Kulkarni Yellow Book Flashcards
(309 cards)
1
Q
What condition has eczema, thrombocytopenia and immunodeficiency associated with it?
What is the platelet size?
What its inheritance pattern and how is it cured?
A
Wiscott Aldrich
Small platelets
Inherited X-linked so boys are more affected
Stem cell transplant
2
Q
For a child with HCM who had chest pain twice in the setting of exercise over the past 3 months, what’s the next best step in management?
A
Beta blockers to decrease heart rate and improve ventricular filling
If the patient had had a documented arrhythmic event, then an AICD - automatic impantable cardioverter defibrillator would be recommended.
3
Q
When a facial palsy involves the ENTIRE right side of a face. Is it central or peripheral?
What then is the most likely etiology if accompanied by malaise and myalgia.
A
It is peripheral. Lyme disease a cause of PERIPHERAL facial palsy when accompanied by fatigue and myalgia
In central disease, there is forehead sparing.
4
Q
A baby with Beckwith-Wiedemann disorder presents with large tongue, neonatal hypoglycemia and is LGA. Which tumors are they at risk for?
A
Wilms tumor, hepatoblastoma, rhabdomyosarcoma, neuroblastoma. Routine ultrasounds are recommended. The hypoglycemia that occurs is transient and due only to pancreatic cell hyperplasia NOT any insulin mass
5
Q
What is the Kocher criteria for evaluating a septic hip vs transient synovitis?
A
Temp > 101.3F
WBC > 12 K
ESR > 40mm/h
Inability to ambulate.
Absence of all four makes the likelihood of septic arthritis 0.2%
6
Q
What is the treatment for transient synovitis?
A
NSAIDs
7
Q
What is the treatment for transient synovitis?
A
NSAIDs usually x 7-10 days
8
Q
What is a typical WBC of synovial fluid in a septic joint?
A
More than 50,000 cells/mm
9
Q
OPEN fractures can be classified using the Gustilo and Anderson classification system to decide on appropriate antibiotic choice.
A
True. The single most important factor in reducing infection rates is early administration of prophylactic antibiotics within 3 hours.
If the open fracture has a wound LESS than 1 cm with minimal contamination, soft tissue damage and no comminution then IV cefazolin (1st gen cephalosporin) is appropriate.
If the wound is > 1 cm or there is moderate or more soft tissue damage or periosteal stripping or MORE then the appropriate prophylaxis is: IV cefazolin + aminoglyside (gentamicin)
10
Q
Why is enoxaparin preferred to IV heparin?
A
It is easier to give outpatient. It only requires once or twice daily monitoring of Xa after initiation but IV heparin requires q6h monitoring of PTT.
However, LMWH is only partially reversible with protamine and has a longer onset of action
11
Q
In the management of bronchiolitis, which of the following 2 is recommended by the AAP (chest PT or nebulizer hypertonic saline)?
A
Nebulized hypertonic saline
12
Q
What is the most helpful way to rule out T1DM and determine Type 2 DM in a new diagnosis of DM?
A
The absence of pancreatic ISLET cell autoantibodies (e.g IA2, GAD, Zinc transporter 8)
13
Q
A 9 month old boy with L arm abscess, recent otitis media and pneumonia, loose malodorous stools, hepatomegaly with elevated ALT, Thrombocytopenia, mild anemia, neutropenia, FTT, is concerning for
A
Schwachman diamond which is associated with pancreatic insufficiency. They are at risk long term of MDS and AML.
Treatment for the condition includes GCSF, pancreatic enzyme replacement and stem cell transplant.
14
Q
Tetralogy of fallot spells happen because crying or agitation/stress increases PVR which worsens RV outflow obstruction and causes increased R to L shunting. What is the treatment?
A
Oxygen, morphine to help with relaxation and phenylephrine to increase SVR. Can also consider fluid bolus to increase RV filling.
Prostaglandins do not have any role in managing tet spells except at the very beginning of life to keep PDA open to minimize impact of severe RVOT obstruction
15
Q
Even if motivated by religious preference, if a family understands the benefit of a treatment like insulin and refuses it for their child, the best action is to
A
Report it to CPS for medical neglect
16
Q
What test is dilute Russell viper venom used for?
A
To diagnose antiphospholipid syndrome
17
Q
A 6 wk old is brought to ED for 2 wks of vomiting. She has been tracking along the 50%ile for wt, episodes of emesis are 5-6 times a day occurring 20 to 30 min after feed. Never bloody or bilious and she is in no pain during worries. She has 3-4 stools per day. What’s best next step?
A
No testing is needed. She has reflux.
18
Q
What do Heinz bodies indicate?
A
G6PD or oxidative damage to RBCs
19
Q
What is ristocetin cofactor testing used for?
A
VWD
20
Q
Reactions to contrast are anaphylactoid not IgE mediated. They can have tachycardia, urticaria, bronchospasm, laryngospasm and the reaction can be prevented by using a steroid. A reaction to contrast that includes hypertension is more physiologic and would not be prevented by a steroid.
A
Repeat.
21
Q
An egg shaped cardiac silhouette on CXR in a neonate with hypoxia suggests transposition of the great arteries (the most common CYANOTIC congenital heart defect) that usually requires the PDA to stay open to oxygen prevent mixing.
A
Repeat
22
Q
Organophosphate are commonly found in pesticide or fertilizer. The toxidroe associated with them include mnemonic DUMBBBELS (defecation, urination, miosis, bronchorrhea, bronchospasm/cough, bradycardia, emesis, lacrimation/watery eyes, salivation/drooling). Also weakness, paralysis. They are cholinesterase inhibitors and lead to increase acetylcholine activation in synapses. It should be treatment with anticholinergic like atropine.
A
Repeat
23
Q
What is Sturge Weber syndrome and what is it associated with?
A
Neurocutaneous disorder associated with port wine stain (vascular malformation of face) with leptomeningeal angiomas of brain and eye. If the port wine includes the ophthalmic branch (upper branch) of the trigeminal nerve then they have a 50% risk of glaucoma and 10-35% risk of brain involvement.
24
Q
What is Sturge Weber syndrome and what is it associated with?
A
Neurocutaneous disorder associated with port wine stain (vascular malformation of face) with leptomeningeal angiomas of brain and eye. If the port wine includes the ophthalmic branch (upper branch) of the trigeminal nerve then they have a 50% risk of glaucoma and 10-35% risk of brain involvement.
25
What genetic disease is associated with cardiac rhabdomyosarcomas?
Tuberous sclerosis
26
In Williams syndrome, what electrolyte abnormality can be seen?
Hypercalcemia
27
What bacterial cause of osteomyelitis is a gram negative coccobacillus?
Kingella Kingae - can be a/w mouth ulcers.
Prior to vaccination, Hib which was the same morphology, was more commonly implicated.
28
A 7 year old with a doughnut shaped mass protruding from the urethra with erythema and a small amount of bleeding (that falsely appeared vaginal prior to exam) has what?
How is it treated?
Urethral prolapse
Treatment: sitz bath and estrogen cream
Most common aged 4-8yrs
29
Enterococcus is resistant to: cephalosporins, often to bactrim, and is not treated with gentamicin motherly. Best treated with ____
Ampicillin
30
In a patient with acute bone or soft tissue infection concern in the lower extremity, what study should be obtained first?
Plain X-rays
31
What is the empiric treatment for erythema migrans?
Amoxicillin or doxycycline for 10-14 days for early localized disease
Or 14-28 days for early disseminated and late disease (depending on the specific extracutaneous disease).
You can do antibody testing in patients who lack the characteristic rash.
32
What is a normal CRP range?
0.8-1.0mg/dL or 8-10mg/L
33
What are the classification for determining degree of envenomation from a snake bite and at what level would anti-venom be considered?
None/dry bite: only snake puncture wounds, no surrounding erythema, no systemic systems or lab abnormalities.
Mild: puncture wounds with local erythema, edema, ecchymosis or pain. No systemic or lab abnormalities
Moderate: puncture wounds with progression of edema or erythema but not involving whole extremity. Systemic
Symptoms: n/v, metallic taste, oral paresthesias, tachycardia, tachypnea, mild hypotension. Abnormal coagulation labs (elevated PT time, low platelets).
Severe: puncture wounds, significant erythema, edema, ecchymosis of extremity, blisters and necrosis. Systemic symptoms: n/v, metallic taste, oral paresthesias, tachycardia, tachypnea, mild hypotension +/- serious bleeding. Labs: abnormal coagulation labs (elevated PT time and low platelets)
Consider antivenom in patients with moderate to severe envenomation.
34
A patient with recent diagnosis of sinusitis who was on amoxicillin develops fever, headache, left arm weakness, AMS, and vomiting? What has happened and what is the right antibiotic choice?
What is the classic triad?
The patient has developed a brain abscess. The right treatment is ceftriaxone and flagyl for common causes (strep, staph, anaerobes, gram negatives). Gentamicin and cefazolin (1st gen cephalosporin) are not used because they have poor CNS penetration.
Triad: fever, headache, and focal neurological deficits
35
Peritonsillar abscesses are more common than RPAs.
RPAs can spread to the mediastinum as a complication.
Both abscesses are usually polymicrobial.
Peritonsillar abscesses greater than 1 cm need surg intervention
All true.
36
What does CHARGE syndrome stand for?
Coloboma of the eye, heart anomalies, choanal atresia, retardation, genital and ear anomalies.
You can distinguish this from DiGeorge because there’s eye involvement in only one of them
37
What are the findings in DiGeorge syndrome?
Thymic aplasia/hypoplasia, parathyroid aplasia or hypoplasia - leading to hypopara, cardiac defects, developmental delay, facial features (bulbous nose etc).
CATCH 22 - Cardiac anomalies, abnormal facies, thymic aplastic, cleft palate, hypocalcemia. 22q11
38
What coagulation study should be severely elevated in hemophilia A (the severe type) and what is the treatment?
PTT should be elevated and the treatment is Factor 8.
39
A child with acute kidney injury, micoangiopathic hemolytic anemia and thrombocytopenia.
What infection is most likely responsible?
When does HUS develop relative to primary infection with strep?
Shiga toxin producing E Coli (STEC) - 90% of case. Also strep pneumoniae and HIV are other acquired causes.
Hereditary causes are usually due to complement gene mutations or inborn errors of Cobalamin C.
Develops 3-13 days after the primary infection with strep
40
A polycyclic rash with central clearing that spares the palms and soles of the feet and can present with fevers, facial and actual edema with antibiotics as a common trigger is …
Serum sickness like reaction. Management includes antihistamines and NSAIDs. If severe case, can consider steroids.
41
What is the most common autosomal dominant form of hereditary pancreatitis?
It’s PRSS1
42
What genes are associated with Alagille syndrome?
JAG1 and NOTCH2
43
A patient with asthma who goes from having a respiratory alkalosis and metabolic acidosis to a hyperbaric respiratory acidosis suggests you need to prepare to get…
An advanced airway
44
A 1 yr old with history of FTT presents with a femur fracture in the ED and the xray shows osteopenia. What should be checked?
Serum and urine electrolytes to rule out Fanconi syndrome (proximal renal tubular acidosis)
45
What is the empiric treatment for PID? Usually caused by Gonorrhea, chlamydia or anaerobes?
Options are Doxycycline and cefoxitin/cefotetan OR
Clindamycin and gentamicin
OR (Unasyn + Doxycycline)
Only for mild PID: azithromycin +/-metronidazole
Floroquinolones are not appropriate due to resistant gonorrhea.
46
A sexually active teen patient with 4 days of knee and ankle joint swelling, conjunctivitis and sacroilitis with normal WBC, normal ESR and mildly elevated CRP without recent diarrhea or urinary symptoms is concerning for…
Reactive arthritis which is likely due to chlamydia trachomatis. Had he had diarrhea, it would have been due yersinia, campylobacter, salmonella, or shigella.
47
What is wet wrap therapy?
Medium potency corticosteroids or emollients followed by two layers of gauze or two layers of cotton pajamas. For gauze or PJs - inner layer is wet and outer layer is dry.
48
A hemodynamically unstable patient with mid-gut malrotation needs what emergently?
Fluid resuscitation and then emergent surgical exploration
49
What heart rate threshold should prompt concern for rentrang SVT?
Older child: above 180bpm
Infant: above 220bpm
50
A patient with moderate acute asthma exacerbation experiences a transient drop in oxygen 30 minutes into treatment with albuterol starting. What’s the next step in management?
Give supplemental oxygen, this hypoxemia comes from V/Q mismatch due to systemic absorption of beta agonist which causes pulmonary vasodilation to previously poorly ventilated areas of the lung. It is transient and oxygen responsive with no new fatigue, or altered mental status from hypercarbia.
51
Parotitis due to a sialolith can be managed with…
If no pus or concern for infection then sialologogues like lemon, or glandular massage posterior to anterior on the SAME side that is affected.
52
What popular class of drugs is contraindicated in asthma patients?
Beta blockers like propranolol
53
What popular class of drugs is contraindicated in asthma patients?
Beta blockers like propranolol
54
The presence of what physical exam findings rule against testicular torsion?
Negative Doppler, normal testicular lie, normal cremasteric reflex
55
Epipidymitis in a non sexually active male who is not at risk of UTI is most likely viral
Supportive care
56
In a sexually active male, UTI due to G/C is treated with?
If they have insertive anal sex, they are at increased risk for GNRs and could be treated with?
Ceftriaxone/Azithromycin or ceftriaxone/doxycycline for G/C
For GNRs, levofloxacin
57
A 4 yr old male is admitted for his fifth admission to manage constipation in 2 years. He passed meconium at 30 hours of life. Has occasional abdominal pain and has been compliant with all meds. What does he have?
Less severe Hirschprung’s disease
58
A 3 yr old male is admitted for pneumonia. He has had recurrent otitis media and sinusitis and this is his 3rd admission for pneumonia. He does not have tonsils on exam. What is his condition? How is the diagnosis confirmed?
His condition is X-linked agammaglobuniemia and the diagnosis is confirmed by a mutation in the gene responsible for BTK kinase so B-cells and thus immunoglobulins are missing. The adenoids and tonsils are B-cell rich.
59
A 3 yr old male is admitted for pneumonia. He has had recurrent otitis media and sinusitis and this is his 3rd admission for pneumonia. He does not have tonsils on exam. What is his condition? How is the diagnosis confirmed?
His condition is X-linked agammaglobuniemia and the diagnosis is confirmed by a mutation in the gene responsible for BTK kinase so B-cells and thus immunoglobulins are missing. The adenoids and tonsils are B-cell rich.
60
What condition is a dihydrorhodamine assay useful to diagnose?
It is useful to diagnose CGD in patients with recurrent pneumonias and skin infections. Patients typically have hepatomegaly, splenomegaly, or lymphadenitis
61
Hypoaldosteronism is associated with what electrolyte derangements? …
Hyponatremia, hyperkalemia, acidosis.
For classic CAH: males can have a normal exam or darkened scrotum and enlarged phallus. Females can have clitoral enlargement or labial fusion.
62
A torn lingual frenulum in a non ambulatory infant (e.g. 8 week old) should prompt concern for…
NAT and if the child is irritable, consider a head CT
63
How is nephrotic syndrome defined?
> 300mg/dL of urinary protein, or loss of more than 3g in 24hrs
64
A patient with history of obliterative bronchiolitis, bronchiectasis, allergic rhinitis and chronic diarrhea who is underweight and has sinus tenderness and prudent rhinorrhea is concerning for
Selective IgA deficiency
65
If a patient ingests lighter fluid (hydrocarbon), they are at risk of aspiration pneumontis and need to be observed. Only if fever persists for more than 48 hrs should bacterial superinfection be considered.
True.
66
A patient with acute asthma exacerbation who suddenly on hospital day 3 develops a new oxygen requirement with bilateral crackles and wheeze on exam is concerning for…
Pulmonary edema and could benefit from a one time diuretic.
67
For acute bacterial cervical lymphadenitis, is there any specific sized abscess that should prompt image guided aspiration or surgical drainage?
No! They should first fail 2nd or third line antibiotics after 48-72hrs before intervention. E.g. if only on augmentin, add MRSA coverage.
68
What are the indications to remove a central line in the setting of CLABSI?
Line is broken irreparably, patient is significantly ill appearing, infection is disseminated, cannot clear bacteremia after 48-72h, or evidence of fungal disease
69
A 2 week old on newborn screen has elevated TSH, the newborn is well appearing. What could most likely give a false positive result?
Maternal history of graves. TSH does not cross the placenta but maternal antibodies from graves can.
70
According to IDSA, abscesses that lack systemic signs and aren’t in an immunocompromised person should be managed with …
I&D
71
HyperIgE is a recurrent infection syndrome that is a rare autosomal
Dominant condition where patients have recurrent skin and pulmonary infection (chronic dermatitis, upper airway infections, sinusitis and AOM) an and eczema due to impairment in JAK STAT pathway. Abnormalities in osteoclastogenesis and osteopenia lead to skeletal and dental anomalies
True
72
What is the gold standard test for myocarditis?
Endomyocardial biopsy NOT echocardiogram
73
A 2 yr old child admitted with respiratory distress who has history of constipation, frequent bouts of coughing, failure to thrive and whose CXR shows nearly opacified L Lung that responds well to chest PT, antibiotics and supplemental
Oxygen should be evaluated for…
Cystic fibrosis
74
A 5 year old girl who has presented with 3 bouts of not feeling well and emesis after a night of not eating well with low blood glucose of 45 is concerning for?
What laboratory abnormalities should be found?
Ketotic hypoglycemia of childhood
Labs should show high ketones, high fatty acids, high amino acids, high cortisol and growth hormone. LOW insulin
75
Benign mature teratomas (dermoid cysts) can be associated with malignant transformation (rarely), hypotension and fever (if they burst), anti NMDA receptor encephalitis, and ovarian torsion.
True. They are NOT associated with Addison disease.
76
Benign mature teratomas (dermoid cysts) can be associated with malignant transformation (rarely), hypotension and fever (if they burst), anti NMDA receptor encephalitis, and ovarian torsion.
True. They are NOT associated with Addison disease.
77
A coombs test only has value in assessing RBCs.
True
78
A coombs test only has value in assessing RBCs.
True
79
Prior to treating ITP with corticosteroids, a peripheral smear should be obtained to rule out leukemia or aplastic anemia.
True
80
In acute migraine management, what drugs would be helpful?
IV toradol, IV prochlorperazine (and a Triptan)
(NOT Promethazine which causes tissue damage)
81
In acute migraine management, what drugs would be helpful?
IV toradol, IV prochlorperazine (and a Triptan)
(NOT Promethazine which causes tissue damage)
82
In a child with suspected JIA who is stable, what is the best next step?
Consult a rheumatologist. Don’t do MRI on own.
83
In a child with suspected JIA who is stable, what is the best next step?
Consult a rheumatologist. Don’t do MRI on own.
84
To diagnose Cushing syndrome (clinical manifestations of round face, supraclavicular fat pads, abdominal striae) you need 2 of 3 first line tests to be abnormal. The tests are
24 hour urinary free cortisol, late night salivary cortisol and overnight dexamethasone suppression test
85
A patient with gross hematuria episodes in the setting of illness (eg strep pharyngitis) including past hematuria episodes with illness is concerning for…
What is the expected C3 and C4 level?
IgA nephropathy. C3 and c4 should be normal.
86
In post infectious glomerulonephritis like post strep GN, what should be the trend of C3 and C4?
C3 should be low and C4 should be normal
87
In a patient with repeated migraines worsened by stress from school, one option is to give non-pharmacologic interventions including
Relaxation training with bio behavioral feedback
88
A 17 yr old healthy male has had recurrent oral ulcers (white-gray base, erythematous halo), genital lesions (including past ones with scarring), sometimes associated with fever. He also report difficulty seeing some items at school. What dx does he have? What's the treatment?
He has Behcet's disease and treatment includes colchicine, steroids, azathioprine, and TNF alpha inhibitors. The illness is common in young males. The criteria requires 3 of these 6 symptoms:
Oral apthosis, genital ulcers, skin involvement (Acneiform, erythema nodosum, necrotic folliculitis), ocular involvement, neurologic signs, vascular signs.
89
A 4 yr old boy who has had itching, scaling, and hair loss on his R scalp for several weeks develops tactile fever and swollen, red purulent pustules in the region of alopecia. What does he have and what is the treatment?
He has tinea capitis with kerion (intense T-cell mediated hypersensitivity to the dermatophyte). He needs systemic antifungals (oral griseofulvin, terbinafine, fluconazole). There can be bacterial co-infection.
90
A 2wk old full term male presents to the ED with jaundice with unconjugated hyperbili of 16. He has been eating well and has normal greenish-brown stools. No evidence of hemolysis. What disease does he have and what is the treatment?
He has Crigler Najjar (Type 2) less severe version which is marked by decreased function of the bilirubin conjugation enzyme as opposed to its abscence (Type 1). He should be treated with phenobarbital.
91
What is the treatment for splenic sequestration?
It's IV crystalloid given to address the hypovolemia cause by the large spleen size. Then after, a simple pRBC transfusion can help (NOT exchange). Surgical intervention is reserved only for those who fail medical mgmt (requiring continued transfusion support, persistent hypersplenism, or repeated episodes of splenic sequestration).
92
In any child with prolonged febrile illness and a neck mass that is not responding to antibiotics, Kawasaki disease should be considered.
yes
93
In sick euthyroid syndrome, what proteins are usually low?
The binding proteins: Thyroxine-binding globulin protein and transthyretin (TTR)
For hormones. Often T3 is low and rT3 is high.
94
In sick euthyroid syndrome, what proteins are usually low?
The binding proteins: Thyroxine-binding globulin protein and transthyretin (TTR)
95
In sick euthyroid…
T3 is low and then T4 is low. Also, TSH is initially LOW and then can rise to well above the normal range.
However reverse T3, the inactive form of thyroid hormone, is always high.
96
In sick euthyroid syndrome…
T3 is low and then T4 is low. Also, TSH is initially LOW and then can rise to well above the normal range.
However reverse T3, the inactive form of thyroid hormone, is always high.
97
What is the biggest risk factor for ovarian torsion?
An ovarian mass including an ovarian cyst is the biggest risk factor for torsion
98
What is first line treatment for infantile spasms?
ACTH, corticosteroids, and vigabatrin
99
What is the baseline work up for tuberous sclerosis?
Brain MRI, echocardiogram and renal ultrasound because the risks are angiofibromas, retinal hematomas, cortical dysplasia, cardiac rhabdomyomas, and renal cysts
100
What is the recommended management when more than one magnet is swallowed? (Including magnetic beads)
If in the esophagus or stomach, then immediate endoscopy. If in the small or large bowel, then can use serial radiographs with or without total bowel clean out
101
What is stage 2 HTN?
Greater than the 95th percentile + 12 mmHg or once aged 13 or older, greater than or equal to 140/90
102
What is stage 1 HTN,
Greater than the 95th percentile to less than the 95th percentile + 12 mmHg or 130/80 to 139/89 or once aged 13 or above, from 130/80 to 139/89
103
What is the definition of acute severe hypertension?
A blood pressure 30mmHg or more above 95th percentile or greater than 180/120 in an adolescent
104
What is a complication of acute inhalant abuse?
Sudden sniffing death - surge of catecholamines leading to CV collapse.
FYI: Non-acute, more long term use can be associated with peripheral neuropathy, toxic leukoenceohalopathy, megaloblastic anemia, and subacute combined degeneration syndrome.
105
A 2 mo old male who presents with poor weight gain, feeding difficulties since birth, moderate head lag and poor suck reflex with birth history notable for hypotonia and undescended testicles is concerning for...
Prader-Willi syndrome. The polyhydramnios from impaired swallowing of amniotic fluid.
106
A 9 yr old with bilateral sensorineural hearing loss, recurrent left lateral neck swelling concerning for abscess with an enhancing tract to the left palatine tonsil is concerning for...
Branchial cleft anomaly and given the sensorineural hearing loss, needs a renal ultrasound to rule out the autosomal dominant condition, branchio-otorenal syndrome (BOR). In BOR, they usually have two of 5 features, branchial cleft anomalies, hearing loss, preauricular pits, pinna abnormalities and renal malformation.
107
In a patient with T1DM for years, who begins requiring less subcutaneous insulin, has fatigue, weight loss, and low-normal blood pressure (99/65) as a 16 yr old is concerning for...
adrenal insufficiency and once the patient has more than 1 autoimmune disease should be considered for autoimmune polyglandular syndrome.
108
A woman with history of migraine with aura who has abnormal uterine bleeding has symptomatic anemia with a Hgb 6.5. pRBC transfusion is ordered. what is the next best treatment for her?
Progestin-only oral contraceptive because she can't have estrogen if she has migraine with aura.
If she had no hx of migraines then if she could tolerate PO, combination oral OCPs would be best and if she could not tolerate PO, then IV estrogen.
109
In a patient with hypertensive emergency (or hypertensive crisis) usually with BP > 30mmHg above the 95th percentile or >180/120 in an adolescent, what is the best next step in treatment and what is the goal?
Short acting anti-hypertensive (esmolol, hydralazine, labetalol, clonidine, isradipine) given oral if patient can't take IV or if a more SEVERE complication (i.e. emergency/crisis) has occurred. The goal is GRADUAL BP reduction with BP decreased by no more than 25% of goal in first 8 hours and then normalize slowly over first 24-48hrs.
110
Idiopathic intracranial hypertension has been linked to several medicines including...
treatment is...
minocycline, excess vit A corticosteroids, growth hormone.
Work-up includes head imaging to rule out other causes, then LP. Treatment is diamox (acetazolamide) which can have adverse effects of metabolic acidosis, paresthesias, and metallic taste when drinking carbonated drinks. Lasix is 2nd line treatment.
111
When and how often does the CDC require a check of my state's PDMP (prescription drug monitoring program) when prescribing an opioid.
Prior to every new prescription and once every 3 months for chronic prescriptions.
112
A teen with known T1DM is admitted with DKA. What is the most likely cause?
Insulin nonadherence. NOT increased needs in puberty.
113
What is the treatment for torsion of the testicular appendage? What would doppler look like in this case?
Warm compresses, NSAIDs and decreased activity. Doppler would usually be normal.
114
Alcohol, infections (such as Hep A), drug reactions, and autoimmune disorders often lead to a conjugated hyperbilirubinemia
Yes
115
For central cathethers, larger diameter cathether size relative to vein size and multiple lumen cathethers have a higher risk of thrombosis due to stagnated blood flow around the cathether.
yes. Similarly, peripherally inserted cathethers have a higher risk of thrombosis because they are in smaller veins.
116
A 10 yr old with 10 seconds of syncope without prodromal symptoms with immediate return to baseline thereafter while playing basketball suggests what cause and what studies would be beneficial?
Cardiac cause. Obtain EKG, Echocardiogram, and cardiac monitoring.
FYI ask about chest pain or palpitations before event. FHx sudden cardiac death under the age of 50 or a FHx congenital deafness which could be associated with long QT syndrome.
117
What is the inheritance pattern of Duchenne Muscular dystrophy?
X-linked recessive
118
In orbital cellulitis, patients under 9 yrs old, with non-frontal sinus involvement and small medial subperiosteal abscesses can be managed medically. Corticosteroids are not routinely recommended.
Yes.
119
A patient is considered having failed the first IVIG for KD treatment only if they have a fever after ___ hours. What should be used to manage their fevers before 36 hrs
36 hours. Use tylenol to avoid using ibuprofen when they are on aspirin.
120
For a patient who has failed outpatient keflex management of a cellulitis and is showing systemic signs, what is the best next step in management?
Admit them and broaden to MRSA coverage (e.g. vancomycin)
121
What does liver biopsy show when caused by drug (e.g. acetaminophen) injury?
Lobular inflammation with focal necrosis
122
What does focal nodular hyperplasia, a benign tumor of the liver more common in women aged 20-40 look like on liver biopsy?
Proliferation of hyperplastic hepatocytes surrounding a central stellate scar
123
By what age have most kids received 3 tetanus vaccines?
For dirty wounds (e.g. animal bite), when should a tetanus booster vaccine be given? For clean, minor wounds?
Age 6 months. Usually DTaP is given at 2 mo, 4 mo, 6 mo, 15 mo, 4-6 yrs.
Dirty wounds or major wound: When a shot has not been received in 5 years.
Clean, minor wound: Booster indicated if not received in 10 years.
124
When is rabies post exposure prophylaxis indicated?
For any wild animals or any animal that cannot be observed for 10 days to see if it develops symptoms, the rabies vaccine AND rabies immunoglobulin is indicated.
For domesticated animals that can be observed for 10 days, no PEP is recommended unless animal develops symptoms.
125
What is a risk factor for hospital acquired pneumonia (which develops after more than 48 hours in the hospital)?
Aspiration risk, neurologic impairment, gastric feeding tubes, antibiotic exposure in past 90 days.
126
In a patient who is seizing with hypoxia to 89%, what is the best next step in management?
Supplemental oxygen FIRST. Then can abort seizure. Stabilize airway, breathing, circulation first.
127
When do the frontal sinuses develop?
Age 7
128
What is the gold standard imaging choice for Pott's puffy tumor (frontal bone osteomyelitis usually in the setting of frontal sinusitis)
MRI is the GOLD standard.
While contrast enhanced CT is good for the sinuses and bone detail, the MRI is better for assessing the extent of the brain infection
129
What is the initial shock amount for a shockable rhythm (V Fib or V Tach)?
2J/kg
130
What do you expect to find on BAL and bronchoscopy of a child with recurrent aspiration pneumonias?
Lipid-laden macrophages
131
An adolescent who started fluoxetine 1 week ago and 2 days ago developed a cough for which he started taking cough medicine presents with fever (T100.6F), HR 120, BP 132/82, DTRs 2+ biceps, 3+ patellar and clonus in ankles with agitation is concerning for...
Serotonin syndrome (from the SSRI and from dextrometorphan which is also a serotonin reuptake inhibitor).
Treatment is stop offending agents, supportive (IV fluids, supplemental oxygen, and if needed, benzodiazepenes for agitation).
132
What is the antibiotic treatment for acute epiglottitis?
anti staphylococcal agent (e.g. vancomycin) AND a 3rd gen cephalosporin (ceftriaxone)
133
A 3 day old infant comes to the ED with hypoglycemia, hepatomegaly, and lethargy. The UA is positive for ketones and reducing substances, what does the patient have?
Galactosemia -- likely due to inability to process galactose. Galactose is present in human and cow's milk so infant with the condition present in first few days of life with liver dysfunction (HSM, or jaundice), FTT, cataracts, and risk of serious infections most common of which is E. Coli sepsis.
The clue is the reducing substances in the urine.
134
What imaging study is the gold standard for diagnosing SMA (superior mesenteric artery) syndrome?
MR arteriography (MRA)
135
In a drowning case with patient who presents unresponsive with hypothermia, what is the preferred intervention?
Warmed fluids at 42 degrees celsius (between 40 and 45 deg celsius is ideal). NOT in the 30s.
136
For neonates with HSV encephalitis with CSF PCR positive, what is the treatment?
IV acyclovir for 21 days followed by 6 months of oral suppressive therapy.
137
For neonates with HSV SEM disease only, what is the treatment?
14 days of IV treatment followed by 6 months of oral suppressive therapy.
138
What is Duke's criteria for diagnosing bacterial endocarditis?
Major criteria:
1) 2 separate positive blood cultures for a HACEK (H. paraflu, H. aphrophilus, H.paraphrophilus, actinobacillus actinomycetemcomitans, cardiobacterium, Eikenella corrodens, or Kingella) organism, strep viridans, or coxiella
2) positive echo
Minor criteria:
1) predisposing heart condition or IV drug use
2) fever (T>38C)
3) vascular phenomenon (arterial emboli, septic pulm infarct, mycotic aneursym, intracranial hemorrhages, conjunctival hemorrhages, janeway lesions)
4) immunologic phenomena (glomerulonephritis, osler nodes, roth spots, rheumatoid factor)
5) positive blood culture that does not meet major criteria.
Diagnosis:
2 major criteria OR 1 major + 3 minor criteria OR 5 minor criteria.
139
What are the strongest predictors of poor outcome in a submersion?
Submersion duration greater than 5 min
Initial blood gas pH less than 7.1
Resuscitation time of more than 25 min
140
What is a normal CSF glucose?
50-80 or greater than 2/3 blood sugar level
141
What are the most common oragnisms isolated in suppurative odontogenic infections?
Usually polymicrobial including bacteroides, streptococcus, peptostreptococcus, actinomyces and fusobacterium.
NOT staph
142
When would a third generation cephalosporin alone be sufficient monotherapy in a febrile neonate?
Ceftriaxone would be sufficient monotherapy greater than 28 days so 29-60 day old.
143
Above what age can the urea breath test be used to diagnose H. pylori?
At age 6 and above.
144
A mid to late systolic click with a high-pitched late systolic murmur is consistent with...
mitral valve prolapse (typically congenital but symptoms may not present until adolescence)
145
In a patient presenting with somolence, vomiting, tachycardia hypertension and tachypnea after a house fire, what is she at risk for?
What is the reversal agent?
Carbon monoxide and cyanide poisoning.
For cyanide, the reversal agent is hydroxocobalamin. It can cause reddish urine. For carbon monoxide, it's 100% oxygen via a non-rebreather.
146
Remember that in acute on chronic respiratory acidosis in a patient with epilepsy with myotonic dystrophy who is newly somnolent on a new dose of valproic acid for example, you should expect to see pH with acidemia, pCO2 notably elevated. Bicarb level may be upper level of normal due to the acute resp failure.
yes
147
What is the reversal agent for acute dystonic reaction to haloperidol, reglan, or prochloperazine?
Benadryl or benztropine. The dystonic reaction results from drugs that block dopamine
148
Organic acidemias present in newborns usually with...
hyperammonemia and metabolic acidosis
149
Urea cycle defects in newborns usually present with...
hyperammonemia and respiratory alkalosis. OTC deficiency, the most common one is inherited in X-linked manner so more common in males.
150
POTS requires what for diagnosis?
Heart rate change of 30 points with no orthostatic hypotension.
151
What's a good way in infants to estimate BSA involved in burn?
18% head
18% each for anterior and posterior thorax so 36% together
9% each arm
14 % each leg
Parkland formula for fluid needs over first 24 hrs. (Percent BSA involved x wt in kg x 4). First half given over first 8 hrs to aim for UOP 1-2ml/kg/hr.
ONLY Severe burns should be included NOT superficial burns.
If they are NPO, you ADD the above result to their maintenance fluid rate.
152
What is the estimated caloric intake need by age for the first 2 years of life?
0-2 months - 100-110kcal/kg/day
3-5 months 85-95 kcal/kg/day
6-8 months 80-85 kcal/kg/day
9-11 months 80 kcal/kg/day
12-24 months 83kcal/kg/day
153
For children with FTT, the formula for calculating caloric intake needed for catch up growth is:
(IBW*Estimated Caloric Intake for Age)/Current weight
So for a 10 month old infant who weighs 8 kg with IBW 10kg, the result (10kg x 80kcal/kg/day)/8kg = 100kcal/kg/day
154
What is the preferred mangement for mild to moderate dehydration with decreased urine output (2 diaper per day) but normal HR, BP and cap refill.
Oral rehydration of 50-100ml/kg over 4 hours.
155
What does right to left shunting refer to?
When deoxygenated blood enters the arterial circulation WITHOUT participating in gas exchange due to anatomic or physiologic shunts.
156
A patient with Crohn's who develops a PE and hypoxemia has hypoxemia from what mechanism?
V/Q mismatch because the PE causes over-perfusion of the non-embolized parts of the lung.
157
How do you calculate IBW from a growth chart.
McLaren method (growth chart): first plot the child's height. Then, from the plotted height, first move horizontally to the 50%ile line for HEIGHT, then drop down to from that point to the 50%ile line for weight and tht gives you IBW
158
How do you calculate IBW from a BMI?
It's IBW =
[BMI at 50%ile for age] x ((height in meters)^2)
159
For a child with a dog bite to the head that CT shows is associated with a small skull fracture, besides tetanus status, what is important to treat with?
Ceftriaxone and flagyl (metronidazole).
Amp-sulbactam or amox-clavulanate is only acceptable for bites involving other parts of the body
160
What testing can be considered in low-risk patients with BRUE who may be developing URI symptoms?
Pertussis testing
161
What are alarm signs for underlying disease with constipation?
No meconium passage in first 2 days of life
Constipation in 1st month of life
Ribbon stools
Bloody stools w/o anal fissures
bilious emesis
Fhx of hirschprung's disease
Ddx: Hirshprung's disease vs celiac vs hypothyroidism vs tethered cord vs cystic fibrosis vs anatomic malformations or botulism and others.
162
What is the right 1st line management for a black widow spider bite which is associated with neurotoxic symptoms (muscle cramping, rigidity, tenderness) and autonomic symptoms (diaphoresis, tachycardia, hypertension, nausea/vomiting)?
Opiates. If opiates don't work then benzodiazepines can be adjunctive.
Anti-venom is not usually available and is reserved for those with severe envenomation that is not responsive to initial treatment.
163
In a patient with severe asthma with several exacerbations in the past year and already on high dose ICS therapy that they are taking appropriately who is noted to have high IgE levels, what is the best next step?
Immunomodulator therapy
164
If a patient has beta blocker toxicity with hypotension and significant bradycardia, what is the first line of treatment?
Normal saline bolus and atropine.
For a refractory patient with other symptoms: you could consider epinephrine and glucagon
165
In a CF patient in a flare who develops hemoptysis, what medications should be stopped?
Hypertonic saline neb and inhaled dornase alpha
166
In a CF flare, what empiric antibiotics should be used if concerned for pseudomonas?
Dual therapy:
Zosyn, Ceftazidime (don't use if staph is also a concern), imipenem or meropenem, Ticarcillin-clavulanate
PLUS
ciprofloxacin, levofloxacin, amikacin or colistin.
167
Primary hyperparathyroidism is seen in...
MEN 1 > MEN 2
168
Pseudohypercalcemia occurs when...
Serum calcium levels are elevated BUT ionized calcium levels are normal.
It is most often cause by additional carrier proteins like in multiple myeloma, MGUS, excessive IgM. It can also occur in heat related illness.
169
How do you calculate the FeCa which can help in familial hypocalciuric hypercalcemia (FHH)
FeCa = (Urine Ca x Serum Creatinine)/(Serum Ca x Urine Creatinine). If the FeCa is greater than 0.01, FHH is unlikely
170
Activated charcoal is not great for ingestions of heavy metals (iron, lead), lithium, alcohols and caustic agents like bleach because they are not well absorbed. It's good for extended release medications or chemicals with extensive enterohepatic recirculation like...
Aspirin
Charcoal is most effective when given within 1 hour of ingestion.
171
What drug classes are most likely to cause SIADH?
anti-epileptics, anti-depressants, anti-psychotics, cytotoxic drugs, some pain medications.
SIADH is associated with a euvolemic hyponatremia. (Water loading also causes euvolemic hyponatremia but the diff is the Urine Na would be low)
172
When can pseudohyponatremia be seen?
It is the result of high lipid or high protein states.
POsm = 2*Na + BUN/2.8 + Glu/18 (Normal is 280-295)
173
What is hypertonic hyponatremia?
This is seen in high glucose states
174
What interventions in severe asthma exacerbation, when given early, decrease NEED for hospitalization?
1) Early administration of 2-3 doses of ipatroprium along with albuterol
2) Steroids in 1st hr
3) IV magnesium
What DOES NOT decrease need for hospitalization? cont albuterol
175
What is the mnemonic for Jones criteria in acute rheumatic fever?
JONES CAFE PAL
Joints (migratory polyarthritis), O looks like heart so carditis, Nodules (subcutaneous), Erythema marginatum, Syndeham chorea
Minor:
CRP elv, arthralgia, Fever, ESR elev
PR prolonged, anamnesis of rheumatism (past infections), leukocytosis
Need 2 major criteria OR one major + 2 minor criteria plus evidence of past GAS infection (throat cx, NAAT, anti-DNAse B, anti-streptolysin O). If Chorea present, doesn't require GAS evidence.
176
A patient with multiple intracranial injuries with sudden increase in urine output could have developed ____
Central DI (known mechanism), SIADH, OR CSW (no known mechanism). Central DI results from deficiency of ADH which leads to polyuria and serum hypernatremia.
Treatment for central DI is desmopressin.
Of note, SIADH and CSW would cause hyponatremia but in CSW, the pt is hypovolemic and in SIADH, the patient is euvolemic.
177
In a child who is splinted for a supracondylar fracture who is showing signs of compartment syndrome, what is the best next step?
Remove constrictive dressings then the surgeon can measure compartment pressure.
178
How is the urine anion gap usually calculated and how can it help distinguish GI from renal losses?
in GI losses, the urine anion gap is negative but in urine losses, the urine anion gap is positive (unchanged from baseline). In urine losses, you lose bicarbonate without losing cations. In GI losses, you also lose cations.
UAG = Cations (Urine Na + Urine K) - Anions (Urine Cl). Normal range is 20-90.
179
If you are starting D10 for neonatal hypoglycemia, what rate should you pick?
5 to 8 mg/kg per minute and titrate to maintain euglycemia
180
In a patient with history of NEC who presents with symptoms of SIBO (abd distension, foul-smelling stools, difficulty advancing enteral feeds), as well as confusion/AMS, what could be causing the AMS?
D-lactic acidosis
181
For new moms with opioid use disorder who are stabiized on methadone or buprenorphine, have not relapsed in the past 90 days, consent to discussing their treatment progress with a counselor, and do not have a contraindication to breastfeeding, they are advised TO BREASTFEED. Decreases NAS.
Yes
182
Contraindications to breastfeeding:
Infant galactosemia
Maternal: HIV without ART and viral suppression
HTLV
Illicit drug use
Ebola
These moms should temp not nurse OR pump:
HSV with active breast lesions - unaffected breast ok
Certain meds or radioactive drugs
Untreated brucellosis
Monkeypox
A mom with active TB or chickenpox can pump & feed but not nurse
183
A gram negative rod in the respiratory tract should be suspicious for...
P. aeruginosa
184
Physically aggressive behavior is normal in a 2-3 year old
yes
185
Glycopyrollate is an anti-cholinergic medication that is contraindicated in what population?
Those with increased intraocular pressure
186
All infants who are exposed to HIV during birth should received ART. The # of drugs and duration is dependent on mom's ART regimen and if she achieved viral suppression.
If mom was on ART and had viral suppression in pregnancy, infant only needs zidovudine x 4 weeks. If mom had a high viral load in pregnancy, requires 3 drug regimen.
Infants should be tested by Nucleid acid/PCR for HIV only at 14-21 days, 1-2 months and again at 4-6 months. Do not use cord blood.
187
To make a diagnosis of conduct disorder, there has to be at least...
3 or more incidents in the past 12 months and at least one in the past 6 months.
188
Per NRP guidelines, at least 1 qualified person whose sole responsibility is a newborn should attend a delivery but if there's any risk factor (including meconium staining, prematurity, pre-E, IUGR, emergency c/s, breech or abnormal presentation, chorio) then at least 2 qualified people should be at the delivery.
yes
189
At 2 min of life in a neonatal resuscitation, an infant's oxygen level is 68% and by 10 min is over 90%. What helps this transition and are these numbers normal?
Yes, these are normal. Infants go from a sat of 60% to >90% at 10 minutes of life. The drop in pulmonary vascular resistance helps with this transition.
190
For peri-stomal G-tube leakage where optimizing nutrition and medical status, barrier creams and skin protectants have already been completed, what is the best next step?
Why does the leakage occur?
Best next step is pulling out the G-tube for a few days to give the tract some time to get a little smaller and then re-inserting the tube.
Leakage can occur due to infection, gastric hypersecretion, excessive cleaning w/hydrogen peroxide, buried bumper syndrome, torsion of tube or lack of bolster.
191
Neonates with brachial plexus injury should be referred to OT or PT. Up to 20-30% of these injuries can have persistent deficits. If they have not regained normal function by 1 month, they should be...
referred for surgical evaluation at a subspecialty center.
192
What symptoms are associated with Vitamin C deficiency?
Poor wound healing, corkscrew hair, gingival swelling, ecchymosis, perifollicular hemorrhages (Esp on lower extremities), hemoarthrosis koilonychia (flat, thing nails often with concavity), bony lesions or brittle bones, ocular hemorrhages
193
What are the symptoms of zinc deficiency?
Alopecia, dermatitis, particularly affecting the perineum, chin, cheeks, acral surfaces
194
What are the symptoms of Vitamin A deficiency?
Corkscrew hair, follicular hyperkeratosis, and Bitot spots (build up of keratin in the conjunctiva).
195
What are the symptoms of copper deficiency?
Kinked hair, skin depigmentation, myelopathy presenting as a sensory ataxia.
196
What are the symptoms of iron deficiency?
Pallor, onychomadesis (periodic shedding of the nails), koilonychia
197
What is the best treatment for a patient with abdominal migraine?
Aerobic exercise, CBT and supportive medical optimization
198
11% down from BW in a 3-day old baby born by C/S who has adequate urine output and maternal supply is okay and requires no changes.
Yes
199
What is the LEAST common complication of IO access?
First of all, IOs in general have very few complications (<1%). The LEAST common complication is bone injury, deformity, or growth arrest due to growth plate destruction. This includes epiphyseal injury
200
A patient with CP, R hemiparesis and R hip subluxation was admitted after varus derotation osteotomy. 4 days into admission, pain is well controlled on oxycodone and diazepam and you begin discharge planning, What is an appropriate next step? (It's not stopping meds).
Have pt and family seen by PT/OT
201
How long should an IO site be used for?
No longer than 24 hours
202
What are the stages of pressure ulcers?
Stage 1 - Non blanching skin erythema with intact skin: red, blue, purplish, may itch, feel warm or burn. The skin does not blanch
Stage II - erythema with partial loss of the skin to the superficial dermis - can be shiny, moist, shallow open ulcer.
(treatment debridement with normal saline cleanser or sterile water).
Stage III - full thickness tissue loss that exposes subcutaneous fat
Stage IV - exposed tendon, fascia, ligament, cartilage, MUSCLE or BONE.
All wounds require more frequent repositioning (every 2 hours), pressure reduction surfaces and adequate intake of zinc, vit C, iron, vit A, protein.
Antibiotics are used if there is concern for infection
203
If a nurse reaches out about a patient transfer from another hospital that uses different connectors for a patient on a specialty feeding formula as well as TPN by PICC that she cannot connect the patient's TPN properly, what is the best next step?
come and make sure all the lines and tubes are appropriately connected. Make sure you have good lighting etc to avoid medical misconnection which can lead to sepsis or emboli.
204
What are the AAP guidelines for criteria for hospitalization in eating disorder pts?
acute food refusal, HR less than 50 during the day or 40 at night, SBP <90, <75% IBW, orthostatic tachycardia (>20 beats diff), orthostatic hypotension, hypothermia (<96F or 35.6C), syncope, electrolyte abnormalities. Failure of outpatient mgmt. Uncontrolled binging and purging. EKG abnormalities.
205
What are some of the screenings that patients with Down syndrome or T21 need?
Echocardiogram after birth to r/o AV canal defects
Yearly eye exam to rule out cataracts.
These don't require screening but can also be present duodenal or anorectal atresia, atlanto-axial instability
206
Which patients benefit from post-pyloric feeds?
Patients with severe reflux, risk of aspiration, gastroparesis, or gastric outlet obstruction
207
Long term use of TPN can be associated with _____
cholestasis with biliary sludging and steatosis, nephropathy, metabolic bone disease,
208
The most common complication of NGT placement and that should be suspected in a pt with an NGT recently placed with persistent coughing is...
pulmonary insertion of the tube. confirmation of placement by abd XR or gastric pH is acceptable but auscultation alone is not.
209
Oppositional defiant disorder is characterized by defiant, disobedient behaviors towards authority figures. The diagnosis can be made with following criteria
under 5 years: episodes on most days for 6 month
over 5 yrs: weekly episodes for 6 months
CBT and parent training are most effective. Reserve meds for refractory patients. Prior to puberty, it is more common in boys but after puberty, there is no sex disparity.
210
In newborns born with CDH, they should be immediately intubated and thereafter received positive pressure ventilation. Bag valve mask is contraindicated because it will just further distend the stomach.
YES. You can decompress the stomach with an NGT or OGT but priority is to secure the airway with intubation because the GI contents in the thoracic cavity may make it too difficult for the pt to generate the negative intrathoracic pressure needed to breathe.
211
What are some meds that can be associated with QT prolongation?
Tacrolimus, ondansetron, azithromycin. Macrolides, fluoroquinolones, azoles, antipsychotics, antidepressants, opioids.
Risk of QT prolongation is torsade de pointes and the treatment is magnesium (should correct hypokalemia before Mg administered).
212
In a 4yr old patient with a tracheostomy tube and vent dependence whose trach tube is dislodged and becomes agitated with turning his head side to side and develops retractions, vitals are HR 183, RR 65, sat 96% on blow-by oxygen, with blood tinged tracheal secretions but the tracheal stoma otherwise appears intact, what is the best next step?
First confirm there is good oxygenation and then reposition head and attempt tube re-insertion after. If that doesn't work, can try inserting a smaller tube.
213
A "seizure" episode with arching of the back, head, and neck, bilateral arm stiffening, pelvic thrusting and eyes tightly closed shut even in a patient with known seizure disorder is concerning for ...
What is the best next step?
PNES (psychogenic non-epileptic seizures) particularly because pelvis thrusting, eyes resistant to opening and lack of post-ictal period are characteristic of PNES
obtain VEEG
214
Antibiotics (Can be oral) are recommended after abscess I&D for infants under 12 months of age regardless of disease severity
yes
215
Which cardiology patients need antibiotic prophylaxis to prevent infective endocarditis prior to procedures?
Unrepaired CYANOTIC CHD, completely repaired CHD with prostethic material or device for 6 months after procedure, repaired CHD with residual defects at site or adjacent to the site of a prostethic patch or prosthetic device.
216
A 4 yr old healthy patient is persistently agitated for 15 min after undergoing a sedated tooth extraction where halothane was used in the OR. What labs would be most helpful?
While this is likely emergence delirium which is a benign condition that lasts 15-20 min and may need pain control/sedatives to manage, it is critically important to rule out hypercarbia, hypoxia, or hypoglycemia immediately post-op so ABG and POC glucose would be best.
217
In a neonate like a premie who is intubated, IV epinephrine by UVC is far more effective than ETT administered epinephrine.
True.
218
In a patient with Treacher-Collins (with micrognathia) causing unsuccessful intubation attempts, what's the best next step?
Try a supraglottic airway aka an LMA. Contraindication to an LMA is active vomiting
219
A patient diagnosed with functional neurologic disorder (or conversion disorder) who is admitted can benefit from what prior to discharge?
Inpatient psychology consultation
220
An infant is born by C/S to a mom with a lesion suspicious for HSV infection on presentation to L&D, what are next steps?
The infant should immediately (at 24 hours of life) have HSV surface cultures, blood PCR and CSF PCR sent regardless of delivery method if this is a primary infection in mom then IV acylovir should be started in the infant while awaiting results.
If this is a recurrent infection, blood PCR and HSV surface cultures can be sent and you can observe the infant off acyclovir if the infant remains asymptomatic.
Mode of delivery reduces but does not eliminate risk so it should not influence plan.
221
What test is most important to obtain prior to starting a typical or atypical antipsychotic?
EKG - assess for QT prolongation
222
What is the greatest risk factor of depression in a child with chronic illness whose parent is also depressed?
Parental depression
223
If a preterm infant (<37 weeks) or LBW (<2500g) infant fails a car seat tolerance test (within 24-48h of discharge time), what's the appropriate next step
Rpt screen in 24 hrs or Discharge in a car bed
Failure is apnea >20 seconds, bradycardia <80 bpm or desat <90 in the span of 90-120min CSTS.
224
If an admitted patient is agitated, and verbal de-escalation techniques are not working, what is the best next step BEFORE physical restraints?
Medical restraint with haldol and reassess in 15 min. you are not trying to achieve sedation.
225
What oral medications besides baclofen can be used for generalized spasticity?
Clonazepam, tizanidine and dantrolene.
Botulism toxin should NOT be used for generalized spasticity, it is first line only for focal spasticity.
226
A newborn with rash, cataracts and extramedullary hematopoeisis is concerning for...
congenital rubella
227
A newborn with rash, bone deformities and interstitial keratitis is concerning for...
congenital syphilis
228
A newborn with rash, macrocephaly (with intracranial calcifications), and chorioretinitis is concerning for...
toxoplasmosis
229
A patient with a pressure ulcer should not be prescribed vitamin C and zinc until...
Blood levels for vitamin C and zinc should be obtained before and during supplementation.
After 1 week of trying other interventions and not noting healing.
Yes.
230
What are the greatest risk factors for cardiac arrest during procedural sedation?
Age less than 1 year old (particularly less than 6 months) and ASA class > II.
Patients who are less than 3 months or ASA III or more should be sedsted by an intensivist or anesthesiologist NOT a hospitalist. Examples of patients with an ASA class III illness (a patient with severe or uncontrolled systemic disease) e.g. asthma w/exacerbation, poorly controlled epilepsy, insulin-dependent DM, morbid obesity
231
For bag valve mask ventilation, what are some things that are true...
continuous flow of oxygen can be provided passively through the reservoir portion of a self-inflating bag.
in patients with poor lung compliance, the normal pressure pop-off valve that release at 35-45cm H20 may need to be CLOSED/overriden to allow higher pressures to pop open the lungs.
232
For an arterial blood puncture
1) you should assess for collateral circulation by occluding both radial and ulnar arteries until fingers are pale then release just the ulnar pressure point.
2) sterile technique is needed if getting blood cultures, otherwise clean technique is okay.
3) the vessel may not feel pulsatile in infants.
4) enter at 90 degrees
5) overlying infection is a contraindication
233
A patient with eating disorder is likely to have:
Heme: cytopenias
GI: delayed gastic emptying, dysmotility, high cholesterol, pancreatitis, elevated LFTs, constipation
Electrolytes: Low k, low Na, low phos
234
When discussing advanced are directive, you should NOT discuss financial burden and cost of providing care up front. Instead, include a discussion of unnecessary therapies that prolong life.
true
235
For patients with bulimia, pharmacotherapy along with what pharmacotherapy is recommended?
SSRI specifically fluoxetine is 1st line to minimize binging and purging behavior. The other SSRIs are 2nd line.
Of note bupropion has been associated with seizures in bulimia patients and is contraindicated in them.
236
A sacral dimple that you cannot see the base of, if within 2.5cm of anus with no hypertrichosis, hemangioma or caudal appendage (tail or pseudotail) does not need further imaging.
Yes
237
How frequently should botulinum toxin injections for sialorrhea be performed?
How frequently can you increase glycopyrollate?
Botulinum toxin injections should be repeated only once every 3-6 months
Glycopyrollate can be increased every 5-7 days until you reach treatment effect
238
An infant who turned blue and choked immediately on trying breastfeeding is concerning for bilateral choanal atresia. Of note, 2/3 of cases are unilateral. What test can be done to confirm diagnosis?
Inability to pass the suction catheter deeper than 3.2cm in the affected nare (no connection between NP and larynx).
239
In a patient with NEC who undergoes extensive bowel resection, what is associated with the best prognosis of achieving full enteral autonomy?
Residual bowel length greater than 50cm (specifically patients with bowel length less than 20cm are unlikely to achieve independence from TPN).
other factors that are positive but less impactful: preservation of IC valve and having the ileum which has the highest ability to adapt post resection.
240
In which newborns should a DSD (disorder of sexual development) be considered?
bilateral undescended testicles, severe hypospadias, uniliateral undecscended testicle with hypospadias or with micropenis (<1.9cm).
If concerned about CAH, you should get serum electrolytes, 17 OHP, and karyotype.
241
How long is appropriate to wait for a unilateral undescended testicle?
4-6 months. The testicle is unlikely to descend after 6 months of age.
242
A child with SLE who was recently started on high dose pulse steroids and develops neuropsychiatric symptoms is most likely to have them from...
Lupus! Steroid induced psychosis usually occurs with prolonged exposure to high dose steroids.
243
A 17 yr old patient with a PEG in place that flushes and develops emesis as well as a 10kg weight loss over the past 3 months, with soft mild upper abdominal distension should first get a ...
PEG contrast study to rule out gastric outlet obstruction from the PEG. This can be addressed by just repositioning the PEG if present.
244
If a mom is HepBsAg negative and baby is greater than 2kg, Hep B vax should be given within first 24 hours. If mom is HepBsAg positive, HepB vax and HBIG should be given within first 12 HOL. If mom is HepBsAg unknown, Hep B vax should be given within 12 HOL and HBIG can be held up to max 7 days until results return.
Yes
245
A patient who has recently undergone gastric fundoplication and experiences tachycardia and hypoglycemia in the post-op period about 1 hour after her feeds is experiencing...____. why? what is the way to address it?
Dumping syndrome where gastric contents (due to smaller volume) are delivered more quickly to the small intestine and the undigested carbs in the small intestine leads to a hyperinsulinemic response. The treatment is to add complex carbs like cornstarch to the formula. You could also slow the feeds or switch to continuous feeds.
246
In an infant born at >= 35 weeks, you can start PPV at 21% FiO2 but for younger infants, you may start at 30% FiO2. If the HR does not improve to >100bpm then you should consider transition to chest compressions 3:1.
True
247
What are the most common symptoms of somatic symptom disorder and what is the best treatment for it?
Most common symptoms: abdominal pain, headache.
Best Treatment: CBT
A thorough medical evaluation is important but unnecessary, invasive testing does not help
248
Dex gel should be followed by feeding for neonatal hypoglycemia
yes
249
A FT newborn baby with tremors, hypertonicity, high pitched cry, exaggerated sucking and some colostrum regurgitation on blanket is concerning for maternal history of...
Anti-depressant use. The syndrome is called poor neonatal adaptation syndrome.
250
What are neonates with in utero exposure to marijuana likely to show?
Low birthweight. Marijuana does not cause neonatal withdrawal symptoms.
251
A patient with epilepsy who is admitted for replacing a dislodged G-tube becomes febrile, tachycardic, diaphoretic, with dystonic posturing. What is occurring? What is the best management for both preventing and aborting symptoms?
Paroxysmal sympathetic hyperactivity or dysautonomia.
Clonidine.
For abortive therapies only: morphine, lorazepam.
For preventive therapy only: gabapentin, baclofen
252
How does phototherapy reduce jaundice?
Light changes the conformation of bilirubin to lumirubin which can then be excreted in both the urine and bile without being conjugated.
253
How does bilirubin metabolism usually work in the body?
Bilirubin is transported bound to albumin to the liver. In the liver, UGT enzyme, converts the unconjugated bilirubin taken up by the hepatocytes to conjugated bilirubin which can then be excreted in bile.
254
What is an intervention that can improve lumbar puncture success rate?
ultrasound guided LP - can occur in ED.
Hydration and diff position don't necessarily improve odds.
255
What are typical colostrum volumes in the first 24-48hrs of life and in the 48-72hr timeframe?
24-48 hrs: 5-15ml
48-72hrs: 15-30ml
256
Who is home BiPAP (not CPAP) usually recommended for?
Patients with central apnea, hypoventilation
257
For healthy children, the leading cause of OSA is adenotonsillar hypertrophy so T&A is the main treatment.
For children with craniofacial anomalies, T&A usually won't work so PPV via CPAP is recommended. Most children only tolerate nasal interfaces with home CPAP but chronic use of these nasal masks or pillows can lead to midface hypoplasia in kids due to maxillary bone pressure. Solution is to have the interface be loose fitting and occasionally rotate with between face mask and nasal interfaces
Yes
258
What is the appropriate testing for a child with congenital syphilis?
serum RPR or VDRL
CBCd
CSF VDRL, cell count, protein
Other studies per provider discretion (LFTs, CXR, long bone XRs, HUS, Ophto exam)
usually concurrent maternal testing recommended. (Moms who received PCN at least 4 wks before delivery and were documented to be negative after are viewed as adequately treated. Baby in these cases should only be treated if their RPR/VDRL titters are more than 4-fold greater than mom.
Treatment is IV PCN G for 10 days.
259
What testing can distinguish a false positive RPR?
Maternal treponemal test such as fluorescent treponema antibody (FTA-ABS)
260
A standardized format for VERBAL handoffs has been shown to reduce patient safety events
yes
261
What are the different types of variables?
Continuous data - numerical scale where separation between each # is same amount (e.g. age)
Nominal or categorical data - unrelated categories (e.g. race variable)
Dichotomous variable - nominal data with only 2 categories
Ordinal - data is categorical but has a clear order of lowest to highest
262
When delivering bad news, it is better to say something like I have some "unexpected" news to deliver --ie. not make a judgement about the diagnosis.
Yes
263
On a receiver operator curve, the y-axis represents sensitivity and the x-axis represents "1-specificity or the false positive rate"
Yes
264
A leadership organizing principle called GRPI represents goals, roles, procedures/processes, and interpersonal relationships suggests addressing these issues in this order and requires conflict to be dealt with in the open.
Yes
265
You do not need a separate consent from an adolescent to screen specifically for HIV when screening for STIs.
Yes
266
When designing a new curriculum, the first step is to identify the method currently being used and the ideal approach from the literature. The next step is to perform a needs assessment. 3rd step is to identify goals/objectives of the curriculum. The 4th step is to identify educational strategies that will be most effective. The 5th step is implementation of the curriculum which helps to identify potential barriers and the last step is to perform evaluation.
Yes
267
To set up the sensitivity/specificity calculation 2x2, what is at the top (columns - disease positive or not), rows (test positive or not)
Yes
268
What is the equation for sensitivity?
TP/TP+FN - true positive rate, given that you have the disease, how likely is the test to be positive
269
What is the equation for specificity?
TN/TN+FP - True negative, given that you are negative, how likely is the test to identify you as negative
270
What is the equation for positive predictive value?
TP/TP+FP, Given a positive test, how likely are you to have the disease.
271
What is negative predictive value?
TN/TN+FN, Given a negative test, how likely are you to not have the disease?
272
From simplest to most complex, Bloom's taxonomy is remember, understand, apply, analyze, evaluate, create
True
273
What are Kotter's 8 steps of change management?
1 - create a sense of urgency
2 - pull together the guiding team which should include members with credibility, communication skills, analytical skills, authority, and leadership skills
3 - Develop the change vision/strategy to achieve the change
4 - communicate the vision to help others understand and buy into it
5 - empower others to work collectively to make the vision a reality
6 - produce short term wins that are visible and unambiguous
7 - don't let up after the first successes
8 - create a new culture over time with improved action and behaviors
274
1`1`What are examples of social determinants of health?
age and conditions in the environments that people are born, live, learn, work and play that affect health outcomes and quality of life. Examples are: access to healthcare or transportation or food, quality of housing conditions, language, literacy, quality of education
275
What statistical tests are appropriate at what times?
2 categorical variables - chi-square test
When the independent variable (Aka exposure/explanatory variable is continuous, regression is used
When the explanatory variable is categorical and the response variable is continuous, multiple tests are options. If both groups of data belong to the same individual, paired t-tests can be used.
276
What is relative risk?
Ratio of risk in exposed group/ratio of risk in the unexposed (untreated) group
277
What is absolute risk?
The difference between risk in the exposed group and risk in the untreated/unexposed group
278
What is the odds ratio?
The ratio between those who do and do not have the disease,
279
What is omission bias?
The tendency to favor inaction over action (watchful waiting over starting antibiotics)
280
What is visceral bias?
When a clinician's feelings about a patient/family impact the diagnoses that are covered (e.g. assuming a parent who is a smoker doesn't correctly use child's asthma meds)
281
What is aggregate bias?
Believing that aggregate data does not apply to your specific patient (e.g. not using evidence-based guidelines when patient meets inclusion criteria)
282
What is health in all policies?
It references improved health as a shared goal across all areas of government. It's strategy that focuses on the goal of improving health and health equity by addressing health in all areas of government...such that legislators need to consider the downstream impact to health of ALL individuals, not just children though health may not be the primary focus of the legislation.
283
What are the rough PTX thresholds by hour for 37 weeker
Goes up by ~3 per day until 72 hrs when it goes up by 2 and then from 96hrs onward, plateaus
24 hrs - 12 (11.7)
48 hrs - 15 (15.4)
72 hrs - 18 (18.1)
96 hrs - 20 (20) - plateaus at 96hrs
120 hrs - 20 (20.2)
284
In a linear regression, r2, represents the percentage difference accounted explained by the independent variable.
True
285
On a run chart, the astronomical point is the point that is distinctively different than all the others,
A shift is 6 or more consecutive points all above or all below the median.
A trend is 5 or more consecutive points all going up or all going down
Yes
286
The Joint Commission requires that a patient's race/ethnicity, preferred language and any communication needs NEED to be documented in the chart
yes
287
Prior to using an interpreter, it is best practice for the provider to prepare the interpreter for what will be discussed in the encounter.
yes
288
If a patient with Anorexia Nervosa is of age of consent and willingly checks in and asks a physician to withhold treatment related information from them, which ethical principle are they exercising?
Therapeutic privilege
289
Positive predictive value and negative predictive value can ONLY be calculated if prevalence is known meaning you cannot calculate them in a case control study or pre-selected group of patients that does not represented the general population.
Yes
290
In a statistical process control chart where there is a center line, an upper bound and a lower bound, a common cause variation is due to random variability in data and is represented by the center line. A shift is thought to have occured if the data after invention has at least 8 points all above or all below the center line. If that's the case, that's a "special-cause variation". The effect can be explained (if it starts at the time of or just after the intervention) or unexplained if it precedes the intervention.
Yes
291
How is assessment different from evaluation?
Evaluation tests what has been learned and happens at the end of an identified period of learning (e.g board exam after fellowship or grade after med student rotation). It identifies weaknesses and is judgmental in that it has an associated score.
Assessment is a diagnostic, ongoing process that identifies how learning is going and areas to improve. It happens DURING learning.
292
A meta-analysis requires homogeneity of the studies (not the type) but in data collection so the data can be pooled for statistical analysis.
Limited outcome data or selective reporting can limit the validity of a meta-analysis meaning if data for non-significant results is mentioned but isn't adequately reported in some included studies.
True
293
What's a good acronym for the types of waste in lean methodology?
DOWNTIME
Defects - errors that don't produce desired outcome - misdiagnosis, med errors
Overproduction - doing/creating more than needed
Waiting - delay in service provided
Not using talent
Transportation - unnecessary movement of materials or patients in system
Inventory - extra supplies that may not be used, may expire or take up space
Motion - unnecessary movement by employees in system
Extra-processing - performing additional tasks or making existing tasks more complex than necessary
294
For a patient in septic shock who needs oxygen, the best way to maximize the patient's fraction of inspired oxygen (FiO2) is to place them on a non-rebreather
Yes. Nasal cannula and facemask do not provide sufficient FiO2.
295
Failure mode and effects analysis is a proactive method to PREVENT errors due to a new system before they occur.
Yes
296
What is "just culture"
Just culture is an approach that focuses on addressing systems issues that lead to patient harm and improving those systems in a way that reduces an individual's likelihood to perform an unsafe task.
297
In just culture, what is a lapse? what is a slip?
Lapse is forgetting to do something that was intended - forgot to prep skin with chlorhexidine for LP
Slip is inadvertently performing a task incorrectly (e.g. pouring salt instead of sugar in coffee)`
298
Even during the COVID-19 pandemic, the AAP said a family member should be at the bedside.
Yes
299
In newborn metabolic screening, sensitivity is more important that specificity and it is ok to include a disease that is present at birth even if it is latent in childhood and does not present until adulthood.
Yes
300
What are the 4 components of healthcare access?
coverage - insurance status/access to health facilities, service - usual source of care for screening and treatment, timeliness - ability to receive healthcare when needed, workforce - access to capable and qualified healthcare providers
301
What is 360 feedback?
Feedback from multiple perspectives (attendings, peers, nurses, and patient families)
302
What is formative feedback?
It is given during or after a particular encounter or task, with the goal of helping the learner make timely adjustments to improve their performance in that area
303
what is summative feedback?
comprehensive assessment of a learner's performance that happens at the end of a course or clinical rotation
304
The reportable pressure injuries to CMS as a hospital aquired infections are...
Stage 3 (full-thickness loss with fat tissue visible)
Stage 4 (full thickness skin and tissue loss with exposed fascia, muscle, bone/cartilage, tendon, ligament)
305
In multiple choice testing, test questions with which of the following DO NOT or all of the following except wording tend to have lower validity and reliability
yes
306
Validity is the degree to which a test measures the learning outcomes it is intended to measure
Reliability is the degree to which a test CONSISTENTLY measures a learning outcome
yes
307
How long can opiate withdrawal symptoms be seen after birth?
5 days
308
If a baby with NAS with increasing morphine needs has a mother who insists on signing them out AMA, what is the best next step?
Notify CPS
309
What is the most common reason for unplanned hospital readmission in the pediatric population in 30 days?
complications from surgical procedures most commonly pain or dehydration. E.g. as many as 1 in 4 adolescents is readmitted after a T&A and nearly all (98%) of appendectomy readmissions are thought to be preventable. Ensuring post op patients have adequate
