1. CASE STUDIES

2. A 5-year-old, formerly healthy female child is seen in emergency department with an onset of vomiting. On physical examination the child is tachypneic (respirations of 55 breaths per minute), febrile (temperature of 38°C), sleepy, and difficult to arouse. The parents explain they are visiting the child’s grandparents. Serum laboratory results are Na + : 148 mEq/L, K + : 3.9 mEq/L, Cl - : 98 mEq/L, glucose: 45 mg/dl, anion gap: 26, BUN: 16 mg/dl, creatinine: 0.3 mg/dl. Arterial blood arterial gas pH: 7.23, PaCO 2 : 18, PaO 2 : 88, HCO 3 - : 18 mEq/L, BE: -14.0. Which of the following is true about this patient’s blood gas analysis? a)Respiratory acidosis with increased anion gap b)Metabolic acidosis with normal anion gap c)Metabolic acidosis with increased anion gap d)Respiratory alkalosis with increased anion gap e)Respiratory alkalosis with normal anion gap

3. Answer: Metabolic acidosis with increased anion gap (c)

4. An infant seven months of age who have vomiting, diarrhea, and malaise for three days was brought to emergency department. He is dehydrated, tachycardic (160/min), tachypneic (52/min), but not dyspneic, and his breath sounds is normal. He has sunken eyes and fontanel, and decreased turgor. His capillary refill time is three second, and blood pressure is 65/45 mmHg. He has not organomegaly in physical examination. His venous blood gases are: pH: 7.11, PCO 2 : 32 mmHg, HCO3: 9 mEq/L, and base excess: - 9. Which of the following is most appropiate option to describe the clinical status of this infant? a) Metabolic alcalosis b) Respiratory alcalosis c) Respiratory acidosis d) Metabolic acidosis e) Respiratory alcalosis and metabolic acidosis

5. Answer: Metabolic acidosis (d)

6. An infant 1.5 months of age who have recurrent vomiting, and malaise for three days was brought to emergency department. He is dehydrated, tachycardic (160/min), tachypneic (52/min), but not dyspneic, and his breath sounds is normal. He has sunken eyes and fontanel, and decreased turgor. His capillary refill time is three second, and blood pressure is 65/45 mmHg. He has not organomegaly in physical examination. His venous blood gases are: pH: 7.51, PCO 2 : 40 mmHg, HCO3: 27 mEq/L, and base excess: + 9. Which of the following is most appropiate option to describe the clinical status of this infant? a)Metabolic alcalosis b)Respiratory alcalosis c)Respiratory acidosis d)Metabolic acidosis e)Respiratory alcalosis and metabolic acidosis

7. Answer: Metabolic alcalosis (a)

8. A child five years old was brought with dry and red dermis, restlessness, mydriasis, decreased bowel sounds, urinary retention Which of the following is most appropiate for this clinical findings? a)Cholinergics – Insecticids b)Symphatomimetics – Theophyllin c)Anticholinergics- Antihistaminics d)Opiates-Methadon e)Antipiretics-Paracetamol

9. Answer: Anticholinergics- Antihistaminics (c)

10. Which of the following intoxication is appropriate for treatment with active carbon? a)Iron b)Lead c)Caustic agents d)Antihistaminic drugs e)Alcohol

11. Answer: Antihistaminic drugs (d)

12. A 3-year-old, formerly healthy male toddler is seen in clinic with an onset of vomiting. On physical examination the child is tachypneic (respirations of 60 breaths per minute), febrile (temperature of 38°C), sleepy, and difficult to arouse. The parents explain they are visiting the child’s grandparents. Serum laboratory results are Na + : 150 mEq/L, K + : 2.9 mEq/L, Cl - : 99 mEq/L, HCO 3 - : 18 mEq/L, glucose: 45 mg/dl, anion gap: 26, BUN: 16 mg/dl, creatinine: 0.3 mg/dl. Blood arterial gas pH: 7.25, PCO 2 : 15, PO 2 : 88, BE: -18.0. Which of the following is true about this patient’s blood gas analysis? a)Respiratory acidosis with increased anion gap b)Metabolic acidosis with normal anion gap c)Metabolic acidosis with increased anion gap d)Respiratory alkalosis with increased anion gap e)Respiratory alkalosis with normal anion gap

13. Answer: Metabolic acidosis with increased anion gap

14. A 3-year-old child is brought to the emergency room 3 hours after he was found playing with an open kerosene bottle. The parents state the child initially had some gagging and coughing and within an hour developed labored breathing. At the time of your evaluation though, the child’s examination is completely normal. What is the most appropriate action at this time? a)Discharge to home, advise parents to return if they note any problems b)Obtain a chest x-ray c)Observe child in emergency room for 1 hour d)Induce emesis with syrup of ipecac e)Admit to the hospital for 24 hours of observation

15. Answer: Obtain a chest x-ray

16. A 4-year-old boy was found playing with an open bottle of drain cleaner about 1 hour ago. His mother reports that he now resuses to drink and talk but appears alert though anxious. You should advise the mother to do which of the following? a)Administer syrup of ipecac b)Closely observe the child and bring to the emergency room if condition worsens c)Administer milk of magnesia d)Give the child cold frozen fruit popsicles e)Immediately bring the child to the emergency room for evaluation

17. Answer: Immediately bring the child to the emergency room for evaluation

18. Directions (Questions 16 through 25): The following group of questions is preceded by a list of lettered answer options. This is an extended-match question. For each question, match the one lettered option that is most closely associated with the question. Each lettered option may be selected once, multiple times, or not at all. Questions 16 through 25 Naloxone Flumazenil N-acetylcysteine Ethanol or 4-methylpyrazole Deferoxamine Sodium bicarbonate Atropine Sodium nitrite and sodium thiosulfate and amil nitrate Methylene blue 16. organophosphates 17. cyanide 18. tricyclic antidepressants 19. benzodiazepines 20. ethylene glycol 21. paracetamol or acetaminophen 22. methemoglobinemic agents 23. opioids 24. methanol 25. iron

19. Answers: (A): 23 (B): 19 (C): 21 (D): 20 and 24 (E): 25 (F): 18 (G): 16 (H): 17 (İ): 22

20. For toxic-appearing 3-36 month of age who do not have focal signs of infection with a rectal temperature of ≥39°C, options include.................................................................................................................................... Which of the following choice is most appropriate for empty space in the sentence above? obtaining a blood culture and administering empirical antibiotic therapy (ceftriaxone, a single dose of 50 mg/kg, not to exceed 1 g); if the WBC count is >15,000/µL, obtaining a blood culture and beginning empirical antibiotic therapy; or obtaining a blood culture and observing as outpatients without empirical antibiotic therapy, with return for re-evaluation within 24 hr. prompt hospitalization and immediate parenteral antimicrobial therapy after cultures of blood, urine, and CSF are obtained. Clindamycin (to cover anaerobic bacteria) plus a macrolid antibiotic should be initiated as an antimicrobial treatment. antibiotherapy should be administered by oral route after sepsis evaluation. laboratory evaluation including blood, urine and CSF studies, and roentgenographic studies is not required.

21. Answer: Prompt hospitalization and immediate parenteral antimicrobial therapy after cultures of blood, urine, and CSF are obtained.(b)

22. Treatment of nontoxic-appearing febrile children 3-36 mo of age who do not have focal signs of infection includes …………………………………………………………………………………………………………………………………………….. Which of the following choice is most appropriate for empty space in the sentence above? a) hospitalization and prompt institution of antimicrobial therapy after specimens of blood, urine, and cerebrospinal fluid are obtained for culture. b) Clindamycin (to cover anaerobic bacteria) plus a macrolid antibiotic should be initiated as an antimicrobial treatment. c) a full sepsis evaluation should be performed, and intravenous antibiotics should be administered immediately. d) obtaining a blood culture and observing as outpatients without empirical antibiotic therapy, with return for re- evaluation within 24 hr. e) laboratory evaluation including blood, urine and cerebrospinal fluid studies, and roentgenographic studies must required.

23. Answer: obtaining a blood culture and observing as outpatients without empirical antibiotic therapy, with return for re-evaluation within 24 hr. (d)