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Josh's RC Questions > ENT/Ophtho/Gen Surg > Flashcards

ENT/Ophtho/Gen Surg Flashcards

1
Q
  1. 4 yo child initially presented with otitis media. Developed post-auricular inflammation consistent with mastoiditis. After the child receives parenteral antibiotics, what is the next best step for management?
    a) Observation
    b) Myringotomy
    c) Steroids
    d) Steroid and antibiotic drops
A

Myringotomy

Early mastoid osteitis may respond to myringotomy + IV ABx

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2
Q
  1. 14yo boy presents with 2 weeks of purulent discharge from his right nostril. He has had fever (39 degrees) for the past 3 days. Other than right nasal erythema, his exam is normal. What is the best next step in management?
    a. Irrigation and nasal corticosteroids
    b. ENT referral
    c. Nasal decongestant
    d. amox/clav
A

Amox clav

Acute bacterial rhinosinusitis
>=2 of PODS AND either O or D
Acute onset, >7d of Sx. Episode lasts <4wks
P - pain/pressure/fullness of face
*O - obstruction of nose
*D - discharge. Nasal purulence or discolored post-nasal discharge
S - smell. Hypo/anosmia

Gold standard Dx: sinus aspirate Cx
Imaging not required for uncomplicated ABRS. If do Xray 3V sinus: complete opacification or air-fluid level

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3
Q
  1. Kid with recurrent AOM. Has myringotomy tubes. Purulent drainage from ear x 7 days. Well and afebrile. Best management?
    a) culture fluid and wait for results to treat
    b) topical antibiotic/corticosteroid tdrop
    c) high dose amox
    d) standard dose amox
A

Topical antibiotic/corticosteroid drop (Ciprodex)

If unwell, choose systemic ABx (Staph + pseudomonas coverage)

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4
Q
  1. A 12 year old boy has a sore throat and fever for several days. Which of the following would be most suggestive of a peritonsillar abscess?
    A.Uvular deviation and dysphonia
    B. Normal tonsils, soft palate swelling, trismus
A

TRISMUS

Fever, sore throat, dysphagia

O/E:

  • Trismus*
  • In palate
  • unilateral tonsillar bulge* (hard to see b/c of trismus)
  • displacement of uvula*

GAS + mixed oropharyngeal anaerobes

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5
Q
  1. 4y boy presents after 5 days of URTI symptoms with fever, dysphagia and refusal to move his neck laterally. Flexion of the neck is fine. Which test is most likely to reveal the diagnosis?
    a. Lateral neck XR
    b. CT neck with contrast
    c. Neck US
A

CT neck with contrast

Retropharyngeal abscess b/c refusal to move neck laterally

Fever, drooling, dysphagia, sore throat
Muffled voice, stridor, WOB
Neck stiffness, limitation of neck extension > torticollis* > limitation of neck flexion

O/E:

  • Posterior to palate
  • Bulging of posterior pharyngeal wall
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6
Q
  1. Which disease is associated with trismus
    a. Retropharyngeal abscess
    b. Peritonsillar abscess
    c. Pharyngitis
    - —————————————–
  2. Trismus is most often associated with:
    a. hyperCa
    b. epiglottitis
    c. peritonsillar abscess
    d. retropharyngeal abscess
A

Peritonsillar abscess

Peritonsillar abscess
- in palate
- trismus
- unilateral bulging
- deviation of uvula
Tx: ABx + Drainage
Retropharyngeal abscess
- posterior to palate
- midline bulge in retropharynx
- torticollis
Tx: ABx +/- drainage
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7
Q
  1. 4 year old boy 4 days post tonsillectomy and adenoidectomy with significant pain despite acetaminophen given regularly. His oropharynx is shown in a picture (granulation tissue shown bilaterally, left side more than right). What is the best strategy to manage his pain:
    a) optimize acetaminophen dosing
    b) amoxicillin
    c) start codeine
A

Optimize acetaminophen dosing

If advil is a choice, can add on.
Avoid ketorolac + ASA b/c increased risk of hemorrhage (not seen with Advil)

Codeine contraindicated (b/c ultra rapid metabolizers)

No signs of infection (fever, tachycardia). Periop ABx not routinely recommended

Pain can last up to 2wks
Keep well hydrated! (Less pain)

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8
Q
  1. A young child who has a history of 2 episodes of croup presents to the ER looking toxic, is febrile, and has significant stridor. What do you do?
    a) Lateral neck X-ray
    b) Call ENT
    c) Give steroids
A

Call ENT

AIRWAY!

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9
Q
  1. An infant presents because the mother is concerned about his breathing. His breathing is generally normal, but when he is feeding or crying, a loud high pitched noise is heard. When the baby is put in the prone position, the noise disappears. What is the next best step in management?
    a) Reassure
    b) Upper GI study
    c) Refer to ENT
A

Reassure

Laryngomalacia
Present within first 2wks of life, increase in severity up to 6mo
Insp stridor
Worse with exertion: crying, agitation, feeding

Dx: Clinical
Can confirm on flex laryngoscopy: 
- omega epiglottis
- short aryepiglottic fold
- arytenoid prolapse
- redundant tissue
- insp squeak

Mgmt

  1. Expectant observation
  2. Manage reflux
  3. Supraglottoplasty for red flags (FTT, cyanosis, resp distress)
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10
Q
  1. Which finding is the most supportive of a diagnosis of vocal cord dysfunction?
    a. Normal CXR
    b. Vocal cord abduction on inspiration
    c. Normal oxygen saturation
    d. Truncated inspiratory curve on spirometry
A

Truncated inspiratory curve on spirometry

Flex scope: normal vocal cords, inappropriately close during inspiration + sometimes expiration

Speech training

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11
Q
  1. Kid with tympanostomy 6 months ago, now presenting with otorrhea for a few days, afebrile. What do you give him?
    a. Cipro drops (written as fluoroquinolone drops)
    b. high dose amox
    c. steroid drops
    d. garamycin drops
A

Topical ABx +/- topical steroids for 7-10d is first line for AOE

Ciprodex is first line for tympanostomy tube otorrhea

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12
Q
  1. Kiddy with AOM on high dose amoxicillin, presenting with fever persistent 3 days later, TM still bulging and red; otherwise well
    a. Amoxiclav
    b. IM Ceftriaxone
    c. Tympanocentesis
A

Amox clav

If unable to tol PO or unwell, then CFTX

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13
Q
  1. A 2 year old child with acute otitis media. Most likely result of “watch and wait” approach?
    a. bacteremia
    b. mastoiditis
    c. prolonged fever
    d. prolonged pain
    —————
    Child had AOM, which is a consequence of withholding treating for 48 hours?
    a. mastoiditis
    b. increased duration of fever
    c. increased pain
    ——————————
    Otitis media - complications of “watch and wait” approach
    a. Bacteremia
    b. Mastoiditis
    c. Prolonged fever
    d. Prolonged pain
A

Prolonged pain

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14
Q
  1. 5 yo girl with nasal congestion. What supports a diagnosis of acute bacterial sinusitis?
    a. fever persisting 3 days
    b. rhinorrhea persisting 12 days
    c. frontal headache
    d. nasal discharge that changes from clear to purulent
A

Nasal discharge that changes from clear to purulent

Acute bacterial rhinosinusitis
>=2 of PODS AND either O or D
Acute onset, >7d of Sx. Episode lasts <4wks
P - pain/pressure/fullness of face
*O - obstruction of nose
*D - discharge. Nasal purulence or discolored post-nasal discharge
S - smell. Hypo/anosmia

Gold standard Dx: sinus aspirate Cx
Imaging not required for uncomplicated ABRS. If do Xray 3V sinus: complete opacification or air-fluid level

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15
Q
  1. Child with fever for a few days, then 2d hx of bilateral painful ear to jaw swelling
    a) amox PO
    b) analgesia
A

Analgesia

Mumps

  • droplet precautions
  • fever, achiness, vomiting
  • meningoencephalitis
  • BL/UL parotid swelling + tenderness. Often assoc’d with ear pain on same side. Peaks at ~3d, improves over 7d
  • orchitis

Mgmt - supportive

  1. Analgeisa
  2. Hydration
  3. Antipyretics
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16
Q
  1. Baby with inspiratory stridor, soft voice, vocals abduct in inspiration, what is the diagnosis?
    a) Laryngomalacia
    b) Tracheomalacia
    c) Vocal cord palsy
A

Laryngomalacia vs vocal cord palsy

b/c of soft voice….

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17
Q
  1. 4 mo male with progressive stridor. ENT scope reveals bilateral vocal cord palsy. What is the next step?
    a. Reassure
    b. MRI brain
A

MRI brain

Bilateral VCP - think CNS
Myelomeningocele
Arnold Chiari malformation
Hydrocephalus

Unilateral VCP - think iatrogenic
- recurrent laryngeal nerve injury

Mgmt

  1. Infants usually resolve in 6-12mo. If not gone by 2-3y, unlikely to go away
  2. Bilat VCP may need temporary trach
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18
Q
  1. Picture of red, round mass in midline of neck. What’s the NEXT step:
    a. I&D
    b. Ultrasound
    c. Antibiotics
    ——————————
  2. An infant presents with a neck mass. Picture of baby with a few cm midline red nodule below chin on upper chest. What is your management?
    a. IV antibiotics
    b. Excision
    c. Surgical incision and drainage
    d. Ultrasound
    —————-
    Picture of a swollen red midline neck mass (? Thyroglossal duct cyst). What do you do?
    a. IV ABx
    b. Incision and drainage
    c. Surgical excision
    d. Ultrasound
A

U/S

Thyroglossal duct cyst

  • midline lesions in anterior neck
  • May move with swallowing or protrusion of tongue
  • 1/3 present with hypothyroidism. Must assess thyroid function pre-op

Dx: CT neck + contrast is preferred

Tx

  • complete excision, incl’g remove middle 1/3 of hyoid bone
  • if infected, manage with ABx until resolved, then definitive surgery (o/w risk of recurrence)
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19
Q
  1. Which is the last sinus to develop:
    a. frontal
    b. maxillary
    c. sphenoidal
    d. anterior ethmoid
    e. posterior ethmoid
A

Frontal

Every Monkey Swings Free
Ethmoid
Maxillary
Sphenoid
Frontal
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20
Q
  1. A 4y old boy presents to ER with 3 hour history of inspiratory stridor, high fever and drooling. Most appropriate initial step:
    a. administer cefuroxime
    b. blood gas
    c. obtain lateral neck xray
    d. request presence of an individual skilled in intubation
A

Request presence of an individual skilled in intubation

Epiglottitis

  • toxic/unwell
  • drooling
  • dysphagia
  • neck hyperext, tripod
  • stridor is late finding! (suggests AWO)
  • Hib
  • Lateral xray: thumb sign

Tx

  • establish airway!
  • NOT effective: racemic epi + corticosteroids
  • IV cefotaxime, CFTX, or mero x 10d (amp-resistant Hib)
  • rifampin ppx x4d for all household members when child in home <4yo + incompletely immunized OR <12mo + incomplete immunization, OR immunocompromised
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21
Q

19 What would be an indication to do radiological studies in sinusitis?

a. orbital cellulitis
b. adolescent with no fever and mucopurulent discharge

A

Orbital cellulitis

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22
Q
  1. When would you do a sinus x-ray, waters view?
    a. 6yo with yellowish nasal discharge, intermittent fevers
    b. teenager afebrile but headaches for 2 weeks
    c. baby with nasal discharge
A

6yo with yellowish nasal discharge, intermittent fevers

Waters’ view = PA Xray of skull, angled 45 deg with pt gazing slightly upwards. Looks at maxillary sinuses

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23
Q
  1. Teen can’t open mouth. Has fever. Dx?
    a. Retrophyarngeal abscess
    b. Peritonsillar abscess
    ————————————–
    14 yo boy with sore throat and high fever. You treated him with amoxicillin x 3 days and he is no better. He can’t open his mouth for examination. What is your diagnosis?
    a. retropharyngeal abscess
    b. peritonsillar abscess
    c. EBV
    ————————————-
  2. 14 y.o with 1 week history of sore throat, odynophagia and fever. Initially treated with Penicillin with defervescence for one day and then return of symptoms and fever. He has pain on opening of the mouth so you can’t see the oropharynx properly. He has bilateral cervical lymphadenopathy and remaining exam is normal. Immunizations are up to date. Most likely diagnosis is:
    a. retropharyngeal abscess
    b. peritonsillar abscess
    c. epiglottitis
    d. croup
A

Trismus = peritonsillar abscess

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24
Q
  1. Patient with trismus and torticollis. Most likely diagnosis?
    a. bacterial tracheitis
    b. peritonsillar abscess
    c. retropharyngeal abscess
    d. Epiglottis
A

Retropharyngeal vs peritonsillar abscess

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25
Q
  1. Child presents with wheezing, stridor. Noted button battery in tracheal bifurcation on Xray. What do you do?
    a. consult ENT for removal
    b. remove with foley tube
    c. intubate and ventilate
A

Consult ENT for removal

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26
Q
  1. A 3 year old child with a 2-3 day history of viral prodrome, sudden onset this morning of stridor, temperature of 40 degrees. IN your ED is anxious but not drooling and very stridorous. There is no significant change with one dose of neb epinephrine. What is the most likely diagnosis?
    a. croup
    b. bacterial tracheitis
    c. retropharyngeal abscess
    d. epiglottitis
A

Bacterial tracheitis

Appears toxic
High fever + resp distress
NO DROOLING OR DYSPHAGIA
Stridor does not improve with epi nebs

Clinical Dx
Lat Xray: pseudomembranes

Tx

  1. Intubation!
  2. IV CFTX/cefotaxime + vanco or clinda (MSSA + MRSA coverage)
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27
Q
  1. 3 yo boy with history of URTI presents with stridor. Vitals normal and stridor present when he is excited. What is the best management?
    a. Oral steroids alone
    b. Racemic epinephrine
    c. Nebulized steroids
    d. Humidified oxygen
A

Oral steroids alone

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28
Q
  1. Of the following, what is the most appropriate indication for removal of tonsils
    a. peritonsillar abscess
    b. 5 severe episodes tonsillitis per year
    c. persistent effusion for 6 months
    —————
    Indication for tonsillectomy
    a. > 5 tonsillitis
    b. occasional snoring
    c. persistent serous effusion
    d. 1 peritonsillar abscess
A

5 severe episodes of tonsilitis per year in past 2y

Indications for tonsillectomy
1. Recurrent infections
- >= 7 in past yr,  >=5 in past 2y, >=3 in past 3y
Need to have pharyngitis and at least 1
- T>38.3
- Tonsillar exudate
- cervical adenopathy
- GAS pos
2. Recurrent infections in context of
1) Multiple ABx allergy/intolerance
2) PFPA
3) Peritonsillar abscess
3. SDB

Tonsillectomy for peritonsillar abscess if

1) doesn’t improve after 24H of ABx + needle aspiration
2) Hx of recurrent PTA or tonsilitis
3) Complication of PTA (ruptured abscess, aspiration pneumonitis)

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29
Q
  1. 3 mo with recurrent URTI. Has had on + off stridor since birth. On exam looks well, afebrile, VSS, intermittent stridor on inspiration. Most likely diagnosis?
    a. Laryngomalacia
    b. Viral croup
    c. Laryngeal web
    d. Vascular ring
A

Laryngomalacia - inspiratory stridor, chronic/recurrent

Viral croup - inspiratory stridor, acute onset

Laryngeal web - inspiratory stridor, chronic/recurrent

  • Dx on laryngoscopy
  • Tx; surgery

Vascular ring - expiratory, chronic/recurrent

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30
Q
  1. Previously well, fully immunized 4 year old presents with fever 40C and stridor. Preceded by several days of mild viral URTI symptoms, but this morning sudden onset of distress. Looks unwell, tachypneic, sitting up but not drooling. No response to racemic epinephrine. What is the most likely diagnosis?
    a. Croup
    b. Retropharyngeal abscess
    c. Laryngeal foreign body
    d. Bacterial tracheitis
    ————–
    A child presents with very high fever, stridor and coughing. There is no drooling and the child is fully immunized. Most likely diagnosis?
    a. retropharyngeal abscess
    b. meningitis
    c. bacterial tracheitis
A

Bacterial tracheitis

Acute onset
Toxic appearing
NO DROOLING OR DYSPHAGIA
Doesn’t respond to epi

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31
Q
  1. Child presents to ED with severe stridor, and has not improved over the past 12 hours despite multiple racemic epinephrine treatments and steroids. Still in distress and unwell. What should be done next?
    a. Heliox
    b. Humidified air
    c. Intubate
    d. Cold air
A

Intubate

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32
Q
  1. What is most likely to be associated with hearing loss?
    a. prematurity
    b. congenital CMV
    c. APGARs of 2 at 1 minute
    d. Sibling with language delay
    - ——————————
  2. What is most likely to be associated with hearing loss?
    a. prematurity
    b. congenital CMV
    c. APGARs of 2 at 1 minute
    d. Sibling with language delay
A

Congenital CMV

Note: genetic causes account for up to 50% of SNHL

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33
Q
  1. 15 yo male with severe retropharyngeal abscess, requiring surgical decompression. On day 3, he has new onset headache. What is the most likely cause?
    a. meningitis
    b. jugular thrombosis
    c. migraine
A

Jugular thrombosis

34
Q
  1. A 6 year-old girl has had a nosebleed for the past 3 days. On exam, she looks well with stable vital signs, but there is a large clot obstructing her left nostril. What should you do?
    a. advise to pinch nose for 10 minutes with future nosebleeds
    b. remove clot and pack
    c. call ENT for cautery
    d. check coagulation profile
    e. check CBC and platelets
    —————————–
  2. Girl presents with frequent nosebleeds over the past three days. Patient looks well, but has a large clot present in one nose. What should you do?
    a. Check PT, PTT, and bleeding time
    b. Tell her to squeeze her nose for 10 minutes with each nosebleed.
    c. Call ENT for cautery
    d. Remove the clot and place an anterior pack.
    —————————-
    A 6 year-old girl has had a nosebleed for the past 3 days. On exam, she looks well with stable vitals signs, but there is a large clot obstructing her left nostril. What should you do?
    a. advise to pinch nose for 10 minutes with future nosebleeds
    b. remove clot and pack
    c. check CBC and platelets
    d. check coagulation profile
    —————————–
  3. A 6 y/o girl has had recurrent nosebleeds for the last 3 days. On exam she looks well, VSS, but there is a large clot obstructing her left nostril. What to do:
    a. Advise to pinch nose for 10 minutes with future nosebleeds.
    b. Remove clot and pack
    c. Call ENT for cautery
    d. Check CBC, platelets and coagulation profile
A

Remove clot and pack

Epistaxis

  • Little’s area, Kiesselbach plexus
  • Cause: trauma (most common), dryness, sprays, infection, coagulopathy, rheum (wegener’s)
  • IVx: CBC, INR/PTT, vWF, platelet function assay
  • Tx
    1) ABCs
    2) Pressure on lower lateral cartilages, lean forward
    3) Suction, lidocaine, otrivin
    4) Silver nitrate, gelfoam/surgicel, epistat, merocel, gauze

If can visualize bleeding point, consider cauterizing
If cannot visualize bleeding point or still bleeding after cautery, anterior pack
-> If still bleeding, put posterior pack
-> if still bleeding, surgery

35
Q
  1. A 9 year old presents with his third episode of stridor. He is otherwise well. Which of the following investigations would you do?
    a. CXR
    b. lateral soft tissue of the neck
    c. MRI
    d. bronchoscopy
    e. culture of his oropharyngeal secretions
A

Bronchoscopy

Visualization of the airways alows definitive Dx of the cause of stridor

a) nasopharyngoscopy: stable a/w, unsedated + awake. Dx laryngomalacia, vocal cord mvmt, anatomical defects in nose + pharynx
b) flex or rigid laryngoscopy +/ bronch: unstable airway, in OR with anestsia. Dx FBA, epiglotittis
c) rigid laryngoscopy + bronchoscopy: gold standard for subglottic, tracheal + central airway lesions

36
Q
  1. Which is the most objective test to detect a middle ear effusion:
    a. otoscopy
    b. audiometry
    c. tympanometry
    d. auditory evoked potentials
    e. Weber and Rhine tests
A

Tympanometry
Graph of middl’e ear’s ability to transmit sound energy (compliance) or impede sound energy (impedance) as a function of air pressure in the external ear canal

37
Q

1) Who is most at increased risk of glaucoma?
a. Infant who had congenital cataracts surgically removed
b. Infant with cystinosis
c. A child with trisomy 21 who has Brushfield spots
d. A child who has had laser surgery for myopia

A

Infant who had congenital cataracts surgically removed

Cystinosis: get cysteine deposits in cornea, not linked to glaucoma

T21 most common eye abN:

  1. Refractive error
  2. Strabismus
  3. Nystagmus
  4. Can get glaucoma, not common

Not a complication of laser surgery

38
Q

2) 10 yo M with bilateral conjunctivitis which he describes as sandpaper foreign body feeling, pseudomembranes are present. Which of the following is the most likely diagnosis?
a. Bacterial conjunctivitis
b. Infectious keratitis
c. Adenovirus keratoconjunctivitis

A

Adenovirus keratoconjunctivitis

  • direct contact, very contagious
  • sensation of FB beneath lids
  • itchy + burning
  • edema (chemosis), photophobia
  • pseudomembranes on conjunctival surface
  • preauricular LND

Tx

  • no medical therapy
  • good hand hygiene
39
Q 
3. Cataracts picture below from boy immigrated from India. What is the most likely cause? 
LOOK AT THIS PICTURE
a) Rubella 
b) Galactosemia 
c) Idiopathic
d) Cystinosis
A

Rubella

Unilateral cataract in an immigrant = Rubella

40
Q
  1. 4 year old with loss of vision, bilateral eye injection, iris fused (sounded like uveitis). What is the treatment?
    a) oral steroids
    b) topical steroids
A

Topical steroid

Uveitis

41
Q
  1. A 3 month old baby presents with a chronic history of mucopurulent discharge from one eye and occasional crusting from the other eye. The conjunctiva are not red. What do you do:
    a. Refer to ophthalmology
    b. Dacryocystectomy
    c. Observe
    d. Topical antimicrobial eyedrops
    e. Systemic Abx
    —————-
    3 month old baby with chronic purulent/flaky discharge from left eye and mild crusting of right eye daily. Normal extra-ocular movements and no conjunctivitis. Best treatment:
    a. observation
    b. dachyrhinoscopy
    c. ophthalmology referral
    d. topical antibiotic
    —————
    3 months old baby with purulent yellow material from one eye. Other eye has slightly yellow crusting. What is the best management?
    a. refer to ophthalmology
    b. reassurance
    c. prescribe drops for eye
    —————
    3 months old with seromucoid discharge from one eye, and occasional yellow crusting from the other eye. What do you do?
    a. refer to an ophthalmologist
    b. reassure
    c. give daily poly-something drops
A

Observe + reassurance

Dacryostenosis
= Congenital nasolacrimal duct obstruction

Tx

  1. Nasolacrimal massage 2-3X/d + cleansing lids with warm water
  2. Topical ABx to control mucopurulent drainage
  3. Surgery
    a) Probing + irrigating
    b) Silicone tube insertion
    c) Dacryocystorhinostomy
42
Q
  1. Child with hyphema, when is rebleeding most likely to occur
    a. 24 h
    b. 4 days
    c. 1 week
    d. 2 week
    ————
    Hyphema. When is the risk for secondary hemorrhage?
    a. 1 day
    b. 4 days
    c. 1 week
    d. 2 weeks
A

4 days

Hyphema = blood in anterior chamber after blunt or penetrating trauma. (spontaneous hyphema is rare)

Secondary hemorrhage most often occurs on 3-4d, can occur 2-7d after trauma
Indicates worse prognosis

43
Q
  1. 15 yo adolescent contact lens wearer. Purulent discharge. Normal EOM. Normal visual acuity. Conjunctivitis. You treated him with ciprofloxacin eye drops. 36 hrs later, no change to clinical exam. What do you do?
    a. refer to ophtho
    b. change to fuscidin drops
    ————-
    Teenager wears contact lenses. Develops purulent conjunctivitis. When you clear away the purulent debris you note you has conjunctivitis but normal EOM and normal vision. You prescribe topical cipro drops and see him in 36 hours. At this time his exam is unchanged. What would you do at this point?
    a. Change to another topical antibiotic
    b. Refer to ophthalmology urgently
    c. See him again in 48 hours to re-assess
A

Refer to optho b/c he wears contacts!

44
Q
  1. 8 year old with red eye for 3 days with clear, mucoid discharge. No visual symptoms, no proptosis, and other eye is not affected. Few family members had same symptoms that resolved last week. You should:
    a. supportive treatment only
    b. topical polymyxin eye drops
    c. ciprofloxacin eye drops
    d. topical steroid
    —————
    5 year old boy, with serous and mucoid discharge from left eye (exact words). No periorbital edema or erythema. Mom and brother had a similar episode a week ago. How do you manage?
    a. reassure
    b. start antibiotics drops
    c. po keflex
    d. CT orbits
A

Supportive Tx only
Reassure

Viral conjunctivitis

45
Q
  1. A 12 month old with crusty yellow discharge from left eye and conjunctivitis. Normal visual acuity, no proptosis, no periorbital swelling, normal EOM. You prescribe cipro topical drops. Mom returns to ER at 36 hr as eyes look unchanged. What is your next step? ***Q
    a. refer to ophthalmology
    b. prescribe IV antibiotics
    c. continue and return in 48 hr
    d. prescribe fucidic acid eye drops
    —————
    Child cannot open eyes because closed by pus discharge, you clean it and see injected conjunctivae, normal EOM, normal visual acuity, no edema/redness of lid. Treated with cipro drops but no resolution after 3 days. Next step:
    a. continue cipro drops
    b. D/C cipro drops and change to fucidin ??
    c. Admit for iv antibiotics
    —————
    Treating an eye infection with cipro drops, still not improving at 36 hours. Mom and sibling had this, plus lots of kids at school. What to do?
    a. change to po cipro
    b. reassess in 48 hours.
    c. iv antibiotics
    d. consult ophthalmology
    —————–
    12 m with crusty yellow discharge from Left eye and conjunctivitis. Normal visual acuity, no propotosis, no periorbital swelling, normal EOM. You prescribe cipro topical drops. At 36 h exam, unchanged. What is your next step?
    a. Refer to ophto
    b. Prescribe IV antibiotic
    c. Continue and return in 48 h
    d. Prescribe fucidic acid drops
A

Continue and return in 48H
Most likely viral conjunctivitis not responding to antibiotic drops

Can consider switch to fucidin if tis is an option d/t concern for bacterial conjunctivitis

46
Q
  1. Picture of retina with huge dependant red area, looked like this (but the level was higher and obscured an even larger portion of the retina)!
    a. Retinopathy of prematurity
    b. Retinal hemorrhage
    c. Cherry red spot (Tay Sachs)
    d. Chorioretinitis
    ————-
    Picture of huge red circular lesion (with a ?fluid level) on the retina. Most likely diagnosis?
    a. Retinal hemorrhage due to SBS
    b. Late ROP
    c. Congenital Toxo
    d. Cherry red spot
    ————-
    Picture of a fundus with a large red spot in the middle. Your diagnosis:
    a. retinal hemorrhage of shaken baby syndrome
    b. late retinopathy of prematurity
    c. chorioretinitis of toxoplasmosis
    d. cherry red macule of Tay-Sachs disease
A

Retinal hemorrhage
(Picture on page 119)

Chorioretinits = posterior uveitis with retina involved

Cherry red spot

  • bright to dull red spot at centre of macula surrounded by grayish-white or yellowish halo
  • Tay-Sachs, gangliosidosis, Niemann-PIck
47
Q
  1. Child with symptoms consistent with orbital cellulitis. What should be done?
    a. IV Ceftriaxone
    b. surgical drainage
    c. PO clindamycin
A

IV ceftriaxone

48
Q
  1. A baby has congenital nasolacrimal duct obstruction (dacrostenosis). What statement is true about this condition?
    a. it is present at birth
    b. baby my develop dacrocystitis
    c. it should be treated with topical antibiotics
    d. it is always symptomatic at birth
A

Baby may develop dacrocystitis

Usually presents once baby has tears with crying ~1-3mo

49
Q
  1. Child 3 y/o referred for behaviour problems. Mom concerned because child refuses to wear patch for amblyopia for the past 8 months. What do you do?
    a. Refer to social work
    b. Immediate referral to ophthalmology for other treatment modalities
    c. Refer to ophthalmology once child has started to wear patch again
    d. Refer to parenting class through public health to learn skills to make child wear patch
A

Immediate referral to ophthalmology for other treatment modalities

E.g. atropine drops to blur the good eye

50
Q
  1. All of the following are true of vision in newborn infants EXCEPT:
    a. should be able to fix on a large object from birth
    b. by 2 months of age the infant can follow through 180 degrees
    c. retinal hemorrhages are rare in newborns and cause permanent deficits
    d. a newborn’s sclera is thin which causes a blue hue
A

Retinal hemorrhages are rare in newborns and cause permanent deficits

FALSE b/c superficial retinal hemorrhages can be seen in many newborns. Usually absorbed promptly, rarely leave any permanent effect. Maj resolve within 2wk. Complete resolution within 4-6wk

CPS: normal visual landmarks
Face follow: Birth to four weeks of age.
Visual following: Three months of age.
Visual acuity measurable with appropriate chart: 42 months of age.

By 8-10wk, normal infant can follow an object through arc of 180 deg

Visual acuity of newborn is 20/400. 20/30 to 20/20 by 2-3yo

51
Q
  1. Which sport is the most common cause of eye injury in Canada:
    a. baseball
    b. hockey
    c. soccer
    d. golf
    e. javelin
    f. basketball
A

?hockey

Eye injuries
30% of all blindness due to trauma
M>F, highest in 11-15yo
Sports, sticks, stones, fireworks, paintballs, BB guns

52
Q
  1. A child is found to have different sized pupils. The physical exam is otherwise normal. Which statement is true:
    a. unequal pupils are seen in 25% of normal children
    b. it is an autosomal recessive trait
    c. the larger pupil is abnormal
    d. the larger pupil will have an abnormal shape
A

Unequal pupils are seen in 25% of normal children

Anisocoria
A. normal variant: <0.4mm difference btwn pupils, no dilation lag
B. local disorders:
- synechiae
- congenital iris defects (coloboma, aniridia)
- topical dilating drops
C. Neuro causes
1. CNS III palsy (diplopia + ptosis)
2. Horner syndrome (anhydrosis, ptosis)
3. Increased ICP

If inequality more pronounced on bright focal illumination or on near gaze, then there is a defect in pupillary constriction. Larger pupil is abN

If inequality more pronounced in reduced illumination, then there is a defect in pupillary dilation. Smaller pupil is abnormal.

53
Q
  1. A 3 month old male infant presents to the emergency department with a 1 month history of “spit ups” and 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, non tender, with no palpable masses. What diagnostic test would MOST likely reveal the underlying abnormality?
    a. Abdominal ultrasound
    b. Barium enema
    c. Upper GI series
    d. Abdominal X ray (anterioposterior and lateral)
    - ——————————-
  2. Kid with abdo pain; describes kid with malrotation and intermittent volvulus; what investigation?
    a. AXR 2 views
    b. U/S
    c. UGI
    d. Barium enema
A

UGI

Malrotation +/- volvulus

54
Q 
2.Newborn baby presents with refractory hypoglycemia and attached photo. What is he most at risk for? 
SEE PAGE 155 = omphalocele
a) Hirschprung’s disease
b) Wilm’s tumour
c) Hypothyroid
A

Wilm’s tumor

Beckwith-Wiedeman

  1. LGA
  2. Transient neonatal hypoglycemia
  3. Taller in childhood, then normal
  4. Hemihypertrophy + hemihyperplasia
  5. Prominent eyes b/c underdeveloped orbital bones (intraorbital hypoplasia)
  6. Macroglossia
  7. Creases in earlobes
  8. Pits in posterior helix
  9. Abdo wall defect: omphalocele, umbilical hernia, diastasis recti
  10. Visceromegaly: liver, spleen, pancreas, kidney, adrenal glands
  11. Capillary nevus flammeus on eyelids + forehead

10% have tumours

  • Wilms
  • hepatoblastoma
  • (neuroblastoma, rhabdomyosarcoma)
55
Q
  1. 17 year old female present with a small firm lump in her breast. What is the MOST likely cause
    a) Fibrocystic changes
    b) Fibroadenoma
A

Fibroadenoma

  • Most common solid mass in adolescent breast masses
56
Q 
4.  5 month old with vomiting for 6 hours intermittently, has had 3 or 4 episodes of flexion and extension of arms and legs, drowsy after, abdomen is distended, which test would reveal diagnosis? 
A. EEG 
B. CT abdomen 
C. Ultrasound abdomen 
D. Abdominal x-ray
A

Ultrasound abdomen

Intussusception

  • vomiting - more frequent in early phase, bile-stained in later phase
  • stools - 60% pass red currant jelly stool
  • Paroxysmal colicky pain - legs + knees flexed, loud cries
  • palpable sausage-shaped mass
  • abdo distension + tenderness develop as intestinal obstruction bcms more acute
  • if not reduced, becomes progressively weaker + lethargic
57
Q
  1. Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
    a. bowel adhesions
    b. superior mesenteric artery syndrome
    c. malrotation with volvulus
    d. pancreatitis
A

SMA syndrome!

S’s
SMA syndrome with post-spinal surgery for scoliosis

  • compression of 3rd duodenal segment by the SMA against the aorta
  • SMA arises at L1, duodenum crosses in front of aorta at L3

Causes: mesenteric fat depletion, extraabdo compression (body cast), mesenteric tension (ileoanal pouch anastomosis)

Classic: underwt adol begins vomiting 1-2wk after scoliosis surgery

Dx: UGI

Mgmt

  1. Relieve obstruction
    - knee-chest, lateral, prone positioning
    - NG for decompression
    - prokinetic
    - may need surgery
  2. Nutritional rehab
  3. Correct fluid + lyte abN
58
Q
  1. 5 mo Kid flexion of arms and legs, and with associated vomiting and abdo distention, sleepy after episodes. What will give diagnosis?
    a) EEG
    b) US abdomen
A

U/S Abdo

- Intussusception

59
Q
  1. Photo of G tube site as below. What would you do?
    (this exact photo shown, brought to you by googling granulation tissues)
    a. Oral antibiotics
    b. Consult surgery
    c. Silver nitrite cautery
    d. Reassure
A

Silver nitrite cautery

60
Q
  1. Teen with large firm symmetrically enlarged thyroid. Negative for thyroid antibodies. What next?
    a. f/u in 6 mo
    b. do ultrasound
    c. Biopsy
A

F/U in 6mo

Goiter

  • usually sporadic
  • usually euthyroid
  • Causes: lymphocytic thyroiditis (most common), excess iodide, amiodarone, lithium

Simple goiter

  • girls, peak before puberty.
  • firm, symmetric
  • normal TSH, T4, no Ab
  • re-evaluate periodically. Bx usually not needed

Multinodular goiter

  • firm, lobulated surface, single/multiple nodules
  • normal thyroid studies
  • FNA if >=1cm to r/o malignancy
  • Toxic multinodular goiter (low TSH, high T4) - McCune-Albright syndrome
61
Q
  1. 2 year old with umbilical hernia. What is the management?
    a) Reassure
    b) Consult Gen Sx for urgent repair
    c) Abdominal U/S
    d) Refer to Gen Sx for elective repair
A

Reassure + observe

Refer to gen surg if

  1. persists after 4-5yo
  2. Progressively larger after 1-2yo
  3. > 2cm in diameter
  4. Symptomatic
  5. Strangulated
62
Q
  1. 6 month old with umbilical hernia. Mother wants to know what should be done. You tell her:
    a. arrange elective repair
    b. surgery at 2 years old
    c. place a coin over the hernia
    d. reassure
    —————
    6 mo old with umbilical hernia, what do you tell the mom:
    a. reassure
    b. will need surgery if not gone by 2 years
    —————
    6 month old with umbilical hernia
    a. refer for a repair now
    b. reassure
    c. surgery is indicated if it doesn’t resolve until 2 years old
    —————
    Umbilical hernia repair?
    a. at 2 years
    b. Observation
A

Reassure

Refer to gen surg if

  1. Persists after 4-5yo
  2. Progressively larger after 1-2yo
  3. > 2cm in diameter
  4. Symptomatic
  5. Strangulated
63
Q
  1. A 1 month old boy is diagnosed with pyloric stenosis. He has a severe metabolic alkalosis, bicarbonate 34. What do you do:
    a. Operate immediately
    b. Give HCl
    c. Give K bolus
    d. Give large amounts of chlorinated fluid IV
    ————-
    3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
    a. give HCL IV
    b. give large amounts of chloride IV
    c. give KCL IV bolus
    d. OR immediately
    ————
    3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
    a. give HCL IV
    b. Give large amounts of chloride IV
    c. Give KCL IV bolus
    d. OR immediately
A

Give a large amount of chlorinated fluids

Pyloric stenosis

  • 1st week to 5mo of life
  • vomit right after feed, usually hungry and wants to feed again
  • progressive, projectile, non-bilious
  • hypochloremic, hypokalemic metabolic alkalosis
    (prolonged vomiting -> loss of gastric fluid rich in HCl -> kidneys try to retain H (by exchanging K) to correct alkalosis)
  • Palpable pyloric olive
    ~2cm in RUQ
  • Dx on AUS (3-4mm thick, 15mm pyloric length, diameter >10mm)

Tx

  1. Correct fluid, acid-base, + electrolyte losses
    - must correct alkalosis to prevent post-op apnea
  2. Pyloromyotomy
64
Q
  1. A previously healthy 15y old boy has cramping periumbilical pain. After several hours, the pain shifts to the right lower quadrant and becomes constant. He vomits several times and is brought to the emergency department. The abdomen is tender on deep palpation of the right lower quadrant. Findings on chest and abdominal xray films are normal. Leukocyte count is 15,000mm which of the following is the most appropriate initial management?
    a. A CT scan of the abdomen
    b. IV hydration
    c. Surgical exploration of the abdomen
    d. U/S of the abdomen
A

IV hydration for initial management

Appendicitis

65
Q
  1. 1 year old with rectal abscess. Mgt?
    a. Systemic abx
    b. Excision by surgery
    c. I and D
    D. observe
A

I+D

66
Q
  1. Picture of newborn with abnormality shown below. (gastroschisis) Most likely associated abnormality:
    a. Renal
    b. Cardiac
    c. Intestinal atresia
    —————
    Infant with gastroschisis, what else is associated?
    a. Intestinal atresia
    b. Heart defects
    —————
    Picture of a baby that looks like this (it was a very low-resolution picture that hasn’t gotten better through the years!). What is an associated defect?
    a. intestinal atresia
    b. cardiac anomalies
    c. renal anomalies
    d. mental retardation
A

Intestinal atresia

Omphalocele: good gut, bad baby
Gastroschisis: bad gut, good baby

67
Q
  1. A 13 year old girl is seen with abdominal pain of 24 hours duration. She rates it as /10. She has a fever. On exam, there is diffusely tender abdomen and guarding. You call general surgery. In the meantime, what is your management?
    a. blood C&S and antibiotics
    b. IV fluid bolus and analgesia
    c. IV fluid bolus and CT abdomen
    d. IV fluid bolus and IV antibiotics
    —————
    Surgical abdomen, what do you do?
    a. Send patient for a CT scan
    b. bolus and give analgesia
    ——————-
    6 year old boy with severe abdo pain 8/10, febrile, tachycardic at 160. Abdomen is rigid. As you call surgeons, what do you do?
    a. Culture and start antibiotics
    b. Bolus with normal saline and give morphine for analgesia
    c. Bolus with normal saline and arrange for urgent CT
    ——————
    6 year old boy presents with severe abdominal pain, 8/10. HR 150, BP 120/80, abdomen is rigid. You immediately call the surgeons; what is your next step?
    a. Culture and start IV antibiotics
    b. IV bolus 20cc/kg NS and arrange for urgent CT abdomen
    c. Ultrasound abdomen
    d. IV bolus 20cc/kg NS and analgesia
A

IV fluid bolus + IV ABx or analgesia?

If hemodynamically unstable, then bolus
If worried about infection, culture + start ABx

Peritonitic picture -> surgery

68
Q
  1. An 8 month old child is admitted for viral gastroenteritis. The child has intermittent episodes of screaming and vomiting. On exam, the child is pale and lethargic. Which of the following investigations is most useful in diagnosis of this patient?
    a. AXR
    b. serum lactate
    c. air enema
    —————
    Infant who has cyclic crying, now presents appearing more lethargic. Abdo is
    distended. Best test?
    a. supine AXR film
    b. air enema
    c. colonoscopy
    d. CT abdomen
A

Air enema b/c both diagnostic + therapeutic for intussuception
AUS if this was an option

69
Q
  1. What is the most common complication after gastroschisis repair?
    a. Bowel obstruction
    b. Abdominal compartment syndrome
A

Bowel obstruction

Complications of gastroschisis: short gut syndrome, bowel obstruction, NEC, anastomotic stricture

Though abdo compartment syndrome very worrisome

  • usually after primary abdo repair
  • tight abdo closure -> abdo HTN -> decreased renal outflow -> oliguria, decreased cardiac venous return + intestinal ischemia -> intestinal necrosis + death
70
Q
  1. What is the most likely complication of a ruptured appendicitis?
    a. Bowel obstruction
    b. Abscess in the abdomen
    c. Wound infection
    d. Enterocutaneous fistula
A

Wound infection (3-10%)

vs intraabdo abscesses (2-9%)

71
Q
  1. 3w old brought to ER because of repeated projectile vomiting after each feed. What to find on lab work:
    a. hyponatremia
    b. hyperkalemia
    c. hypochloremia
    d. Metabolic acidosis
    ———————–
    1 month old has progressive non-bilious vomiting. On exam has a small palpable olive in the RUQ. Most likely lab abnormality:
    a. Metabolic acidosis
    b. Respiratory acidosis
    c. Hypokalemia
    d. Alkalotic urine hypernatremia
A

Hypochloremia

Hypokalemia

Pyloric stenosis
- hypochloremic, hypokalemic metabolic alkalosis
(prolonged vomiting -> loss of gastric fluid rich in HCl -> kidneys try to retain H (by exchanging K) to correct alkalosis)

72
Q
  1. 8m old infant brought to ER with gastroenteritis. Mom reported history of intermittent screaming and pain. On examination dehydrated and pale looking. Best to determine cause :
    a. abdominal xray
    b. air enema
    c. barium upper GI study
A

Air enema

For intussusception
AUS if available

Note: if they mentioned bilious vomiting, then UGI for malrotation +/- volvulus

73
Q
  1. A baby and X-ray done and it is not clear if it is diaphragmatic eventration or actually diaphragmatic hernia. What is the best initial investigation to differentiate?
    a. Ultrasound
    b. Diaphragmatic fluoroscopy
    c. Surgical exploration
    d. MRI
    ——————-
    5 yo with cough and fever. Crackles on the RLL. CXR shows either diaphragmatic eventration vs hernia. What is the best next test for diagnosis?
    a. Diaphragm fluoroscopy
    b. Ultrasound
    c. Exploratory laparatomy
    d. MRI
A

Ultrasound

74
Q
  1. 1 m baby irritable, not feeding well, vomited once, distended abdomen. On exam VSS except mild tachycardia. There is a mass in the right scrotal, firm and non-reducible. Does not transilluminate. What is the next step?
    a. Ultrasound
    b. Urgent surgical consultation
    c. Nuclear scan
    d. Testicular Doppler
A

Urgent surgical consultation

Incarcerated inguinal hernia

  • If not treated, most non-reducible inguinal hernias rapidly progress to strangulation (ischemic or gangrenous)
  • Repair 24-48H later b/c less edema, less complications

Inguinal hernia

  • If <1yo, repair within 2-3wks
  • If >1yo, less urgent repair b/c lower risk of incarceration
75
Q
  1. 10 mo irritable. Acute onset of red scrotal swelling. Parents had noted on + off swelling in the past few days. Today irritable, VSS mild tachycardia. On exam Rt red swollen and transilluminates well. What is the diagnosis?
    a. Epididimytis
    b. Testicular torsion
    c. Acute hydrocele
    d. Incarcerated hernia
A

Incarcerated hernia

Hydroceles are usually asymptomatic, though can be secondary to testicular torsion, appendix testis torsion, epididymitis

76
Q
  1. 3-week old baby presents with gastroenteritis and intermittent abdominal pain and severe irritability. Best investigation to reveal the diagnosis?
    a. abdominal x-ray
    b. abdominal ultrasound
    c. air enema
    d. EEG
A

AUS

77
Q
  1. What is true about intussusception?
    a. Meckel’s diverticulum is the most common lead point
    b. 75% of cases are idiopathic
    c. most patients present with red currant jelly stools
A

Meckel’s

78
Q
  1. 2 week old girl with rectal bleeding. HR 220, BP 60/35, abdomen tense and sensitive. What is the next step in your diagnostic approach:
    a. Call general surgery
    b. Abdominal ultrasound
    c. IV antibiotics
    d. Abdominal x-ray
    e. Ba meal with small bowel follow through
A

AXR to r/o perforation + assess for signs of NEC

This question is asking DIAGNOSIS not management (IV ABx, Gen surg)

79
Q
  1. 15 y/o status post therapeutic abortion. Sudden onset of respiratory distress, chest pain. On exam, bilateral crackles. She is coughing blood. What is the best test:
    a. ECG
    b. Pulmonary angiography
    c. CXR
    d. Pulmonary V/Q scan
    e. Leg dopplers
    f. CT scan
A

Pulmonary angiography

Gold standard for PE
CT helical CT is diagnostic test of choice

RFs:

  1. pregnancy
  2. surgery
  3. malignancy (higher risk with solid tumour than hematologic)
  4. infection
  5. immobility
  6. thrombophilia
  7. indwelling central venous catheter

Common SSx: hypoxia, dyspnea, cough, hemoptysis, pleuritic chest pain, localized crackles

Other workup

  • CBC, U/A, coags, D dimer
  • Fibrinogen assay, protein C+S, antithrombin III, factor V leiden, lupus anticoagulant, anticardiolipin antibodies

Tx

  1. ABCs
  2. Anticoagulation
    - LMWH (preferred in children) or unfractionated heparin (better if high risk of bleeding, or compromised renal function)
80
Q
  1. Omphalocele. What do you tell nurse to do?
    a. elective surgery
    b. dry dressing
    c. wet dressing
    d. topical flamazine
A

Wet dressing

Note: flamazine = silver sulfadizine. Used for leg ulcers, burns, sking rafts

Josh's RC Questions (39 decks)

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