Pediatric Psychiatry, Neurology, Ophthalmology

Question 1

ADHD subdivisions

Answer 1

• ADHD/I: ADHD with at least 6 of 9 inattention behaviors
• ADHD/HI: ADHD with at least 6 of 9 hyperactivity and impulsivity behaviors
• ADHD/C: Both of the above combined

Question 2

Requisites for a diagnosis of ADHD

Answer 2

• Fulfills 6 of 9 of the ADHD/I or ADHD/HI criteria
• Present for at least 6 months in two or more settings
• Some symptoms present before age 7
• Must result in impaired function

Question 3

Therapy for ADHD

Answer 3

• Coordination with caregivers and teachers is key
• Referral to child psychiatry is a must, as there are often comorbid pediatric psychiatric conditions or learing disabilities
• Behavioral modification and coordinated plan with teachers and caregivers is first-line
• Medical therapy comes next:
  
  • Methylphenidate or dextroamphetamine are tried first
  • Atomoxetine (a SNRI) has shown benefit
  • Tricyclics and buproprion may be attempted if the above fail
• 50% of individuals with childhood ADHD will function well in adulthood, while others will demonstrate continued inattention and impulsivity symptoms

Question 4

“Simple” vs “Complex” seizures

Answer 4

“Simple” : no LOC

“Complex” : LOC

Question 5

Grand mal seizure

Answer 5

Generalized complex seizure

Question 6

Treatment for absence seizures

Answer 6

Ethosuximide

Question 7

Treatment for trigeminal neuralgia

Answer 7

effetively a seizure of the trigeminal nerve

Treat w/ carbamazepine

Question 8

Most common antiepileptic for non-absence seizures

Answer 8

Levetiracetam

Usually the best choice. However, may be too expensive or unavailable. In that case, phenytoin, valproate, or lamotrigine may be used.

Question 9

Antiepileptics in febrile seizures

Answer 9

Start them for complex, not for simple

Remember: Complex febrile seizure is an unmasking of underlying epilepsy due to the epileptogenic state of fever in the developing brain

Question 10

Infantile Spasms aka West syndrome

Answer 10

• NOT A TRUE SEIZURE, it is a seizure mimic
• Patient will be < 1 year old and present with bilateral symmetric jerking
• Will NOT be generalized and there will be NO fever
• Dx: Interictal EEG showing hypsarrhythmia
• Treat with ACTH
• Often associated with developmental delay and tuberous sclerosis

Question 11

Tuberous sclerosis

Answer 11

• Genetic disease
• Patient will typically be < 2 years old, have ash leaf spots (visible w/ Wood’s lamp) and angiofibromas on skin, afebrile or complex febrile seizures
  
  • On brain imaging, cortical tubers
• Diagnose w/ CT or MRI of brain
• Treatment of supporting
• Risk of development of benign tumors anywhere in body

Question 12

Special features of absence epilepsy

Answer 12

• Loss of consciousness, but no loss of tone
• No post-ictal state
• Hundreds to thousands of seizures per day
• “Spacing out” or “ADHD”
• Diagnose with EEG, treat w/ ethosuximide (valproate as backup or if combined generalized seizures)

Question 13

Prerequisite to genetic screening for intellectual disability disorder

Answer 13

Mother must be willing to terminate

Otherwise, the procedure only puts both mom and fetus at risk

Question 14

Diagnosis of intellectual disability disorder

Answer 14

Clinical diagnosis based upon loss of adaptive functioning

Question 15

Stereotypy

Answer 15

Doing the same thing over and over, repetitive behaviors

Symptom of autism spectrum

Question 16

Tic disorder diagnosis and treatment

Answer 16

• Consistent vocal or motor tic
• Patient < 18 years of age
• Duration > 1 year
• Clinical diagnosis
• Treatment is D2 antagonist and cognitive-behavioral therapy

Question 17

Learning disability

Answer 17

• Must rule-out vision and hearing problems, language incongruence, and dyslexia
• Often ADHD, ASD, or IDD

Question 18

Managing enuresis

Answer 18

• Two conditions: dry vs not dry (could hold vs never learned)
• Not dry:
  
  • Typically < 7
  • Need training in form of alarm blankets and positive reinforcement
  • Try less water before bed
  • ddAVP theoretically, but probably not right answer
• Dry:
  
  • Functional problem
  • Get UA and ultrasound
  • UTI, regression, or anatomical problem
  • Keep T1DM in mind
  • Keep in mind that UTI and regression may both be caused by sexual abuse

Question 19

Conduct disorder vs oppositional defiant disorder

Answer 19

• Conduct disorder:
  
  • “Criminal behavior”, effectively anti-social personality disorder but < 18 years old
  • Fights peers, fights authority
  • Bullying, destruction, rule violating
  • Hurt animals, force sex
  • Diagnosis is clinical, treatment is juvenile detention and rehabilitation
• Oppositional-defiant disorder:
  
  • “Teen acting out”
  • Pathology is incongruent parenting
  • Cooperates with peers, fights authority
  • May lie, cheat, steal
  • No bullying, no harming animals, no cruelty or torture
  • Diagnosis is clinical, treatment is. . . rehab for the parents. Teach the parents how to parent.

Question 20

Selective mutism

Answer 20

Child consistently refuses to speak when expected to (e.g., when asked a question in school) although his/her communication skills are not impaired.

Typically has a negative impact on normal life (e.g., academic performance) and is not exhibited in settings in which the child feels comfortable and safe (e.g., talking to family members or friends).

Question 21

Reactive attachment disorder

Answer 21

Reactive attachment disorder occurs in children with a history of neglect or abuse and typically manifests before 5 years of age.

Affected children show a consistently withdrawn behavior towards caregivers, express minimal emotion towards others, and do not seek comfort when distressed.

Question 22

Social communication disorder

Answer 22

Children with social communication disorder present at an early age with difficulties in both verbal and nonverbal communication, such as adapting to social settings (e.g., being quiet during a performance) and using communication methods adequately (e.g., body language, eye contact).

Question 23

Amblyopia is ___ and may develop through ___ or ___

Answer 23

Amblyopia is a form of cortical blindness and may develop through strabismus or congenital cataract

Question 24

Congenital strabismus must be fixed by ___ to prevent amblyopia.

Acquired strabismus must be fixed by ___ to prevent amblyopia.

Answer 24

Congenital strabismus must be fixed by surgery before 6 months of age to prevent amblyopia.

Acquired strabismus must be fixed by patching of good eye or glasses to prevent amblyopia.

Question 25

Two ways to have “congenital” cataracts

Answer 25

• If they were truly there at birth, TORCH infection
• If they appear in the first few days, inborn error of metabolism (namely galactosemia)

Question 26

__ must be differentiated from congenital cataracts

Answer 26

Retinoblastoma must be differentiated from congenital cataracts

No red reflex, DEEP white mass (as opposed to more superficial cloudy cataract)

Diagnosis is clinical, treatment is surgical removal of globe. DO NOT use radiation – this will trigger cancer in the other eye.

If discovered, patient is high risk for osteosarcoma.

Question 27

Retinopathy of prematurity usually occurs in the context of. . .

Answer 27

. . . premature infant with lung dysfunction who is receiving high FiO2

Treat w/ ablation of abnormal neovascularization

These infants are at high risk for bronchopulmonary dysplasia

Question 28

Agents that cause chemical conjunctavitis in a neonate

Answer 28

Silver nitrate

Question 29

If a baby missed its chance to get topical erythromycin and presents with suspected gonorrheal conjunctavitis, treat with. . .

Answer 29

. . . ceftriaxone

but do make sure to get cultures or PCR to ensure you know what you are treating. Remember that Neisseria species grow on chocolate agar.

Question 30

Most non-gonococcal, non-chlamydial conjunctavitis in the newborn presents at day. . .

Answer 30

. . . 5-14, just like chlamydia

So we will take cultures, treat presumptively for gonorrhea and chlamydia, and change course depending on culture results