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ctjghjkbgf > Psychiatry/ Child abuse > Flashcards

Psychiatry/ Child abuse Flashcards

1
Q

Definition of colic? (wessel criteria)

A 
crying for no apparent reason 
that lasts for ≥3 hours per day 
and occurs on ≥3 days per week 
for > 1 week
in an otherwise healthy infant < 3 months of age
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2
Q

DDx of inconsolable crying

A 
FB or corneal abrasion** *maybe up to 21%! Fluorescein for diagnosis)
otitis media
meningitis
CMPA
constipation, GERD
CHD
hernia or torsion
hair tourniquet
NAI
drug withdrawal
irritability after pertussis vaccine (up to 24 hours)
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3
Q

Colic counseling (list 4)

A

o Soothing baby: rocking, riding in a car, white noise, swing
o Family support
o Normalize but acknowledge how difficult it is
o Most improve by 3 months
o Risk for NAI: place baby down in safe space if feeling overwhelmed

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4
Q

6 non-psychiatric causes of a violent/aggressive patient?

A
  1. CNS (tumour, abscess, head injury)
  2. Hypoxia
  3. Hypoglycemia/calcemia
  4. Hyperthyroidism/wilsons’
  5. Vasculitis (i.e. SLE)
  6. Infections (i.e. meningitis, HIV)
  7. Toxins (i.e. cocaine, amphetamines, PCP, corticosteroids)
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5
Q

4 psychiatric causes of a violent/aggressive patient?

A
  1. Disruptive behavioural disorders (ex. ODD, ADHD, CD)
  2. Depression
  3. Mania/mixed manic-depressive states
  4. PDD (ex. ASD)
  5. Psychosis
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6
Q

4 predictors of violence and aggression in agitated patient

A
  1. Recent acts of violence
  2. Verbal or physical threats
  3. Carrying weapons
  4. Intoxication (alcohol vs others)
  5. Concrete plan
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7
Q

Delirium DDx?

A

I Watch Death:
Infectious

Withdrawal
Acute metabolic
Trauma
CNS pathology
Hypoxia
Deficiencies (B12, folate)
Endo
Acute vascular (ie. stroke)
Toxins
Heavy metals
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8
Q

Major side effects of typical antipsychotics

A

Anti-dopaminergic:

EPS (acute dystonic reactions, akathisia, parkinsonian effect)

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9
Q

Treatment of acute dystonic reaction

A

Tx with PO/IV/IM diphenhydramine or PO/IM benztropine, benzo’s

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10
Q

Worrisome side effect of buproprion

A

Seizures

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11
Q

Diagnostic criteria of depression

A

MSIGECAPS: at least 5 for at least 2 weeks

at least one of the symptoms is either dysphoria or anhedonia

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12
Q

What is the most dangerous side effect of SSRIs in adolescents?

A

Serotonin syndrome

QTC prolongation – citalopram > 40 mg

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13
Q

Clinical features of serotonin syndrome?

A 
o	Use of an SSRI
o	Agitation
o	Stupor
o	Myoclonus
o	Hyperreflexia
o	Diaphoresis
o	Shivering
o	Tremor
o	Diarrhea
o	Incoordination
o	Fever
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14
Q

Tx of serotonin syndrome

A

Supportive
Discontinue offending agent
benzo’s
cyproheptadine

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15
Q

Clinical features of neuroleptic malignant syndrome

A 
o	Fever
o	Axial muscle rigidity
o	Autonomic instability/shock
o	Altered LOC
o	Elevated CPK
o	Leukocytosis
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16
Q

Tx of NMS

A 
o	Supportive
o	IV fluids
o	Antipyretics
o	D/C medication
o	Bromocriptine and Dantrolene  specific antidotes
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17
Q

3 autonomic and 3 neuromuscular findings of serotonin syndrome?

A
  • Autonomic findings: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, and diarrhea
  • Neuromuscular findings: tremor, muscle rigidity, myoclonus, hyperreflexia, and bilateral Babinski sign
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18
Q

Criteria for diagnosis Bipolar disorder

A

DIG FAST
Elation or elevated mood or irritability (irritability more common in Peds):

  • Distractibility
  • Impulsivity
  • Grandiosity
  • Flight of ideas
  • Activity increase
  • Sleep (decreased)
  • Talkative

(need at least 3 for 1 week duration, or shorter if hospitalization required)

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19
Q

Definition of conversion disorder

A

one or more symptoms of altered voluntary motor or sensory function that are incompatible with recognized neurologic or medication conditions that cause significant distress and/or impairment of functioning

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20
Q

Tips for dealing with child with autism in the ED

A
  • Communicate directly with child
  • Simple and concrete language
  • Brief instructions
  • Warn about transition
  • Offer positive reinforcement
  • Allow frequent breaks
  • Recognize when tasks are overwhelming
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21
Q

What is the school refusal triad?

A
  • Vague physical symptoms
  • Normal physical and laboratory findings
  • Poor school attendance
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22
Q

3 comorbidities associated with school phobia

A
  • Anxiety
  • Depression
  • Specific phobias
  • Conduct disorder
  • Substance abuse
  • Familial psychopathology
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23
Q

Basic mental status exam? (ABC’s)

A

ABC’s of mental status exam:
appearance/affect
behavior
cognition (thought content, thought process, LOC)

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24
Q

4 ways to talk down an agitated patient (ie. no meds)

A 
Introduce yourself
Simple language
Explain what is happening/next steps
Reduce environmental stimulation (dark room, less people)
Offer food or drink
Room for pacing, if possible
Listen and empathize
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25
Q

Examples of chemical restraints

A
  • Mild agitation: antihistamines, alpha-adrenergic agents such as clonidine or benzodiazepines
  • Moderate to severe: benzodiazepines, alpha-adrenergic, typical antipyschotics, atypical antipsychotics. Can give combo of benzo and antipsychotic together for rapid tranquilization.
  • Commonly used medications include benzodiazepines (eg. lorazepam IV/IM/SL), and typical antipsychotics (Haloperidol) and atypical antipsychotics (olanzapine or risperdal IM/PO)
  • Classic adult combo = 2 mg lorazepam + 5 mg Haldol
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26
Q

List five things to do when applying restraints.

A 
o	Explain to the patient why physical restraints are necessary
o	Have at least 5 caretakers (trained) to apply – 1 for the head and 1/limb
o	Avoid pressure on the patient throat or chest
o	Avoid placement of a restrained child in prone position
o	Close (1:1) supervision while the child is in restraints
o	Assess restraints q2 hrs (teenager)
o	Face to face with physician at 1 hour mark
o	Remove restraints with adequate staff present and when patient has regained control (may choose to remove one limb at a time – but don’t leave only 1 limb in place)
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27
Q

Complications of physical restraints?

A 
o	PTSD
o	Shame/violation
o	Injury
o	Asphyxiation, airway obstruction
o	Also: pressure sores (skin breakdown), paresthesias, rhabdomyolysis
28
Q

Name 4 reasons to put someone in physical restraints:

A

o To prevent imminent harm to the patient or other persons when the means of control (verbal) are not effective or appropriate
o To prevent serious disruption of the treatment plan or significant damage to the physical environment
o To decrease the stimulation a patient receives (PCP, ethanol intoxication)
o When the patient feels out of control and is requesting it
o Unable to give chemical restraint (safety or refusal and continued aggression

29
Q

Risk factors for suicide?

A

SAD PERSONS mnemonic

Sex: male
Age < 19, > 65
Depression

Prev attempt
Excessive alcohol/drugs
Rational thinking loss
Separated/divorces
Organized attempt
No social supports
Stated future intent
30
Q

What are the 3 most commons causes of mortality in teenagers ages 15-19y in North America.

A
  • Accident death – MVC
  • Homicide
  • Suicide
31
Q

Teenage female brought in to ED with desire to die. List six common risk factors of suicide completion in teenagers.

A
  • Adolescents >16
  • Previous suicide attempts
  • History of comorbid psychiatric condition (Depression, Anxiety)
  • Recent stressor, change in life
  • Substance abuse, alcohol or drug abuse
  • Poor social support
  • Family history of mental illness
  • Homosexual orientation
  • History or recent sexual/physical abuse
  • Males>Females
  • Access to lethal weapons or medications
32
Q

Indications for psych admission after suicide attempt

A
  • no rapport with physician
  • serious attempt (lethality, intent)
  • still actively suicidal
  • can’t engage in safety planning
  • psychosis
  • no family support
  • child denying significance of attempt
33
Q

Time cutoff after which physical exam in the ED for suspected abuse is NOT indicated

A

72 hours

34
Q

Examples of date rape drugs (3)

A

Rohypnol (flunitrazepam) and GHB (Y-hydroxybutyrate), ketamine

35
Q

List 5 conditions associated with genital redness

A 
vulvovaginitis
contact dermatitis
perianal strep
candida diaper rash
lichen sclerosis
36
Q

Teen sexually assaulted 12 hours ago, vaginal pain and bleeding. List 5 things to do in management

A
  1. genital exam
  2. Contact scan
  3. sexual assault evidence kit
  4. EC, pregnancy test
  5. STI testing and prophylaxis
  6. Hep B and HIV prophylaxis
37
Q

When to screen for STI’s in a prepubertal victim of sexual assault?

A

screened for STI if symptoms are present, history or evidence ejaculation or oral/genital penetration, assailant has STI, high community prevalence STI, patient or parents requests STI testing

38
Q

When to screen for STI’s in a post-pubertal victim of sexual assault?

A

screen ALL

39
Q

Which 4 STI’s are diagnostic of sexual assault (if excluded vertical transmission)

A

gonorrhea, chlamydia, syphilis, HIV

40
Q

Adams paper - list findings diagnostic of injury

A

Acute laceration to external genital/anal tissue
Hymenal laceration
bruising of the hymen
hymenal transection
missing segment of hymenal tissue (particularly at posterior pole)

41
Q

Sexual assault post-exposure prophylaxis for STI’s?

A

GC+ chlamydia: Azithromycin 1g, ceftriaxone 250 mg
Trich: flagyl 2g PO x 1
HIV: consider HIV PEP
Hep B immunization

42
Q

Timing for emergency contraception after sexual assault, and what to use

A

offer in pubertal females within 120 hours (ex progestin only ECP 1.5 mg levonogestrel); repeat testing in 2 weeks

43
Q

What are 4 psychosocial risk factors for pediatric sexual abuse

A
  1. Non-two parent household
  2. foster care
  3. single parent with live in partner
  4. female
  5. age 7-13
  6. African American/Hispanic
  7. disabled
  8. behaviour difficulties
  9. Previous abuse/neglect
44
Q

What are 4 clinical presentation of child sexual assault

A

Anxiety, nightmares, PTSD, inappropriate sexual behavior, aggression, school problems, hyperactivity, and regressive behavior.

45
Q

Sexual assault - name 3 viruses of concern that you would discuss with the parents

A

HIV
HPV
Hep B/C

46
Q

5 Risk factors for STI in sexual assault:

A

a. High prevalence of STI in the community
b. Presence of STI in family member
c. Suspected perpetrator has known STI
d. Suspected perpetrator is at high risk for STI
e. Evidence of penetration or ejaculation
f. Multiple assailants

47
Q

A 13 year old presents with concern about STI acquisition

A

15 years old (non-exploitative, not in a position of power).

12-13: 2 years older
14-15: 5 years older
age of consent = 16 years old (18 for exploitative)

48
Q

What are 3 reportable STI

A

HIV/AIDS
Chlamydia
Syphilis
Gonorrhea

49
Q

AN - DSM5 criteria for diagnosis

A
  1. Restriction of energy intake
  2. Intense fear of gaining weight
  3. Distorted perception of body weight and shape
    (not amenorrhea)
50
Q

List five cardiac problems in anorexia nervosa.

A
  • Orthostatic vital sign changes
  • Hypotension
  • Bradycardia
  • Myocardial atrophy
  • Mitral valve prolapse
  • Pericardial effusion
  • Arrythmias
    o QT prolongation
    o Torsades  ventricular fibrillation
    o AV block
    o Prolonged PR – interval
    o ST-T wave abnormalities
51
Q

Anorexia - What are 4 investigations to order in the ER in initial work up

A

CBC/diff, electrolytes/extended electrolytes, ECG, renal function
TSH
Orthostatic vitals

52
Q

Anorexia - 5 indications for admission

A 
HR < 45
BP < 80/50
electrolyte abnormalities
arrythmias/ QT prolongation
orthostatic changes
suicidality
acute food refusal
failed outpt treatment
53
Q

Features of refeeding syndrome

A 
Hypophosphatemia (hallmark)
Hypokalemia
Vitamin (e.g. thiamine) deficiencies
CHF
Peripheral edema
54
Q

Bulimia - 4 physical signs

A
  • enlarged parotids
  • poor dentition/erosion of enamel
  • callused knuckles/fingers (Russell’s Sign)
  • xerosis (dry skin)
  • edema
  • hair loss
55
Q

Bulimia - 2 serious complications

A
  • arrhythmias
  • electrolyte disturbances
  • esophageal rupture
  • dehydration
  • metabolic acidosis
  • menstrual irregularities
56
Q

What is the definition of child neglect?

A

Neglect refers to omissions (physical, emotional, educational), resulting in actual or potential harm. Neglect occurs when a need is not adequately met and results in actual or potential harm, whatever the reasons.

57
Q

What are four physical findings seen with neglect?

A 
●	Weight loss or failure to thrive
●	Poor hygiene
●	Diaper rash
●	Flat and balding occiput
●	Dull apathetic facies
●	Body posture of an under-stimulated child
●	Excessive oral self-stimulation
●	Developmental delay, particularly in social adaptive and language areas
58
Q

List five features that would make a history suspicious for non-accidental trauma?

A
  • Changing story
  • Delayed presentation for injury
  • Unexplained injuries
  • Injury pattern not consistent with developmental age
  • Vague history
  • Nature of interaction between parent – child and parent – ED staff
  • Child brought in by a different caregiver who was not present at time of injury
59
Q

List 5 factors that increase the risk of child abuse

A
  • Child factors: developmental handicaps, chronic illness, behavioral issues, prematurity, other associated injuries, multiples (twins)
  • Parent factors: young age, lower SES, substance use, mental health disorders, personal hx of childhood abuse, hx of criminality, violence
  • Environment factors: low education, lack of supports, unemployment, intimate partner violence, non-related adult male in home
60
Q

Concerning bruising for child abuse

A

TEN4
Bruising of the Torso, Ear, or Neck in a child ≤4 years old, or bruising in any location in a child <4 months old worrisome

61
Q

Concerning fractures for child abuse

A 
CML (classic metaphyseal lesions)
Posterior rib
scapula
vertebral spinous process
sternum
62
Q

DDX of causes fractures (for NAI):

A

trauma (including accidental and birth injuries), nutritional (rickets, osteopenia, copper deficiency), genetic (OI, menkes), infectious/inflammatory (osteomyelitis), neoplastic (leukemia, bone tumor)

63
Q

How to screen for other injuries in NAI?

A
  • Skeletal survey if < 2 years old
  • CT head or MRI if < 1 year old or symptomatic
  • Ophtho exam if + head imaging
  • Abdo labs (AST, ALT (cutoff > 80), amylase) +/- CT abdomen
  • Labs for bruising work-up (CPS): CBC, diff, smear, INR, PTT, vWF studies, blood group, fibrinogen, factor 8, 9, LFT’s, urea/creatinine
64
Q

Examples of abnormal sexualized behavior

A

behaviours btw children 4 or more years apart, one child takes charge and directs time/place/type, asking adults to engage in specific sexual acts, obsessive masturbation difficult to distract

65
Q

List the five most common historical features of Munchausen Syndrome by Proxy.

A
  • Single parent – usually mother. Distant relationship with father
  • Articulate and cooperative
  • History of ‘Doctor Shopping’
  • Multiple work ups without any medical diagnoses
  • Episodes of illness witness by parent only – always present when episode happens, not witnessed during admissions or by medical professionals
  • Secondary gain from medicalization or admission
  • Symptoms and course, response to treatment are incompatible with identifiable diagnosis
  • Parental history of factitious or somatoform disorders or extensive medical care
66
Q

Breath-holding spell. 2 tests to do in ED?

A

ECG, CBC (R/O anemia)

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