Transcript Board Review

General Pediatrics Board Review
Nephrology
Fluids and Electrolytes
Acid-Base
UTI
Hypertension
Jeffrey M. Saland, M.D.
Chief, Nephrology and Hypertension
Department of Pediatrics
Icahn School of Medicine at Mount Sinai
Summer Board Review
I Don’t Decide What’s On the Boards
An 8 year old proudly announces to you that she did a
report on jellyfish and they are 96% water. She asks you
what is her “percent water?” What is the best estimate of
her fluid compartments by percent of body weight?
A.
B.
Total Body
Water
80%
70%
Extracellular
Fluid
45%
30%
Intracellular
Fluid
35%
40%
C.
60%
20%
40%
D.
50%
20%
30%
E.
Same as the jellyfish
4
An 8 year old proudly announces to you that she did a
report on jellyfish and they are 96% water. She asks you
what is her “percent water?” What is the best estimate of
her fluid compartments by percent of body weight?
A.
B.
Total Body
Water
80%
70%
Extracellular
Fluid
45%
30%
Intracellular
Fluid
35%
40%
C.
60%
20%
40%
D.
50%
20%
30%
E.
Same as the jellyfish
5
Composition of Body Fluids
Babies are moist– but not quite jellyfish!
6
Finberg L.
Water and
Electrolytes in
Pediatrics 1993
(data from FriisHansen BJ
Pediatrics 1961)
TBW
ICW
ECW
7
Distribution of body water as a
percentage of body weight
Age
Total Water
ECW
ICW
0-1 day
79
43.9
35.1
1-10 days
74
39.7
34.3
1-3 mo
72.3
32.2
40.1
3-6 mo
70.1
30.1
40
6-12 mo
60.4
27.4
33
1-2 yr
58.7
25.6
33.1
2-3 yr
63.5
26.7
36.8
3-5 yr
62.2
21.4
40.8
5-10 yr
61.5
22
39.5
10-16 yr
58
18.7
39.3
Compiled by Finberg, L. from data by BJ Friis-Hansen, Acta Paed Scand 1958
Technique: D2O for TBW and thiosulfate for ECW
8
Approx Body Composition > 1 year
TBW = 60% Lean Body Mass: ICF = 2/3 TBW
ECF = 1/3 TBW
Plasma = 1/4 ECF
(rest is interstitial fluid)
TBW
ICF
Na ~ 140
K~4
Plasma
Na ~ 13
K ~ 140
ECF
9
A previously healthy 23 kg child is admitted for
gingivostomatitis and refusal of oral intake. What is the
most appropriate maintenance intravenous fluid
prescription?
A.
B.
Base
0.9% NS
D5 ½ 0.9% NS
Potassium
None
20 mEq/L
Rate
65 ml/hr
100 ml/hr
C.
D.
D5 ½ 0.9% NS
D5 W
20 mEq/L
20 mEq/L
65 ml/hr
50 ml/hr
E.
D5 ¾ 0.9% NS
20 mEq/L
65 ml/hr
10
A previously healthy 23 kg child is admitted for
gingivostomatitis and refusal of oral intake. What is the
most appropriate maintenance intravenous fluid
prescription?
A.
B.
Base
0.9% NS
D5 ½ 0.9% NS
Potassium
None
20 mEq/L
Rate
65 ml/hr
100 ml/hr
C.
D.
D5 ½ 0.9% NS
D5 W
20 mEq/L
20 mEq/L
65 ml/hr
50 ml/hr
E.
D5 ¾ 0.9% NS
20 mEq/L
65 ml/hr
11
What are maintenance fluids?
The fluid and electrolytes necessary for a person to
remain in net balance over the long term
INTAKE
ECF
Plasma
ICF
OUTPUT
12
Sounds Easy!
13
What are maintenance fluids?
Barratt M: Pediatric Nephrology 4th Ed 1998
14
What are maintenance fluids?
Why did that graph estimate caloric needs?
We need to know how many mL of fluid to
order, not how many calories!
15
For the “average” patient, the use of 1 Cal
corresponds to the use of 1 mL of water
Insensible losses:
respiratory
+ evaporative not sweat
30 cc / 100 Cal
15 cc / 100 Cal
45 cc / 100 Cal
Urine output losses
Stool losses
Growth “loss”
50-75 cc / 100 Cal
5-10 cc / 100 Cal
0-15 cc / 100 Cal
Water of oxidation (a gain)
10-15 cc / 100 Cal
TOTAL
Approximately 100 cc / 100 Cal
16
Summary “maintenance fluids”
Fluid needs are linked to the metabolic rate.
Maintenance is approximately insensible
plus urine losses.
Maintenance fluids of the “average” patient
are approximately:
1st 10 kg:
2nd 10 kg:
100 cc / kg / day
50 cc / kg / day
the rest:
20 cc / kg / day
17
Changes in the metabolic rate or the
environment change insensible fluid loss
Increased INSENSIBLE Losses
Fever (each deg > 38):
Prematurity
Radiant warmer
Phototherapy
Increased activity
12.5%
100-300%
50-100%
25-50%
5-25%
Decreased INSENSIBLE Losses
Ventilation (humidified air)
Sedation
Decreased activity
Hypothermia
Enclosed Incubator
25-40%
5-25%
5-25%
5-15%
25-50%
18
Maintenance Fluid DOES NOT
Include Abnormal Losses
Common / “Community” losses
Gastrointestinal: diarrhea, vomiting
Activity: sweating, increased ventilation, heat
Burns: (even sunburn!)
Uncommon / “Nosocomial” losses
Drainage (eg chest tube, NG tube, et cetera)
Bleeding
Pathological renal losses (eg salt wasting, diabetes)
These losses are universally hypo- or isotonic
19
Composition of Various Body Fluids
Fluid
Gastric
Pancreatic
Small bowel
Bile
Ileostomy
Diarrhea
Burns
Sweat
Normal
Cystic fibrosis
Harriet Lane Handbook
Na
(mEq/L)
20–80
120–140
100–140
120–140
45–135
10–90
140
K
(mEq/L)
5–20
5–15
5–15
5–15
3–15
10–80
5
Cl
(mEq/L)
100–150
90–120
90–130
80–120
20–115
10–110
110
10–30
50–130
3–10
5–25
10–35
50–110
20
“Salt” Maintenance Requirements
Na:
K:
2-5 mEq / kg /day
1-2 mEq / kg /day
There is a large variability in the intake of Na, and to a
lesser extent K, by healthy people.
Renal ability to conserve or excrete Na is very large.
The ability to conserve or secrete K is also larger than
the average variation in intake.
21
22
An 18 month old boy presents to the ER with a history of
vomiting and diarrhea for several days. He is lethargic, has
poor skin turgor, dry mucus membranes, and has
tachycardia. He took 5 ml oral fluid but vomited almost
immediately. The next most appropriate step is to:
A. Give 20 ml/kg of D5 0.45%
. ..
0%
ec
tro
lyt
NS
i
f3
%
NS
el
go
um
l/ k
Aw
ait
se
r
0m
e1
Gi
v
0%
es
.. .
0%
...
N.
..
f0
.9
%
go
0.
9%
0m
Gi
v
e2
m
e5
0%
l/ k
0.
45
...
l/ k
go
fD
5
fD
5
go
l/ k
Gi
v
E.
0%
0m
D.
e2
C.
Gi
v
B.
NS intravenously over 20-30
min
Give 5 ml/kg of D5 0.9% NS
intravenously over 20-30 min
Give 20 ml/kg of 0.9% NS
intravenously over 20-30 min
Give 10 ml/kg of 3% NS
intravenously over 20-30 min
Await serum electrolytes
before giving IV fluid
23
6
A nearly 1 month old boy has been vomiting his feedings
forcefully for 2 days. He is afebrile and has no diarrhea. He
had 1 wet diaper in the last day. He appears dehydrated.
He eagerly takes fluids but vomits (non-bilious) immediately
and while he does so you note “waves” on his abdomen.
What is the most likely set of labs?
Serum pH Serum Na
A.
Low
High
Serum K
Low
Serum Cl
Low
B.
C.
D.
High
High
Normal
Normal
Normal
Low
High
Low
Low
Low
Low
Low
E.
High
Low
Low
High
24
A nearly 1 month old boy has been vomiting his feedings
forcefully for 2 days. He is afebrile and has no diarrhea. He
had 1 wet diaper in the last day. He appears dehydrated.
He eagerly takes fluids but vomits (non-bilious) immediately
and while he does so you note “waves” on his abdomen.
What is the most likely set of labs?
Serum pH Serum Na
A.
Low
High
Serum K
Low
Serum Cl
Low
B.
C.
D.
High
High
Normal
Normal
Normal
Low
High
Low
Low
Low
Low
Low
E.
High
Low
Low
High
25
Signs & Symptoms of Dehydration I
(fairly reliable)
Mild
Weight Loss
Sensorium
Severe
5% (infant)
10% (infant)
15% (infant)
2% (child/adult) 6% (child/adult) 9% (child/adult)
Normal
Urine Output Slight decrease
hrs w/o UOP
2-3 hours
range 0.5-1.5 cc/kg/hr
Harriet Lane Handbook
Moderate
Fussy
Lethargic
Poor
arousability
Notable
decrease
4-6 hours
<0.5 cc/kg/hr
Anuric
6-12 hours
None
26
Signs & Symptoms of Dehydration II
(less reliable)
Mild
Skin turgor or 1+ decrease
quality
pale
Moderate
Severe
2+ decrease
“gray”
3+ decrease
mottled
Drier
“parched”
Slightly
increased
Increased
Very
increased
Fontanelle
Normal
Intermediate
Sunken
Eyes
Normal
Intermediate
Sunken
Blood Pressure
Normal
About normal
Low
Mucus
Dry / “tacky”
Membranes
Pulse
Harriet Lane Handbook
27
A 2 year-old presents with a 1 day history diarrhea and
a 5% weight loss. Which of the following best
represents the distribution of the fluid loss?
A.
B.
C.
D.
E.
Extracellular Intracellular
80%
20%
60%
40%
40%
60%
20%
80%
None of the above
28
A 2 year-old presents with a 1 day history diarrhea and
a 5% weight loss. Which of the following best
represents the distribution of the fluid loss?
A.
B.
C.
D.
E.
Extracellular Intracellular
80%
20%
60%
40%
40%
60%
20%
80%
None of the above
3 or more days: the correct answer would have been B.
The ICF is relatively protected from volume loss.
Harriet Lane Handbook
29
A nearly 13 month old girl has had diarrhea for 5 days.
She has few wet diapers. Her BP is 86/40, pulse is 135.
She weighs 9 kg and you estimate she is 10% dehydrated
based on clinical parameters. Disregarding Na losses from
the ICF, which of the following estimates is best?
A.
B.
Total Deficit
900 mL
1000 mL
ECF loss
540 ml
800 ml
ICF loss
360 ml
200 ml
Na Loss
75 mEq
110 mEq
C.
D.
1000 mL
1000 mL
400 ml
600 ml
600 ml
400 ml
55 mEq
85 mEq
E.
100 mL
80 mL
20 mL
10 mEq
30
A nearly 13 month old girl has had diarrhea for 5 days.
She has few wet diapers. Her BP is 86/40, pulse is 135.
She weighs 9 kg and you estimate she is 10% dehydrated
based on clinical parameters. Disregarding Na losses from
the ICF, which of the following estimates is best?
A.
B.
Total Deficit
900 mL
1000 mL
ECF loss
540 ml
800 ml
ICF loss
360 ml
200 ml
Na Loss
75 mEq
110 mEq
C.
D.
1000 mL
1000 mL
400 ml
600 ml
600 ml
400 ml
55 mEq
85 mEq
E.
100 mL
80 mL
20 mL
10 mEq
31
A 13 month old child was seen for a checkup and
weighed 10 kg. 10 days later in the ER with
gastroenteritis she weighs 9 kg. 10% Dehydration.
A liter weighs 1 kg.
A pint’s a pound the world around.
32
A high school student and her friend have multiple
episodes of vomiting and watery diarrhea after sharing
lunch from a food cart at the park earlier in the day. Her
bp is 95/45 and her pulse increases from 90 to 115
standing. She feels light-headed and has not urinated in
the last 6 hours. Which is the most likely type of
dehydration?
A.
Isotonic
B.
C.
D.
Hypotonic
Hypertonic
All are equally likely
33
A high school student and her friend have multiple
episodes of vomiting and watery diarrhea after sharing
lunch from a food cart at the park earlier in the day. Her
bp is 95/45 and her pulse increases from 90 to 115
standing. She feels light-headed and has not urinated in
the last 6 hours. Which is the most likely type of
dehydration?
A.
Isotonic
B.
C.
D.
Hypotonic
Hypertonic
All are equally likely
34
A 14 year old girl is treated with a prolonged course of
antibiotics for sinusitis. She develops profuse watery
diarrhea that lasts several days. She had not been
eating due to abdominal pain but had taken at least 2
liters of a yellow sports drink each day. In the ER, she
still appears moderately dehydrated. You diagnose C.
Dificile colitis. The most likely type of dehydration is:
A.
B.
Isotonic
Hypotonic
C.
Hypertonic
D.
All are equally likely
35
A 14 year old girl is treated with a prolonged course of
antibiotics for sinusitis. She develops profuse watery
diarrhea that lasts several days. She had not been
eating due to abdominal pain but had taken at least 2
liters of a yellow sports drink each day. In the ER, she
still appears moderately dehydrated. You diagnose C.
Dificile colitis. The most likely type of dehydration is:
A.
B.
Isotonic
Hypotonic
C.
Hypertonic
D.
All are equally likely
36
A 14 year old boy with cerebral palsy and mental
retardation develops fever to 40 °C. He is able to
tolerate his usual liquid formula diet by gastric tube. You
diagnose him with streptococcal pharyngitis but also
note he has very dry mucus membranes and his skin
feels thick. Which is the most likely set of lab findings?
Serum Na
A.
B.
C.
D.
E.
High
Low
High
Low
Normal
Serum
Osm
High
Low
High
Normal
Normal
Urine Na
Urine Osm
Low
High
High
High
Low
High
High
High
High
Low
37
A 14 year old boy with cerebral palsy and mental
retardation develops fever to 40 °C. He is able to
tolerate his usual liquid formula diet by gastric tube. You
diagnose him with streptococcal pharyngitis but also
note he has very dry mucus membranes and his skin
feels thick. Which is the most likely set of lab findings?
Serum Na
A.
B.
C.
D.
E.
High
Low
High
Low
Normal
Serum
Osm
High
Low
High
Normal
Normal
Urine Na
Urine Osm
Low
High
High
High
Low
High
High
High
High
Low
38
Tonicity Classification of Dehydration
Tonicity Plasma Na Incidence
(mEq/L)
Example etiologies
Iso
130-150
60%
diarrhea, vomiting
Hyper
>150
25%
Hypo
<130
15%
A loss PLUS:
no thirst or
no tolerance for or
no access to water
Any loss PLUS water
replacement in excess of
solute replacement.
Worse if loss had some
Na (CF, salt-wasting )
39
40
A 10 year old boy has high fever and dehydration due to
seasonal influenza. He has not urinated in over 24 hours.
His serum creatinine is elevated from 0.7 to 1.6. Urine is
taken to calculate fractional excretion of Na. Two days
later he is rehydrated and has normal urine output and his
creatinine is baseline. What best describes his diagnosis
and most likely FENa on presentation?
A. Acute kidney injury –
N
...
–
–
az
ot
em
ia
na
l
re
Pr
e-
na
l
re
Pr
e-
0%
FE
FE
FE
..
az
ot
em
ia
ju
ry
in
y
dn
e
ki
e
cu
t
A
0%
..
0%
–
F.
..
–
ju
ry
in
y
dn
e
ki
e
D.
0%
cu
t
C.
A
B.
FENa 3%
Acute kidney injury –
FENa 0.3%
Pre-renal azotemia –
FENa 3%
Pre-renal azotemia –
FENa 0.3%
41
6
Consider a child with sepsis and decreased urine output
with the following labs:
SERUM:
Na 124, K 4, Cl 94, Total CO2 12
Creat 0.8 mg/dL, BUN 40, Glucose 70
URINE: specific gravity 1.030, trace protein, no blood or
glucose, small ketones; urine Na 15, creat 40
42
FENa is a useful test when:
• The urine output is low.
• No current use of diuretics.
< 1% (0.01): pre-renal azotemia (“acute renal success”)
> 2% (0.02): acute kidney injury (“acute renal failure”)
Exceptions: acute GN has low FENa, obstruction can vary
43
A 4 year-old girl with a ventriculoperitoneal shunt
presents with a week of vague symptoms progressing
toward listlessness and decreased speech, finally with a
5 minute seizure. The bulb of the shunt empties with
pressure but is slow to refill. She does not appear
dehydrated. The most likely set of laboratory findings is:
Serum Na Urine Na
mEq/L
mEq/L
Serum Osm
mOsm/kg
Urine Osm
mOsm/kg
A
B
C
D
150
140
130
120
5
40
25
50
320
295
275
265
90
400
450
90
E
120
50
265
500
44
A 4 year-old girl with a ventriculoperitoneal shunt
presents with a week of vague symptoms progressing
toward listlessness and decreased speech, finally with a
5 minute seizure. The bulb of the shunt empties with
pressure but is slow to refill. She does not appear
dehydrated. The most likely set of laboratory findings is:
Serum Na Urine Na
mEq/L
mEq/L
Serum Osm
mOsm/kg
Urine Osm
mOsm/kg
A
B
C
D
150
140
130
120
5
40
25
50
320
295
275
265
90
400
450
90
E
120
50
265
500
45
SIADH: Too Much ADH
Etiologies:
• CNS disease (hydrocephalus, meningitis, etc)
• Lung (pneumonia, RSV, etc)
• Nausea or Pain
• Cancer or Stem Cell transplantation
• Drugs (SSRI’s)
Should exclude:
• Thyroid, adrenal, cardiac, or renal disease
• Volume deficits / dehydration
Hyponatremia, inappropriately high urine Osm (>100)
Urine Na can be variable– usually “highish”
46
A 7 year-old girl presents for secondary enuresis. On
review of systems she has significant polyuria,
polydipsia, and severe daily headaches that awaken her
in the morning. Urinalysis in your office is negative for
glucose and ketones. The most likely set of laboratory
findings is:
Serum Na Urine Na
mEq/L
mEq/L
Serum Osm
mOsm/kg
Urine Osm
mOsm/kg
A
B
C
D
160
150
150
140
40
25
5
5
330
315
320
295
900
350
200
90
E
130
25
275
275
47
A 7 year-old girl presents for secondary enuresis. On
review of systems she has significant polyuria,
polydipsia, and severe daily headaches that awaken her
in the morning. Urinalysis in your office is negative for
glucose and ketones. The most likely set of laboratory
findings is:
Serum Na Urine Na
mEq/L
mEq/L
Serum Osm
mOsm/kg
Urine Osm
mOsm/kg
A
B
C
D
160
150
150
140
40
25
5
5
330
315
320
295
900
350
200
90
E
130
25
275
275
48
Diabetes Insipidus: Not Enough ADH
Or ADH not Effective
Etiologies:
• CNS disease (pituitary infiltration, damage)
• Drugs (lithium)
• Nephrogenic (V2 receptor or aquaporin defect)
• Others more rare
With access to water, just polyuria, polydipsia
Without access to water, hypernatremia, polyuria, polydipsia
Hypernatremic dehydration
• Inappropriately dilute urine
• Water deprivation test diagnostic but dangerous
• Response to DDAVP diagnostic of central DI
• Genetic testing for nephrogenic DI
49
An overweight 15 year old girl is admitted with polyuria and
severe dehydration. Severe hyperglycemia of 800 mg/dl
without ketoacidosis is discovered. Serum electrolytes are
significant for Na of 140, K of 4.3, Cl of 98, CO2 of 19, BUN
is 53, Creatinine is 1.6. Which of the following is NOT
true?
A. Excessive 0.9% NS may
re
su
lt
..
...
0%
n
ia
is
ca
th
e
us
e
pe
c
at
io
m
De
h
yd
r
ce
gly
0%
st
he
te
..
...
0%
ex
n
ca
Hy
pe
r
NA
ru
m
Se
be
ex
pe
be
ca
n
K
0%
ct
ed
e.
..
ay
NS
m
0.
9%
ru
m
E.
0%
Se
D.
ss
ive
C.
Ex
ce
B.
exacerbate the situation.
Serum K can be expected
to fall with rehydration
Serum NA can be expected
to rise with rehydration
Hyperglycemia causes the
lab equipment to
malfunction and produce
falsely low NA values
Dehydration is the result of
osmotic diuresis
50
6
Acid / Base
Mr. Osborne, may I be excused? My brain is full.51
A 6 month old girl born at term and with no apparent
illnesses presents with failure to thrive. She is mildly
tachypneic at rest. Lab evaluation is remarkable for serum
Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and
creatinine of 0.3 mg/dL. Which of the following is most
consistent with distal (type I) renal tubular acidosis (RTA)?
A
Urine
pH
6.5
Urine Urine Urine
Ca Citrate
K
High
Low
High
B
C
D
6.5
< 5.5
>7
Low
High
High
Low
Low
Low
High
High
High
> 0 (positive)
< 0 (negative)
> 0 (positive)
E
>7
Low
High
Low
< 0 (negative)
** CORRECTION
Urine Anion Gap
(Na+ + K+) - Cl> 0 (positive)
52
A 6 month old girl born at term and with no apparent
illnesses presents with failure to thrive. She is mildly
tachypneic at rest. Lab evaluation is remarkable for serum
Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and
creatinine of 0.3 mg/dL. Which of the following is most
consistent with distal (type I) renal tubular acidosis (RTA)?
A
Urine
pH
6.5
Urine Urine Urine
Ca Citrate
K
High
Low
High
Urine Anion Gap
(Na+ + K+) - Cl> 0 (positive)
B
C
D
6.5
< 5.5
>7
Low
High
High
Low
Low
Low
High
High
High
> 0 (positive)
< 0 (negative)
> 0 (positive)
E
>7
Low
High
Low
< 0 (negative)
53
Renal Tubular Acidosis
Associated with growth failure
Low anion gap metabolic acidosis
May be compensated by pulmonary hyperventilation
Urine anion gap should be positive: (Na+ + K+) > ClClinical pearls:
• Confirm metabolic acidosis with a VBG
• Distal RTA (type I) is most common
• Types I and II have hypokalemia
• Type IV has hyperkalemia (aldosterone defect)
• Can be treated with bicitra with varying success
54
Renal Tubular Acidosis: Urine Anion Gap
Na+
+ K+
__– Cl-____
Anion Gap
What is NOT
measured is
ammonium
(NH4+)
Na++K+ < ClUAG Negative
Non-renal acidosis
Carmody, PREP 2011
Na++K+ > ClUAG Positive
RTA
55
Renal Tubular Acidosis: Distal vs Proximal
Distal (type 1)
• Commonly associated with hypercalcURIA, stone risk
• Late nephron defect, urine pH “always”
• Low urine citrate
• Distal RTA (type I) can associate with deafness
Proximal (type 2)
• More rare
• Often associated with Renal Fanconi Syndrome
• Lower threshold of bicarbonate reabsorption
• Urine pH depends on plasma bicarbonate, may be < 5.5
56
An 8 year-old with type 1 diabetes mellitus is admitted to
the ICU with pneumonia. His blood sugar is 450 mg/dL,
serum Na is 133, K is 5.1, Cl 95, HCO3- 8. The most likely
acid-base disturbance is:
A
B
C
Normal anion gap metabolic acidosis
Low anion gap metabolic acidosis
High anion gap metabolic acidosis
D
E
High anion gap respiratory alkalosis
None of the above
57
An 8 year-old with type 1 diabetes mellitus is admitted to
the ICU with pneumonia. His blood sugar is 450 mg/dL,
serum Na is 133, K is 5.1, Cl 95, HCO3- 8. The most likely
acid-base disturbance is:
A
B
C
D
E
Normal anion gap metabolic acidosis
Low anion gap metabolic acidosis
High anion gap metabolic acidosis
High anion gap respiratory alkalosis
None of the above
Don’t forget– we ASSUMED the pH was low because
metabolic acidosis is so likely. We really need a blood gas
to know for sure!
58
High Anion Gap Metabolic Acidosis:
M:
U:
D:
P:
I:
L:
E:
S:
methanol (and metabolic diseases)
uremia
diabetes (ketoacids), d-lactic acidosis
(paraldehyde); propylene glycol
Isoniazid, Iron
Lactate
Ethanol, Ethylene glycol
Salicylates
59
A 3 day old male is referred to the ER by his pediatrician
because he seems mildly lethargic. Electrolytes are Na
140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40
and a rr of 52. A blood ammonia level is markedly
elevated. The MOST likely arterial blood gas result is:
A
B
pH
7.53
7.25
pCO2
15
55
paO2
134
81
BE
9
-3
C
D
7.21
7.48
31
52
106
85
-14
13
E None of the above
60
A 3 day old male is referred to the ER by his pediatrician
because he seems mildly lethargic. Electrolytes are Na
140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40
and a rr of 52. A blood ammonia level is markedly
elevated. The MOST likely arterial blood gas result is:
A
B
pH
7.53
7.25
pCO2
15
55
paO2
134
81
BE
9
-3
Interpretation
R. Alkalosis
R. Acidosis
C
D
7.21
7.48
31
52
106
85
-14
13
M. Acidosis
M. Alkalosis
E None of the above
61
A 10 year old girl with ALL and neutropenia after
chemotherapy develops shock. She has stable ventilatory
status but is mildly tachypneic. Electrolytes and an arterial
blood gas is obtained while she is provided isotonic fluid
boluses and dopamine infusion is prepared. The most
likely results of the ABG and plasma bicarbonate are:
A
B
pH
7.53
7.21
C
D
7.48
7.25
E
HCO3- pCO2
12
15
16
40
37
23
52
55
paO2
134
100
85
81
None of the above
62
A 10 year old girl with ALL and neutropenia after
chemotherapy develops shock. She has stable ventilatory
status but is mildly tachypneic. Electrolytes and an arterial
blood gas is obtained while she is provided isotonic fluid
boluses and dopamine infusion is prepared. The most
likely results of the ABG and plasma bicarbonate are:
A
B
pH
7.53
7.21
C
D
7.48
7.25
E
HCO3- pCO2
12
15
16
40
37
23
52
55
paO2 Interpretation
134 R. Alkalosis
100 M. Acidosis
85
81
M. Alkalosis
R. Acidosis
None of the above
63
A 10 year old with dilated cardiomyopathy is admitted with
pulmonary edema, intubated, and given 72 hours of
continuous IV furosemide. The laboratory results return:
pH
7.43
pCO2 HCO345
12
BE
paO2
-4
85
What is the best interpretation of these results?
A
B
C
Metabolic alkalosis due to diuretics
Respiratory alkalosis due to hyperventilation
Metabolic acidosis due to heart failure
D
E
Respiratory acidosis due to pulmonary edema
None of the above / Lab Error
64
A 10 year old with dilated cardiomyopathy is admitted with
pulmonary edema, intubated, and given 72 hours of
continuous IV furosemide. The laboratory results return:
pH
7.43
pCO2 HCO345
12
BE
paO2
-4
85
What is the best interpretation of these results?
A
B
C
Metabolic alkalosis due to diuretics
Respiratory alkalosis due to hyperventilation
Metabolic acidosis due to heart failure
D
E
Respiratory acidosis due to pulmonary edema
None of the above / Lab Error
65
A 6 month old boy develops diarrhea for 4 days. He appears
dehydrated and is given a bolus of 0.9% NS and promptly
produces a generous wet diaper. Electrolytes are obtained
with difficulty during the blood draw and return the following
values: Na 143, K 7.3, Cl 109, CO2 14, Ca is 10.1 mg/dl.
The next step in management is
A
B
Repeat the laboratory tests in 24 hours
Administer intravenous Calcium gluconate
C
D
Administer intravenous sodium bicarbonate
Begin intravenous D5 0.45% NS with 20 mEq KCl
per liter at 1.5 times maintenance rate
E
None of the above
66
A 6 month old boy develops diarrhea for 4 days. He appears
dehydrated and is given a bolus of 0.9% NS and promptly
produces a generous wet diaper. Electrolytes are obtained
with difficulty during the blood draw and return the following
values: Na 143, K 7.3, Cl 109, CO2 14, Ca is 10.1 mg/dl.
The next step in management is
A
B
Repeat the laboratory tests in 24 hours
Administer intravenous Calcium gluconate
C
D
Administer intravenous sodium bicarbonate
Begin intravenous D5 ½ 0.9% NS with 20 mEq KCl
per liter at 1.5 times maintenance rate
E
None of the above
67
A 9 year old boy is chronically treated with oral
furosemide for vascular congestion related to dilated
cardiomyopathy. All of the following electrolyte
disturbances are likely EXCEPT:
A
B
Hypokalemia
Hypophosphatemia
C
D
E
Hypocalcemia
Hyponatremia
Hypomagnesemia
68
A 9 year old boy is chronically treated with oral
furosemide for vascular congestion related to dilated
cardiomyopathy. All of the following electrolyte
disturbances are likely EXCEPT:
A
B
Hypokalemia
Hypophosphatemia
C
D
E
Hypocalcemia
Hyponatremia
Hypomagnesemia
69
Hyperkalemia can be induced by all of the following
medications EXCEPT:
A
B
Intravenous terbutaline
Epinephrine
C
D
E
Angiotensin converting enzyme inhibitor
Hydrochlorthiazide (HCTZ)
Spironolactone
70
Hyperkalemia can be induced by all of the following
medications EXCEPT:
A
B
Intravenous terbutaline
Epinephrine
C
D
E
Angiotensin converting enzyme inhibitor
Hydrochlorthiazide (HCTZ)
Spironolactone
71
UTI’s and So on…
72
An otherwise healthy, well-grown 4 year-old girl has had 3
febrile UTIs, the first at age 3 years. She has been taking
TMP/SMX since the 2nd UTI. Review of systems reveals
constipation. She has occasional enuresis but no frequency
or dysuria. Renal sonography and voiding cystourethrogram
(VCUG) are normal. Which of the following is likely to be
helpful in her evaluation and treatment?
A
B
C
D
E
Renal scintigraphy
Evaluation for immunodeficiency
Increase daily fluid intake to 2 – 2.5 liters/day
Prescribe stool softener & a regular bowel routine
Switch prophylaxis to nitrofurantoin
73
An otherwise healthy, well-grown 4 year-old girl has had 3
febrile UTIs, the first at age 3 years. She has been taking
TMP/SMX since the 2nd UTI. Review of systems reveals
constipation. She has occasional enuresis but no frequency
or dysuria. Renal sonography and voiding cystourethrogram
(VCUG) are normal. Which of the following is likely to be
helpful in her evaluation and treatment?
A
B
C
D
E
Renal scintigraphy
Evaluation for immunodeficiency
Increase daily fluid intake to 2 – 2.5 liters/day
Prescribe stool softener & a regular bowel routine
Switch prophylaxis to nitrofurantoin
74
A 3 month old male has a febrile UTI with E. Coli.
His renal ultrasound is negative. The best test to evaluate
for vesicoureteral reflux (VUR) is:
A
B
99Tc
C
Voiding cystourethrogram
D
E
Urodynamics study
Magnetic resonance (MR) urogram
DTPA renal scintigraphy
99Tc DMSA renal scintigraphy
75
A 3 month old male has a febrile UTI with E. Coli.
His renal ultrasound is negative. The best test to evaluate
for vesicoureteral reflux (VUR) is:
A
B
99Tc
C
Voiding cystourethrogram
D
E
Urodynamics study
Magnetic resonance (MR) urogram
DTPA renal scintigraphy
99Tc DMSA renal scintigraphy
76
All of the following statements about UTI are correct
EXCEPT:
A Under the age of 1 year, the risk of UTI in females is
greater than in males
B Circumcision of boys does not affect the risk of UTI
C The prevalence of UTI in febrile infants under 3
months of age and without an obvious source on
clinical examination is 5-10%
D The incidence of UTI in patients with abnormal urinary
tract anatomy is greater than in those with normal
urinary tract anatomy
E There is controversy whether a 1st UTI requires
evaluation if a prenatal sonogram was normal.
77
All of the following statements about UTI are correct
EXCEPT:
A Under the age of 1 year, the risk of UTI in females is
greater than in males
B Circumcision of boys does not affect the risk of UTI
C The prevalence of UTI in febrile infants under 3
months of age and without an obvious source on
clinical examination is 5-10%
D The incidence of UTI in patients with abnormal urinary
tract anatomy is greater than in those with normal
urinary tract anatomy
E There is controversy whether a 1st UTI requires
evaluation if a prenatal sonogram was normal.
78
An 8 month old male is found to have grade II VUR on the
right and grade IV VUR on the left with mild hydronephrosis.
Which of the following are immediately appropriate:
A Daily antibiotic prophylaxis
B Antibiotic prophylaxis and repeat VCUG in 6 months
C Antibiotic prophylaxis and schedule correction of VUR
by bilateral endoscopic injection of gel in the bladder
wall under the ureteral orifice
D Antibiotic prophylaxis and left ureteral reimplant
E None of the above
79
An 8 month old male is found to have grade II VUR on the
right and grade IV VUR on the left with mild hydronephrosis.
Which of the following are immediately appropriate:
A Daily antibiotic prophylaxis
B Antibiotic prophylaxis and repeat VCUG in 6 months
C Antibiotic prophylaxis and schedule correction of VUR
by bilateral endoscopic injection of gel in the bladder
wall under the ureteral orifice
D Antibiotic prophylaxis and left ureteral reimplant
E None of the above
80
Besides fever, signs and symptoms of UTI in infants include:
A Irritability
B Diarrhea
C Difficulty feeding
D Jaundice
E Any of the above
81
Besides fever, signs and symptoms of UTI in infants include:
A Irritability
B Diarrhea
C Difficulty feeding
D Jaundice
E Any of the above
82
An 8 year old boy in the 3rd grade develops secondary
nocturnal enuresis. On review of systems he has
constipation. When he was a newborn you had ordered a
spinal ultrasound and x-ray after noting a sacral dimple, and
both were normal. Urinalysis is negative for leukocyte
esterase and nitrates. The next most appropriate steps are:
A
B
C
D
Renal and bladder ultrasound
Spine MRI and referral to pediatric neurosurgery
Prescribe stool softener & a regular bowel routine
Referral to pediatric urology
E Reduce evening fluids & use a bedtime wetting alarm
83
An 8 year old boy in the 3rd grade develops secondary
nocturnal enuresis. On review of systems he has
constipation. When he was a newborn you had ordered a
spinal ultrasound and x-ray after noting a sacral dimple, and
both were normal. Urinalysis is negative for leukocyte
esterase and nitrates. The next most appropriate steps are:
A
B
C
D
Renal and bladder ultrasound
Spine MRI and referral to pediatric neurosurgery
Prescribe stool softener & a regular bowel routine
Referral to pediatric urology
E Reduce evening fluids & use a bedtime wetting alarm
84
Nephrology
85
A 3 year-old boy is referred to pediatric nephrology for
sudden onset of edema and 4+ proteinuria. True
statements about the nephrotic syndrome in this child
include:
A The majority of children will respond to corticosteroid
treatment within 1 week
B IV infusion of 25% albumin and furosemide will
decrease recovery time
C Progression to renal failure is likely
D Steroid response is predictive of renal histology
E A family history of nephrotic syndrome is common
86
A 3 year-old boy is referred to pediatric nephrology for
sudden onset of edema and 4+ proteinuria. True
statements about the nephrotic syndrome in this child
include:
A The majority of children will respond to corticosteroid
treatment within 1 week
B IV infusion of 25% albumin and furosemide will
decrease recovery time
C Progression to renal failure is likely
D Steroid response is predictive of renal histology
E A family history of nephrotic syndrome is common
87
A 14 year-old overweight girl has proteinuria 100 mg/dL on
two separate occasions, first noted during a screening
examination for summer camp. The remainder of the
urinalysis is normal and the blood pressure is normal. The
most appropriate next step in management is:
A Request a hemoglobin A1C
B Renal and bladder ultrasonography
C Request a urine culture
D Request a first morning urine protein and creatinine
E Request a 24 hour urine collection for protein
88
A 14 year-old overweight girl has proteinuria 100 mg/dL on
two separate occasions, first noted during a screening
examination for summer camp. The remainder of the
urinalysis is normal and the blood pressure is normal. The
most appropriate next step in management is:
A Request a hemoglobin A1C
B Renal and bladder ultrasonography
C Request a urine culture
D Request a first morning urine protein and creatinine
E Request a 24 hour urine collection for protein
89
A 14 year old boy has microscopic hematuria on a urinalysis
done for a school form. Family history is significant for his
mother having microscopic hematuria since childhood. A
maternal uncle required dialysis. Which of the following is
true of this boy’s condition?
A It is associated with conductive hearing loss
B It is associated with retinal abnormalities
C Immunoglobulin A levels are elevated in 50% of cases
D Female carriers are at risk of kidney failure
E Skin biopsy may reveal leukocytoclastic vasculitis
90
A 14 year old boy has microscopic hematuria on a urinalysis
done for a school form. Family history is significant for his
mother having microscopic hematuria since childhood. A
maternal uncle required dialysis. Which of the following is
true of this boy’s condition?
A It is associated with conductive hearing loss
B It is associated with retinal abnormalities
C Immunoglobulin A levels are elevated in 50% of cases
D Female carriers are at risk of kidney failure
E Skin biopsy may reveal leukocytoclastic vasculitis
91
A 14 year old boy has microscopic hematuria on a urinalysis
done for a school form. Family history is significant for his
father and a paternal grandparent having long-standing
microscopic hematuria. There is no family history of kidney
failure. There is no proteinuria. Blood pressure, urine
calcium, and renal/bladder sonography is normal. Which of
the following is true?
A There is an elevated risk of kidney stones
B Renal biopsy is indicated
C The glomerular basement membrane often appears
thick by electron microscopic examination.
D Female carriers are at risk of kidney failure
E None of the above
92
A 14 year old boy has microscopic hematuria on a urinalysis
done for a school form. Family history is significant for his
father and a paternal grandparent having long-standing
microscopic hematuria. There is no family history of kidney
failure. There is no proteinuria. Blood pressure, urine
calcium, and renal/bladder sonography is normal. Which of
the following is true?
A There is an elevated risk of kidney stones
B Renal biopsy is indicated
C The glomerular basement membrane often appears
thick by electron microscopic examination.
D Female carriers are at risk of kidney failure
E None of the above
93
A 3 day old male infant has been is brought to the ER for
blood in the diaper, which the family produces. The diaper
has multiple brick-red discolorations in the front. There is no
significant perinatal history. Exam finds a vigorous infant in
no distress with normal blood pressure. Bagged urinalysis
is negative for blood by dipstick and by microscopy. The
most likely cause of these findings is:
A Hemoglobinuria
B Sickle cell trait
C Calcium oxalate crystals
D Uric acid crystals
E Porphyria
94
A 3 day old male infant has been is brought to the ER for
blood in the diaper, which the family produces. The diaper
has multiple brick-red discolorations in the front. There is no
significant perinatal history. Exam finds a vigorous infant in
no distress with normal blood pressure. Bagged urinalysis
is negative for blood by dipstick and by microscopy. The
most likely cause of these findings is:
A Hemoglobinuria
B Sickle cell trait
C Calcium oxalate crystals
D Uric acid crystals
E Porphyria
95
Hematuria
Red Urine  Hematuria
See Harriet Lane list– favorites for the boards!
(eg beets, blackberries, urates, rifampin)
In reality, red urine that is not blood is not commonly
encountered in practice, except maybe red diaper
urates.
Important uncommon causes:
hemoglobinuria
myoglobinuria
96
A 16 year old boy develops sharp flank pain and gross
hematuria. Sonography shows multiple large “soap bubble”
cysts in each kidney. The mother reports that her mother,
who lived in a developing country, suffered from episodes of
painful blood in the urine and died with a kidney disease in
her 40’s. Which of the following is true?
A The disease is associated with hearing loss
B The disease is associated with intracranial aneurysms
C An older brother, age 20, has a normal sonogram and
therefore does not carry the gene
D Both parents are carriers of the gene
E This disease is found in about 1 in 5000 people
97
A 16 year old boy develops sharp flank pain and gross
hematuria. Sonography shows multiple large “soap bubble”
cysts in each kidney. The mother reports that her mother,
who lived in a developing country, suffered from episodes of
painful blood in the urine and died with a kidney disease in
her 40’s. Which of the following is true?
A The disease is associated with hearing loss
B The disease is associated with intracranial aneurysms
C An older brother, age 20, has a normal sonogram and
therefore does not carry the gene
D Both parents are carriers of the gene
E This disease is found in about 1 in 5000 people
98
Polycystic Kidney Disease
Autosomal Dominant PKD (ADPKD)
• More commonly affects adults
• Larger cysts, liver cysts
• Intracranial aneurysms
• Mitral valve prolapse, aortic root dilitation
• Common: affects about 1:1000
Autosomal Recessive PKD (ARPKD)
• More commonly affects infants
• Smaller cysts, liver fibrosis (ductal plate malformation)
• May need liver and/or kidney transplant
• Rare: affects about 1 in 20,000
99
2 days following a fall trip to a farm and apple cider press in
the country, a 3 year old boy develops bloody diarrhea
which his parents manage at home with fluids. The next
week, the is brought to the ER lethargic and pale. He has
not urinated in over 8 hours. Lab testing finds WBC of
26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum
creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following
statements about this condition are true EXCEPT:
A It is precipitated by infection with enteric bacteria
producing shiga toxin such as E. Coli O157:H7
B It is preventable by early treatment with antibiotics
C End stage renal failure is uncommon
D Recurrence is atypical
E Hypertension is common and may be severe
100
2 days following a fall trip to a farm and apple cider press in
the country, a 3 year old boy develops bloody diarrhea
which his parents manage at home with fluids. The next
week, the is brought to the ER lethargic and pale. He has
not urinated in over 8 hours. Lab testing finds WBC of
26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum
creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following
statements about this condition are true EXCEPT:
A It is precipitated by infection with enteric bacteria
producing shiga toxin such as E. Coli O157:H7
B It is preventable by early treatment with antibiotics
C End stage renal failure is uncommon
D Recurrence is atypical
E Hypertension is common and may be severe
101
A 4 month old girl is brought to the ER lethargic and pale.
She has not urinated in over 8 hours. Lab testing finds WBC
of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum
creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear
shows schistocytes and helmet cells. True statements about
this case include all of the following EXCEPT:
A Defective complement system regulation is likely
B
C
D
E
Hypertension is common and may be severe
End stage renal failure is common
Recurrence is common
Treatment is symptomatic
102
A 4 month old girl is brought to the ER lethargic and pale.
She has not urinated in over 8 hours. Lab testing finds WBC
of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum
creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear
shows schistocytes and helmet cells. True statements about
this case include all of the following EXCEPT:
A Defective complement system regulation is likely
B
C
D
E
Hypertension is common and may be severe
End stage renal failure is common
Recurrence is common
Treatment is symptomatic
103
A 6 year-old girl develops tea-colored urine. Urine dip finds
4+ blood and 3+ protein. There is mild edema present
and the blood pressure is 114/74. Review of systems is
negative. Her twin brother currently has fever and a sore
throat. Which of the following statements is CORRECT?
A. Complement C3 & C4 may
..
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te
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n
is
n
an
un
co
d
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rh
e.
es
sio
pr
og
r
pi
d
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.
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f
h
hi
g
sa
ei
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r is
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en
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remain low for 4-6 weeks
The brother can be protected
from the same condition by
prompt antibiotic treatment
The is a high risk of
rheumatic heart disease also
Rapid progression and need
for dialysis is uncommon and
requires renal bipsy
Hypertension is uncommon
and requires renal biopsy
104
6
A 14 year old boy is uncharacteristically tired in the
afternoons and appears somewhat pale to his mother.
Laboratory findings consistent with chronic kidney disease
with decreased glomerular filtration rate (GFR) include:
MCV = mean corpuscular volume
PTH = parathyroid hormone
A
B
MCV
Low
Normal
Na
Normal
Low
Ca
High
Low
PTH
High
Low
HCO3Low
High
C
D
Normal
High
Normal
High
Low
Normal
High
Low
Low
Low
E
Low
Normal
Low
Normal
Low
105
A 14 year old boy is uncharacteristically tired in the
afternoons and appears somewhat pale to his mother.
Laboratory findings consistent with chronic kidney disease
with decreased glomerular filtration rate (GFR) include:
MCV = mean corpuscular volume
PTH = parathyroid hormone
A
B
MCV
Low
Normal
Na
Normal
Low
Ca
High
Low
PTH
High
Low
HCO3Low
High
C
D
Normal
High
Normal
High
Low
Normal
High
Low
Low
Low
E
Low
Normal
Low
Normal
Low
106
A 7 year-old boy with a history of posterior urethral
valves and stage 3 CKD has short stature. All of the
following factors commonly contribute to short stature
in children with CKD EXCEPT:
IGF: insulin-like growth factor
A Growth hormone deficiency
B Resistance to growth hormone
C Decreased bioavailability of IGF-1 due to increased
IGF binding proteins
D Vitamin D deficiency and renal osteodystrophy
E Nutritional disturbances
107
A 7 year-old boy with a history of posterior urethral
valves and stage 3 CKD has short stature. All of the
following factors commonly contribute to short stature
in children with CKD EXCEPT:
IGF: insulin-like growth factor
A Growth hormone deficiency
B Resistance to growth hormone
C Decreased bioavailability of IGF-1 due to increased
IGF binding proteins
D Vitamin D deficiency and renal osteodystrophy
E Nutritional disturbances
108
A newborn has a sonogram due to an abnormal prenatal
sonogram. The left kidney is bit large but otherwise normal.
The right kidney has multiple cystic areas and abnormal
cortex. The right side shows no uptake on nuclear renal
scan. All of the following statements are correct EXCEPT:
A
B
C
D
Vesicoureteral reflux is a common finding
Genetic testing is not likely to be useful
The left kidney will eventually develop cysts and fail
There is an increased risk of hypertension
E ALL of the above are correct
109
A newborn has a sonogram due to an abnormal prenatal
sonogram. The left kidney is bit large but otherwise normal.
The right kidney has multiple cystic areas and abnormal
cortex. The right side shows no uptake on nuclear renal
scan. All of the following statements are correct EXCEPT:
A
B
C
D
Vesicoureteral reflux is a common finding
Genetic testing is not likely to be useful
The left kidney will eventually develop cysts and fail
There is an increased risk of hypertension
E ALL of the above are correct
110
The parents of a 15 year-old followed in the renal clinic for
advancing kidney disease ask your advice about what will
happen as his kidneys fail. All of the following are true
about End Stage Renal Disease (ESRD) EXCEPT:
A A kidney from a live donor is usually better than from a
deceased donor.
B Hemodialysis does not replace all of the function of
the kidneys
C Peritoneal dialysis is usually done at home
D Nutritional restrictions frequently include potassium,
phosphorus, and sodium.
E All of the above are true
111
The parents of a 15 year-old followed in the renal clinic for
advancing kidney disease ask your advice about what will
happen as his kidneys fail. All of the following are true
about End Stage Renal Disease (ESRD) EXCEPT:
A A kidney from a live donor is usually better than from a
deceased donor.
B Hemodialysis does not replace all of the function of
the kidneys
C Peritoneal dialysis is usually done at home
D Nutritional restrictions frequently include potassium,
phosphorus, and sodium.
E All of the above are true
112
Blood Pressure and
Hypertension
113
A 9 year-old girl with no symptoms has BP 145-165 / 90-100
discovered on a routine physical and confirmed several
times. The remainder of her examination is normal. True
statements about this case include:
A Two additional measurements of BP are required to
make the diagnosis of hypertension
B The most likely diagnosis is essential hypertension
C Best initial treatment is intravenous nicardipine
infusion to lower the BP to normal
D Normal renal ultrasonography can rule out renal and
renovascular causes of hypertension.
E The elevated blood pressure is likely long-standing
114
A 9 year-old girl with no symptoms has BP 145-165 / 90-100
discovered on a routine physical and confirmed several
times. The remainder of her examination is normal. True
statements about this case include:
A Two additional measurements of BP are required to
make the diagnosis of hypertension
B The most likely diagnosis is essential hypertension
C Best initial treatment is intravenous nicardipine
infusion to lower the BP to normal
D Normal renal ultrasonography can rule out renal and
renovascular causes of hypertension.
E The elevated blood pressure is likely long-standing
115
All of the following statements about normal blood pressure
in children are true EXCEPT:
A Normal BP increases with age during childhood
B
C
D
E
Boys normally have higher BP than girls
Normal BP is higher in taller children
Normal BP is higher in overweight and obese children
ALL of the above are true statements
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All of the following statements about normal blood pressure
in children are true EXCEPT:
A Normal BP increases with age during childhood
B
C
D
E
Boys normally have higher BP than girls
Normal BP is higher in taller children
Normal BP is higher in overweight and obese children
ALL of the above are true statements
Increased BP with height is physiologic and normal.
Increased BP with obesity is pathophysiological and abnormal.
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Blood Pressure Tables
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Blood Pressure Tables
PEDIATRICS Vol. 114 No. 2 August 2004, pp. 555-576
119
4th Report BP Designations
Percentile
Designation (Diastolic or Systolic)
< 90th
Normal
90th to 95th
“pre-hypertension”
95th to 99th + 5
Hypertension (“stage 1”)
Over 99th + 5
Severe hypertension (“stage 2”)
120
A 9 year-old girl with asymptomatic stage 2 HTN is
evaluated first by renal sonography then by magnetic
resonance arteriography. A long right-sided renal arterial
narrowing with high velocities is suspicious for renal artery
stenosis. She was not in the NICU after birth and never had
central venous nor arterial access. The MOST likely etiology
of this disease is:
A Tuberous sclerosis
B Neurofibromatosis
C Williams Syndrome
D Bartter Syndrome
E Fibromuscular dysplasia
121
A 9 year-old girl with asymptomatic stage 2 HTN is
evaluated first by renal sonography then by magnetic
resonance arteriography. A long right-sided renal arterial
narrowing with high velocities is suspicious for renal artery
stenosis. She was not in the NICU after birth and never had
central venous nor arterial access. The MOST likely etiology
of this disease is:
A Tuberous sclerosis
B Neurofibromatosis
C Williams Syndrome
D Bartter Syndrome
E Fibromuscular dysplasia
122
A 13 year old girl with a BMI in the 96th percentile is
referred for stage 1 HTN. Initial management should
include all of the following EXCEPT:
A Therapeutic lifestyle changes
B Evaluation of lipid levels
C Urinalysis
D Thorough review of possible diet supplements, overthe-counter medications, caffeine intake, and illicit
drug use
E Renal angiography
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A 13 year old girl with a BMI in the 96th percentile is
referred for stage 1 HTN. Initial management should
include all of the following EXCEPT:
A Therapeutic lifestyle changes
B Evaluation of lipid levels
C Urinalysis
D Thorough review of possible diet supplements, overthe-counter medications, caffeine intake, and illicit
drug use
E Renal angiography
Just making a point here– obesity-related HTN is common and
frequently responds to diet and exercise (TLC). Don’t forget these
other items– all are fair game for questions.
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Keep Studying and Good Luck!
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