurable sensations, distraction from negative emotions, and inadvertent reinforcement (attention) from primary caregivers. Treatment is focused on resolving the social issue and behavioral treatment is to reinforce correct eating behavior while minimizing attention to rumination. A and C can have similar presentation but in absence of rechewing and developmental delay. D can present earlier with completely different scenario. In E usually the child mood is very cheerful. 2.(D) Pica involves the persistent eating of nonnutritive, nonfood substances (e.g., paper, soap, plaster, charcoal, clay, wool, ashes, paint, earth) over a period of at least 1 mo. The eating behavior should be inappropriate to the developmental level therefore minimum age of 2 yr is suggested. Numerous etiologies have been proposed but not proved, ranging from psychosocial causes to physical ones. They include nutritional deficiencies (e.g., iron, zinc, and calcium), low socioeconomic factors (e.g., lead paint exposure), child abuse and neglect, family disorganization (e.g., poor supervision), mental disorder, learned behavior, underlying (but undetermined) biochemical disorder, and cultural and familial factors. Regarding distracters; nutritional deficiencies are less likely because of balance diet, child neglect is also less likely because of normal growth and development. Pica and autism can be a co-morbidities but not in such scenario. 3.(E) Habits involve an action or pattern of behavior that is repeated often. Habits are common in childhood and range from usually benign and transient behavior (e.g., thumb sucking, nail biting) to more problematic (e.g., trichotillomania, bruxism). The last distracter is representing a simple motor tics, other examples: eye blinking, shoulder shrugging, extension of the extremities, all are fast, brief movements involving one or a few muscle groups. 27 4.(A) Anxiety disorders are the most common psychiatric disorders of childhood, occurring in 5–18% of all children and adolescents, prevalence rates comparable to physical disorders such as asthma and diabetes. 5.(B) Acute phobic hallucinations are benign and common and occur in previously healthy preschool children. The hallucinations are often visual or tactile, last 10-60 min, and occur at any time but most often at night. The child is quite frightened and might complain that bugs or snakes are crawling over him or her and attempt to remove them. The cause is unknown. The differential diagnosis includes drug overdose or poisoning, high fever, encephalitis, and psychosis. The child's fear is not alleviated by reassurance by the parents or physician, and the child is not amenable to reason. Physical and mental status examination is otherwise normal. Symptoms can persist for 1-3 days, slowly abating over 1-2 wk. 6.(D) Truancy is more common in older children and can be a function of multiple factors, including but not limited to learning difficulties, social anxiety, depression, traumatic exposure, bullying, peer pressure, and substance use. In any of these cases, the child should be referred for further evaluation to assess the barriers to returning to school. Best practices for dealing with truancy resulting from school avoidance and anxiety include addressing the underlying psychological symptoms causing the school avoidance and empowering parents, children, and school staff to work on a consistent plan for a return to school. 7.(C) For patients with anorexia nervosa and low weight, the nutrition prescription should work toward gradually increasing weight at the rate of about 0.5-1 lb/wk, by increasing energy intake by 100-200 kcal increments every few days, toward a target of approximately 90% of average body weight for sex, height, and age. In addition, with extremely low weight, refeeding syndrome (a result of the rapid drop in serum phosphorus, magnesium, and potassium with excessive reintroduction of calories, especially carbohydrates), is associated with acute tachycardia and heart failure and neurologic symptoms. 8.(D) Classification of anorexia nervosa AN, Mild: BMI ≥ 17 kg/m2, Moderate: BMI 16-16.99 kg/m2, Severe: BMI 15-15.99 kg/m2, Extreme: BMI < 15 kg/m2. Indication for admission AN, Heart rate 25 beats/min increase, hypokalemia, hypoglycemia hypophosphatemia, dehydration, body temperature