2018 SAQ Flashcards
A teenager presents to the ED with Methanol toxicity. Na 140, K 4, Cl 96, Bicarb 11, BUN 11, Glucose 4, Serum osmolarity–396. Metabolic acidosis.
A. Calculate anion gap.
B. Would you anticipate the osmolar gap to be elevated? If anything,
C. What is the most significant long term complication of methanol toxicity/ingestion.
D. What oral medication would be most effective in the treatment of methanol ingestion
Anion gap = 140 - (96 + 11) = 33 Yes I would expect the osmolar gap to be elevated, due to the methanol, which is an unmeasured osmol (methanol, ethanol, ethylene glycol, acetone, or isopropanol) measured – calculated = 2xNa + glu + urea Long term complication – blindness Folate Ethanol drink!
The mother of a two year old presents after her child swallowed a quarter.
A. What are x-ray findings that would result in an urgent removal?
B. If the coin does not need to be removed, what two pieces of advice would you provide the family in order to help to keep the child safe. (2)
C. What are two ECG findings of hyperkalemia
A. Suggestive of button battery or in esophagus
B. RTC if resp compromise, signs of obstruction (vomiting abdo pain)
C. 1. Peaked T waves
2. Long PR
3. Wide QRS
4. flat/absent P waves
8 year old female presents with difficulty breathing, cough and laryngeal edema after sustaining a minor facial scratch. She has had multiple similar episodes in the past. Her family members have had similar presentations in the past.
a) What is your initial management?
b) What is her most likely diagnosis?
c) What is the definitive management for this patient?
Hereditary Angioedema Initial Management: Immediate medical attention ABCs (assessment and protection of airway). Intubate immediately if signs of stridor or respiratory arrest impending. SKILLED (ENT best, then Anesthesia) May need advanced airway if very swollen Admit to ICU Once stable - decide on product to give Recombinant C1 inhibitor if available Icabitant (bradykinin receptor antagonist) FFP also other option Definitive Management: C1 inhibitor concentrate replacement
Baby presents with diarrhea and frequent infections. You are concerned for SCID.
a) What is one thing on CBC that is specific to it (1)
b) What initial test can you do to confirm your suspected diagnosis? What would the result be?
c) After the child is started on antimicrobials, what are 3 other treatments/elements of management that you would need to do?
Lymphopenia (ALC) <3000 Lymphocyte subset - low CD3 (T cell specific); low CD4; CD8 also Management of SCID: Refer to immunology. Prophylactic antibiotics Bone marrow transplant. CMV negative irradiated blood products only. No Live vaccines. IVIG Protective Isolation
A baby presents with a hemangioma.
A. What are three indications to treat an infantile hemangioma with oral propranolol?
Blocking vision/periorbital
- Risk of airway involvement
- Large size leading to high output heart failure
- High risk of ulceration (segmental, very large, lower lip or anogenital region)
- Large hepatic hemangioma
SE include hypoglycemia, bradycardia, hypotension, GERD, hyperkalemia, wheeze, sleep disturbances
6 month old baby with severe diaper dermatitis and bluish crusted lesions, resistant to routine treatment for candida for 6 month (not sure of duration). Noted to have petechiae and brownish lesions at periphery.
A) What are the 3 DDx?
B) What’s the most important test to order?
LCH, psoriasis, immunodeficiency, seborrheic dermatitis
skin biopsy
Baby boy born at term with no problems. You’re seeing him at 6 weeks now, mom had noticed he is not feeding well. You note he has been gaining weight poorly. Exam is remarkable for a harsh pansystolic murmur at the left sternal border, radiating to the right.
A) What is the most likely diagnosis? (1 point)
B) Explain the reason he is presenting with these symptoms now. (2 points)
VSD
After birth, PVR declines which leads to an increase in the size of the L->R shunt, which exposes the pulmonary vascular bed to high systolic pressures/high flow, leading to pulmonary vascular obstructive disease and clinical symptoms
An ECG is provided (Delta waves).
What is the most significant abnormality (prominent) on the ECG?
What is the most likely diagnosis?
What is the most likely arrhythmia noted with this?
If the child had significant recurrent episodes, what would be the definitive management?
Narrow PR interval with Delta wave (slow upstroke of QRS)
Wolff-Parkinson-White syndrome
SVT
Catheter ablation
An adolescent comes in after an episode of fainting. They describe a prodrome of dizziness followed by syncope with no movements or Urinary incontinence.
A. What is the most likely diagnosis?
B. What would your investigation be?
C. What three features on history would make you concerned about cardiac causes of syncope?
Neurocardiogenic (vasovagal) syncope ECG No prodromal symptoms History of heart disease Family history of sudden death Syncope on exertion
A four month old male presents to the emergency department with irregular respirations, and lethargy. His toxicology screen is positive for methadone. His mother took methadone throughout pregnancy for chronic pain.
A. What is your initial management?
B. Why is the child’s urine screen positive for methadone?
C. What are the next two steps in management?
Support respirations; Naloxone treatment
Likely secondary to Methadone ingestion. Methadone passed to baby via breastmilk is minimal; delayed NAS (5-7 days), Extremely minimal amount passed in breastmilk, but could cause a positive result, but wouldn’t explain the symptoms
CAS, Hospitalize
Skeletal survey
A 16 month old child presents to the emergency department for inconsolable crying. You take off his pajamas and find the following picture (scald burn)
- Describe the features of this that are concerning for non-accidental injury
- After you have addressed the burn, what are your 2 next steps in the management of the patient?
Sharp demarcation
symmetric burn, sock/glove distribution,
no splash marks
Call CAS.
Admit
Perform complete physical exam looking for other injuries.
Skeletal survey
A pharmaceutical industry representative comes to your office, gives you lots of free samples, pens and
stationary with the drug company name for your office staff, brings you industry sponsored research and
invites you to an industry sponsored CME event.
1) What are THREE things you should do to avoid a conflict of interest?
Do not accept personal gifts or significant monetary/value from industry.
Be aware of how accepting a gift can influences your clinical decision making
Disclose any relationship to industry
Do not accept renumeration
6 y.o. With night terrors disturbing the whole family.
- List 2 features that differentiate between night terrors and nightmares.
- List 2 differential diagnoses
- List 2 non-pharmacological approaches for night terrors
Occur during the first 3rd of nocturnal sleep ( 2 hours after sleep initiation )
They do not remember the episode later
Nightmares (REM sleep disorder)
Seizures (complex partial seizures)
Scheduled awakenings before the events may help to extinguish them
Reassure and comfort the parents
Sleep Hygiene
A young child presents with a history of not talking at school, but talking at home. She does not talk in your
office.
1) What is the most likely diagnosis (1)?
2) What treatment/management recommendations will you make to the family (2)?
Selective mutism
CBT
SSRI ( to treat underlying anxiety )
6 year old F, brought in with puberty concerns: breast dev (Tanner 3) and pubic hair (Tanner 2), no menses.
1) What investigation would you do to confirm the etiology of the precocious puberty? (1)
2) What is the most common cause of this type of precocious puberty?
3) What medication could you use to halt the progression of her puberty?
4) How does this medication work? (drug class)
5) What are two indications for this treatment?
GnRH Stim test (want to see if LH >6-8U/L → sign puberty has started and is central)
Idiopathic
Of CNS causes - hypothalamic hamartoma
Lupron
Blocks action of pulsatile GnRH
Girls <6yo; boys <9yo to preserve height
The mother of an 8 year old baby presents with concerns of intermittent strabismus.
a) What are two tests you can use in your office to differentiate strabismus from pseudostrabismus
(b) ?
Cover/uncover test
Corneal Light reflex
Girl with obesity, kissing tonsils on exam and adenotonsillar hypertrophy evident on lateral
study done with AHI 10 events per hour and desaturation to 50% with episodes. You consult
and the surgery is scheduled in one week.
1) What one investigation should she have done before the surgery (1)?
2) What are two things that you would do to manage her before the surgery (2)?
3) Name two consequences of OSA (2)?
4) What are four possible complications for the patient post-tonsillectomy?
Coags: PT, INR and CBC for platelets.
Intranasal corticosteroids and leukotriene
Cpap or Bipap
Positional therapy ( avoid sleeping in the supine position)
Weight Loss
neurobehavioral deficits
Daytime sleepiness
FTT (less common)
PHT ± cor pulmonale, systemic HTN, LVH
Hemorrhage Dehydration pain Anesthesia related Respiratory complications: mild desaturation to life-threatening airway obstruction
The mother of a two year old presents after her child swallowed a quarter.
A. What are x-ray findings that would result in an urgent removal?
B. If the coin does not need to be removed, what two pieces of advice would you provide the family in order to help to keep the child safe. (2)
If Coin is in the esophagus
Coin versus disk battery may see “double-halo sign” on Xray
When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)
A child with a history of repaired cleft palate (repaired at age 1), undergoes a tonsillectomy. After the surgery he has nasal air leakage, and a change in his voice quality.
What complication has he experienced?
Velopharyngeal insufficiency, characterized by a hypernasal voice
Mom of 3 year old boy telling him to swallow his toothpaste because she thinks it prevents caries.
Name 1 physical exam finding consistent with severe fluorosis (1 mark).
Name 1 indication for fluoride supplementation in a child over 6 months of age (1 mark).
Dental fluorosis (abnormal enamel development) can cause:
- Unsightly mottling and pitting of the teeth
- Enamel striations
- In severe cases, “snow-capped cusps” and chalky-white teeth
Fluoride should be added prior to 3yo if:
- The concentration in the drinking water is <0.3ppm
- They do not brush their teeth at least twice daily
- If they are at risk of dental caries (family history, caries trends, patterns in communities, geographic areas)
