General Pediatrics Board Review

Nephrology

Fluids and Electrolytes

Jeffrey M. Saland, M.D.

Department of Pediatrics

Mount Sinai School of Medicine

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?

Total Body

Water

Extracellular

Fluid

Intracellular

Fluid

A. 80% 45% 35%

B. 70% 30% 40%

C. 60% 20% 40%

D. 50% 20% 30%

E. Same as the jellyfish

2

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?

Total Body

Water

Extracellular

Fluid

Intracellular

Fluid

A. 80% 45% 35%

B. 70% 30% 40%

C. 60% 20% 40%

D. 50% 20% 30%

E. Same as the jellyfish

3

Composition of Body Fluids

Babies are moist– but not quite jellyfish!

4

Finberg L. Water and Electrolytes in Pediatrics 1993 (data from Friis-Hansen BJ Pediatrics 1961)

ICW

ECW

TBW

5

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

Distribution of body water as a

percentage of body weight

Compiled by Finberg, L. from data by BJ Friis-Hansen, Acta Paed Scand 1958 Technique: D2O for TBW and thiosulfate for ECW

6

TBW = 60% Lean Body Mass:

Approx Body Composition > 1 year

ICF = 2/3 TBW

ECF = 1/3 TBW

Plasma = 1/4 ECF

(rest is interstitial fluid)

Na ~ 13 K ~ 140

Na ~ 140 K ~ 4

Pla

sm

a

ICF

ECF

TBW

7

A previously healthy 23 kg child is admitted for

gingivostomatitis and refusal of oral intake. What is the

most appropriate maintenance intravenous fluid

prescription?

Base Potassium Rate

A. 0.9% NS None 65 ml/hr

B. D5 ½ 0.9% NS 20 mEq/L 100 ml/hr

C. D5 ½ 0.9% NS 20 mEq/L 65 ml/hr

D. D5 W 20 mEq/L 50 ml/hr

E. D5 ¾ 0.9% NS 20 mEq/L 65 ml/hr

8

A previously healthy 23 kg child is admitted for

gingivostomatitis and refusal of oral intake. What is the

most appropriate maintenance intravenous fluid

prescription?

Base Potassium Rate

A. 0.9% NS None 65 ml/hr

B. D5 ½ 0.9% NS 20 mEq/L 100 ml/hr

C. D5 ½ 0.9% NS 20 mEq/L 65 ml/hr

D. D5 W 20 mEq/L 50 ml/hr

E. D5 ¾ 0.9% NS 20 mEq/L 65 ml/hr

9

What are maintenance fluids?

The fluid and electrolytes necessary for a person to

remain in net balance over the long term

ICF ECF

Pla

sm

a

INTAKE

OUTPUT

10

Sounds Easy!

11

What are maintenance fluids?

Barratt M: Pediatric Nephrology 4th Ed 1998 12

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!

13

Insensible losses:

respiratory 30 cc / 100 Cal

+ evaporative not sweat 15 cc / 100 Cal

45 cc / 100 Cal

Urine output losses 50-75 cc / 100 Cal

Stool losses 5-10 cc / 100 Cal

Growth “loss” 0-15 cc / 100 Cal

Water of oxidation (a gain) 10-15 cc / 100 Cal

TOTAL Approximately 100 cc / 100 Cal

For the “average” patient, the use of 1 Cal

corresponds to the use of 1 mL of water

14

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: 100 cc / kg / day

2nd 10 kg: 50 cc / kg / day

the rest: 20 cc / kg / day

15

Increased INSENSIBLE Losses

Fever (each deg > 38): 12.5%

Prematurity 100-300%

Radiant warmer 50-100%

Phototherapy 25-50%

Increased activity 5-25%

Decreased INSENSIBLE Losses

Ventilation (humidified air) 25-40%

Sedation 5-25%

Decreased activity 5-25%

Hypothermia 5-15%

Enclosed Incubator 25-50%

Changes in the metabolic rate or the

environment change insensible fluid loss

16

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

Maintenance Fluid DOES NOT

Include Abnormal Losses

17

Fluid Na

(mEq/L) K

(mEq/L) Cl

(mEq/L)

Gastric 20–80 5–20 100–150

Pancreatic 120–140 5–15 90–120

Small bowel 100–140 5–15 90–130

Bile 120–140 5–15 80–120

Ileostomy 45–135 3–15 20–115

Diarrhea 10–90 10–80 10–110

Burns 140 5 110

Sweat

Normal 10–30 3–10 10–35

Cystic fibrosis 50–130 5–25 50–110

Composition of Various Body Fluids

Harriet Lane Handbook 18

Na: 2-5 mEq / kg /day

K: 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.

“Salt” Maintenance Requirements

19

20

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:

21 1 2 3 4 5

27%

30%

10%

20%

13%

1. Give 20 ml/kg of D5 ½ NS intravenously over 20-30 min

2. Give 5 ml/kg of D5 NS intravenously over 20-30 min

3. Give 20 ml/kg of NS intravenously over 20-30 min

4. Give 10 ml/kg of 3% NS intravenously over 20-30 min

5. Await serum electrolytes before

giving IV fluid

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 Serum K Serum Cl

A. Low High Low Low

B. High Normal High Low

C. High Normal Low Low

D. Normal Low Low Low

E. High Low Low High

22

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 Serum K Serum Cl

A. Low High Low Low

B. High Normal High Low

C. High Normal Low Low

D. Normal Low Low Low

E. High Low Low High

23

Mild Moderate Severe

Weight Loss 5% (infant)

2% (child/adult)

10% (infant)

6% (child/adult)

15% (infant)

9% (child/adult)

Sensorium Normal Fussy

Lethargic

Poor

arousability

Urine Output

hrs w/o UOP

range

Slight decrease

2-3 hours

0.5-1.5 cc/kg/hr

Notable

decrease

4-6 hours

<0.5 cc/kg/hr

Anuric

6-12 hours

None

Signs & Symptoms of Dehydration I

(fairly reliable)

Harriet Lane Handbook 24

Mild Moderate Severe

Skin turgor or

quality

1+ decrease

pale

2+ decrease

“gray”

3+ decrease

mottled

Mucus

Membranes Dry / “tacky” Drier “parched”

Pulse Slightly

increased Increased

Very

increased

Fontanelle Normal Intermediate Sunken

Eyes Normal Intermediate Sunken

Blood Pressure Normal About normal Low

Signs & Symptoms of Dehydration II

(less reliable)

Harriet Lane Handbook 25

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?

Extracellular Intracellular

A. 80% 20%

B. 60% 40%

C. 40% 60%

D. 20% 80%

E. None of the above

26

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?

Extracellular Intracellular

A. 80% 20%

B. 60% 40%

C. 40% 60%

D. 20% 80%

E. 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 27

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?

Total Deficit ECF loss ICF loss Na Loss

A. 900 mL 540 ml 360 ml 75 mEq

B. 1000 mL 800 ml 200 ml 110 mEq

C. 1000 mL 400 ml 600 ml 55 mEq

D. 1000 mL 600 ml 400 ml 85 mEq

E. 100 mL 80 mL 20 mL 10 mEq

28

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?

Total Deficit ECF loss ICF loss Na Loss

A. 900 mL 540 ml 360 ml 75 mEq

B. 1000 mL 800 ml 200 ml 110 mEq

C. 1000 mL 400 ml 600 ml 55 mEq

D. 1000 mL 600 ml 400 ml 85 mEq

E. 100 mL 80 mL 20 mL 10 mEq

29

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.

30

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. Hypotonic

C. Hypertonic

D. All are equally likely

31

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. Hypotonic

C. Hypertonic

D. All are equally likely

32

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. Isotonic

B. Hypotonic

C. Hypertonic

D. All are equally likely

33

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. Isotonic

B. Hypotonic

C. Hypertonic

D. All are equally likely

34

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 Serum

Osm Urine Na Urine Osm

A. High High Low High

B. Low Low High High

C. High High High High

D. Low Normal High High

E. Normal Normal Low Low 35

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 Serum

Osm Urine Na Urine Osm

A. High High Low High

B. Low Low High High

C. High High High High

D. Low Normal High High

E. Normal Normal Low Low 36

Tonicity Plasma Na

(mEq/L)

Incidence Example etiologies

Iso 130-150 60% diarrhea, vomiting

Hyper >150 25% A loss PLUS:

no thirst or

no tolerance for or

no access to water

Hypo <130 15% Any loss PLUS water

replacement in excess of

solute replacement.

Worse if loss had some

Na (CF, salt-wasting )

Tonicity Classification of Dehydration

37

38

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?

39 1 2 3 4

30%

17%

23%

30%

1. Acute kidney injury 3%

2. Acute kidney injury 0.3%

3. Pre-Renal Azotemia 3%

4. Pre-Renal Azotemia 0.3%

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

40

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

41

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

mEq/L

Urine Na

mEq/L

Serum Osm

mOsm/kg

Urine Osm

mOsm/kg

A 150 5 320 90

B 140 40 295 400

C 130 25 275 450

D 120 50 265 90

E 120 50 265 500

42

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

mEq/L

Urine Na

mEq/L

Serum Osm

mOsm/kg

Urine Osm

mOsm/kg

A 150 5 320 90

B 140 40 295 400

C 130 25 275 450

D 120 50 265 90

E 120 50 265 500

43

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”

44

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

mEq/L

Urine Na

mEq/L

Serum Osm

mOsm/kg

Urine Osm

mOsm/kg

A 160 40 330 900

B 150 25 315 350

C 150 5 320 200

D 140 5 295 90

E 130 25 275 275

45

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

mEq/L

Urine Na

mEq/L

Serum Osm

mOsm/kg

Urine Osm

mOsm/kg

A 160 40 330 900

B 150 25 315 350

C 150 5 320 200

D 140 5 295 90

E 130 25 275 275

46

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 47

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?

48 1 2 3 4 5

20%

33%

20%

23%

3%

1. Excessive 0.9% NS may exacerbate the situation

2. Serum K can be expected to fall with rehydration

3. Serum Na can be expected to rise with rehydration

4. Hyperglycemia causes the lab equipment to malfunction and produce falsely low Na values

5. Dehydration is the result of osmotic diuresis

Acid / Base

Mr. Osborne, may I be excused? My brain is full. 49

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)?

Urine

pH

Urine

Ca

Urine

Citrate

Urine

K

Urine Anion Gap

(Na+ + K+) - Cl-

A < 5.5 High Low High > 0 (positive)

B < 5.5 Low Low High > 0 (positive)

C < 5.5 High Low High < 0 (negative)

D > 7 High Low High > 0 (positive)

E > 7 Low High Low < 0 (negative)

50

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)?

Urine

pH

Urine

Ca

Urine

Citrate

Urine

K

Urine Anion Gap

(Na+ + K+) - Cl-

A < 5.5 High Low High > 0 (positive)

B < 5.5 Low Low High > 0 (positive)

C < 5.5 High Low High < 0 (negative)

D > 7 High Low High > 0 (positive)

E > 7 Low High Low < 0 (negative)

51

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+) > Cl-

Clinical 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

52

Renal Tubular Acidosis: Urine Anion Gap

Na+

+ K+

__– Cl-____

Anion Gap

What is NOT

measured is

ammonium

(NH4+)

Carmody, PREP 2011

Na++K+ < Cl-

UAG Negative Non-renal acidosis

Na++K+ > Cl-

UAG Positive RTA

53

Renal Tubular Acidosis: Distal vs Proximal

Distal (type 1)

• Commonly associated with hypercalcURIA, stone risk

• Late nephron defect, urine pH “always” < 5.5

• 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, “always” > 5.5

54

A Normal anion gap metabolic acidosis

B Low anion gap metabolic acidosis

C High anion gap metabolic acidosis

D High anion gap respiratory alkalosis

E None of the above

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:

55

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!

A Normal anion gap metabolic acidosis

B Low anion gap metabolic acidosis

C High anion gap metabolic acidosis

D High anion gap respiratory alkalosis

E None of the above

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:

56

High Anion Gap Metabolic Acidosis:

M: methanol (and metabolic diseases)

U: uremia

D: diabetes (ketoacids), d-lactic acidosis

P: (paraldehyde); propylene glycol

I: Isoniazid, Iron

L: Lactate

E: Ethanol, Ethylene glycol

S: Salicylates

57

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:

pH pCO2 paO2 BE

A 7.53 15 134 9

B 7.25 55 81 -3

C 7.21 31 106 -14

D 7.48 52 85 13

E None of the above

58

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:

pH pCO2 paO2 BE Interpretation

A 7.53 15 134 9 R. Alkalosis

B 7.25 55 81 -3 R. Acidosis

C 7.21 31 106 -14 M. Acidosis

D 7.48 52 85 13 M. Alkalosis

E None of the above

59

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:

pH HCO3

- pCO2 paO2

A 7.53 12 15 134

B 7.21 16 40 100

C 7.48 37 52 85

D 7.25 23 55 81

E None of the above

60

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:

pH HCO3

- pCO2 paO2 Interpretation

A 7.53 12 15 134 R. Alkalosis

B 7.21 16 40 100 M. Acidosis

C 7.48 37 52 85 M. Alkalosis

D 7.25 23 55 81 R. Acidosis

E None of the above

61

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:

What is the best interpretation of these results?

pH pCO2 HCO3- BE paO2

7.43 45 12 -4 85

A Metabolic alkalosis due to diuretics

B Respiratory alkalosis due to hyperventilation

C Metabolic acidosis due to heart failure

D Respiratory acidosis due to pulmonary edema

E None of the above / Lab Error

62

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:

What is the best interpretation of these results?

pH pCO2 HCO3- BE paO2

7.43 45 12 -4 85

A Metabolic alkalosis due to diuretics

B Respiratory alkalosis due to hyperventilation

C Metabolic acidosis due to heart failure

D Respiratory acidosis due to pulmonary edema

E None of the above / Lab Error

63

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 Repeat the laboratory tests in 24 hours

B Administer intravenous Calcium gluconate

C Administer intravenous sodium bicarbonate

D Begin intravenous D5 ½ 0.9% NS with 20 mEq KCl

per liter at 1.5 times maintenance rate

E None of the above

64

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 Repeat the laboratory tests in 24 hours

B Administer intravenous Calcium gluconate

C Administer intravenous sodium bicarbonate

D Begin intravenous D5 ½ 0.9% NS with 20 mEq KCl

per liter at 1.5 times maintenance rate

E None of the above

65

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 Hypokalemia

B Hypophosphatemia

C Hypocalcemia

D Hyponatremia

E Hypomagnesemia

66

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 Hypokalemia

B Hypophosphatemia

C Hypocalcemia

D Hyponatremia

E Hypomagnesemia

67

Hyperkalemia can be induced by all of the following

medications EXCEPT:

A Intravenous terbutaline

B Epinephrine

C Angiotensin converting enzyme inhibitor

D Hydrochlorthiazide (HCTZ)

E Spironolactone

68

Hyperkalemia can be induced by all of the following

medications EXCEPT:

A Intravenous terbutaline

B Epinephrine

C Angiotensin converting enzyme inhibitor

D Hydrochlorthiazide (HCTZ)

E Spironolactone

69

UTI’s and So on…

70

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 Renal scintigraphy

B Evaluation for immunodeficiency

C Increase daily fluid intake to 2 – 2.5 liters/day

D Prescribe stool softener & a regular bowel routine

E Switch prophylaxis to nitrofurantoin

71

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 Renal scintigraphy

B Evaluation for immunodeficiency

C Increase daily fluid intake to 2 – 2.5 liters/day

D Prescribe stool softener & a regular bowel routine

E Switch prophylaxis to nitrofurantoin

72

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 99Tc DTPA renal scintigraphy

B 99Tc DMSA renal scintigraphy

C Voiding cystourethrogram

D Urodynamics study

E Magnetic resonance (MR) urogram

73

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 99Tc DTPA renal scintigraphy

B 99Tc DMSA renal scintigraphy

C Voiding cystourethrogram

D Urodynamics study

E Magnetic resonance (MR) urogram

74

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.

75

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.

76

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

77

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

78

Besides fever, signs and symptoms of UTI in infants include:

A Irritability

B Diarrhea

C Difficulty feeding

D Jaundice

E Any of the above

79

Besides fever, signs and symptoms of UTI in infants include:

A Irritability

B Diarrhea

C Difficulty feeding

D Jaundice

E Any of the above

80

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 Renal and bladder ultrasound

B Spine MRI and referral to pediatric neurosurgery

C Prescribe stool softener & a regular bowel routine

D Referral to pediatric urology

E Reduce evening fluids & use a bedtime wetting alarm

81

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 Renal and bladder ultrasound

B Spine MRI and referral to pediatric neurosurgery

C Prescribe stool softener & a regular bowel routine

D Referral to pediatric urology

E Reduce evening fluids & use a bedtime wetting alarm

82

Nephrology

83

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

84

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

85

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

86

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

87

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

88

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

89

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

90

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

91

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

92

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

93

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

94

A 16 year old boy develops sharp flank pain and gross

hematuria. Sonography shows multiple large 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

95

A 16 year old boy develops sharp flank pain and gross

hematuria. Sonography shows multiple large 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

96

Polycystic Kidney Disease

Autosomal Dominant PKD (ADPKD)

• More commonly affects adults

• Larger cysts, liver cysts

• Intracranial aneurysms, mitral valve prolapse

• Common: affects about 1:500 to 1:800

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

97

2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea. The next day, 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

98

2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea. The next day, 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

99

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 Hypertension is common and may be severe

C End stage renal failure is common

D Recurrence is common

E Treatment is symptomatic

100

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 Hypertension is common and may be severe

C End stage renal failure is common

D Recurrence is common

E Treatment is symptomatic

101

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?

102 1 2 3 4 5

27%

33%

20%

3%

17%

1. Complement C3 & C4 may remain low for 4-6 weeks

2. The brother can be protected from the same condition by prompt antibiotic treatment

3. There is high risk of rheumatic heart disease also

4. Rapid progression and need for dialysis is uncommon and requires renal biopsy

5. Hypertension is uncommon and requires renal biopsy

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

MCV Na Ca PTH HCO3

-

A Low Normal High High Low

B Normal Low Low Low High

C Normal Normal Low High Low

D High High Normal Low Low

E Low Normal Low Normal Low

103

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

MCV Na Ca PTH HCO3

-

A Low Normal High High Low

B Normal Low Low Low High

C Normal Normal Low High Low

D High High Normal Low Low

E Low Normal Low Normal Low

104

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

105

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

106

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 Vesicoureteral reflux is a common finding

B Genetic testing is not likely to be useful

C The left kidney will eventually develop cysts and fail

D There is an increased risk of hypertension

E ALL of the above are correct

107

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 Vesicoureteral reflux is a common finding

B Genetic testing is not likely to be useful

C The left kidney will eventually develop cysts and fail

D There is an increased risk of hypertension

E ALL of the above are correct

108

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

109

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

110

Blood Pressure and

Hypertension

111

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

112

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

113

All of the following statements about normal blood pressure

in children are true EXCEPT:

A Normal BP increases with age during childhood

B Boys normally have higher BP than girls

C Normal BP is higher in taller children

D Normal BP is higher in overweight and obese children

E ALL of the above are true statements

114

All of the following statements about normal blood pressure

in children are true EXCEPT:

A Normal BP increases with age during childhood

B Boys normally have higher BP than girls

C Normal BP is higher in taller children

D Normal BP is higher in overweight and obese children

E ALL of the above are true statements

Increased BP with height is physiologic and normal.

Increased BP with obesity is pathophysiological and abnormal.

115

Blood Pressure Tables

116

Blood Pressure Tables

PEDIATRICS Vol. 114 No. 2 August 2004, pp. 555-576 117

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”)

118

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

119

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

120

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, over-

the-counter medications, caffeine intake, and illicit

drug use

E Renal angiography

121

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, over-

the-counter medications, caffeine intake, and illicit

drug use

E Renal angiography

122

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.

Keep Studying and Good Luck!

123