2018 Flashcards
In tuberculosis, what are two differences between the clinical presentation of early primary disease and reactivation disease? (2)
Primary: highest risk <4yo, risk of disseminated disease is higher. Reactivation: highest risk >10yo, low risk of disseminated disease.
What is the most sensitive screening test for tuberculosis in children under 2 years?
a. Chest XR
b. TST
c. IGRA
d. Blood culture
b: TST is more sensitive <2 and IGRA is always more specific
A 4 year old child was exposed to active pulmonary TB. They are asymptomatic. The chest x-ray is normal. A tuberculin skin test measures 3mm. What is the most appropriate management?
a. No treatment
b. Treat for latent TB infection with the standard four-drug regimen
c. Single drug prophylaxis for 8 to 10 weeks, then repeat TST, and treat if ≥5mm
d. No treatment at this time, repeat TST in 8 to 10 weeks, and treat if ≥5mm
c: because <5yo. Otherwise no prophylaxis.
Name 5 organs or tissues that can be involved in disseminated TB disease. (5)
Lungs, brain, retina, liver, spleen, joints, bone, bone marrow, muscle
Name 5 possible manifestations of reactivation TB disease. (5)
Cavitary pulmonary lesions, pleural effusions, osteoarticular infections, spleen abscess, liver abscess, CNS abscess, disseminated disease
List six “red flag” findings concerning for alternate diagnoses on history, physical exam, and initial investigations for a patient with presumed ITP. (3 total, 0.5 each)
B-symptoms, bone pain, recurrent thrombocytopenia, lack of response to treatment, lymphadenopathy, hepato/splenomegaly, signs of chronic disease, moderate-severe anemia, high or low WBC, high MCV, abnormal smear
Name two factors that will affect your decision of whether to choose active treatment or observation for a patient with ITP. (2)
Severity of bleeding, parental preference / risk tolerance level, child wanting to return to activities and sports (NOT absolute platelet count)
If choosing conservative management / observation for typical newly diagnosed ITP, name three essential parts of your followup plan. (3)
Physical examination for signs of bleeding, check CBC to follow platelets and other cell lines, advise to avoid contact sports or activities that may cause hits to the head, advise to avoid NSAID/ASA/any meds or herbal supplements with anti-platelet activity, continue regular appointments until counts have recovered
What are the five recommended elements of working with vaccine-hesitant parents? (5)
Keep them in your practice; identify parental concerns with presumptive, motivational interviewing; present risks/benefits with clear, effective language; manage immunization pain; discuss herd immunity / community protection.
Mnemonic: PPPPP (Practice they shouldn’t get kicked out of, Parental concerns / presumptive interviewing, Present the risks/benefits, Pain management, Protect the community)
Which of the following is the best tactic to employ with a vaccine-hesitant family?
a. Explaining to the family that you cannot provide medical care to the child if they choose not to immunize
b. Providing a list of vaccine concerns frequently raised by parents along with comprehensive rebuttals
c. Using a participatory approach when introducing the topic of the child’s routine vaccinations
d. Telling an emotionally powerful true story about vaccine-preventable illnesses
d: don’t introduce concerns not brought up by the family, use a presumptive not participatory approach
List two reasons why it is not advisable for parents to rely on “herd immunity” to protect their child from vaccine-preventable diseases. (2)
Outbreaks still occur which overwhelm herd immunity and generally by that time it is too late to vaccinate, some diseases eg tetanus have no herd immunity, choosing not to vaccinate puts others in our orbit at risk eg neonates and pregnant women
What term is currently preferred over “herd immunity”? (1)
“Community protection”
A patient presents to ED after a bee sting. In which situation(s) do you need to prescribe an EpiPen when the patient is well enough to go home?
a. Lip swelling, wheeze, and hypotension starting 10 minutes after being stung
b. Generalized urticaria starting 10 minutes after being stung
c. A 15cm-diameter area of swelling, erythema, and pruritus around the sting site that has been worsening since the sting 24 hours ago
d. A and B
e. A, B, and C
a: not needed for isolated cutaneous reactions as these do not presage life-threatening reactions in the future
A patient presents to ED with an anaphylactic reaction after a bee sting. You manage the patient appropriately in the ED with epinephrine followed by a period of observation. The patient is now well and ready for discharge home.
a) Aside from making a referral to an allergist, what are two important elements of your discharge plan for this patient? (2)
b) Name two reasons why is it necessary to refer the patient to an allergist. (2)
a) prescribe EpiPen, arrange for a serum tryptase when well, provide instructions on how to avoid stinging insects, anticipatory guidance on signs of anaphylaxis; b) to confirm anaphylactic allergy, to assess eligibility for venom immunotherapy
List three measures that a patient or family can use to avoid stinging insects. (3)
Do not walk barefoot outdoors, exercise caution when eating and drinking outdoors, avoid drinking from opaque cans or straws outdoors, wear gloves and long sleeves for gardening and a long sleeve shirt for play in high-risk areas, remove all insect nests around the home and call a professional for insect control or nest removal in confined or hard-to-reach spaces
Mnemonic: NOSES (Nest removal, Opaque cans, Shoes when outdoors, Eating carefully outdoors, Shirt)
A young woman in your clinic is asking about the difference between “typical use” and “perfect use” failure rates for contraceptives. What property of a contraceptive method is most important in determining its “typical use” failure rate? (1)
How user-dependent the method is
Describe the three tiers of contraceptive options for youth and give an example of each. (6)
First-tier: act over a long time period without needing any intervention; IUD/IUS
Second-tier: act over a shorter time period, require periodic intervention; OCP, patch, Nuva, DP
Third-tier: act only at the moment and depend on individuals’ motivation, skill, and timing; condoms, withdrawal, rhythm, diaphragm, cap, sponge
Name the major health complication associated with Depo-Provera (1) and two recommendations you might make to a patient starting it in order to reduce the risk of this complication (2).
Bone demineralization; optimize Ca++ and VitD intake, weight-bearing exercise, reduce caffeine/alcohol/tobacco use
When prescribing an oral contraceptive, which of the following is true?
a. Close followup — providing an OCP prescription for only two to three months at a time and requiring the patient to return for refills — improves adherence to the OCP and decreases the overall rate of contraceptive failures
b. It is important to be screened for pregnancy before starting OCPs because they can be teratogenic in early pregnancy
c. If breakthrough bleeding occurs during ‘extended use’ or ‘continuous use’ OCP, the pill should be stopped for 4 to 7 days or else the breakthrough bleeding may continue indefinitely
d. The risk of stroke or VTE is approximately doubled by using combined oral contraceptives
d: yearlong prescriptions improve adherence and outcomes, OCPs are not teratogenic, breakthrough bleeding stops on its own
List three medications that may be used in the management of neonatal abstinence syndrome. (3)
Morphine, methadone, clonidine, phenobarbital, buprenorphine
Which of the following statements is false?
a. 50-75% of babies born to mothers using opioids will require treatment for opioid withdrawal
b. Symptoms of neonatal opioid withdrawal generally start within the first 72h of life, but may not present until day 5-7 of life if the mother has been on methadone or buprenorphine
c. A trained pediatric team, rather than the routine healthcare provider, should be present at the delivery when the mother is known to have been using opioids
d. Preterm babies are probably less likely to experience neonatal opioid withdrawal
c: routine is fine unless other indications
List six signs/symptoms of neonatal opioid withdrawal. (6)
High pitched cry, short sleep cycles, hyperactive Moro reflex, tremor, increased tone, myoclonic jerks, convulsions/seizures, diaphoresis, increased temperature, yawning, mottling, nasal stuffiness or sneezing, nasal flaring, tachypnea, excessive sucking, poor feeding, regurgitation, loose stools
Name the three essential elements of informed consent. (3)
Capacity, fully informed, free from coercion.
What is the difference between ‘consent’ and ‘assent’, and why is this distinction relevant to the pediatric population? (2)
Assent: patient agrees to the proposal but without true consent (may be incompletely informed, may be coerced, may not be capable of consent). Relevant because many of our patients are not able to give consent, yet it is important to still get their assent when possible
A patient on your ward is a 10-year-old male who has just been diagnosed with pre-B ALL. Despite the overwhelming likelihood of cure with chemotherapy, his parents refuse. They do not trust your hospital after a previous bad experience, and they would prefer to treat the cancer with cranial-sacral therapy and Himalayan salt crystals. The patient himself refuses treatment as well, saying that losing his hair would be worse than dying.
a) You are concerned that this refusal of chemotherapy does not represent the patient’s best interest. What are four potential steps you could take at this point to address the conflict over the patient’s plan of care? (4)
b) If the patient were unstable in the emergency department with severe tumor lysis syndrome, and his parents were refusing acute treatment, how would this affect your plan in part a)? (1)
a) Agree to delay care for the moment pending discussion; exploring parents’ values and potential for collaborative decision-making; referral for second medical opinion; consult with social work; consult a religious leader if relevant; consult a hospital bioethicist; consult CAS
b) if emergent / life-or-limb, provide care now and debate later (beneficence and non-maleficence)
- In a head lice infestation, what is meant by the term ‘nit’? (1) What is the clinical significance of finding ≥5 nits within 0.6cm of the scalp? (1)
Nits are louse eggs or empty egg shells glued to hair shafts. They can easily indicate past infestation rather than active infestation. Finding at least 5 nits within 0.6cm of the scalp is a risk factor for active infestation, but only about 1/3 of patient with this many nits actually have an active infestation
In a typical head lice infestation, how many live adult lice typically infest the patient’s scalp?
a) 1-10
b) 10-100
c) 100-1000
d) 1000-10000
a: “Less than 10” per CPS
Which of the following would be provide the best evidence for an active head lice infestation?
a) Excoriated scalp in the context of a known contact with head lice infestation
b) A single live louse detected on the patient’s scalp
c) Ten nits found glued to the patient’s hair shafts within 0.6cm of the scalp
d) Five nits found glued to the patient’s hair shafts within 0.6cm of the scalp, in the context of a known contact with head lice infestation
b: can’t diagnose from nits alone, doesn’t matter if they have a contact
Some medications that can be used in the treatment of head lice are insecticidal and some are not. Please list one medication from each class. (2)
Insecticidal: pyrethrin (R&C Shampoo), permethrin (Nix, Kwellada).
Noninsecticidal: Isopropyl myristate/ ST-cyclomethicone (Resultz), dimethicone (NYDA)
What diagnostic criteria differentiates GDD from ID?
a) Age group
b) Deficits in adaptative learning
c) Age at onset
d) Intellectual quotient
e) Number of developmental domains affected
a: diagnosis of GDD is for kids under 5
What is the most common cause of GDD/ID?
a) Prenatal intrinsic
b) Postnatal
c) Perinatal
d) Prenatal extrinsic
e) Idiopathic
c: up to 55%. Next highest is prenatal intrinsic at up to 47%
What are the first-line investigations for GDD/ID when no apparent cause can be identified by history/physical, neurodevelopmental exams, and vision/hearing screening? (3)
Microarray, fragile X testing, and tier 1 metabolic panel (blood and urine)
List five “red flags” on history, physical, and initial investigations that are concerning for an inborn error of metabolism. (5)
Family history of IEM or developmental disorder or unexplained neonatal or sudden infant death; Consanguinity; Intrauterine growth retardation; Failure to thrive; Head circumference or stature growth abnormality (>2 SD above or under the mean); Recurrent episodes of vomiting, ataxia, seizures, lethargy, coma; History of being severely symptomatic and needing longer to recover with benign illnesses (e.g., upper respiratory tract infection); Unusual dietary preferences (e.g., protein or carbohydrate aversion); Regression in developmental milestones; Behavioural or psychiatric problems (e.g., psychosis at a young age); Movement disorder (e.g., dystonia); Facial dysmorphism (e.g., coarse facial features); Organomegaly; Severe hypotonia; Congenital nonfacial anomalies; Sensory deficits, especially if progressive (e.g., cataracts, retinopathy); Noncongenital progressive spine deformities; Neuro-imaging abnormalities
Concerning Salmonella infections, which is true:
a) Positive stool cultures for non-typhoidal Salmonella do not require action
b) Typhoidal types are often responsible for osteomyelitis in sickle cell patients
c) Non-typhoidal infections are not associated with bloody diarrhea
d) Non-typhoidal infections are associated with septic arthritis in sickle cell patients
e) Infection with typhoidal species comes from animal-to-human spread
d: action is needed if the patient is unwell or under 3mo, only non-typhoidal types cause osteoarticular infex in SC disease
Concerning management of Salmonella infections, which is true:
a) Azithromycin is favored over Ciprofloxacin as a step-down therapy
b) For return to school/daycare, authorities require a document proving negative stools
c) There is a licensed vaccine for children > 12mo
d) Immunocompromised patients cannot receive the typhoid immunization because it is a live vaccine
e) Resolution of fever, good clinical condition and negative blood cultures are required before switch to po Abx
a: cipro is starting to face resistance, there is an inactivated typhoid vaccine as well as a live one, don’t need resolution of fever to switch to PO abx
You have admitted a febrile returning traveller with a blood culture positive for Salmonella typhi, and started the patient on ceftriaxone. What are three factors that would necessitate an infectious disease consultation and/or a prolonged course of IV antibiotics? (3)
Blood cultures don’t clear in 48h, patient still unwell after blood cultures clear, evidence of disseminated disease
What are three of the recommended preventative measures to avoid needle stick injuries in the community? (3)
Education of parents/educators and health care providers about the problem of discarded needles; Age-appropriate education of children and youth about potential dangers of injection drug use; Teaching children not to touch or handle needles and syringes, and to report to a responsible adult; Community programs for safe disposal of needles in areas accessible to children; Programs for treatment and control of injection drug addiction; Programs for support of HIV prevention; Programs for HBV vaccination; Programs for safer distribution of drug use equipment
What are three of the factors that should be considered to assess transmission risk of blood-borne infections after a needle stick injury in the community? (3)
Status of source blood/patient; Circumstance of injury: date/time, location, mechanism, presence of syringe attached to needle, blood visible on syringe and/or needle, presence of bleeding; Description of needle: size, hollow-bore; Depth of penetration (extent of trauma); Potential injection of blood; Amount of blood injected; Concentration of virus in injected blood
Concerning needle stick injuries in the community, which is true:
a) HBV is a fragile virus and survival and is unlikely to survive if exposed to dry, hot or freezing environment
b) Risk of acquiring HIV is higher than for HCV
c) No hepatitis B testing is needed if child has been fully vaccinated against HBV
d) Splashes, even if large volume of blood coming into contact with extensive areas of nonintact skin, are NOT considered high risk for HIV transmission
e) HIV prophylaxis is not indicated if cannot be initiated within 72 hours of exposure
e) HIV prophylaxis is not indicated if cannot be initiated within 72 hours of exposure
Concerning acute osteoarticular infections, which is true:
a) Optimal empiric therapy is IV Cefazolin
b) When an acute osteoarticular infection is suspected, there is no need to do baseline radiographs if the patient can have a MRI right away
c) CRP is not sensitive for monitoring response to therapy
d) S. pneumoniae is more common than K. kingae in children younger than 4 years old
e) Routine radiographs are indicated for follow-up
a) Optimal empiric therapy is IV Cefazolin
List 3 conditions to consider in the differential diagnosis of acute focal pain in limb or near bone. (3)
Acute bacterial osteoarticular infection; Transient synovitis of hip; Fracture or trauma; Lyme disease arthritis; Cellulitis; Chronic recurrent multifocal osteomyelitis (CRMO); Hematologic malignancy; Bone neoplastic lesion; JIA; SLE; Reactive arthritis
Concerning HPV infections, which is true:
a) Marijuana is a risk factor
b) HPV 6 and 11 are responsible for majority of genital cancers
c) If previously received immunized with a different HPV vaccine, there is no need to administer the full HPV-9 schedule
d) Females should get the vaccine earlier
e) A 3-dose schedule is recommended for children 9-14yo
a) Marijuana is a risk factor
List two at-risk populations for which HPV vaccination is strongly recommended. (2)
MSM, immunocompromised, HIV positive
List four individual-level risk factors for HPV infection. (4)
higher lifetime number of sexual partners, previous other sexually transmitted infections, history of sexual abuse, early age of first sexual intercourse, partner’s number of lifetime sexual partners, tobacco or marijuana use, immune suppression, human immunodeficiency virus (HIV) infection
Concerning high-flow nasal cannula, which is true:
a) Provides continuous positive nasopharyngeal and intrathoracic pressure
b) Is effective in heart failure because allows reduction of systemic afterload and preload
c) Does not allow wash out of anatomic dead space
d) Not recommended for transport
b) Is effective in heart failure because allows reduction of systemic afterload and preload
List three conditions for which there is evidence to support the use of HHHFNC. (3)
Upper airway obstruction (OSA), lower airway obstruction (bronchiolitis, asthma), parenchymal lung disease (pneumonia, pneumonitis), heart failur
What makes a teen more likely to quit smoking? What makes a teen less likely to quit?
