2018

Question 1

In tuberculosis, what are two differences between the clinical presentation of early primary disease and reactivation disease? (2)

Answer 1

Primary: highest risk <4yo, risk of disseminated disease is higher. Reactivation: highest risk >10yo, low risk of disseminated disease.

Question 2

What is the most sensitive screening test for tuberculosis in children under 2 years?

a. Chest XR b. TST c. IGRA d. Blood culture

Answer 2

b: TST is more sensitive <2 and IGRA is always more specific

Question 3

A 4 year old child was exposed to active pulmonary TB. They are asymptomatic. The chest x-ray is normal. A tuberculin skin test measures 3mm. What is the most appropriate management?

a. No treatment
b. Treat for latent TB infection with the standard four-drug regimen
c. Single drug prophylaxis for 8 to 10 weeks, then repeat TST, and treat if ≥5mm
d. No treatment at this time, repeat TST in 8 to 10 weeks, and treat if ≥5mm

Answer 3

c: because <5yo. Otherwise no prophylaxis.

<5yrs + neg TST

Receive preventive prophylaxis (also known as ‘window prophylaxis’, with one TB drug), using a drug that has been identified as effective for treating the source case strain.

• A second TST is done at 8 to 10 weeks following last contact (sometimes termed “break of contact”), while the index case was still infectious.

If second TST is negative, can discontinue window prophylaxis

Question 4

What are isolation requirements for a patient with respiratory illness when TB is suspected and smear is positive for AFB?

Answer 4

• Typically, when respiratory secretions from an index case smear positive, the individual is isolated in hospital or at home until three sputum specimens smear negative or, if initial smears are negative, after a full 2 weeks of directly observed therapy has been administered

Question 5

Name 5 organs or tissues that can be involved in disseminated TB disease. (5)

Answer 5

Lungs, brain, retina, liver, spleen, joints, bone, bone marrow, muscle

Question 6

What is considered a positive TST?

Answer 6

• Cut-offs for TST induration indicative of possible infection are:
  
  • ≥5 mm induration for individuals who are immunocompromised (HIV), for contacts of known cases within 2 years
  • Infants or young children with suspected TB disease may even have 0 mm or <5 mm induration.
  • ≥10 mm for others
    
    • Of individuals who received BCG at or soon after birth, only 1% will have a TST of ≥10 mm after 10 years of age.
    • Therefore, a TST of this size usually should not be attributed to past receipt of BCG vaccine

Question 7

List six “red flag” findings concerning for alternate diagnoses on history, physical exam, and initial investigations for a patient with presumed ITP. (3 total, 0.5 each)

Answer 7

B-symptoms, bone pain, recurrent thrombocytopenia, lack of response to treatment, lymphadenopathy, hepato/splenomegaly, signs of chronic disease, moderate-severe anemia, high or low WBC, high MCV, abnormal smear

Question 8

Name two factors that will affect your decision of whether to choose active treatment or observation for a patient with ITP. (2)

Answer 8

Severity of bleeding, parental preference / risk tolerance level, child wanting to return to activities and sports (NOT absolute platelet count)

Question 9

If choosing conservative management / observation for typical newly diagnosed ITP, name three essential parts of your followup plan. (3)

Answer 9

Physical examination for signs of bleeding, check CBC to follow platelets and other cell lines, advise to avoid contact sports or activities that may cause hits to the head, advise to avoid NSAID/ASA/any meds or herbal supplements with anti-platelet activity, continue regular appointments until counts have recovered

Question 10

What are the five recommended elements of working with vaccine-hesitant parents? (5)

Answer 10

Keep them in your practice; identify parental concerns with presumptive, motivational interviewing; present risks/benefits with clear, effective language; manage immunization pain; discuss herd immunity / community protection. Mnemonic: PPPPP (Practice they shouldn’t get kicked out of, Parental concerns / presumptive interviewing, Present the risks/benefits, Pain management, Protect the community)

Question 11

Which of the following is the best tactic to employ with a vaccine-hesitant family? a. Explaining to the family that you cannot provide medical care to the child if they choose not to immunize b. Providing a list of vaccine concerns frequently raised by parents along with comprehensive rebuttals c. Using a participatory approach when introducing the topic of the child’s routine vaccinations d. Telling an emotionally powerful true story about vaccine-preventable illnesses

Answer 11

d: don’t introduce concerns not brought up by the family, use a presumptive not participatory approach

Question 12

List two reasons why it is not advisable for parents to rely on “herd immunity” to protect their child from vaccine-preventable diseases. (2)

Answer 12

Outbreaks still occur which overwhelm herd immunity and generally by that time it is too late to vaccinate, some diseases eg tetanus have no herd immunity, choosing not to vaccinate puts others in our orbit at risk eg neonates and pregnant women

Question 13

What term is currently preferred over “herd immunity”? (1)

Answer 13

“Community protection”

Question 14

A patient presents to ED after a bee sting. In which situation(s) do you need to prescribe an EpiPen when the patient is well enough to go home? a. Lip swelling, wheeze, and hypotension starting 10 minutes after being stung b. Generalized urticaria starting 10 minutes after being stung c. A 15cm-diameter area of swelling, erythema, and pruritus around the sting site that has been worsening since the sting 24 hours ago d. A and B e. A, B, and C

Answer 14

a: not needed for isolated cutaneous reactions as these do not presage life-threatening reactions in the future

Question 15

A patient presents to ED with an anaphylactic reaction after a bee sting. You manage the patient appropriately in the ED with epinephrine followed by a period of observation. The patient is now well and ready for discharge home. a) Aside from making a referral to an allergist, what are two important elements of your discharge plan for this patient? (2) b) Name two reasons why is it necessary to refer the patient to an allergist. (2)

Answer 15

a) prescribe EpiPen, arrange for a serum tryptase when well, provide instructions on how to avoid stinging insects, anticipatory guidance on signs of anaphylaxis; b) to confirm anaphylactic allergy, to assess eligibility for venom immunotherapy

Question 16

List three measures that a patient or family can use to avoid stinging insects. (3)

Answer 16

Do not walk barefoot outdoors, exercise caution when eating and drinking outdoors, avoid drinking from opaque cans or straws outdoors, wear gloves and long sleeves for gardening and a long sleeve shirt for play in high-risk areas, remove all insect nests around the home and call a professional for insect control or nest removal in confined or hard-to-reach spaces Mnemonic: NOSES (Nest removal, Opaque cans, Shoes when outdoors, Eating carefully outdoors, Shirt)

Question 17

A young woman in your clinic is asking about the difference between “typical use” and “perfect use” failure rates for contraceptives. What property of a contraceptive method is most important in determining its “typical use” failure rate? (1)

Answer 17

How user-dependent the method is

Question 18

Describe the three tiers of contraceptive options for youth and give an example of each. (6)

Answer 18

First-tier: act over a long time period without needing any intervention; IUD/IUS Second-tier: act over a shorter time period, require periodic intervention; OCP, patch, Nuva, DP Third-tier: act only at the moment and depend on individuals’ motivation, skill, and timing; condoms, withdrawal, rhythm, diaphragm, cap, sponge

Question 19

Name the major health complication associated with Depo-Provera (1) and two recommendations you might make to a patient starting it in order to reduce the risk of this complication (2).

Answer 19

Bone demineralization; optimize Ca++ and VitD intake, weight-bearing exercise, reduce caffeine/alcohol/tobacco use

Question 20

When prescribing an oral contraceptive, which of the following is true? a. Close followup — providing an OCP prescription for only two to three months at a time and requiring the patient to return for refills — improves adherence to the OCP and decreases the overall rate of contraceptive failures b. It is important to be screened for pregnancy before starting OCPs because they can be teratogenic in early pregnancy c. If breakthrough bleeding occurs during ‘extended use’ or ‘continuous use’ OCP, the pill should be stopped for 4 to 7 days or else the breakthrough bleeding may continue indefinitely d. The risk of stroke or VTE is approximately doubled by using combined oral contraceptives

Answer 20

d: yearlong prescriptions improve adherence and outcomes, OCPs are not teratogenic, breakthrough bleeding stops on its own

Question 21

List three medications that may be used in the management of neonatal abstinence syndrome. (3)

Answer 21

Morphine, methadone, clonidine, phenobarbital, buprenorphine

Question 22

Which of the following statements is false? a. 50-75% of babies born to mothers using opioids will require treatment for opioid withdrawal b. Symptoms of neonatal opioid withdrawal generally start within the first 72h of life, but may not present until day 5-7 of life if the mother has been on methadone or buprenorphine c. A trained pediatric team, rather than the routine healthcare provider, should be present at the delivery when the mother is known to have been using opioids d. Preterm babies are probably less likely to experience neonatal opioid withdrawal

Answer 22

c: routine is fine unless other indications

Question 23

List six signs/symptoms of neonatal opioid withdrawal. (6)

Answer 23

High pitched cry, short sleep cycles, hyperactive Moro reflex, tremor, increased tone, myoclonic jerks, convulsions/seizures, diaphoresis, increased temperature, yawning, mottling, nasal stuffiness or sneezing, nasal flaring, tachypnea, excessive sucking, poor feeding, regurgitation, loose stools

Question 24

Name the three essential elements of informed consent. (3)

Answer 24

Capacity, fully informed, free from coercion.

Question 25

What is the difference between ‘consent’ and ‘assent’, and why is this distinction relevant to the pediatric population? (2)

Answer 25

Assent: patient agrees to the proposal but without true consent (may be incompletely informed, may be coerced, may not be capable of consent). Relevant because many of our patients are not able to give consent, yet it is important to still get their assent when possible

Question 26

A patient on your ward is a 10-year-old male who has just been diagnosed with pre-B ALL. Despite the overwhelming likelihood of cure with chemotherapy, his parents refuse. They do not trust your hospital after a previous bad experience, and they would prefer to treat the cancer with cranial-sacral therapy and Himalayan salt crystals. The patient himself refuses treatment as well, saying that losing his hair would be worse than dying. a) You are concerned that this refusal of chemotherapy does not represent the patient’s best interest. What are four potential steps you could take at this point to address the conflict over the patient’s plan of care? (4) b) If the patient were unstable in the emergency department with severe tumor lysis syndrome, and his parents were refusing acute treatment, how would this affect your plan in part a)? (1)

Answer 26

a) Agree to delay care for the moment pending discussion; exploring parents’ values and potential for collaborative decision-making; referral for second medical opinion; consult with social work; consult a religious leader if relevant; consult a hospital bioethicist; consult CAS b) if emergent / life-or-limb, provide care now and debate later (beneficence and non-maleficence)

Question 27

26. In a head lice infestation, what is meant by the term ‘nit’? (1) What is the clinical significance of finding ≥5 nits within 0.6cm of the scalp? (1)

Answer 27

Nits are louse eggs or empty egg shells glued to hair shafts. They can easily indicate past infestation rather than active infestation. Finding at least 5 nits within 0.6cm of the scalp is a risk factor for active infestation, but only about 1/3 of patient with this many nits actually have an active infestation

Question 28

In a typical head lice infestation, how many live adult lice typically infest the patient’s scalp? a) 1-10 b) 10-100 c) 100-1000 d) 1000-10000

Answer 28

a: “Less than 10” per CPS

Question 29

Which of the following would be provide the best evidence for an active head lice infestation? a) Excoriated scalp in the context of a known contact with head lice infestation b) A single live louse detected on the patient’s scalp c) Ten nits found glued to the patient’s hair shafts within 0.6cm of the scalp d) Five nits found glued to the patient’s hair shafts within 0.6cm of the scalp, in the context of a known contact with head lice infestation

Answer 29

b: can’t diagnose from nits alone, doesn’t matter if they have a contact

Question 30

Some medications that can be used in the treatment of head lice are insecticidal and some are not. Please list one medication from each class. (2)

Answer 30

Insecticidal: pyrethrin (R&C Shampoo), permethrin (Nix, Kwellada). Noninsecticidal: Isopropyl myristate/ ST-cyclomethicone (Resultz), dimethicone (NYDA)

Question 31

What diagnostic criteria differentiates GDD from ID? a) Age group b) Deficits in adaptative learning c) Age at onset d) Intellectual quotient e) Number of developmental domains affected

Answer 31

a: diagnosis of GDD is for kids under 5

Question 32

What is the most common cause of GDD/ID? a) Prenatal intrinsic b) Postnatal c) Perinatal d) Prenatal extrinsic e) Idiopathic

Answer 32

c: up to 55%. Next highest is prenatal intrinsic at up to 47%

Question 33

What are the first-line investigations for GDD/ID when no apparent cause can be identified by history/physical, neurodevelopmental exams, and vision/hearing screening? (3)

Answer 33

Microarray, fragile X testing, and tier 1 metabolic panel (blood and urine)

Question 34

List five “red flags” on history, physical, and initial investigations that are concerning for an inborn error of metabolism. (5)

Answer 34

Family history of IEM or developmental disorder or unexplained neonatal or sudden infant death; Consanguinity; Intrauterine growth retardation; Failure to thrive; Head circumference or stature growth abnormality (>2 SD above or under the mean); Recurrent episodes of vomiting, ataxia, seizures, lethargy, coma; History of being severely symptomatic and needing longer to recover with benign illnesses (e.g., upper respiratory tract infection); Unusual dietary preferences (e.g., protein or carbohydrate aversion); Regression in developmental milestones; Behavioural or psychiatric problems (e.g., psychosis at a young age); Movement disorder (e.g., dystonia); Facial dysmorphism (e.g., coarse facial features); Organomegaly; Severe hypotonia; Congenital nonfacial anomalies; Sensory deficits, especially if progressive (e.g., cataracts, retinopathy); Noncongenital progressive spine deformities; Neuro-imaging abnormalities

Question 35

Concerning Salmonella infections, which is true: a) Positive stool cultures for non-typhoidal Salmonella do not require action b) Typhoidal types are often responsible for osteomyelitis in sickle cell patients c) Non-typhoidal infections are not associated with bloody diarrhea d) Non-typhoidal infections are associated with septic arthritis in sickle cell patients e) Infection with typhoidal species comes from animal-to-human spread

Answer 35

d: action is needed if the patient is unwell or under 3mo, only non-typhoidal types cause osteoarticular infex in SC disease

Question 36

Concerning management of Salmonella infections, which is true: a) Azithromycin is favored over Ciprofloxacin as a step-down therapy b) For return to school/daycare, authorities require a document proving negative stools c) There is a licensed vaccine for children > 12mo d) Immunocompromised patients cannot receive the typhoid immunization because it is a live vaccine e) Resolution of fever, good clinical condition and negative blood cultures are required before switch to po Abx

Answer 36

a: cipro is starting to face resistance, there is an inactivated typhoid vaccine as well as a live one, don’t need resolution of fever to switch to PO abx

Question 37

You have admitted a febrile returning traveller with a blood culture positive for Salmonella typhi, and started the patient on ceftriaxone. What are three factors that would necessitate an infectious disease consultation and/or a prolonged course of IV antibiotics? (3)

Answer 37

Blood cultures don’t clear in 48h, patient still unwell after blood cultures clear, evidence of disseminated disease

Question 38

What are three of the recommended preventative measures to avoid needle stick injuries in the community? (3)

Answer 38

Education of parents/educators and health care providers about the problem of discarded needles; Age-appropriate education of children and youth about potential dangers of injection drug use; Teaching children not to touch or handle needles and syringes, and to report to a responsible adult; Community programs for safe disposal of needles in areas accessible to children; Programs for treatment and control of injection drug addiction; Programs for support of HIV prevention; Programs for HBV vaccination; Programs for safer distribution of drug use equipment

Question 39

What are three of the factors that should be considered to assess transmission risk of blood-borne infections after a needle stick injury in the community? (3)

Answer 39

Status of source blood/patient; Circumstance of injury: date/time, location, mechanism, presence of syringe attached to needle, blood visible on syringe and/or needle, presence of bleeding; Description of needle: size, hollow-bore; Depth of penetration (extent of trauma); Potential injection of blood; Amount of blood injected; Concentration of virus in injected blood

Question 40

Concerning needle stick injuries in the community, which is true: a) HBV is a fragile virus and survival and is unlikely to survive if exposed to dry, hot or freezing environment b) Risk of acquiring HIV is higher than for HCV c) No hepatitis B testing is needed if child has been fully vaccinated against HBV d) Splashes, even if large volume of blood coming into contact with extensive areas of nonintact skin, are NOT considered high risk for HIV transmission e) HIV prophylaxis is not indicated if cannot be initiated within 72 hours of exposure

Answer 40

e) HIV prophylaxis is not indicated if cannot be initiated within 72 hours of exposure

Question 41

Concerning acute osteoarticular infections, which is true: a) Optimal empiric therapy is IV Cefazolin b) When an acute osteoarticular infection is suspected, there is no need to do baseline radiographs if the patient can have a MRI right away c) CRP is not sensitive for monitoring response to therapy d) S. pneumoniae is more common than K. kingae in children younger than 4 years old e) Routine radiographs are indicated for follow-up

Answer 41

a) Optimal empiric therapy is IV Cefazolin

Question 42

List 3 conditions to consider in the differential diagnosis of acute focal pain in limb or near bone. (3)

Answer 42

Acute bacterial osteoarticular infection; Transient synovitis of hip; Fracture or trauma; Lyme disease arthritis; Cellulitis; Chronic recurrent multifocal osteomyelitis (CRMO); Hematologic malignancy; Bone neoplastic lesion; JIA; SLE; Reactive arthritis

Question 43

Concerning HPV infections, which is true: a) Marijuana is a risk factor b) HPV 6 and 11 are responsible for majority of genital cancers c) If previously received immunized with a different HPV vaccine, there is no need to administer the full HPV-9 schedule d) Females should get the vaccine earlier e) A 3-dose schedule is recommended for children 9-14yo

Answer 43

a) Marijuana is a risk factor

Question 44

List two at-risk populations for which HPV vaccination is strongly recommended. (2)

Answer 44

MSM, immunocompromised, HIV positive

Question 45

List four individual-level risk factors for HPV infection. (4)

Answer 45

higher lifetime number of sexual partners, previous other sexually transmitted infections, history of sexual abuse, early age of first sexual intercourse, partner’s number of lifetime sexual partners, tobacco or marijuana use, immune suppression, human immunodeficiency virus (HIV) infection

Question 46

Concerning high-flow nasal cannula, which is true: a) Provides continuous positive nasopharyngeal and intrathoracic pressure b) Is effective in heart failure because allows reduction of systemic afterload and preload c) Does not allow wash out of anatomic dead space d) Not recommended for transport

Answer 46

b) Is effective in heart failure because allows reduction of systemic afterload and preload

Question 47

List three conditions for which there is evidence to support the use of HHHFNC. (3)

Answer 47

Upper airway obstruction (OSA), lower airway obstruction (bronchiolitis, asthma), parenchymal lung disease (pneumonia, pneumonitis), heart failur

Question 48

List three underlying medical conditions with increased risk for invasive meningococcal disease. (3)

Answer 48

Functional or anatomical asplenia; Complement deficiency; HIV

Question 49

List four exposures associated with potential increased risk for invasive meningococcal disease. (4)

Answer 49

Lab workers who work with meningococcus; Military personnel in close quarters; Travelers to endemic areas (sub-Saharan Africa and Hajj pilgrims); Close contacts with invasive meningococcal disease

Question 50

Concerning meningococcal vaccine, which is true: a) Men-C is routinely offered at 12 mo b) In case of exposure, booster dose is not indicated when contact has previously been fully immunized c) Booster are recommended q 5 years d) Post-transplant vaccines are not effective for HSCT patients

Answer 50

a) Men-C is routinely offered at 12 mo

Question 51

List 6 red flags on history and physical for inflicted trauma in a young child with fracture. (6)

Answer 51

No history of trauma/unwitnessed injury; History incompatible with age/developmental stage OR with injury; History changes with repetition; Delay in seeking medical attention; Age < 1 year; High-risk fracture (Rib fractures, Metaphyseal fractures, Humerus fracture < 18 months, Femur fracture in a non-ambulatory child); Multiple fractures; Fractures of different ages; Presence of other injuries

Question 52

Concerning inflicted skeletal trauma, which is true: a) Presence of a blue sclera is specific for OI in young infants b) In an ambulatory child, femoral fractures following a short fall ( 1.5m) are suggestive of a non-accidental mechanism c) Vit A deficiency is part of the differential diagnosis d) Skeletal survey can be considered between 2-5 years of age

Answer 52

d) Skeletal survey can be considered between 2-5 years of age

Question 53

Safe discharge depends, in part, on identification of potential infant risk factors and issues that require follow-up. Please list 5. (5)

Answer 53

maternal medical/mental health concerns, psychosoial/economic stressors/domestic violence, maternal meds/smoking/alcohol/substance use, abnormal prenatal screening/US findings, BW, maternal hepB, syphilis, HIV, rubella, blood group, GBS RF, low glu RF, NAS RF, jaundice RF, DDH, birth injury, APGAR score/cord pH

Question 54

Name 3 important components of parental education prior to discharge of a healthy term infant. (3)

Answer 54

feeding (BF=best), normal behaviour/care, signs of illness (dehydration/sepsis), safety (back to sleep, car seat), infection control, smoke free

Question 55

Name 4 things on your checklist that should be accomplished before a healthy newborn is discharged home. (4)

Answer 55

Maternal readiness (feeding, understands illness recognition, psychosocial RF assessed) Infant health (exam, BW/length/HC, stable temp/HR/RR, passed urine and mec, weight loss <10%, 2 successful feeds, RF assessed, serology reviewed, no excessive bleeding with circ) Screening tests (NBS, hearing, bili, pulse ox) Treatments (vit K, opthalmia neonatorum proph, vaccines) Education (routine care, safety, feeding, when to seek help, circ care, vit D if BR) Follow up arranged (fam doc, follow up, lactation support, referrals/ix as needed, offer community supports) Written record provided to parents

Question 56

What are 5 ways to address vaccine hesitancy in the design and administration of immunization programs? (5)

Answer 56

Detect underimmunized groups and target interventions; educate healthcare workers; employ evidence-based strategies to increase uptake; educate the public (children and adults) about immunization; work with provincial and federal govt, community leaders

Question 57

What are the recommendations for returning to school in children with VZV? (3)

Answer 57

Child can return to school as soon as well enough; parents should be notified there is a case of VZV in the classroom; parents of immune compromised children should contact their HCPs for advice re PEP

Question 58

What are the CPS recommendations for summer camps regarding VZV? (5)

Answer 58

Camp should have a complete list of campers/workers and their VZV vax status; list of susceptible individuals should be made ahead of time; susceptible individuals should be offered vax; camps should review their varicella exclusion policies, taking the immune status of the camp clientele and the camp staff into consideration; when the camp includes persons with immunocompromising conditions, campers or staff with active VZV disease (varicella or zoster), or who have had an exposure to VZV in the past 21 days and are non-immune, should be excluded

Question 59

What are three potential strategies to improve childhood immunization rates in Canada? (3)

Answer 59

Electronic immunization registries; automatically notify parents when immunizations are due; promote the CANimmunize app; clinic hours should be convenient for working parents; mandatory vaccination records for school entry; annual school-based immunization programs; school curriculums should cover the importance of vaccination

Question 60

What are the three broad sources of decisional conflict around G tube placement? (3)

Answer 60

Context: The unique circumstances of each child and family Values: A struggle between the value and meaning (for parents) of oral feeding and potential losses associated with G-tube feeding Processes of care: Inadequate information-sharing and support for families

Question 61

Name 3 potential steps for clinicians to take in their conversation with families as they discuss moving toward a G tube. (3)

Answer 61

Build a decision-making partnership with the family Allow adequate time for repeated discussions and for families to ‘work through’ their decision Clarify the goals of G-tube feeding Be clear about risks and benefits, but frame the intervention in positive terms Elicit family values and preferences Be sensitive to family context, including culture, decision-making styles, financial resources and caregiving support at home. Involve social workers, nurses and/or dieticians, as appropriate Provide concrete examples of how G-tube feeding or continued oral feeding can impact child and family life Engage extended family members in discussions (when parents wish) Help parents to meet and share experiences with other families who have faced this decision A decision not to start G-tube feeding may be appropriate. Ensure follow-up to reassess

Question 62

The proper nomenclature surrounding perinatal loss is sometimes used inconsistently. Please define the following terms: miscarriage, stillbirth, neonatal death. (3)

Answer 62

Miscarriage <20 wks, stillbirth >20 wks or neonatal death (0-28d)

Question 63

How can HCPs support families through perinatal loss? Give two examples. (2)

Answer 63

compassionate communication, shared decision-making, creating meaningful memories, acknowledging grief, sibling care, and family care in the period following their loss

Question 64

Name 3 types of system failure that can lead to adverse events. (3)

Answer 64

failure to plan, failure to communicate, failure to recognize deteriorating patient

Question 65

Name the 4 essential components of a rapid response system. (4)

Answer 65

event detection and response triggering arm (early warning score, VS monitoring), planned response arm, quality monitoring arm, administrative support arm

Question 66

Name 3 of the steps involved in establishing a rapid response system. (3)

Answer 66

establish timeline, identify team members, define roles, develop call criteria/activation process, physician order sets/call records, pilot testing, record keeping, data collection, educational program

Question 67

What are 4 significant adverse outcomes in childhood and adolescence linked to ADHD? (4)

Answer 67

Education problems Lower grade Substance misuse (especially when comorbid disease exists) Accidents Difficult peer relationships

Question 68

What are 5 factors that predict the likelihood for ADHD to continue into adulthood? (5)

Answer 68

Inattention/hyperactivity combined type of ADHD Increased sx severity Comorbid MDD or other mood disorder High burden of comorbidity Parental anxiety Parental antisocial personality disorder

Question 69

What are 6 common differentials for ADHD? (3, 0.5 each)

Answer 69

Learning disorder Sleep disorder ODD Anxiety Mood disorder Tic disorder Intellectual disability / GDD ASD Developmental Coordination disorder

Question 70

What is the first line therapy for treatment of ADHD in the preschooler? (1)

Answer 70

Parent behaviour training

Question 71

List 4 non-pharmacological management options in ADHD. (5)

Answer 71

Psychoeducational assessment Exercise Classroom management Daily report cards Parent behaviour training

Question 72

What is the first line choice of treatment for ADHD in school-age children? (1)

Answer 72

A long-acting stimulant medication

Question 73

How should families be counselled to store firearms? (3)

Answer 73

Locked Unloaded Separate from ammunition If youth present in the home with depression or mood disturbance or substance abuse – strong recommendation to remove firearm

Question 74

What are three risk factors for being a school shooter? (3)

Answer 74

Exposure to firearms in their home or relative’s home Bullied Depressive sx or suicidality before the incident Advanced planning (telling people about plans) and not usually impulsive

Question 75

For each of the following scenarios, list how long after completion of therapy it is safe to give live vaccines. (5 total: 1 mark each for i-iii, 2 marks for iv) i) High dose steroids ii) Immunosuppressive therapy iii) Anti-B cell biologics iv) Hematopoietic stem cell transplant

Answer 75

1 month; 3 months; 6 months; 24 months AND no GvHD AND off immune suppression AND specialist has cleared them

Question 76

A child is going to start immunosuppressive therapy, and their vaccination status is being optimized prior to beginning treatment. What is the minimum time before starting therapy that they should receive any a) live vaccines; b) inactivated vaccines?

Answer 76

4 weeks; 2 weeks

Question 77

List 3 reasons why travelers who are “visiting friends and relatives” are at higher risk for contracting infections while abroad. (3)

Answer 77

Less likely to seek pre-departure advice More likely to travel for longer periods Are more likely to be exposed to local food, drink and infectious contacts, for longer Often underappreciate the severity of endemic infections Often underappreciate that immunity to malaria wanes over time

Question 78

List 5 features of the history or physical exam and 5 findings on initial investigations that would indicate severe malaria. (5 total, 2.5 each)

Answer 78

History/physical: Unable to walk or sit Impaired consciousness or coma Respiratory distress Multiple convulsions Shock Respiratory failure/ARDS Abnormal bleeding Jaundice Hemoglobinuria Labwork: Hyperparasitemia (>2% in non-immune, >5% in semi-immune) Severe anemia Hypoglycemia Acidosis Renal impairment Hyperlactatemia

Question 79

What are 3 potential poor patient outcomes as a result of ineffective cross-cultural communication? (3)

Answer 79

Misdiagnosis, Repeated hospital admissions, Lower treatment adherence

Question 80

What is cultural competence in terms of providing health care? (2) What are 3 benefits of being culturally competent? (3)

Answer 80

Awareness of one’s own and one’s patients cultural background and the values implicit in current medical models. Allows mutual understanding, working collaboratively, communicate effectively

Question 81

What are the five components of the LEARN model for cross-cultural communication? (5 total: 0.5 per component name, 0.5 per description)

Answer 81

1. Listen -assess understanding from patient -be curious and humble 2. Explain -convey your perceptions of the health condition 3. Acknowledge -be respectful when discussing differences between perceptions 4. Recommend -develop and propose a treatment plan 5. Negotiate -reach agreement on treatment plan in partnership with patient and family

Question 82

What is a high-context communication style? (1)

Answer 82

Communication style found in many cultures where meaning is conveyed using non-verbal cues, such as body language and tone of voice

Question 83

Your patient in the ED is the newborn infant of a recently arrived refugee. The mother’s native language is not spoken by any member of the ED team, her English is very rudimentary, and she does not speak any other language. It is 2:00 AM and no medical interpreter is available, either in person or by telephone service. Your medical student suggests using freely available online translation software on her smartphone. What are three key elements of your response to her suggestion? (3)

Answer 83

Google Translate etc. may be appropriate for simple questions However, not adequate for a proper history Does not communicate nuances of language and culture which may be key to understanding the patient’s situation

Question 84

What is meant by the term “treatment goal weight” in anorexia nervosa? (3)

Answer 84

TGW is the weight necessary to support: -puberty -growth -development -physical activity -psychosocial functioning

Question 85

What are 3 methods a clinician can use to determine the treatment goal weight of a child with anorexia nervosa?

Answer 85

1. TGW based on prior growth curves -eg if previously followed 75th percentile, then assume 75th is goal 2. TGW based on height percentile -if current height percentile 50th, then aim for 50th of weight 3. TGW based on median BMI for age/sex -aim 50th percentile BMI for age and sex 4. TGW based on menstrual threshold + 2kg -for girls who stop menstruating at a certain weight

Question 86

How often should the treatment goal weight (TGW) be reassessed in treating anorexia nervosa? (1)

Answer 86

Every 3-6mo

Question 87

What is the most important test to consider in cases of anorexia nervosa where there is slowed growth velocity? (1) Why? (2)

Answer 87

Bone age. If Bone age is delayed, then potential for future growth and TGW may be best reflected by premorbid growth pattern to maximize growth potential and allow catch-up growth

Question 88

What are 5 situations in which determining an optimal TGW might be particularly difficult? (5)

Answer 88

History of dieting, Chaotic eating habits, Binge-eating, Compensatory behaviours (fasting, laxative misuse, vomiting), Other mental health conditions, Medication use (stimulants, atypical antipsychotics, etc.), Prior growth info unavailable

Question 89

When treatment goal weight cannot be reliably determined due to clinical uncertainty, what are 3 treatment goals that can be targeted instead? (3)

Answer 89

Normalizing eating patterns, Establishing more balanced lifestyle, Normalized vital signs, Normalized lab markers, Normalized physical exam findings, No ED symptoms/behaviours

Question 90

In hypothermia for HIE, which of the following is false: a) Hypothermia should be maintained for 72 hours b) Hypothermia slows the metabolism of morphine c) The target temperature for cooling is 33.5ºC rectal, +/- 0.5º d) After cooling is finished, infants should be rewarmed over 12-24 hours

Answer 90

d: should be 0.5º every 1-2hrs (so, over 6-12 hours)

Question 91

In hypothermia for HIE, which of the following is true: a) Strong evidence suggests that the risks of cooling greatly outweigh the benefits in neonates with mild HIE, which is why this practice is not recommended b) Neonates should be NPO during the cooling period c) Hypothermic treatment in preterm neonates (<35 week) is not recommended because even though there is evidence that it is effective, there is also an increased risk of mortality d) The number needed to treat to prevent a case of mortality or moderate/severe disability is 7

Answer 91

d: evidence for a) is actually positive but insufficient, for b) trophic feeds, and in c) it’s also ineffective

Question 92

What are 5 adverse effects of cooling in HIE? (5)

Answer 92

Sinus bradycardia Hypotension requiring ionotropes Thrombocytopenia PPHN with impaired oxygenation Coagulopathy Cardiac arrhythmia Urinary retention Leukopenia Hypoglycemia Hypokalemia SQ fat necrosis with hypercalcemia (rare)

Question 93

What are 3 long term sequelae of HIE? (3)

Answer 93

Cerebral palsy, visual impairment, SNHL, cognitive deficits, epilepsy

Question 94

What are the recommendations for brain imaging in infants undergoing cooling for HIE? (2)

Answer 94

If can do MRI while undergoing active cooling, MRI with DWI on days 2-4. Else, MRI once rewarmed (day 4-5). Repeat MRI at days 10-14 if ambiguity persists.

Question 95

What are the criteria for defining moderate to severe encephalopathy in HIE? (6)

Answer 95

Three of: Moderate 1. Lethargy 2. Decreased activity 3. Distal flexion 4. Hypotonia 5. Weak suck or incomplete Moro 6. Autonomic dysfunction (constricted pupils, or bradycardia, or periodic breathing) Severe 1. Stupor/coma 2. No spontaneous activity 3. Decerebrate posturing (arms extended and internally rotated, legs extended with feet in plantarflexion) 4. Flaccid tone 5. Suck/Moro absent 6. Severe autonomic dysfunction (Skewed/dilated/nonreactive pupils, variable HR, apneic) Mnemonic: LAP RAT (Level of consciousness, Activity, Posture, Reflexes, Autonomic, Tone)

Question 96

What are the criteria for an infant to be considered for cooling in HIE? (3)

Answer 96

1. GA 36+ wk who are <= 6 hrs old 2. Either: a) Cord pH <= 7 or base deficit >= -16, OR b) pH 7.01-7.15 or base deficit -10 to -15.9 within 1 hr AND both: i) Hx of acute perinatal event (cord prolapse, abruption, uterus rupture) ii) APGAR <= 5 at 10 min or 10+min of PPV 3. Evidence of moderate-severe encephalopathy

Question 97

Name 4 scenarios in which cooling would not be an option despite meeting the criteria for consideration. (4)

Answer 97

Moribund (dying) infants Infants with major congenital/genetic abnormalities who are otherwise likely palliative Severe IUGR Clinically significant coagulopathy Evidence of severe head trauma Intracranial bleeding

Question 98

You are the pediatrician on call at a community hospital where an encephalopathic infant is born who meets criteria for cooling. You decide to initiate passive cooling. Which of the following is NOT a step that you would take as part of this process? a) Consult the neonatologist at your tertiary referral centre b) Remove the infant’s blanket/hat c) Turn off the overhead warmer d) Monitor temperature rectally q4h to ensure temperature above 33 C

Answer 98

d: monitor every 15 minutes

Question 99

What are two advantages and two disadvantages of ultrasound in imaging neonatal brains? (4)

Answer 99

Advantages: 1. No ionizing radiation 2. Portable technology 3. Imaging is easily repeated 4. Economical 5. No special preparation required

Question 100

What are three scenarios in which a CT head could be considered for imaging a neonatal brain? (3)

Answer 100

1.Unstable neonate who cannot tolerate long MRI to detect basal nuclei pattern of injury 2. Urgent and MRI unavailable 3. Trauma or skull fracture suspected

Question 101

hat are 5 possible underlying etiologies for neonatal encephalopathy? (5)

Answer 101

HIE, IEM, Perinatal Infection, Bilirubin toxicity, Metabolic disturbances, Cerebral dysgenesis, Congenital infection, Stroke

Question 102

For parents who decline intramuscular Vitamin K at birth, what is the specific treatment option to offer including dosage and timing? (3)

Answer 102

Oral Vit K, 2mg, at birth and then two more doses at 2-4wk and 6-8wk

Question 103

For parents who decline intramuscular Vitamin K at birth, what three pieces of counseling must be provided? (3)

Answer 103

Can choose PO instead, but it is less effective than IM to prevent bleeding F/u doses of PO Vit K are very important Baby remains at risk for late onset bleeding manifesting as ICH

Question 104

What are the typical etiologies of each of the three types of hemorrhagic disease of the newborn, and what are the timelines for when they occur? (6 total, 1 per answer)

Answer 104

Early: first 24h, maternal medication inhibiting Vit K (ie antiepileptic); Classic: 2-7d, insufficient prenatal storage of Vit K and insufficient Vit K in breastmilk; Late: 2wk-6mo, chronic malabsorption and low Vit K intake

Question 105

Name 5 groups of patients who are predisposed to severe influenza. (5)

Answer 105

Children < 59 months of age Children 6+ months with chronic health condition -cardiac/pulmonary (including asthma) -DM -Renal disease -Anemia/hemoglobinopathy -Cancer -Obesity -Neuro or neurodev conditions -<18 yo with chronic ASA treatment Indigenous persons Residents of chronic care facilities Pregnant women Adults > 65 yrs

Question 106

What is the time window within which influenza treatment is beneficial in otherwise healthy individuals? (1) Name 3 situations where antiviral therapy should be used for influenza even if that time window has been exceeded. (3)

Answer 106

< 48 hours from symptom onset 1. Requires hospitalization 2. Illness is progressive/severe/complicated 3. High risk for severe disease (other than young age)

Question 107

What are the 3 principles of current infection control guidelines? (3)

Answer 107

1. Routine practices -required for all patients determined by task being performed 2. Additional precautions -required for specific patients with specific presentations and determined by method of transmission of expected/known micro-organisms 3. Respiratory Etiquette -source containment measures beginning at point of initial patient encounter with the healthcare facility

Question 108

What are 4 illnesses that require N95 mask usage? (4)

Answer 108

1. Measles -suspected, diagnosed, or nonimmune contact in incubation period 2. SARS 3. MERS-CoV 4. Tuberculosis 5. Varicella -suspected, diagnosed, or nonimmune contact in incubation period

Question 109

In terms of infection control, how long should additional precautions be used for the following illnesses: (6) i) Hepatitis A ii) Measles iii) Mumps iv) Pertussis v) Rubella vi) Varicella

Answer 109

Hepatitis A - 7 days after onset Measles - 4 days after rash onset (for duration if immunocomp) Mumps - 9 days after onset of swelling Pertussis - 5 days if appropriate Abx Rubella - 7 days after rash onset Varicella - until lesions crusted and dried

Question 110

What are 3 situations when tuberculosis should be considered contagious? (3)

Answer 110

Untreated cavitary pulmonary disease, Laryngeal disease, Smear-positive sputum, Extensive lung involvement, Disseminated congenital infection

Question 111

What are 3 recommendations regarding toys in waiting rooms? (3)

Answer 111

1. Remove toys unless adequate supervision and able to be easily cleaned 2. Parents to bring their own toys and not share 3. Provide small toys/books that can be given to child or disposed of after use

Question 112

List 5 situations in which a HCP should perform hand hygiene. (5)

Answer 112

1. Immediately before and after patient contact 2. Before moving from contaminated body site to clean site on same patient 3. After contact with blood, secretions, excretions 4. After direct hand contact with a live vaccine 5. After contact with likely contaminated enviro surface 6. Before invasive procedures 7. Before handling sterile meds/products 8. After removing gloves

Question 113

A 15 y/o F presents to the ED with hypotension, vomiting and SOB after being stung by an insect. She has no urticaria. Which test is most important to order? a) CBC b) C4 c) Tryptase now d) Tryptase in 24 hours

Answer 113

d) Tryptase in 24 hours

Question 114

A 3 y/o M was eating outdoors when he was stung by an insect. He developed facial angioedema, diffuse urticaria, and wheeze. He was treated in the ED and is ready to be discharged home. In addition to an anaphylaxis action plan, what will you include in your discharge plan? a) Referral to pediatric allergist and EpiPen Rx b) Referral to pediatric allergist and course of oral steroids c) Epipen and course of oral steroids d) Venom immunotherapy

Answer 114

a) Referral to pediatric allergist and EpiPen Rx

Question 115

Each of the following patients has had a reaction to a stinging insect. Which patient does NOT need to carry an EpiPen? a) 3 y/o F with hypotension, hives, vomiting immediately following an insect sting b) 5 y/o M with facial angioedema, diffuse urticaria and syncope immediately following an insect sting c) 17 y/o M that has recently completed VIT d) 18 y/o F who is on VIT, in build-up phase, and is a bee-keeper

Answer 115

c) 17 y/o M that has recently completed VIT