49.

(C) An earlier symptom of vitamin A deficiency is delayed dark adaptation, as

a result of reduced resynthesis of rhodopsin; this may progress to night
blindness.
50.(E) The mainstay of the initial treatment is aggressive therapy with normal
saline, often in conjunction with a loop diuretic to further increase calcium
excretion; this is often adequate for treating mild or moderate hypercalcemia.
51.(A) Thiamine is water soluble and heat labile; most of the vitamin is lost
when the rice is repeatedly washed and the cooking water is discarded.
52.(D) Ataxia with isolated vitamin E deficiency (AVED), a rare autosomal
recessive disorder, there are mutations in the gene for α-tocopherol transfer
protein (TTPA). Because children with AVED do not have symptoms of
malabsorption, a correct diagnosis requires a high index of suspicion. Patients
with this disorder are unable to incorporate vitamin E into lipoproteins before
their release from the liver, leading to reduced serum levels of vitamin E. There
is no associated fat malabsorption, and absorption of vitamin E from the
intestine occurs normally.
53.(A) There are few natural dietary sources of vitamin D. Fish liver oils have a
high vitamin D content. Other good dietary sources include fatty fish and egg
yolks. Most children in industrialized countries receive vitamin D via fortified
foods, especially formula and milk (both of which contain 400 IU/L) and some
breakfast cereals and breads.
54.(A) Breast milk has a low vitamin D content, approximately 12-60 IU/L.
55.(B) Vitamin D deficiency most frequently occurs in infancy because of a
combination of poor intake and inadequate cutaneous synthesis.
56.(B) Transplacental transport of vitamin D, mostly 25-D, typically provides
enough vitamin D for the 1st 2 mo of life unless there is severe maternal vitamin
D deficiency.
57.(C) In chronic kidney disease, unlike the other causes of vitamin D deficiency,
patients have hyperphosphatemia as a result of decreased renal excretion.
58.(B) McCune Albright syndrome, an entity that includes the triad of
polyostotic fibrous dysplasia, hyperpigmented macules, and polyendocrino-
pathy. Affected patients have inappropriately low levels of 1,25-D and elevated
ALP levels.
59.(A) Most infants with rickets of prematurity have no clinical manifestations,
and the diagnosis is based on radiographic and laboratory findings. Rickets of
prematurity occurs 1-4 mo after birth. Infants can have nontraumatic fractures.
Some infants have respiratory distress from atelectasis and poor ventilation.
These infants have poor linear growth. There may be classic rachitic findings,
57
such as frontal bossing, rachitic rosary, craniotabes, and widened wrists and
ankles
60.(A) Hypervitaminosis D is caused by excessive intake of vitamin D. It can
occur with long-term high intake or with a substantial, acute ingestion. Most
cases are secondary to misuse of prescribed or nonprescription vitamin D
supplements, but other cases have been secondary to accidental
overfortification of milk, contamination of table sugar, and inadvertent use of
vitamin D supplements as cooking oil. Vitamin D intoxication is never secondary
to excessive exposure to sunlight.
61.(B) The recommended upper limits for long-term vitamin D intake are 1,000
IU for children <1 yr old and 2,000 IU for older children and adults.
62.(C) The classic findings in vitamin D intoxication are hypercalcemia, elevated
levels of 25-D (>100 ng/mL), hypercalciuria, and suppressed PTH.
Hyperphosphatemia is also common. Hypercalciuria can lead to
nephrocalcinosis, which is visible on renal ultrasound. Surprisingly, levels of
1,25-D are usually normal. Anemia is sometimes present; the mechanism is
unknown.

58
Chapter 6
Fluid and Electrolyte Disorders
Questions
KHALID ALAARJI
1. A 6-month-old infant waiting for surgery, should begin receiving maintenance
IV fluids within
A. 4 hr of the last feeding
B. 6 hr of the last feeding
C. 8 hr of the last feeding
D. 10 hr of the last feeding
E. 12 hr of the last feeding

2. What is the percentile of body weight for height to calculate the maintenance
IV fluid in an overweight child?
A. 10th
B. 25th
C. 50th
D. 75th
E. 90th

3. The upper limit of maintenance IV fluid in an overweight child (adult-sized

patients) is
A. 1L/24 hr
B. 1.6L/24 hr
C. 2L/24 hr
D. 2.4L/24 hr
E. 3L/24 hr

4. Calculating daily maintenance fluid volume for children weighing 11-20 kg is

A. 100 mL/kg
B. 150 mL/kg
C. 1,000 mL + 50 mL/kg for each kg >10 kg
D. 1,000 mL + 20 mL/kg for each kg >10 kg
E. 1,500 mL + 20 mL/kg for each kg >10 kg
59
5. Which of the following intravenous solutions is composed from Na+ (77
meq/L) and Cl− (77 meq/L)?
A. Normal saline (0.9% NaCl)
B. ½ normal saline (0.45% NaCl)
C. 0.2 normal saline (0.2% NaCl)
D. ½ Glucose saline
E. Ringer lactate

6. Administration of 0.2 NS (osmolality=68) peripherally as maintenance therapy

is contraindicated due to risk of
A. hemolysis
B. hyponatremia
C. hypernatremia
D. brain edema
E. central pontine myelinolysis

7. As maintenance IV fluid, surgical patients during surgery and in the recovery

room for 6-8 hr postoperatively typically should receive
A. normal saline (0.9% NaCl)
B. ½ normal saline (0.45% NaCl)
C. 0.2 normal saline (0.2% NaCl)
D. ½ glucose saline
E. 5% dextrose

8. The BEST solution for replacement of ongoing losses in a 3-year-old child

presented with diarrhea and a limited ability to take oral fluid is
A. Ringer lactate
B. normal saline + 10 mEq/L KCl
C. ½ normal saline + 10 mEq/L KCl
D. NS + 30 mEq/L sodium bicarbonate + 20 mEq/L KCl
E. D5 ½ NS + 30 mEq/L sodium bicarbonate + 20 mEq/L KCl

9. A 15-year-old girl admitted to the hospital for evaluation; investigation

reveals serum Na+ (131 mEq/L), serum K+ (2.6 mEq/L), serum Cl- (82 mEq/L),
BUN (42 mg/dl), and serum creatinine (0.9 mg/dl), pH (7.52), HCO3− (41 mEq/L),
PCO2 (51 mm Hg) and urine for [Cl−] (25 mEq/L)
Of the following, the MOST likely diagnosis is
A. frequent emesis
60
 B. chloride-losing diarrhea
C. low chloride formula
D. Gitelman syndrome
E. cystic fibrosis

10. Which of the following is a feature of mild dehydration?

A. Thirst
B. Tachycardia
C. Lethargy
D. Sunken fontanel
E. Decreased tears

11. Which of the following is a clue to severe dehydration?

A. Cold and mottled skin
B. Oliguria
C. Sunken eyes and fontanel
D. Dry mucous membranes
E. Irritability

12. An 18-hour-old newborn with normal vaginal delivery without complication

admitted to NICU with repeated apneic attacks and hypotonia with history of
severe maternal preeclampsia treated with IV magnesium and hydralazine; O/E
floppy, decrease deep tendon reflexes, and hypotension. ECG shows prolonged
PR interval, QRS complex, and QT interval.
Of the following, the MOST likely diagnosis is
A. perinatal asphyxia
B. early onset sepsis
C. hypermagnesemia
D. hypocalcemia
E. Werdnig-Hoffmann disease

13. A 15-year-old girl presents to emergency unit with breathlessness and chest
pain; ECG and chest radiograph are normal; yesterday she was notified with
school failure.
Of the following, the MOST likely arterial blood gases in this condition is
A. pH (7.09), HCO3− (28 mEq/L), PCO2 (68 mm Hg)
B. pH (7.12), HCO3− (14 mEq/L), PCO2 (65 mm Hg)
C. pH (7.35), HCO3− (20 mEq/L), PCO2 (45 mm Hg)
61
 D. pH (7.55), HCO3− (16 mEq/L), PCO2 (18 mm Hg)
E. pH (7.52), HCO3− (40 mEq/L), PCO2 (48 mm Hg)

14. An 11-month-old baby, who has small bowel resection at age of 2 months
brought to emergency unit with seizure; Examination shows failure to thrive
and seatorrhea; serum calcium (6.5 mg/dl); treated with IV infusion of 10%
calcium gluconate 10 ml but still no response. ECG shows flattening of the T
wave and lengthening of the ST segment.
Of the following, the MOST likely explanation is
A. incorrect dose
B. hypoparathyroidism
C. hypomagnesemia
D. hyperphosphatemia
E. hyponatremia

15. An 18-month-old child presents with history of vomiting, diarrhea, and

decreased urine output. Examination shows irritable child with capillary refill of
2 sec, dry mucous membranes, and tachycardia.
Of the following, the MOST likely percent of dehydration is
A. <3%
B. 3-6 %
C. 7-9%
D. 10–12%
E. >12%

16. A 12-month-old infant presents with vomiting, diarrhea, and no urine

output. Examination shows depressed consciousness with capillary refill of 4 sec
and very sunken eyes.
Of the following, the BEST initial fluid therapy is
A. 0.9% NS
B. ½ NS
C. ¼ NS
D. 0.2 NS
E. ½ GS

17. Which of the following should be avoided in a child with isolated vomiting?
A. Isotonic NS
B. Ringer lactate
62
 C. ½ NS
D. ½ GS
E. 0.2 NS

18. A 7-year-old girl admitted to intensive care unit for management of Guillain-
Barré syndrome, at morning of 7th day, the patient develops severe headache
and repeated vomiting; O/E well hydrated, afebrile, no neck stiffness, and blood
pressure 100/60 mm Hg; serum Na+ (120 mEq/L), serum K+ (4.1 mEq/L), serum
Chloride (75 mEq/L), blood glucose (98 mg/dl), BUN 20 mg/dl), serum creatinine
(0.5 mg/dl), and urine sodium (80 mEq/L).
Of the following, the MOST likely explanation of this condition is
A. meningitis
B. side effect of IVIG
C. syndrome of inappropriate antidiuretic hormone secretion
D. cerebral salt wasting
E. acute tubular necrosis

19. A 4-month-old girl present with sudden onset of rapid deep breathing and
mild dehydration; serum Na+ (145 mEq/L), serum K+ (6 mEq/L), serum Cl- (90
mEq/L), pH (7.11), HCO3− (10 mEq/L), lactate 4 mmol/L and PCO2 (23 mm Hg)
Of the following, the MOST likely cause is
A. diarrhea
B. distal (type I) RTA
C. proximal (type II) RTA
D. urinary tract diversion
E. isovelaric acidemia

20. Which of the following is a risk factor for hyponatremic dehydration in

children with diarrhea?
A. Consumption of diluted formula
B. Inability to take oral fluid
C. Poor thirst mechanism
D. Intractable emesis
E. Hyperpyrexia

21. Hyponatremia is defined as serum sodium less than

A. 125 mEq/L
B. 130 mEq/L
63
 C. 135 mEq/L
D. 140 mEq/L
E. 145 mEq/L

22. In hyponatremic dehydration, the serum sodium SHOULD NOT be corrected

more than
A. 10 mEq/L/24 hr
B. 12 mEq/L/24 hr
C. 14 mEq/L/24 hr
D. 16 mEq/L/24 hr
E. 18 mEq/L/24 hr

23. A bottle fed 18-month-old boy presents with history of vomiting and
diarrhea. Examination shows severe degree of dehydration; serum Na+ (126
mEq/L), serum K+ (4.5mEq/L), pH (7.25), HCO3 (14 mEq/L), and PCO2 30 mm
Hg; he received IV fluid therapy and after 12 hours, the patient became
confused and agitated. Serum electrolytes were done revealing serum Na+ (145
mEq/L), serum K+ (3.7mEq/L), serum Ca+ (8.7 mg/dl), and blood glucose (98
mg/dl).
Of the following, the MOST likely cause of his deterioration is
A. cerebral edema
B. central pontine myelinolysis
C. arrhythmias
D. brain herniation
E. intracranial hemorrhage

24. An 11-month-old bottle fed infant was brought to emergency unit with
tonic-clonic seizure. He complains from vomiting and diarrhea with excessive
water intake for the last 3 days. Examination shows moderate degree of
dehydration; serum Na + (116 mEq/L), serum K+ (3.8mEq/L), serum Ca+ (8.7
mg/dl), and blood glucose (98 mg/dl).
Of the following, the FIRST line of treatment is
A. 0.9% NS
B. 3% NS
C. Ringer lactate
D. ½ NS
E. 0.2 NS

64
25. A 10-month-old infant presents with frequent loose bowel motions and
excessive thirst over the past 24 hours. Examination shows restlessness, sunken
eyes, and skin pinch goes back slowly.
Of the following, the MOST appropriate therapy is
A. IV normal saline (0.9% NaCl)
B. IV ½ normal saline + 10 mEq/L KCl
C. IV D5 ½ NS + 30 mEq/L sodium bicarbonate
D. Standard oral rehydration solution (ORS)
E. Low osmolarity ORS

26. An 18-month-old bottle fed girl was presented with vomiting and diarrhea.
Examination showed moderate degree of dehydration; serum Na+ (172 mEq/L),
serum K+ (4.5mEq/L), pH (7.25), HCO3 (14 mEq/L), and PCO2 30mm Hg; she
received IV fluid therapy and after 12 hours, the patient develops convulsion
with decerebrate posture, repeat serum electrolyte reveals; serum Na+ (156
mEq/L), serum K+ (3.7 mEq/L), serum Ca+ (8.7 mg/dl), and blood glucose (98
mg/dl).
Of the following, the MOST likely cause of his deterioration is
A. cerebral edema
B. central pontine myelinolysis
C. arrhythmia
D. renal failure
E. intracranial hemorrhage

27. A 14-month-old bottle fed girl presents with vomiting and diarrhea for the
last 24 hours. Examination shows an irritable child with doughy skin and
capillary refill of 3 seconds; serum Na+ (160 mEq/L), serum K+ (4.1 mEq/L), BUN
(110 mg/dl), and serum creatinine (1.3 mg/dl).
Of the following, the BEST initial fluid therapy is
A. Isotonic N S
B. ½ N S
C. ¼ N S
D. 0.2 N S
E. Ringer lactate

28. A 5-year-old child admitted to emergency unit with rapid deep breathing,
polyuria, polydipsia, and dehydration for the last 2 weeks; serum Na + (110
mEq/L) and serum osmolality 320 mOsm/kg.
65
Of the following, the MOST likely cause of hyponatremia is
A. leukocytosis
B. increased blood urea
C. acidosis
D. increased blood glucose
E. water depletion

29. A 9-month-old girl presents with vomiting and diarrhea for the last 24 hours.
Examination shows an irritable child with doughy skin and capillary refill of 3
seconds; serum Na+ (168 mEq/L), serum K+ (4.1 mEq/L), BUN (110 mg/dl), and
serum creatinine (1.3 mg/dl); the patient shows improvement on two shots of
isotonic N S (each 20 mL/kg over 20 min) and has passed urine.
Of the following, the NEXT step in management is administration of
A. oral rehydration solution
B. 5% dextrose + ½ normal saline over 24 hr
C. 5% dextrose + ½ normal saline over 48 hr
D. 5% dextrose + ¼ normal saline over 24 hr
E. 5% dextrose + ¼ normal saline over 48 hr

30. A 9-month-old girl presents with rapid deep breathing and mild
dehydration; serum Na+ (132 mEq/L), serum K+ (3 mEq/L), serum Cl- (114
mEq/L), pH (7.05), HCO3− (12 mEq/L), and PCO2 (25 mm Hg).
Of the following, the MOST likely cause is
A. lactic acidosis
B. diabetic ketoacidosis
C. renal tubular acidosis
D. renal failure
E. proprionic acidemia

31. In acute respiratory acidosis; each 10 mm Hg increase in PCO2 is

compensated by increase plasma bicarbonate of
A. 1
B. 1.5
C. 2
D. 2.5
E. 3

66
32. A 6-month-old infant is evaluated for failure to thrive, has past history of
frequent hospital admissions because of repeated vomiting, dehydration, and
increased urine output with constipation; abdominal ultrasound reveals
nephrocalcinosis; serum K+ (2mmol/L).
Of the following, the EXPECTED arterial blood gases of this patient is
A. pH (7.09), HCO3− (28 mEq/L), PCO2 (68 mm Hg)
B. pH (7.12), HCO3− (14 mEq/L), PCO2 (65 mm Hg)
C. pH (7.35), HCO3− (20 mEq/L), PCO2 (45 mm Hg)
D. pH (7.50), HCO3− (16 mEq/L), PCO2 (25 mm Hg)
E. pH (7.52), HCO3− (40 mEq/L), PCO2 (40 mm Hg)

33. Evaluation of a 6-month-old infant with failure to thrive reveals serum Na+
(128 mEq/L), serum K+ (2.3 mEq/L), serum Cl- (82 mEq/L), BUN (32 mg/dl), and
serum creatinine (0.6 mg/dl). Blood gas analysis showed pH (7.52), HCO3− (36
mEq/L), and PCO2 (46 mm Hg).
Of the following, the MOST helpful test for the diagnosis of this condition is
A. urine for Na+
B. urine for Cl−
C. urine for K+
D. serum chloride
E. serum calcium

34. What is the FIRST electrocardiogram (ECG) finding in hyperkalemia?

A. Peaked T wave
B. ST-segment depression
C. Increased PR interval
D. P wave flattening
E. QRS complex widening

35. A 14-year-old boy with sickle cell disease presents with generalized muscle
weakness; examination shows irregular heart rate with decreased muscle
strength; ECG shows peaked T wave, ST-segment depression, and increased PR
interval.
Of the following, the FIRST line of therapy is
A. dialysis
B. insulin and glucose
C. kayexalate
D. I V calcium
67
 E. albuterol nebulizer

36. What is the MOST likely cause of hypokalemia and metabolic acidosis?
A. Emesis
B. Diarrhea
C. Aldosterone excess
D. Use of diuretics
E. Bartter syndrome

37. A 6-year-old girl presents to emergency unit with deep rapid breathing and
dehydration; blood glucose (560 mg/dl).
Of the following, the EXPECTED arterial blood gas analysis is
A. pH (7.05), HCO3− (12 mEq/L), PCO2 (25 mm Hg)
B. pH (7.09), HCO3− (28 mEq/L), PCO2 (68 mm Hg)
C. pH (7.12), HCO3− (14 mEq/L), PCO2 (65 mm Hg)
D. pH (7.35), HCO3− (20 mEq/L), PCO2 (45 mm Hg)
E. pH (7.45), HCO3− (32 mEq/L), PCO2 (65 mm Hg)

68
Chapter 6
Fluid and Electrolyte Disorders
Answers
KHALID ALAARJI
1.(C) A normal teenager who is given nothing by mouth (NPO) overnight for a
morning procedure does not require maintenance fluids because a healthy
adolescent can easily tolerate 12 or 18 hr without oral intake. In contrast, a 6
mo old child waiting for surgery should begin receiving IV fluids within 8 hr of
the last feeding. Infants become dehydrated more quickly than older patients.
2.(C) Calculations of maintenance IV fluid based on weight do overestimate the
water needs of an overweight child, in whom it is better to base the calculations
on the lean body weight, which can be estimated by using the 50 th percentile of
body weight for the child's height.
3.(D)
4.(C)
5.(B)
6.(A) A normal plasma osmolality is 285-295 mOsm/kg. Infusing an IV solution
peripherally with a much lower osmolality can cause water to move into red
blood cells, leading to hemolysis. Thus, 0.2 NS (osmolality = 68) should not be
administered peripherally, but D5 0.2NS (osmolality = 346) or D5 ½ NS + 20
mEq/L potassium chloride (KCl) with an osmolality of 472 can be administered.
7.(A) Surgical patients typically receive isotonic fluids (NS, LR) during surgery
and in the recovery room for 6-8 hr postoperatively; the rate is typically
approximately two-thirds the calculated maintenance rate, with dextrose added
if clinically indicated.
8.(E) Average composition of diarrhea; sodium: 55 mEq/L, potassium: 25 mEq/L,
bicarbonate: 15 mEq/L; Approach to replacement of ongoing losses; Solution
(D5 ½ NS + 30 mEq/L sodium bicarbonate + 20 mEq/L KCl). Average composition
of gastric fluid; sodium: 60 mEq/L, potassium: 10 mEq/L, chloride: 90 mEq/L;
Approach to replacement of ongoing losses; Solution (normal saline + 10 mEq/L
KCl).

69
9.(D)
Causes of Chloride-Responsive Metabolic Alkalosis (urinary chloride <15
mEq/L)
Gastric losses (Emesis or Nasogastric suction)
Diuretics (loop or thiazide)
Chloride-losing diarrhea
Low chloride formula
Cystic fibrosis
Posthypercapnia
Causes of Chloride-Resistant Metabolic Alkalosis (urinary chloride >20
mEq/L)
Normal Blood Pressure High Blood Pressure
Adrenal adenoma or hyperplasia Gitelman syndrome
Glucocorticoid-remediable Bartter syndrome
aldosteronism AD hypoparathyroidism
Renovascular disease EAST syndrome
Renin-secreting tumor Base administration
17α-Hydroxylase deficiency
Cushing syndrome
Liddle syndrome
10.(A) Mild dehydration (<5% in an infant; <3% in an older child or adult):
Normal or increased pulse; decreased urine output; thirsty; normal physical
findings
11.(A) Severe dehydration (>10% in an infant; >6% in an older child or adult):
Peripheral pulses either rapid and weak or absent; decreased blood pressure;
no urine output; very sunken eyes and fontanel; no tears; parched mucous
membranes; delayed elasticity (poor skin turgor); very delayed capillary refill (>3
sec); cold and mottled; limp, depressed consciousness.
12.(C) Clinically significant hypermagnesemia is almost always secondary to
excessive intake. It is unusual, except in neonates born to mothers who are
receiving IV magnesium for preeclampsia or eclampsia. Symptoms usually do
not appear until the plasma magnesium level is >4.5 mg/dL. Hypermagnesemia
inhibits acetylcholine release at the neuromuscular junction, producing
hypotonia, hyporeflexia, and weakness; paralysis occurs at high concentrations.
The neuromuscular effects may be exacerbated by aminoglycoside antibiotics.
Direct CNS depression causes lethargy and sleepiness; infants have a poor suck.
Elevated magnesium values are associated with hypotension because of
vascular dilation, which also causes flushing.
70
13.(D) Respiratory alkalosis due to hyperventilation and washout of CO 2.
Hyperventilation may be secondary to an underlying disease that causes pain,
stress, or anxiety. In psychogenic hyperventilation or in panic attacks, there is
no disease process accounting for the hyperventilation. This disorder may occur
in a child who has had an emotionally stressful experience. Alternatively, it may
be part of a panic disorder, especially if there are repeated episodes of
hyperventilation.
14.(C) Hypomagnesemia causes secondary hypocalcemia by impairing the
release of PTH by the parathyroid gland and through blunting of the tissue
response to PTH. Thus, hypomagnesemia is part of the differential diagnosis of
hypocalcemia. It usually occurs only at magnesium levels < 0.7 mg/dL. The
dominant manifestations of hypomagnesemia are caused by hypocalcemia:
tetany, presence of Chvostek and Trousseau signs, and seizures. However, with
severe hypomagnesemia, these same signs and symptoms may be present
despite normocalcemia.
ECG changes with hypomagnesemia include flattening of the T wave and
lengthening of the ST segment. Arrhythmias may occur, almost always in the
setting of underlying heart disease. Gastrointestinal and renal losses are the
major causes of hypomagnesemia. Diarrheal fluid contains up to 200 mg/L of
magnesium; gastric contents have only approximately 15 mg/L, but high losses
can cause depletion. Steatorrhea causes magnesium loss as a result of the
formation of magnesium-lipid salts; restriction of dietary fat can decrease
losses.
15.(B)
 Mild dehydration (<5% in an infant; <3% in an older child or adult):
Normal or increased pulse; decreased urine output; thirsty; normal
physical findings
 Moderate dehydration (5–10% in an infant; 3–6% in an older child or
adult): Tachycardia; little or no urine output; irritable/lethargic; sunken
eyes and fontanel; decreased tears; dry mucous membranes; mild delay
in elasticity (skin turgor); delayed capillary refill (>1.5 sec); cool and pale
 Severe dehydration (>10% in an infant; >6% in an older child or
adult):Peripheral pulses either rapid and weak or absent; decreased
blood pressure; no urine output; very sunken eyes and fontanel; no
tears; parched mucous membranes; delayed elasticity (poor skin turgor);
very delayed capillary refill (>3 sec); cold and mottled; limp, depressed
consciousness

71
16.(A)
 Restore intravascular volume: Isotonic fluid (NS or LR): 20 mL/kg over 20
min and repeat as needed
 Calculate 24 hr fluid needs: maintenance +deficit volume
 Subtract isotonic fluid already administered from 24 hr fluid needs
 Administer remaining volume over 24 hr using 5% dextrose NS +20
mEq/L KCl
 Replace ongoing losses as they occur
17.(B) In a child with a known or probable metabolic alkalosis (e.g., child with
isolated vomiting), LR or PlasmaLyte should not be used because the lactate or
acetate would worsen the alkalosis. However, LR or PlasmaLyte may be
preferable to NS in shock since it is a balanced solution; NS may cause a
hyperchloremic metabolic acidosis.
18.(C) SIADH typically occurs with disorders of the CNS (infection, hemorrhage,
trauma, tumor, thrombosis, Guillain-Barré syndrome), but lung disease
(infection, asthma, positive pressure ventilation) and malignant tumors
(producing ADH) are other potential causes.
Diagnostic Criteria for Syndrome of Inappropriate Antidiuretic Hormone
Secretion
 Absence of: Renal, adrenal, or thyroid insufficiency - Heart failure,
nephrotic syndrome, or cirrhosis - Diuretic ingestion - Dehydration
 Urine osmolality >100 mOsm/kg (usually >plasma)
 Serum osmolality <280 mOsm/kg and serum sodium <135 mEq/L
 Urine sodium >30 mEq/L
 Reversal of “sodium wasting” and correction of Hyponatremia with
water restriction
19.(E) Metabolic Acidosis with Increased Anion Gap
 Lactic Acidosis
 Tissue hypoxia (Shock, Hypoxemia, Severe anemia)
 Liver failure
 Malignancy
 Intestinal bacterial overgrowth
 Inborn errors of metabolism
 Medications (Metformin, Propofol, Linezolid)
 Ketoacidosis (Diabetic ketoacidosis, Starvation ketoacidosis, Alcoholic
ketoacidosis)
 Kidney Failure
 Poisoning (Ethylene glycol, Methanol, Salicylate, Toluene, Paraldehyde)
72
20.(A)
21.(C)
22.(A) Even though central pontine myelinolysis (CPM) is rare in pediatric
patients, it is advisable to avoid correcting the serum [Na+] by >10 mEq/L/24 hr
or >18 mEq/L/48 hr.
23.(B) With all causes of hyponatremia, it is important to avoid overly rapid
correction, which may cause central pontine myelinolysis (CPM). This syndrome,
which occurs within several days of rapid correction of hyponatremia, produces
neurologic symptoms, including confusion, agitation, flaccid or spastic
quadriparesis, and death. There are usually characteristic pathologic and
radiologic changes in the brain, especially in the pons, but extrapontine lesions
are quite common and may cause additional symptoms. Despite severe
symptoms, full recovery does occur in some patients. Even though CPM is rare
in pediatric patients, it is advisable to avoid correcting the serum [Na+] by >10
mEq/L/24 hr or >18 mEq/L/48 hr.
24.(B) Patients with hyponatremia can have severe neurologic symptoms, such
as seizures and coma. The seizures associated with hyponatremia generally are
poorly responsive to anticonvulsants. The child with hyponatremia and severe
symptoms needs treatment that will quickly reduce cerebral edema. This goal is
best accomplished by increasing the extracellular osmolality so that water
moves down its osmolar gradient from the ICS to the ECS. Intravenous
hypertonic saline rapidly increases serum [Na+], and the effect on serum
osmolality leads to a decrease in brain edema. Each mL/kg of 3% NaCl increases
the serum [Na+] by approximately 1 mEq/L. A child with active symptoms often
improves after receiving 4-6 mL/kg of 3% NaCl.
25.(E) The World Health Organization defines some dehydration as the presence
of two or more of the following signs: restlessness/irritability, sunken eyes,
drinks eagerly, thirsty, and skin pinch goes back slowly. Infants and children with
some dehydration need rehydration therapy with ORS: ORS, 50-100 mL/kg over
3-4 hr. Continue breast feeding. After 4 hr, give food every 3-4 hr for children
who normally receive solid foods. Item D is old ORS recommended in 1976 and
item E is new ORS recommended in July, 2001c,
26.(A) The goal is to decrease the serum [Na+] by <10 mEq/L every 24 hr.
Idiogenic osmoles are generated within the brain during the development of
hypernatremia; they increase the osmolality within the cells of the brain,
providing protection against brain cell shrinkage caused by movement of water
out of the cells and into the hypertonic ECF. Idiogenic osmoles dissipate slowly
during the correction of hypernatremia. With overly rapid lowering of the
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extracellular osmolality during the correction of hypernatremia, an osmotic
gradient may be created that causes water movement from the ECS into the
cells of the brain, producing cerebral edema. Symptoms of the resultant
cerebral edema can range from seizures to brain herniation and death.
27.(A) The initial resuscitation of hypernatremic dehydration requires
restoration of the intravascular volume 20 mL/kg over 20 min with isotonic N S.
Ringer lactate should not be used because it is more hypotonic than NS and may
cause to rapid a decrease in the serum [Na+], especially if multiple fluid boluses
are necessary.
28.(D) Hyperosmolality, as may occur with hyperglycemia, causes a low [Na +]
because water moves down its osmotic gradient from the ICS into the ECS,
diluting the [Na+]. However, because the manifestations of hyponatremia are a
result of the low plasma osmolality, patients with hyponatremia resulting from
hyperosmolality do not have symptoms of hyponatremia. When the etiology of
the hyperosmolality resolves, such as hyperglycemia in diabetes mellitus, water
moves back into the cells, and the [Na++ rises to its “true” value. Mannitol or
sucrose, a component of intravenous immune globulin (IVIG) preparations, may
cause hyponatremia because of hyperosmolality.
29.(C) Treatment of Hypernatremic Dehydration
 Restore intravascular volume: Normal saline: 20 mL/kg over 20 min
(repeat until intravascular volume restored)
 Determine time for correction on basis of initial sodium concentration:
• *Na+ 145-157mEq/L: 24 hr
•*Na+ 158-170 mEq/L: 48 hr
•*Na+ 171-183 mEq/L: 72 hr
•*Na+ 184-196 mEq/L: 84 hr
 Administer fluid at constant rate over time for correction: Typical fluid:
5% dextrose + half-normal saline (with 20 mEq/L KCl unless
contraindicated)
 Typical rate: 1.25-1.5 times maintenance
30.(C) Metabolic Acidosis with Normal Anion Gap
 Diarrhea
 Renal tubular acidosis (RTA)
 Distal (type I) RTA
 Proximal (type II) RTA
 Mixed (type III) RTA
 Hyperkalemic (type IV) RTA
 Urinary tract diversions
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  Posthypocapnia
 Ammonium chloride intake
31.(A) In chronic respiratory acidosis; plasma bicarbonate increases by 3.5 for
each 10 mm Hg increase in the PCO2 (chronic compensation).
32.(E) In Bartter syndrome there are severe hypokalemia (usually <2.5 mmol/L),
metabolic alkalosis, hypercalciuria, and increased urinary chloride with normal
blood pressure; hypomagnesemia is seen in a minority of patients but is
more common in Gitelman syndrome.
33.(B) Measurement of the urine *Cl−+ is the most helpful test in differentiating
among the causes of a metabolic alkalosis. The urine *Cl−+ is low in patients with
a metabolic alkalosis resulting from volume depletion, unless there is a defect in
renal handling of Cl−. The urine *Cl−+ is superior to the urine *Na++ in assessment
of volume status in patients with a metabolic alkalosis, because the normal
renal response to a metabolic alkalosis is to excrete bicarbonate. Because
bicarbonate is negatively charged, it can be excreted only with a cation, usually
Na+ and K+. Therefore, a patient with a metabolic alkalosis may excrete Na+ in
the urine despite the presence of volume depletion, which normally causes avid
Na+ retention. The urine *Cl−+ is usually a good indicator of volume status, and it
differentiates Cl−-resistant and Cl−-responsive causes of a metabolic alkalosis.
34.(A)
35.(D) The goal of treatment of hyperkalemia is to stabilize the heart to prevent
life-threatening arrhythmias with calcium which stabilizes the cell membrane of
heart cells, preventing arrhythmias; it is given intravenously over a few minutes,
and its action is almost immediate. Bicarbonate causes potassium to move
intracellularly, lowering the plasma [K+]; it is most efficacious in a patient with a
metabolic acidosis. Insulin causes K+to move intracellularly but must be given
with glucose to avoid hypoglycemia. The combination of insulin and glucose
works within 30 min. Nebulized albuterol, by stimulation of β1-adrenergic
receptors, leads to rapid intracellular movement of K +. While other measures
(dialysis and kayexalate) are to remove K + from the body.
36.(B) The combination of hypokalemia and metabolic acidosis is characteristic
of diarrhea and distal and proximal RTA. A concurrent metabolic alkalosis is
characteristic of emesis or nasogastric losses, aldosterone excess, use of
diuretics, and Bartter and Gitelman syndromes.
37.(A) In insulin-dependent diabetes mellitus, inadequate insulin leads to
hyperglycemia and DKA. Production of acetoacetic acid and β-hydroxybutyric
acid causes the metabolic acidosis.

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Chapter 7
Pediatric Drug Therapy
Questions
HAIDAR A. N. ABOOD
1. Which of the following terms is BEST to describe the study of genetic
variations that give rise to interindividual differences in response to drugs?
A. Pharmacoproteomics
B. Pharmacokinetics
C. Pharmacogenetics
D. Pharmacodynamic
E. Pharmacogenomics

2. Which of the following drug responses is due to the effect of gene

polymorphism?
A. Hyperpyrexia following aspirin overdose
B. Prolonged paralysis after succinylcholine administration
C. Antipyretic effect of paracetamol
D. Bradycardia after administration of small dose of atropine
E. Hypoglycemia associated with insulin therapy

3. Drug biotransformation reactions are conveniently classified into 2 main

types, which occur sequentially and serve to terminate biologic activity and
enhance elimination, phase I and phase II reactions.
Which of the following is phase I reaction?
A. Glucuronidation reaction
B. Conjugation with glutathione
C. Sulphation reaction
D. Oxidation reaction
E. Conjugation with glycine

4. Which of the following is the major consequence of pharmacogenetic

polymorphisms in drug metabolizing enzymes?
A. Increased drug toxicity
B. Increased drug metabolism

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 C. Increased drug clearance
D. Decreased drug efficacy
E. Decreased drug accumulation

5. A case of acute lymphoblastic leukemia, on maintenance treatment regime,

has recurrent attacks of severe myelosuppression that required stopping of
chemotherapy for a long time. On screening, the patient was found genetically
having low TPMT (Thiopurine S-methyltransferase) activity. TMPT is cytosolic
enzyme that catalyses the S-methylation of sulfur-containing drugs, hence,
reducing their cytotoxic effects on bone marrow. For this reason, which of the
following anticancer drugs should be removed from the regime?
A. Methotrexate
B. Vincristine
C. Prednisolone
D. L-asparaginase
E. 6-thioguanine

6. Polymorphisms of the β2-adrenergic receptor gene (ADRB2) are associated

with variable responses to bronchodilator drugs.
Of the following, the MOST likely claimed drug is
A. ipratropium
B. salbutamol
C. theophylline
D. aminophylline
E. tiotropium

7. Drug bioavailability represents the fraction of the drugs that reach the
systemic circulation after administration. It is always 100% if the drug is given by
IV route.
Which age group has the LEAST bioavailability of drugs given by IM route?
A. Neonates
B. Infants
C. Toddlers
D. Preschool children
E. School children

8. Aminoglycoside antibiotics have a higher volume of distribution in neonates

and infants (0.4-0.7 L/kg) than in adults (0.2-0.3 L/kg) because

77
 A. the percentage of total body water is lower in neonates and infants
B. adults have higher percentage of intracellular water
C. the percentage of intracellular water is higher in neonates and infants
D. adults have higher percentage of extracellular water
E. the percentage of extracellular water is higher in neonates and infants

9. Which of the following age groups has the HIGHEST drug absorption after
administration through rectal route?
A. Neonates
B. Infants
C. Toddlers
D. Preschool children
E. School children

10. Which of the following is the primary organ responsible for the elimination
of drugs and their metabolites in pediatric age group?
A. Liver
B. Kidney
C. GIT
D. Skin
E. Lung

11. Which of the following dosing interval is recommended for gentamicin in

young children who have serious infections?
A. 4 hours interval
B. 6 hours interval
C. 8 hours interval
D. 12 hours interval
E. 24 hours interval

12. In therapeutic drug monitoring (TDM), plasma drug concentration is used for
dose individualization for a given patient. Which of the following drugs are
frequently requiring TDM?
A. NSAIDs like aspirin
B. Beta-blockers like atenolol
C. Anticonvulsants like phenytoin
D. Antibiotics like penicillins
E. Anticoagulants like warfarin

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