Hypertension in Children — MCQs

10 questions

How is catecholamine resistant shock managed in children?

Estimation of which of the following will help in the diagnosis of a five-year-old boy who has precocious puberty along with a blood pressure of 130/80 mm Hg?

In the context of clinical monitoring, what does BP tracking primarily involve?

A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

In a child, non-functioning kidney is best diagnosed by

Commonest cause of sustained severe hypertension in children

What is the most appropriate initial fluid for severe dehydration with shock in a 2-year-old with acute gastroenteritis?

A 10 year old boy presents to the pediatric emergency unit with seizures. Blood pressure in the upper extremity is measured as 200/140 mm Hg. Femoral pulses were not palpable. The most likely diagnosis is:

Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

Q10

Most common cause of persistent hypertension in a child with intrinsic renal disease is -

Hypertension in Children Indian Medical PG Practice Questions and MCQs

Question 1: How is catecholamine resistant shock managed in children?

A. Hydrocortisone (Correct Answer)
B. Nor-adrenaline
C. Activated protein-C
D. Vasopressin

Explanation: ***Hydrocortisone*** - **Hydrocortisone** is the primary treatment for catecholamine-resistant shock in children by addressing the underlying mechanism of receptor unresponsiveness. - It works by **upregulating adrenergic receptors** on vascular smooth muscle, restoring sensitivity to endogenous and exogenous catecholamines. - Additionally provides anti-inflammatory effects and treats relative adrenal insufficiency, which is common in prolonged shock states. - **Standard dosing:** 50-100 mg/m² or 1-2 mg/kg every 6 hours in pediatric shock. *Nor-adrenaline* - **Nor-adrenaline** is a potent catecholamine (alpha and beta agonist) already used in shock management. - In catecholamine-resistant shock, adrenergic receptors are **desensitized or downregulated**, making additional catecholamines less effective. - This is part of the existing therapy that has failed, not the solution to resistance. *Activated protein-C* - **Activated protein-C** (drotrecogin alfa) was used in severe sepsis but has been **withdrawn from the market** due to lack of efficacy and increased bleeding risk. - Not recommended in current pediatric shock guidelines. - Does not address catecholamine receptor unresponsiveness. *Vasopressin* - **Vasopressin** is an important adjunctive agent for catecholamine-resistant shock, acting through **V1 receptors** (non-adrenergic pathway). - Provides vasoconstriction when adrenergic receptors are unresponsive, making it useful in refractory cases. - However, it does not restore catecholamine receptor sensitivity—it bypasses the problem rather than correcting it. - **Hydrocortisone** is preferred as the primary intervention because it addresses the underlying receptor dysfunction, while vasopressin serves as an alternative vasopressor pathway.

Question 2: Estimation of which of the following will help in the diagnosis of a five-year-old boy who has precocious puberty along with a blood pressure of 130/80 mm Hg?

A. Aldosterone
B. DOCA
C. 11-Deoxycortisol (Correct Answer)
D. 17-Hydroxyprogesterone

Explanation: ***11-Deoxycortisol*** - The combination of **precocious puberty** and **hypertension** in a 5-year-old boy strongly suggests **11β-hydroxylase deficiency** CAH, where 11-deoxycortisol is the most specific diagnostic marker. - In 11β-hydroxylase deficiency, **11-deoxycortisol accumulates** due to impaired conversion to cortisol, making it the most diagnostically accurate test for this specific enzyme deficiency that causes both virilization and hypertension. *17-Hydroxyprogesterone* - While this is the standard **general screening test** for CAH, it may be **normal or only mildly elevated** in 11β-hydroxylase deficiency [1]. - It's more useful for diagnosing **21α-hydroxylase deficiency** (the most common CAH) but less specific for the 11β-hydroxylase deficiency suggested by this clinical presentation [1]. *Aldosterone* - **Aldosterone levels** are typically **suppressed** in 11β-hydroxylase deficiency CAH due to negative feedback from elevated mineralocorticoid precursors like **DOC**. - Elevated aldosterone would suggest **primary hyperaldosteronism**, which rarely causes precocious puberty in children. *DOCA* - **DOCA (11-deoxycorticosterone)** is indeed elevated in 11β-hydroxylase deficiency and directly causes the hypertension through its **mineralocorticoid activity** [1]. - However, **direct measurement of DOCA** is less commonly available and not routinely used as a first-line diagnostic test compared to 11-deoxycortisol.

Question 3: In the context of clinical monitoring, what does BP tracking primarily involve?

A. Daily BP measurement and recording for monitoring purposes (Correct Answer)
B. Blood pressure should be monitored regularly using appropriate methods
C. Adults with high BP today are likely to have had high BP as children
D. High BP in childhood tends to persist into adulthood

Explanation: ***Daily BP measurement and recording for monitoring purposes*** - **BP tracking** in clinical practice primarily involves routinely taking and documenting **blood pressure readings** over time. - This systematic approach helps in monitoring blood pressure trends, assessing treatment effectiveness, and identifying potential issues like **hypertension** or **hypotension**. - The term "tracking" specifically refers to the **serial measurement and documentation** of BP values. *Blood pressure should be monitored regularly using appropriate methods* - This is a general **recommendation** for BP monitoring, but it is broader than the specific activity of "tracking." - It describes the necessity for surveillance, whereas tracking specifically implies the **recording and systematic analysis of data** over time. *Adults with high BP today are likely to have had high BP as children* - This statement describes the **epidemiological phenomenon** of BP tracking (correlation between childhood and adult BP). - While "BP tracking" can refer to this concept in epidemiology, in the **clinical monitoring context**, it refers to serial measurements. - This relates to the **natural history and epidemiology** of hypertension, not the clinical practice of BP tracking. *High BP in childhood tends to persist into adulthood* - This also describes the **epidemiological tracking phenomenon** rather than the clinical practice. - It highlights a **prognostic trend** and risk factor for adult hypertension. - Does not explain what the clinical activity of BP tracking entails.

Question 4: A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

A. Reflux nephropathy
B. Polycystic kidney disease
C. Chronic glomerulonephritis (Correct Answer)
D. All of the options

Explanation: ***Chronic glomerulonephritis*** - The combination of **microscopic hematuria, proteinuria, and RBC casts** is pathognomonic for **glomerular disease**. - **RBC casts** specifically indicate glomerular bleeding and are highly specific for **glomerulonephritis**. - **Hypertension** in chronic glomerulonephritis results from sodium retention, fluid overload, and activation of the renin-angiotensin-aldosterone system. - The absence of acute features suggests a **chronic** process rather than acute post-streptococcal glomerulonephritis. *Reflux nephropathy* - While reflux nephropathy can cause hypertension and proteinuria, it typically presents with a history of **recurrent urinary tract infections**, which is explicitly absent in this case. - **RBC casts are NOT a feature** of reflux nephropathy; urinalysis may show proteinuria and occasionally WBCs/bacteria if infection is present. - Diagnosis requires imaging (VCUG, DMSA scan) showing vesicoureteral reflux and renal scarring. *Polycystic kidney disease* - **Autosomal dominant PKD** rarely presents with symptoms in childhood; it typically manifests in the 3rd-4th decade. - **Autosomal recessive PKD** presents in infancy/early childhood with enlarged kidneys and renal failure. - While PKD can cause hematuria (from cyst rupture), **RBC casts are not characteristic** as the pathology is cystic, not glomerular. - Diagnosis is made by ultrasound showing multiple bilateral renal cysts. *All of the options* - This is incorrect because the **specific urinalysis findings** (particularly **RBC casts**) point definitively to **glomerular pathology**. - RBC casts are the hallmark of glomerulonephritis and are not seen in reflux nephropathy or polycystic kidney disease. - The clinical presentation with specific laboratory findings allows differentiation between these conditions.

Question 5: In a child, non-functioning kidney is best diagnosed by

A. Creatinine clearance
B. Ultrasonography
C. IVU
D. DTPA renogram (Correct Answer)

Explanation: ***DTPA renogram*** - A **DTPA renogram** (diethylene triamine pentaacetic acid scan) is a nuclear medicine study that assesses **renal blood flow** and **glomerular filtration rate (GFR)**. - It is highly effective in determining if a kidney is non-functioning because it directly measures the **uptake and excretion of a radiotracer** by the kidney, providing quantitative data on its functional capacity. *Creatinine clearance* - **Creatinine clearance** is a measure of overall kidney function, reflecting the GFR of **both kidneys combined**. - It cannot specifically identify a non-functioning individual kidney, as the other kidney might compensate for the non-functioning one, leading to a near-normal overall creatinine clearance. *Ultrasonography* - **Ultrasonography** is excellent for evaluating **renal anatomy**, such as size, shape, and presence of cysts, hydronephrosis, or stones. - While it can show structural abnormalities, it provides limited direct information about the **functional status** of the kidney, and a structurally normal kidney can still be non-functional. *IVU (Intravenous Urography)* - **Intravenous Urography (IVU)** uses contrast dye injected intravenously to visualize the kidneys, ureters, and bladder, assessing both anatomy and some aspects of function. - If a kidney is non-functioning, it would show **no uptake or excretion of the contrast dye**, but IVU involves radiation exposure and nephrotoxic contrast, making DTPA renogram often preferred in children for functional assessment.

Question 6: Commonest cause of sustained severe hypertension in children

A. Pheochromocytoma
B. Endocrine causes
C. Renal parenchyma disease (Correct Answer)
D. Coarctation of aorta

Explanation: ***Renal parenchyma disease*** - **Renal parenchymal diseases** such as **glomerulonephritis**, **pyelonephritis**, and **polycystic kidney disease** are the most frequent causes of sustained severe hypertension in children. - These conditions lead to **impaired renal function**, affecting fluid and electrolyte balance and activating the **renin-angiotensin-aldosterone system**, thereby increasing blood pressure. *Pheochromocytoma* - While a **pheochromocytoma** can cause severe hypertension, it is an extremely rare cause in children, typically presenting with paroxysmal episodes of high blood pressure, palpitations, and sweating. - This condition arises from **catecholamine-producing tumors** of the adrenal medulla, leading to distinct and episodic hypertension rather than sustained. *Endocrine causes* - **Endocrine causes** like **Cushing's syndrome** or **thyrotoxicosis** can lead to hypertension, but they are less common causes of sustained severe hypertension in children compared to renal pathologies. - These conditions are also associated with other systemic symptoms specific to the hormonal imbalance, which would typically be evident. *Coarctation of aorta* - **Coarctation of the aorta** is a congenital narrowing of the aorta that can cause hypertension, particularly in the upper extremities. - While significant, it is less common than renal parenchymal disease as a cause of *sustained severe hypertension* across the board in children and presents with characteristic differences in blood pressure between upper and lower limbs.

Question 7: What is the most appropriate initial fluid for severe dehydration with shock in a 2-year-old with acute gastroenteritis?

A. Half-strength saline
B. Normal saline bolus (Correct Answer)
C. Ringer lactate
D. ORS

Explanation: ***Normal saline bolus*** - **Normal saline (0.9% NaCl)** is an appropriate initial fluid for **severe dehydration with shock** due to its **isotonicity**, which helps rapidly expand intravascular volume without causing fluid shifts. - In a 2-year-old with shock, rapid resuscitation with **20 mL/kg bolus** of isotonic fluid is critical for restoring circulating blood volume. - In **acute gastroenteritis**, normal saline may be particularly appropriate as it helps replace **sodium and chloride losses** from diarrhea and vomiting. *Half-strength saline* - **Half-strength saline (0.45% NaCl)** is **hypotonic** and is **contraindicated** for initial resuscitation in shock, as it cannot effectively expand intravascular volume. - It can cause fluid to shift into the intracellular space, worsening hypotension and potentially causing **hyponatremia** and **cerebral edema**. - Hypotonic solutions are only used for maintenance therapy after stabilization, never for shock resuscitation. *Ringer lactate* - **Lactated Ringer's** is also an **isotonic crystalloid** and is equally acceptable for shock resuscitation in children according to current PALS guidelines. - Both NS and LR are recommended first-line fluids for pediatric shock, though **NS may be preferred in gastroenteritis** as it more directly replaces the specific electrolyte losses (Na+ and Cl-) typical of diarrheal dehydration. - LR contains lactate that is metabolized to bicarbonate, making it slightly hypotonic and containing less sodium than NS, which may be less ideal for gastroenteritis-specific losses. *ORS* - **Oral Rehydration Solution (ORS)** is the treatment of choice for **mild to moderate dehydration** but is **contraindicated in shock** due to hemodynamic instability requiring immediate intravenous volume expansion. - A child in shock cannot absorb fluids adequately from the GI tract and requires rapid IV resuscitation before oral therapy can be considered. - ORS is only appropriate after initial stabilization with IV fluids and restoration of adequate perfusion.

Question 8: A 10 year old boy presents to the pediatric emergency unit with seizures. Blood pressure in the upper extremity is measured as 200/140 mm Hg. Femoral pulses were not palpable. The most likely diagnosis is:

A. Renal parenchymal disease
B. Coarctation of aorta (Correct Answer)
C. Takayasu arteritis
D. Grand mal seizures

Explanation: ***Coarctation of aorta*** - The combination of **severe hypertension in the upper extremities** (200/140 mm Hg), **impalpable femoral pulses**, and seizures in a 10-year-old boy is highly suggestive of **aortic coarctation**. - Aortic coarctation causes a **pressure gradient** across the narrowed aorta, leading to high pressure proximal to the coarctation (upper body) and low pressure distal to it (lower body). *Renal parenchymal disease* - While renal parenchymal disease can cause **hypertension**, it typically does not present with **differential blood pressures** between upper and lower extremities or absent femoral pulses. - The hypertension in renal disease is usually due to **fluid overload** and **renin-angiotensin-aldosterone system activation**. *Takayasu arteritis* - Takayasu arteritis is a form of **large vessel vasculitis** that can affect the aorta and its branches, leading to differential pulses and hypertension. - However, it more commonly affects **young adult women** (typically 10-40 years old) and often presents with systemic symptoms like **fever, malaise**, and **arterial bruits**, which are not mentioned here. *Grand mal seizures* - Grand mal seizures are a neurological symptom, not a diagnosis of the underlying cause. - While **severe hypertension** from any cause can lead to seizures (hypertensive encephalopathy), this option does not explain the specific cardiovascular findings of **differential blood pressure** and **impalpable femoral pulses**.

Question 9: Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

A. Pedal oedema
B. JVP
C. Liver enlargement (Correct Answer)
D. Basal crepitations

Explanation: ***Liver enlargement*** - **Hepatomegaly** is a reliable sign of **heart failure in infants** because the infant's liver is very compliant and readily distends with increased systemic venous pressure. - Due to a less developed compensatory mechanism, infants often manifest heart failure with signs related to **systemic congestion**, with liver enlargement being a primary indicator. *Pedal oedema* - **Pedal edema is uncommon in infants** with heart failure compared to adults, as they are often supine and have less hydrostatic pressure effect on their lower extremities. - When present, it might be due to other causes or a sign of very severe, chronic heart failure rather than an early or "sure" sign. *JVP* - **Jugular venous distension (JVD) is difficult to assess accurately in infants** due to their short, fat necks and the difficulty in positioning and visualizing the neck veins. - Therefore, it is generally considered an **unreliable physical sign** for diagnosing heart failure in this age group. *Basal crepitations* - **Basal crepitations (rales)** indicate pulmonary congestion and can be a sign of left-sided heart failure. - However, in infants, these can also be caused by **bronchiolitis**, **pneumonia**, or other respiratory infections, making them a less specific "sure sign" than liver enlargement.

Question 10: Most common cause of persistent hypertension in a child with intrinsic renal disease is -

A. CGN (Correct Answer)
B. Obstructive uropathy
C. Renal tumor
D. Chronic Pyelonephritis

Explanation: ***CGN*** - **Chronic glomerulonephritis (CGN)** is a leading cause of persistent hypertension in children with intrinsic renal disease due to widespread glomerular damage leading to **renin-angiotensin-aldosterone system** activation and fluid retention. - The damaged kidneys are unable to filter waste and regulate blood pressure effectively, contributing to sustained hypertension. *Chronic Pyelonephritis* - While chronic pyelonephritis can cause hypertension, it is typically due to **scarring and inflammation** affecting renal function. - However, it is not as common a cause of persistent hypertension as CGN in children with intrinsic renal disease. *Obstructive uropathy* - **Obstructive uropathy** is classified as a **post-renal (obstructive) disorder** rather than intrinsic renal disease, though it can lead to secondary renal parenchymal damage. - It can cause hypertension through renal parenchymal damage and **renin release** due to increased pressure, but it is not a primary intrinsic renal disease. *Renal tumor* - **Renal tumors**, such as Wilms' tumor, can cause hypertension through **compression of renal arteries** or increased renin production. - While a significant cause of hypertension, it is generally less common than CGN as a cause of persistent hypertension in children with *intrinsic renal disease* overall.

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