MS Flashcards
How should you treat an infected puncture wound to the foot?
- Cleanse the wound
- Update tetanus
- Consider x-ray for retained foreign bodies or possible bony involvement
If infection develops after puncture through sole of a shoe (esp. sneakers), treat for Pseudomonas in addition to Staph and Strep
What eye finding do atropine, amphetamines, antihistamines, and cocaine cause?
Mydriasis (dilated pupils)
Assuming prompt treatment, which has a better prognosis - epidural or subdural hematoma?
Epidural
The underlying brain tissue is uninjured in epidural hematomas, whereas in subdural hematomas, there is usually a severe brain injury.
What is the most common organism found in an infect cat bite wound?
Pasteurella multocida, followed by Staph aureus. Pasteurella infection can progress rapidly and should be treated with amoxicillin/clavulanic acid
A 9-year-old boy includes genitals in a drawing of his family. What should you consider as a possibility?
Sexual abuse
Ingestion of which substance produces these signs and symptoms:
- Diarrhea
- Urination
- Miosis
- Bronchorrhea/Bronchospasm
- Emesis
- Lacrimation
- Salivation
These are symptoms of cholinergic toxicity. Common causes are organophosphates and carbamate. Also causes CNS and nicotinic muscarinic effects, which are not included in the DUMBELS mnemonic.
Antidotes:
- Atropine for both organophosphates and carbamate
- Pralidoxime for organophosphates
What is the most common physical exam finding of the genital/anal area in sexually abused children?
Normal exam
A 5-year-old has a supracondylar elbow fracture that is displaced significantly. Should orthopedics be consulted?
Yes
Displaced supracondylar elbow fractures have a high risk of neurovascular complications such as compartment syndrome of the forearm, which can lead to Volkmann contractures in the wrist and hand. Must evaluate for damage from the brachial artery, median and radial nerves
A 3-year-old child is seen after eating Grandma’s blood pressure pills. She is somnolent, bradycardic, and hypotensive. Her blood sugar is 55 mg/dL. What do you suspect?
Beta-blocker ingestion
- CNS depression
- bradycardia
- hypotension
- arrhythmias
- hypoglycemia
A 6-month-old infant presents with a large, unexplained swelling over the parietal region. What should you do?
CT scan
Infants < 2 years with nonfrontal scalp injuries are at increased risk of intracranial injuries. Suspect abuse in this case.
What test should be performed in well-appearing <2-year-old siblings of physically abused children?
Skeletal survey
A significant number of siblings of abused children have fractures that are not suspected clinically. Twins are especially at risk.
Name 6 sexually transmitted infections that can be congenitally acquired
- HPV
- HSV
- HIV
- Syphilis
- Gonorrhea
- Chlamydia
A 6-year-old is seen after an ankle injury. He is tender over the distal fibula. X-ray does not show a fracture. What injury is most likely?
Salter-Harris fracture, type 1
If a young child (with open growth plates) is tender over the distal fibular physis, consider this fracture even if the x-ray is normal.
Why should infants with abusive head trauma be evaluated by an ophthalmologist?
To evaluate for retinal hemorrhages
62-100% of infants with severe abusive head trauma have bilateral retinal hemorrhages. Infants can be born with bilateral retinal hemorrhages, but these tend to disappear by 2-6 weeks of life.
List 3 possible signs or symptoms of abusive head injury
- Vomiting
- Fussiness
- “Not acting right”
- Lethargy
- Seizures
- Scalp hematomas
- Coma
- Apnea
- Cardiac arrest
+/- Spinal trauma
An 11-year-old male presents due to ankle injury at a basketball game. He has point tenderness over the distal lateral malleolus and a moderately swollen ankle. He has limited ROM in all directions. He cannot bear weight due to severe pain.
What are indications for x-ray according to the Ottawa ankle rules?
X-ray the ankle if:
- Unable to bear weight for 4 steps immediately after the injury
- Tender over distal 6cm of either malleolus
X-ray the foot if:
- Unable to bear weight for 4 steps
- Bony tenderness at base of 5th metatarsal or navicular bone
You are seeing an 18-month-old male with multiple bruises concerning for abuse. What radiologic study should you perform?
Skeletal survey in patients < 2 years
A 16-year-old presents with displaced tibial fracture with pain that appears to be out of proportion to the fracture and pain remote to the fracture. What is the suspected complication?
Compartment syndrome
- Most common with tibial and supracondylar fractures
- Fracture causes hemorrhage or swelling in an enclosed fascial compartment
- Pulses may still be palpable
Biggest keys are pain out of proportion to fracture, remote to fracture
It is wintertime, and a family presents with the following symptoms:
- Headache
- Nausea
- Lethargy/malaise
- Flu-like symptoms
- Normal pulse oximetry
What is the likely diagnosis?
Carbon monoxide poisoning
Be suspicious if presents with these symptoms during wintertime or during prolonged power outage with use of a gas generator. Diagnosed by co-oximetry
A 6-month-old presents with a spiral fracture of the femur. What should you suspect as the etiology of the injury?
Abuse
A pregnant teen presents in active labor. She has an active genital herpes infection. What type of delivery should she have?
C-section to avoid transmission of HSV to the newborn
- Risk of transmitting HSV from a mother with primary genital infection to her baby at or near delivery is 40-45% (very high)
- If the mother does not have prodromal or clinical s/s of herpes at delivery, she can delivery vaginally
A 1-year-old presents with the following:
- White sclerae
- Fractures at birth
- Tibial bowing
- Delayed fontanelle closure
Most likely diagnosis
Osteogenesis imperfecta type 4
- milder form like type 1 (which has blue sclerae)
** Tibial bowing is a hallmark of Type 4
By how much does pRBC 10cc/kg raise hemoglobin?
2.5-3 g/dL
Newborn presents with jitteriness, irritability, tremulousness, muscle rigidity, and intracranial hemorrhages.
What illicit drug used by the mother during pregnancy is most likely responsible for these findings?
Cocaine
- There is an increased risk of placental abruption and intracranial hemorrhage with cocaine use near delivery
Newborn girl presents with IUGR, microcephaly, small face and mouth, rocker bottom feet, clenched fist, and hypoplastic nails.
Most likely diagnosis?
Trisomy 18
A 6-year-old girl who has been attending summer camp presents with fever, pharyngitis, conjunctivitis, rhinitis, and cervical adenitis.
Most likely etiology?
Adenovirus - causes a pharyngoconjunctival fever, especially in the summer months, and can cause epidemic keratoconjunctivitis (conjunctivitis, painful corneal involvement, and preauricular lymph node enlargement)
- Associated with outbreaks at swimming pools in summer camps
4-year-old presents with frequent falling, waddling gait, toe walking, calf muscle pseudohypertrophy, positive Gowers sign, and elevated CK. Diagnosis?
Duchenne muscular dystrophy
Which disorder has the following:
- X-linked dominant
- Patterned blistering that follows lines of Blaschko (especially in the extremities)
- Delayed eruption of teeth that are peg or cone-shaped, commonly missing teeth
- Strabismus
Incontinentia pigmenti
4-month-old presents with severe, unremitting pruritus, diarrhea, conjugated hyperbilirubinemia, and normal GGT. Most likely diagnosis?
PFIC 1
- mutation in the FIC1 gene on chromosome 18
- presents between 3-6 months of age with the above findings
A young child understands 50 words and follows simple commands, often points at and identifies objects, is able to name several body parts, and has just started using 2-word sentences. He parallel plays with other children.
What is his age?
18 months
** Absence of any words by 18 months requires evaluation for language delay
A newborn presents on DOL2 with difficulty breastfeeding and difficulty extending tongue past alveolar ridge. Diagnosis?
Lingual ankyloglossia (tongue tie)
Newborn has 1-2 mm firm, white papules that appear on the surface of pilosebaceous units on the face. Most likely diagnosis?
Milia
15-year-old boy with fever, weight loss, rib pain, and primary lytic lesion with “onion skinning” of the diaphysis of the right femur on x-ray.
Most likely diagnosis?
Ewing sarcoma - undifferentiated sarcoma of the bone, typically affecting the diaphyses of long bones and flat bones (ribs, pelvis)
Remember that osteosarcoma has metaphyseal involvement and a “sunburst” pattern!
What is the treatment for juvenile myasthenia gravis?
- PO anticholinesterase medications (pyridostigmine), which increase Ach at the receptor site
- Other treatments include: immunosuppression, thymectomy, plasmapheresis, IVIG
A 9-month-old presents with increased lethargy. Grandmother says she has seen mother shaking child vigorously in the past.
What type of intracranial bleed should you be concerned about in this child?
Subdural hematoma - due to shaken baby syndrome
7-year-old with seizure that presented with LOC, unresponsiveness, repetitive lip smacking, hallucination before seizure and recollection of the seizure, and post-ictally is aggressive and angry towards mother.
What type of seizure did she have?
Focal seizure with impaired consciousness
Patient with history of left cryptorchidism s/p orchiopexy presents years later with a nontender firm non-reducible testicular mass. Next diagnostic step?
Ultrasound of the scrotum - can delineate between testicular neoplasm vs nonmalignant process
Guidelines for screening lipids in childhood
Universal screening between ages 9-11 years (prior to onset of puberty) and again between ages 17 - 21 years (as lipid levels decrease during puberty)
** Children with +Fhx or moderate to high risk medical condition should be screened at ages:
- 2-8 years
- 12-16 years
With 2 fasting lipid profiles which are averaged to dictate next steps
Mechanism of action of progestin-only pills or progestin-only IUDs
Causes amenorrhea due to thinning of the uterine lining as well as thickening cervical mucus; varying effects on inhibiting ovulation
Side effects of progestin-only (Medroxyprogesterone) pills
1) Weight gain
2) Loss of bone mineral density
Serology consistent with recent acute EBV infection
+ EBV VCA IgM, negative EBV NA antibodies
Jejunal and ileal atresia have been associated with maternal ____ and ____ use during pregnancy.
1) cigarette smoking
2) cocaine
Why are phosphorus levels low in X-linked hypophosphatemic rickets?
Renal phosphate wasting AND impaired stimulation of 1-alpha-hydroxylase that normally occurs in response to low Phos levels
1-a-OH converts 25-OH-Vit D to 1,25-OH2-Vit D (the active form of vitamin D, a.k.a CALCITRIOL)
A 2-month-old full term infant with previously normal development has recently been having muscle weakness (sparing the face), hypotonia, hyporeflexia, and tongue fasciculations.
How does this condition cause these symptoms?
Progressive degeneration and loss of anterior horn cells in the spinal cord and brainstem nuclei
Spinal muscular atrophy
What is the Paradise criteria for tonsillectomy?
Minimum frequency of sore throat episodes:
- 7(+) in the preceding year
- 5(+) in each of the last 2 years
- 3(+) in each of the last 3 years
Clinical features in addition to sore throat:
- Temp > 38C or
- Cervical LAD (tender nodes or size > 2cm) or
- Tonsillar exudate or
- Positive cx for GAS
Medical error that does not cause harm to the patient
Potential adverse events or near misses
Unexpected event that threatens or results in serious injury or death
Sentinel event
Error that occurs when an incorrect action is taken
Error of commission
Error that occurs when a correct action is not taken
Error of omission
Error that was not previously recognized and reached the patient, but does not result in harm
Nonintercepted error
Error that is recognized and corrected before it reaches the patient
Intercepted error
A teenager running in a race on a hot humid day is having abdominal cramping, fatigue, and on VS has an elevated temperature (38.9C) and elevated HR. She is able to respond to questions appropriately. She appears pale and sweaty.
Most likely diagnosis?
Heat exhaustion
A teenager running in a race on a hot humid day comes to the midway point, appearing confused and unable to answer questions appropriately. On physical exam, she has hot, dry skin without sweat. Her temperature is 40.1C.
Most likely diagnosis?
Heat stroke
Ethical principle that allows or enables patients to make informed decisions about which health care interventions they will or will not receive
Autonomy
Ethical principle - the obligation to act for the benefit of other or to do good
Beneficence
Ethical principle - the obligation to minimize or eliminate harm
Nonmaleficence
Ethical principle - the obligation to treat others equally and distribute benefits and burdens fairly
Justice
As compared to cow milk, human milk has:
- More available iron
- More available carb
- Less protein
- Less calcium
- Similar amounts of fat
- Less amounts of minerals (Na, K, Cl, Phos, Ca)
As compared to human milk, cow milk has:
- Less available iron
- Less available carb
- More protein
- More calcium
- Similar amounts of fat
- Higher amounts of minerals (Na, K, Ca, Cl, Phos)
Why should cow milk not be introduced until 12 months age?
- Risk of GI bleeding
- Risk of iron deficiency anemia
- Excessive renal solute load, which can lead to dehydration and hypernatremia in infants
