General

Question 1

When should the mother expect milk to come in abunduntly?

Answer 1

3-5 days post delivery

Question 2

Describe physiologic jaundice:

• why it happens
• when it’s mostly seen
• bilirubin levels

Answer 2

Physiologic jaundice:

• newborn’s liver is unable to process the RBC load from the birth experience, as this was previously the job of the placenta.
• most notable at 2-4 days. Gone by 2 weeks.
• indirect bilirubin: 12 or less

Question 3

Describe pathologic jaundice

• why it happens
• when it occurs

Answer 3

Pathologic jaundice: AKA direct hyperbilirubinemia

• caused by sepsis, ABO incompatibility, toxoplasmosis, or occult hemorrhage
• appears at 24 hours of life

Question 4

When should a clinician worry about jaundice?

Answer 4

1 Major risk factor + High Bhutani score

Known FHx of inherited disorder

Presentation varies widely from typical

Infant is not responding to phototherapy

Question 5

What are the major risk factors of jaundice? (6)

Answer 5

• High bilirubin levels
• Jaundice within first 24 hours
• Gestational age 35-36 weeks
• Previous sibling treated with phototherapy
• Bruising
• Exclusive breastfeeding

Question 6

Describe breast milk jaundice:

• when it occurs
• bilirubin levels
• how long it lasts

Answer 6

Breast milk jaundice: AKA indirect hyperbilirubinemia

• occurs after 7 days of life and peaks between 2-3 weeks of life
• indirect bilirubin: 15-17 or less
• lasts 1+ months

Question 7

What child characteristics puts a child at risk for abuse?

Answer 7

• Prematurity
• Physical / developmental disabilities
• < 4 years old

Question 8

What is the single most common presentation of child physical abuse?

Answer 8

Bruising

Question 9

Bruises are rare in children of what age?

Answer 9

Less than 6 months as they are not mobile at this time.

“No cruise, no bruise”

Question 10

What patterns of bruising in childhood are suggestive of abuse?

Answer 10

• away from bony prominences
• MC: head, neck, face (excluding forehead)
• buttocks, trunk (excluding spinous processes), arms
• large, multiple, and clustered
• patterned

Question 11

What is the MC cause of death from abuse?

Answer 11

Head trauma due to a direct blow and/or shaking

Question 12

A toddler presents with posterior rib fractures and no altered mental status. Does this warrant a head CT?

Answer 12

Yes – neurologically asymptomatic kids with rib fractures, multiple fractures, facial injury, and anyone less than 6 months of age with suspicious injury require a head CT/MRI.

Additionally, all patients with neurological symptoms and with concerns of child physical abuse require a head CT/MRI.

Question 13

An 18 month old comes in with bruising and abdominal trauma. What is your next best step in management?

Answer 13

Skeletal survey.

All children <2 years of age with concerns of physical abuse require a skeletal survey.

Skeletal surveys have little value in those >5 yo.

Question 14

Who needs screening for occult abdominal injury and when would you consider an abdominal CT?

Answer 14

Children less than 5 years old and suspected victim of physical abuse.

Screening test – AST and ALT
- if AST or ALT >80, obtain abdominal CT.

Question 15

Drowning is the process of experiencing respiratory impairment through submersion or immersion. Describe the difference between submersion and immersion.

Answer 15

Submersion: airway under water

Immersion: significant amount of water enters oropharynx through splashing

Question 16

Drowning has a higher chance of having a fatal outcome before coming to the hospital under what conditions?

Answer 16

No supervision

Age <2

Under water for >5 minutes or unknown

Question 17

What are the best preventative methods one should utilize to prevent drowning?

Answer 17

Pool fencing - BEST

Life jackets

Swim lessons (1+ yo)

Supervision

Lifeguards

Question 18

What are the most common scenarios of drowning by age group - babies, toddlers, teens?

Answer 18

Babies - bathtubs and buckets

Toddlers - swimming pools

Teens - freshwater

Question 19

What is first line treatment for drowning?

Answer 19

Initiate CPR (respiratory first, then cardiac) at the scene, call EMS

Prioritize respiratory support

No need to stabilize C-spine

Question 20

Under which drowning conditions would you observe a patient for 4-8 hours? What are you looking for in those 4-8 hours?

Answer 20

Conscious with no respiratory distress

Looking for:

• Cough, tachypnea
• Vomiting
• Mental status changes

Question 21

In order for a child to be defined as having a febrile seizure, they must have what?

Answer 21

Be 6 months to 60 months (5 yo)

Have a temperature of >38 C (100 F)

No known intracranial, metabolic cause or history of afebrile convulsions

Question 22

For a seizure to be defined as a simple febrile seizure, what characteristics must it have?

Answer 22

Lasts less than 15 min

Generalized tonic-clonic activity

No recurrence within 24hrs

No underlying neurologic disease

Question 23

For a seizure to be defined as a complex febrile seizure, what characteristics must it have?

Answer 23

Last more than 15 mins

Focal

Recur within 24hrs

Associated with postictal neurological abnormalities

Question 24

Under what conditions is a lumbar puncture warranted in those who have a simple febrile seizure?

Answer 24

If less than 6 months of age

If 6-12 months of age and immunizations are incomplete or unknown due to Hib or Strep. pneumo meningitis

If persistent lethargy (beyond typical post-ictal length), meningeal signs, or clinical suspicion

Question 25

If a neonate has a fever, what diagnostic workup do you do? How would you treat?

Answer 25

Dx: - CBC w/ diff - U/A - CSF Tx: Ampicillin + Gentamycin until cultures are negative for 48 hours

Question 26

When should you start checking BMI in office screenings?

Answer 26

2+ yo

Question 27

What are the very toxic substances we worry about most for poisoning?

Answer 27

Prenatal vitamin supplements – due to iron content Antidepressants – TCAs especially Hydrocarbons – kerosene, lamp oils

Question 28

What is considered a normal temperature in pediatrics?

Answer 28

96-100 F

Question 29

At what age can you start introducing soft pureed foods once they sit with little support and have good head/neck control?

Answer 29

4-6 months

Question 30

At what age can you introduce small soft pieces of foods that can be offered on a spoon or fork and they may start to self-feed with hands?

Answer 30

6-9 months

Question 31

At what age can kids start eating a full variety of foods, may use a spoon or fork if food is on it, may try sippy cups or small open cups; small pieces of foods the rest of the family is eating?

Answer 31

9-12 months

Question 32

At what age should the child be eating meals with families, small snacks in between, and transition to WHOLE milk and discontinue bottles/pacifiers?

Answer 32

12+ months

Question 33

Define colic

Answer 33

An otherwise healthy 2-3 month old infant who seems to be in pain, cries for > 3 hours a day, for > 3 days a week, for > 3 weeks

Question 34

Those with oppositional defiance disorder have a higher risk of what?

Answer 34

developing conduct disorder and suicide

Question 35

Diagnostic criteria for oppositional defiant disorder includes what?

Answer 35

Must have at least four of the following and must last 6 months or longer with a negative impact on functioning: - Angry and/or Irritable Mood - Vindictive at least twice within past 6 months - Argumentative and/or Defiant Behavior - Often deliberately annoys others - Often blames others for mistakes or misbehaviors

Question 36

What screening tools are used to diagnose oppositional defiant disorder?

Answer 36

Conners and Vanderbilt screening tools (comorbid ADHD common)

Question 37

A patient younger than 12 comes in presenting with oppositional defiant disorder. How would you treat them?

Answer 37

Cognitive behavioral therapy, peer group therapy, or family therapy. Treat comorbid conditions. Monitor for suicidal ideations. Meds are NOT effective.

Question 38

Which psych disorder is associated with developing antisocial disorder in adulthood?

Answer 38

Conduct Disorder

Question 39

Diagnostic criteria for conduct disorder includes what?

Answer 39

3 of the criteria in past 12 months must be met + at least one criterion present in the past 6 months - Aggression to People and Animals - Destruction of Property - Serious Violations of Rules - Often stays out at night despite parental prohibitions, beginning <13 years - Deceitfulness or Theft

Question 40

A patient comes in with conduct disorder. How would you treat them?

Answer 40

Cognitive behavioral therapy Peer group therapy Family therapy Treat comorbid disorders Monitor for suicidal ideation Meds NOT effective

Question 41

A patient comes in with breast engorgement. In your patient education, what do you tell the patient causes engorgement and how would you treat it?

Answer 41

Causes: - Intrapartum fluids - Increased blood flow - Normal postpartum fluid shift - Poor or infrequent feeding Treatment: - Breast massage - Warmth before feeding & Cool compresses after feeding - Brief period of expression prior to feeding to soften the areola and evert the nipple - Reverse pressure softening - Anti-inflammatories

Question 42

A patient comes in with local tenderness and erythema on the L breast and a lump. She is afebrile. She notes that the pain radiates while she breastfeeds and complains of reduced milk supply. Upon further questioning, she notes that she has long sleep stretches overnight due to increased fatigue. What is the most likely diagnosis and how would you treat it?

Answer 42

Blocked Duct Tx: - WARMTH and massage - FREQUENT BREAST EMPTYING - Rest - Change nursing positions - Lecithin Follow up if not resolved within 48 hrs

Question 43

A patient comes in complaining of a white spot on her nipple. She notes it looks "creamy". What is the most likely diagnosis and how would you treat it?

Answer 43

Bleb/Blocked nipple pore Gentle compression Keep the nipple well moisturized Lecithin to prevent recurrent plugged ducts (1000 mg x4/day) Steroid ointment to reduce inflammation (triamcinolone 0.1% Ointment, 3-4x/d) F/U: Sterile de roofing if not resolved

Question 44

A G1P1 patient comes in with fever, chills, and body aches 2 weeks postpartum. On PE, her R breast is red, swollen, hot, and tender to the touch. What is the most likely diagnosis and how would you treat it?

Answer 44

Mastitis Breastmilk culture to r/o MRSA Warm compresses, continue breastfeeding, & antibiotics

Question 45

A patient comes in with mastitis for 2 months. What are you most concerned of it developing into and how would you treat it?

Answer 45

Abscess Abscess tx: - antibiotics - drainage Baby may continue to breastfeed/receive expressed milk so long as milk is not purulent

Question 46

A G1P1 patient comes in complaining of itchy, chapped nipples that burn when breastfeeding. On PE, you notice fissures around the base of the nipple shaft. What is the most likely diagnosis and how would you treat it?

Answer 46

Candida Topical nystatin ointment/clotrimazole Oral Diflucan. Clean everything that comes in contact with breasts, milk, baby's mouth. If you’re treating the mom or the infant, the other has to be treated.

Question 47

A postpartum breastfeeding woman comes in complaining of her R nipple turning blue after breastfeeding or when she is exposed to cold temperatures. She notes associated pain, which lasts about 35 minutes. What is the most likely diagnosis, common causes, and how would you treat it?

Answer 47

Vasospam Causes: - poor latch/suck trauma - baby biting - autoimmune diseases: Reynauds or rheumatoid arthritis Treatment: - avoid the trauma, obvs - Keep warm

Question 48

A new mom comes in wanting to talk about breastfeeding. She asks about the benefits of breastfeeding compared to formula. In addition to talking about improved developmental outcomes and improved immune system of the baby, you also discuss reduced morbidity and mortality related to what?

Answer 48

SIDS & NEC

Question 49

What can be accurately described as providing baby's first immunization and how?

Answer 49

Colostrum - has high concentrations of antibodies, immune modulating factors, and anti-inflammatory substances. This protects the infant while preparing the gut for mature milk feeding. These protective factors function without causing inflammation or tissue damage in the baby.

Question 50

How much milk is mom expected to produce and on what day?

Answer 50

Average production of 556-705 g/d on day 6 postpartum. Onset of copious milk secretion: days 3-8 postpartum

Question 51

What is/are the diagnostic criteria of gender dysphoria in prepubescent girls?

Answer 51

Dysphoria must be present for at least 6 months Persistent and intense distress about being a girl, states desire to be a boy or insists is a boy Assertion that she has or will grow a penis Rejection of urination in a sitting position Assertion that she does not want to grow breasts or menstruate

Question 52

What is/are the diagnostic criteria of gender dysphoria in prepubescent boys?

Answer 52

Dysphoria must be present for a least 6 months Persistent and intense distress about being a boy, states desire to be a girl or insists is a girl Preoccupation with stereotypic female activities (cross-dressing or intense desire to participate in pass times of girls and rejection of stereotypical boy toys, games, and activities) He will grow up to be a woman His penis and testes are disgusting or will disappear It would be better not to have a penis or testes

Question 53

Antidote for Cyanide

Answer 53

Cyanide: sodium nitrite

Question 54

Antidote for Iron

Answer 54

Iron: Deferoxamine

Question 55

Antidote for Severe cyanosis

Answer 55

Severe cyanosis: Methylene blue 1%

Question 56

Antidote for Acetaminophen

Answer 56

Acetaminophen: N-Acetylcysteine

Question 57

Antidote for anticholinergics

Answer 57

Anticholinergics: Physostigmine

Question 58

Antidote for Organophosphates

Answer 58

Organophosphates: Atropine or Pralidoxime

Question 59

Antidote for Benzodiazepine

Answer 59

Benzodiazepine: Flumazenil

Question 60

Antidote for Beta blockers

Answer 60

Beta Blockers: Glucagon

Question 61

Antidote for TCAs

Answer 61

TCAs: NaHCO3

Question 62

Antidote for Warfarin

Answer 62

Warfarin: Vitamin K