2019 SAQ

Question 1

5 year old with osteomyelitis.
Name the 2 most common organisms for THIS child.
What is the most sensitive and specific test to diagnose osteomyelitis?
What empiric antibiotics would you start (1)
Name 3 criteria that need to be met for the child to switch to oral antibiotics.

Answer 1

Staphylococcus aureus and Kingella kingae
MRI
Cefazolin IV
Clinically improved (afebrile, ability to weight-bear or use affected limb)
CRP decreased
Compliance and follow up assured.

Question 2

14 year old with heavy bleeding for 10 days, menarche at 12. Bleeding disorders have been ruled out.
Name 4 conditions you need to rule out.(4 conditions you “need to consider” was exact wording.)

Answer 2

Ectopic pregnancy
Threatened abortion
PID (Endometritis)
Foreign body
Trauma (sexual abuse)
Endocrine (PCOS, Anovulatory cycles, Thyroid disease)

Question 3

2 month old with vascular malformation of right face including eye and forehead. You suspect Sturge-Weber Syndrome.
What are FOUR complications of, or associations with Sturge Weber Syndrome? (exact exam wording)
What are FOUR investigations you would do for Sturge Weber?

Answer 3

A, Seizures
Glaucoma
Intracranial calcifications
Developmental Delay
Hypothyroid
GH deficiency

B.Brain MRI
Ophthalmology assessment
EEG
TSH

Question 4

You are in the emergency department seeing a 3 year old who just returned from travelling in Southeast Asia. He had a fever and diarrhea 3 weeks ago, and now presents with 1 week of fever. You suspect typhoid fever.
What are TWO modes of transmission (exact wording) for Salmonella typhi or Salmonella paratyphi?
Excluding bacteremia and gastroenteritis, what are THREE complications of typhoid fever?
What are your next THREE immediate management steps for this child?

Answer 4

A. Water/food contaminated with feces from carrier
From direct person to person spread

B. GI bleed
Intestinal perforation
Encephalopathy
Myo/endocarditis

C. Physical examination for complications
Send blood culture x2
Start empiric IV ceftriaxone

Question 5

14y old complaining of dizziness and lightheadedness exclusively on standing associated with palpitations. You suspect POTS. (no vitals given)
What is the one test you could do to confirm diagnosis (1point)
What are two management recommendations you could give her to prevent future symptoms (2 points)

Answer 5

Head- up tilt-table

To drink more than 80 oz/day (2.5L) and add 2g of salt in the morning and early afternoon meals
Exercise - increase slowly until reach 45 minutes 5x per week

Question 6

13y old CF loss 5kg and low energy. Drop in FEV1 by 10%. States she’s compliant with meds, physiotherapist and enzyme replacement.
Write 3 etiologies to explain this. (3points)

Answer 6

Chest exacerbation
ABPA (Allergic Bronchopulmonary Aspergillosis)
Pulmonary hypertension
Non-compliance with medications

Question 7

8 year old girl with 2 months of hair loss, normal weight and height. Otherwise asymptomatic.
What are three common causes of hair loss in children?
Then they tell you she is vegan. What are two nutritional deficiencies that would put her at risk of hair loss?

Answer 7

A.
Alopecia areata
Tinea capitis
Traumatic alopecia

B. Iron deficiency and Zinc deficiency

Question 8

10 year old boy with poor school performance, behaviour issues and decreased attention who was diagnosed with ADHD by his family doctor. Failed 2 stimulant trials.
What are 4 other possible causes of his symptoms?

Answer 8

Learning Disorder
Obstructive sleep apnea/sleep disorder
ODD
Anxiety disorder
Intellectual disability
Language, mood, tic, conduct disorder
ASD
DCD

Question 9

Newborn term male. HC at 85th percentile and weight and length between 50-85th percentile. Large anterior fontanelle.
What 2 investigations MUST you do?
All investigations come back normal. What do you tell the parents? (1 point)

Answer 9

A. Head US
TSH
Karyotype (Down Syndrome)

B. To follow up HC growth and development with family doctor as there is a wide variation of normal Fontanelle’s sizes.
Go to ED if fontanelle is bulging, lethargy, vomiting.

Question 10

4 risk factors for child abuse aside from social and environmental (child factors)

Answer 10

Chronic illness or disability
Prematurity
Previous history of involvement with CAS
Behavioural issues in the child

Question 11

In regards to influenza vaccination:
What are 3 contraindications to LAIV influenza vaccine
What are 3 populations other than children with chronic illness who should receive the inactivated influenza vaccine

Answer 11

A.Age below 24 months
Immunodeficiency
Severe asthma (current high dose of inhaled steroids or systemic steroids)
ASA treatment

B. Any child [>6 months - 59 months]
All Indigenous persons
Pregnant women
Family members who have siblings who cannot receive the vaccine
Residents of chronic care facilities

Question 12

Patient 1 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 36 PCO2 28.
Patient 2 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 20 PCO2 38.
Which patient do you see first?
Explain your choice

Answer 12

I would see the patient 2 first because he has a slower respiratory rate and higher PCO2 in the context of respiratory distress. It could indicate that he is tiring and progressing to respiratory failure.

Question 13

Kid with William’s syndrome.

Name FOUR long term complications for monitoring.

Answer 13

Cardiovascular - supravalvular aortic stenosis, peripheral pulmonary valve stenosis, HTN
Developmental delay, ADHD
GI - feeding difficulty, constipation
Hypercalcemia

Question 14

Term newborn born to mom on methadone
List FOUR signs of neonatal abstinence syndrome
List FOUR non-pharmacological strategies for neonatal abstinence syndrome

Answer 14

Jittery, feeding intolerance, loose stools, poor sleep, sneezing

Breast feeding
Skin-to-skin
Quiet environment
Swaddling
Music/massage therapy

Question 15

In regards to lupus:
What are TWO medication classes implicated in drug induced lupus?
Other than medications, what is ONE possible cause of exacerbation in systemic lupus erythematosus?

Answer 15

Antibiotics (minocycline, penicillamine)
Antiarrhythmic agents (procainamide)
Antiepileptics

Sun exposure

Question 16

A mother brings in her 2 year old son with a runny nose, fever, and cough. His throat is erythematous. (does not mention exudate)
Would you do a throat culture on this boy? Explain your rationale.
His mother asks if she can give him cough syrup. What do you recommend?

Answer 16

No, like viral. Low risk due to age, viral URTI symptoms, no exudate

Not recommended. No benefit, potential harm (mortality high risk if <2yo)

Question 17

12 month old with infantile acne
What are 2 things on your differential?
What are 3 laboratory blood tests to do?
What is 1 non-laboratory investigation that you would do?

Answer 17

Neonatal cephalic pustulosis
Miliaria

Testosterone
17-OH progesterone
DHEAS
FSH/ LH
Prolactin

Abdominal US (look for adrenal tumor)
     Bone Age

Question 18

You are seeing an 18-month old and are suspicious for a primary immunodeficiency. Fill in chart with one functional screening test for each of the immune cells

Answer 18

T-cell - In vivo lymphocyte proliferation in response to mitogens and antigens, T-cell receptor excision circles (TRECs) (I think?) mitogen stimulation test

B-cell - Vaccine titres to childhood vaccines, diphtheria, tetanus

Granulocyte - Neutrophil oxidative burst index

Question 19

Teen girl with symptoms of generalized anxiety disorder.
What is the most evidenced based psychotherapy treatment for anxiety? (1)
Her anxiety worsens and she agrees to start a medication. What is your first line pharmacological treatment for this patient? (1)
This medication is known to have side effects and a black-box warning; list two ways you would approach treatment and management? (2)

Answer 19

Cognitive behavioural therapy

Selective Serotonin Reuptake Inhibitor (fluoxetine)

Risk of increase suicidality - make the home safe, ask parent to remove guns, lock up medications, ask patient to please inform trusted adult if thoughts of suicide
Start low dose and slowly titrate up according to symptomatology
Close follow up, next in 2 weeks
Warn about common SE, like abdominal discomfort, and that it should improve with time

Question 20

4 year old girl presents with interstitial pneumonia. She was living with her grandfather who had tuberculosis. He died 1 month ago.
What are two ways you would provide adequate isolation precautions for her? (they weren’t asking what kind of isolation she needs, but how you would do it; 2)
What are two reasons to perform a TST in this case? (2)

Answer 20

Admit to hospital with airborne isolation, with 3 negative sputums/
Home isolation until 3 negative sputums

TST is more sensitive than IGRA
Want to work up for tuberculosis - has symptoms and known contact with index case
Based on age, needs treatment. Require TSTs to monitor for treatment/prophylaxis discontinuation (based on results)

Question 21

For pulse oximetry screening of newborns
What is the ideal timeframe to screen post-natally?
Where should the probe be placed? (it was written like this, but should really be probes!)
What are considered borderline values?

Answer 21

24-36h
Right hand and either foot
90-94% or more than 3% difference between arm and leg

Question 22

You are seeing a term newborn with a large panniculitis (subcutaneous fat necrosis) on his back.
What is 1 potential complication of this condition?
What are 2 signs/symptoms to ask parents to monitor for?

Answer 22

Hypercalcemia

Irritability
Poor feeding/vomiting
Also can have hypotonia

Possible to have symptoms up to 6 months of age, but rare later than 10 weeks
If they have hypercalcemia, they should have it checked weekly until resolved
If very high, twice weekly checks

Question 23

Mom just had baby and has questions about vitamin K
Explain why you want to administer parenteral vitamin K
For babies that DO get late HDN what is the % that get intracranial bleed
If she refuses parenteral what would you recommend, be specific

Answer 23

To prevent Vitamin K Deficiency Bleeding (Hemorrhagic Disease of the NEwborn)
ICH up to 50% chance
Can be given two doses of oral Vitamin K
2mg within 6h of birth, then 2 more doses at 2-4weeks; then 6-8 weeks

Question 24

Boy with hard infrequent stools, some overflow stool, dad asks about management
What two medications can you use initially
What 2 non-pharmacological treatments would you suggest

Answer 24

PEG3350
Lactulose
Mineral oil (watch age)
Senna

1. Increase fluid intake
2. Increase fiber intake
3. Increase physical activity
4. Scheduled toileting (Behavioural strategies)

Question 25

Child is 1.5%ile for height. His father is 5 feet 4, his mother is 5 feet. What is the definition of short stature What are 2 requirements to make a diagnosis of familial short stature?

Answer 25

A height that is 2 standard deviations below the mean for age and sex [or <5th %tile] Normal growth velocity Bone age equivalent to chronological age (BA=CA) Family History of Short stature

Question 26

7 year old girl with orbital cellulitis Where does orbital cellulitis commonly originate from? (most common infectious source) What are two features unique to orbital cellulitis? (compared to pre-orbital cellulitis) What are two of the most common organisms that cause orbital cellulitis What are two ophthalmologic complications or orbital cellulitis?

Answer 26

Ethmoid sinusitis ``` Proptosis Pain with extraocular movements Restricted ocular motility Staphylococcus aureus, Streptococcus spp. (anginosus, then GAS, then pneumoniae) Loss of vision Orbital abscess ```

Question 27

Newborn baby boy has a renal u/s showing unilateral grade 4 hydronephrosis with no dilation of the ureter What is the most likely diagnosis? What are 4 steps you need to take to confirm the diagnosis/manage the condition?

Answer 27

Uretero-pelvic junction (UPJ) obstruction - due to significant hydronephrosis without hydroureter Referral to pediatric urology Renal function testing (creatinine/blood urea nitrogen [BUN]) Monitor output closely Order VCUG MAG3 with lasix scan to confirm diagnosis (urology to order)

Question 28

A child comes to you and he is diagnosed with Kawasaki disease. List TWO therapies for treatment of Kawasaki disease with specific dosing. List TWO important parts of your management plan when this patient is in the convalescent phase of the disease

Answer 28

IVIG 2g/kg IV x 1 dose ASA 80-100mg/kg/day divided QID until fever subsides ASA 3-5mg/kg daily continued until normal echo, platelets and inflammatory markers Echocardiogram 6-8wks after treatment

Question 29

6 month old with eczema. Parents have been using topical corticosteroids with limited improvement. Apart from corticosteroids and antihistamines, what are four practices you would advise the parents on to improve his eczema? (2 marks) What are two viruses that can exacerbate eczema? (2 marks)

Answer 29

Avoidance of triggers Daily warm bath/short timing (5-10 minutes) Frequent liberal use of bland emollients Avoid restrictive diets Education of when to seek care with signs of bacterial superinfection Bleach baths Molluscum contagiosum Herpes simplex virus Coxsackie (less commonly)

Question 30

Name 4 features to differentiate between regular childhood tantrums and tantrums experienced by children with Autism Spectrum Disorder

Answer 30

Misbehaves in ways that are dangerous (e.g. refuses to hold hand and instead runs into street) Acts aggressively to try to get something they want Tantrums lasting >5 minutes Daily temper tantrums Behaviours atypical for developmental age (>5y) Persisting for ≥6 months Occur in several situations, resulting in impaired functioning Cause significant distress for both child and family

Question 31

Child with hypercalcemia (3.6) secondary to hyper-Vitamin D, which has already been stopped. The child is constipated but otherwise well. What’s your initial management? (Be specific) What fluids would you run and at what rate? (weight was given). What is the initial pharmacologic intervention to give?

Answer 31

Admission to hospital Cardiorespiratory monitors and IV insertion ECG - assess for shortened QT interval Labs: Lytes, creatinine, PTH, 25-OH Vit D, ALP, urine calcium/Cr, ionized calcium, magnesium, phosphate X-ray of left wrist Normal saline 1-1.5X maintenance ``` Calcitonin IV q12h (2-4 IU/kg) Bisphosphonates IV (Pamidronate 0.5mg/kg over 4h or Zoledronate 0.01-0.02mg/kg over 20 min) Once a good state of hydration and baseline electrolytes available = furosemide 0.5-1mg/kg/dose IV ```

Question 32

Smoking cessation Name 4 factors that increase success of cessation. Name 4 factors that may impede quitting attempts. (and do not put the opposite of the 4 above)

Answer 32

``` More likely to quit: Older teenager Male sex Teen pregnancy/parenthood Scholastic success Team sport participation Peer and family support for cessation CYP2A6 slow nicotine metabolizer ``` ``` Less likely to quit: Nicotine addiction Mental health conditions (ADHD) Drug and/or alcohol use Chronic illness Family stress Peer and family tobacco use Overweight or weight preoccupation Developmental drive to experiment Fear of peer rejection Perceived lack of privacy and autonomy ```

Question 33

Child with headaches. What are 3 signs/symptoms of an infratentorial brain tumour?

Answer 33

``` Ataxia/gait abnormality Nystagmus (cerebellar) Head tilt Obstructive hydrocephalus Parinaud syndrome (paresis of upward gaze, pupillary caliber reactive to accommodation but not light [pseudo Argyll Robertson pupil], nystagmus to convergence or retraction and eyelid retraction) ```

Question 34

Suspected Guillain Barré syndrome What test would you perform and what results would you expect? What are two specific management interventions?

Answer 34

EMG/NCS: features of demyelination; “increased F wave latency” LP: CSF - elevated protein (>2X upper limit of normal) and lack of cellular response (cytoalbuminologic dissociation) + no pleocytosis (<10 WBC/mm3), normal glucose IVIG Plasmapheresis

Question 35

Steven Johnson’s Syndrome/TEN. Admitted to hospital and all your consultations have been made. Hemodynamically stable. Name 4 initial management strategies (you have already consulted all services). Name 2 pharmacologic management options

Answer 35

Discontinue suspected causal medication Consider transfer to burn centre/dressings to open wounds Narcotics for pain relief Meticulous fluid/electrolyte therapy IVIG Systemic glucocorticosteroids

Question 36

Infant with cryptorchidism. Name 2 findings that would make you concerned for disorders of sexual development. When should he have surgery by to avoid issues later?

Answer 36

Bilateral cryptorchidism Unilateral cryptorchidism with hypospadias Between 6-12 months (6-18mo if you use Canadian urological association)

Question 37

Name 2 etiologies for primary Fanconi syndrome.

Answer 37

``` Galactosemia Cystinosis Wilson disease Tyrosinemia Lowe syndrome ```

Question 38

Kid with Marfan’s comes in with chest pain and difficulty breathing. He then arrests. He receives shock therapy from a defibrillator and has return of spontaneous circulation. What rhythm was he likely in? (No ECG given) What was the likely etiology of his symptoms?

Answer 38

``` Ventricular arrhythmia (likely ventricular tachycardia or fibrillation) leads to sudden death in Marfan’s patients Left Ventricular failure secondary to mitral prolapse and regurgitation (causing ventricular dilatation) ```

Question 39

14 year old female found to have gallstones. | Name 3 conditions that predispose you to gallstones in this age range.

Answer 39

``` Obesity Ethnic background (Hispanic highest risk) Low socioeconomic status Teenage pregnancy Sickle Cell Anemia ```

Question 40

4 month old female, not feeling well. In ER, HR 182, BP 70/40, RR 36, T39˚C, CRT 2s. Lethargic, bounding pulses, otherwise fine. No weight given. What is her cardiac output currently compared to baseline? What is her systemic vascular resistance compared to baseline? Classify her physiologic state. What IV fluid order would you write (be specific).

Answer 40

``` HR within norm (100-190; close to upper limit) BP low (normal 72-104/37-56) RR normal: 30-53 Temp: high CRT normal. Lethargy - not normal. ``` Cardiac output is increased Systemic Vascular resistance is decreased Physiologic state: ? compensated warm shock (end organ dysfunction: altered mental status?) Bolus 0.9% Normal saline IV (no weight) 20cc/kg given IV push

Question 41

4 year old with nasal discharge for 2 weeks and fever for 1 day, which improved. Now he has had fever x 2 days (38.5˚C) with yellow rhinorrhea. List 2 reasons why this would be in keeping with sinusitis Name 4 intracranial complications

Answer 41

Purulent Nasal discharge ongoing x 2 weeks (yellow rhinorrhea) Fever ``` Meningitis Venous sinus thrombosis Epidural abscess Subdural abscess Brain abscess ```

Question 42

6mo infant with an older sibling who has multiple food allergies. Mom wants advice regarding decreases the infant’s chances of also having food allergies. What would you recommend in regards to breastfeeding? What 3 strategies would you suggest to minimize risk of food allergies in this child?

Answer 42

Breastfeeding has many additional benefits, and no restrictions should be made on mother’s diet. Continue to breastfeed up to 2 years or beyond, as per parental preference Introduce common high risk allergens between 4-6months of age Allergenic foods should be introduced one at a time, to gauge reaction, without significant delay between each food Once allergenic food is introduced and tolerated, continue to administer it 2-3x per week to maintain tolerance

Question 43

17 yo with Duchenne’s (or SMA type 2), currently on BiPAP and G-tube feeds. Apart from informed consent, what 3 criteria do you need to fulfill to apply for MAID in Canada?

Answer 43

18 years or older and deemed capable of making medical decisions Have grievous and irremediable medical condition (ie serious, incurable with disability, or in an advanced state or irreversibility, experienced induring, intolerable suffering) Make voluntary request

Question 44

8-year-old developmentally normal child in foster care is sent to you because teacher is worried about sexual abuse. The child is found putting her hands down other children’s pants. Name 3 other sexual behaviours that would be concerning.

Answer 44

Any sexual behaviours that involve children > 4 years apart in age Sexualized behaviours that are associated with emotional distress or physical pain Sexual behaviours that involve coercion Behaviours that are persistent and child becomes angry if distracted Sexual behaviours that are displayed in a variety of ways and on a daily basis

Question 45

Kid with acne. | What 4 psychosocial consequences may occur that are independent of severity of disease?

Answer 45

``` Anxiety/Depression Poor self-image Poor self-esteem Social isolation Poor academic functioning and decreased ability to gain employment ```

Question 46

In regards to circumcision: What are the indications What are the contraindications What are possible complications.

Answer 46

NB - there are only 2 ABSOLUTE medical indications: Phimosis secondary to Balanitis xerotica obliterans Recurrent balanoposthitis Relative indications (but controversial) include - paraphimosis, trauma, prevention of UTI in boys with urological abnormality, prevention of STI, prevention of penile cancer Contraindications: Hypospadias Bleeding disorders (known) ``` Minor bleeding Local infection Severe infection Unsatisfactory cosmetic results Meatal stenosis ```

Question 47

Child with acute renal failure and hyperkalemia. Currently on maintenance IV fluids with D5NS. What are indications for RRT What treatment would you recommend if ECG is normal? Advise regarding further fluid management recommendations

Answer 47

Severe fluid overload Refractory HTN Uncontrollable hyperkalemia Severe metabolic acidosis BUN >70-100mg/dL (25-250mmol/L) Lethargy, seizures, encephalopathy, asterixis Pericarditis Bleeding diathesis Treatment if ECG normal: Kayexelate (sodium polystyrene sulfonate) can be used, alternatively, so can IV insulin with glucose and a nebulized beta-2 agonist (or both) If ECG changes - need calcium gluconate IV Further fluid recommendations: Consult Nephrology for further fluid recommendation Daily weights Daily lytes, BUN, Cr Replace fluid according to insensible losses and any losses (urine output)

Question 48

When screening for type 2 diabetes: What test should be used to screen in high-risk children? Name 3 complications or comorbidities Name 3 indications to screen for type 2 diabetes

Answer 48

Fasting plasma glucose (or random PG) and HbA1c Neuropathy - screen at diagnosis, then annually Retinopathy - screen at diagnosis, then annually Nephropathy - screen at diagnosis, then annually (ACR preferred) Dyslipidemia - screen at diagnosis, then annually HTN - screen at diagnosis, then at every visit Type2 Screening Indications Obesity (BMI >85th percentile for age, sex) High risk ethnic group (Indigenous, African, Arab, Asian, Hispanic) 1st degree or 2nd degree relative with T2DM Signs/symptoms of insulin resistance: acanthosis nigricans, HTN, dyslipidemia, NAFLD, PCOS Impaired GTT/FGT Atypical antipsychotic use

Question 49

4mo with uncomplicated UTI, started on ampicillin and gentamicin. What is the interval of dosing for gentamicin and why? What monitoring is required for this? (be specific)

Answer 49

For any child >2months of age - gentamicin is dosed 5-7.5mg/kg IV or IM once daily [cps statement] Monitoring includes pre (trough level) gentamicin concentration level prior to administration of the 3rd dose. In many centres, a post concentration (taken after administration of the third dose) is also required. This is done to prevent renal and ototoxicity

Question 50

List 4 non-psychiatric causes of psychosis.

Answer 50

Encephalitis Systemic Lupus Erythematosus Cushing disease Medication adverse effect