Rosh Review Flashcards
If a patient with status migrainosus is about to get DHE, what is the most important test to check before?
Pregnancy test due to fetal risk
After the migraine cocktail of metclopramide, ketorolac/ibuprofen and NS bolus, besides DHE, other meds that can be tried include
Benadryl, steroid, magnesium
A full term healthy 18hr old infant in nursery is jittery, what blood glucose level should prompt IV glucose? What would be the threshold of less than 4hrs old?
Less than 40mg/dL. It would be 25mg/dL
What are the 4 ethical principles of biomedical research?
Beneficence - for patient’s good e.g. benefits outweigh risks
Justice - equitable allocation
Nonmaleficence - do no harm
Autonomy - respect the person and their right to self-determination
What are the 6 domains of health care quality by IOM?
Safety
Effectiveness
Patient-centeredness
Timeliness
Efficiency
Equitability
A NICU finds only 60% adherence to hand hygeine. What QI tool can be used to determine primary drivers that contribute to poor hand hygeine? As a follow up, what prior to the answer would have been the first step?
Driver diagram.
1st step is a clear, time-bound and realistic project aim.
Cushing syndrome is ACTH independent if the ACTH level returns XXX at XXX pg/mL
Less than 5-10 pg/mL
Cushing disease NOT syndrome refers to a XXX type of malignancy
Pituitary adenoma
A 14 yr old girl has completed N-AC after intentional Tylenol ingestion with normalized liver enzymes. She is suicidal. What’s the most appropriate transport to psych facility for her?
Ground transport with EMT NOT ground transport with paramedics.
How is an EMT different than a paramedic?
An EMT just can operate AEDs but a paramedic can staff IVs, interpret EKGs, defibrillate, start meds
A girl is getting a transfusion and sometime within the first 6 hours has fever, hypoxia and respiratory distress. What reaction is she having?
Transfusion-related acute lung injury
What drugs can be used to treat absence seizures?
Ethosuximide (blocks T-type calcium channels) or valproate but valproate has more side effects
direct hyperbilirubinemia in a child with Alagille syndrome is the result of what?
Paucity of interlobular bile ducts. It is an autosomal dominant disease. They have butterfly vertebrae
A girl who presents with fever, rash, lymphadenopathy and fatigue with elevated LFTs, pancytopenia and an elevated ferritin (greater than 500 range - normal: less than 150) is concerning for?
HLH. Signs/symptoms are acute or subacute fever, multi organ involvement (splenomegaly, hepatitis, neurologic findings), cytopenias, hypertriglyceridemia, low fibrinogen, high ferritin.
What is the bullseye rash of Lyme called? How do you test for the disease. how long does a deer tick have to be attached for the greatest risk of disease? How long does a tick have to be attached for prophylaxis to be indicated?
Erythema migrans. You do an ELISA or immunofluorescent antibody test with confirmatory western blot
Greater than 72 hours = greatest risk
Prophylaxis if tick on for more than 36 hours
How is pericarditis treated?
NSAIDs and colchicine
By what age should a cleft palate be surgically repaired to minimize speech issues?
12 months
When is an isolated cleft lip usually repaired?
3 months of age
What is the bacterial morphology of cat scratch or Bartonella henselae? What’s its incubation period? How do you test for it? What’s the stain for it called? Do you treat with antibiotics or does it self resolve?
Gram negative rod. Incubates for 7 days to 2 months. Presents with cervical adenopathy and papules on same side as cat scratch. Likely to have abcesses in 10-20% if affected nodes
You test antibody levels.
Alternately nodes can be stained with Warthin-Starry stain
You treat immunocompromised patients or severely ill immunocompetent patients with azithromycin or rifampin. The treatment includes alternate agents if it’s neuroretinitis
What is the diagnostic test for a PE?
Helical or spiral CT with IV contrast
What is the mechanism of direct oral anticoagulants?
Direct thrombin inhibition or Xa inhibitors
What kind of bacteria morphology is Neisseria gonorrhea
Oxidase positive, gram NEGATIVE coccus
A 2 day old with an infection of a scalp electrode that grows an oxidase-positive, gram negative coccus is concerning for what bacterial infection and should be treated with what?
Neisseria gonorrhea and should be treated with CTX x 7 days
What are two common gram negative, OXIDASE NEGATIVE bacilli bacteria?
E. Coli and Klebsiella oxytoca
A 4 year old boy with 5 hours periumbilical pain and purpuric rash on his bilateral lower extremities and arthralgias is concerning for what disease and is likely to have what in his urine?
HSP or IgA vasculitis (small vessel) and proteinuria (or hematuria)
What are risk factors for neonatal hypocalcemia? What regulates these levels?
Fetal growth restriction, prematurity (calcium transfer occurs late in the third trimester), hyponagnesemia.
PTH related peptide
A boy burns himself and has acute pain from these burns. What type of pain is this?
Somatic pain
Why is orbital cellulitis more common in children?
Tiny bony septa and sinus wall and more porous bones
When can a burn be classified as minor and this managed with cleaning the area with tap water/saline, confirming tetanus vaccination status, and dressing the area as well as giving prophylactic topical antibiotic? (as an outpatient)
When the patient is 10-50 years old and has a PARTIAL thickness burn involving less than 10% of total BSA
OR if patient is less than 10 or greater than 50 and has a PARTIAL thickness burn less than 5% of total BSA.
Or any age patient with an ISOLATED full thickness burn less than 2% of total BSA
What areas can a minor burn NOT involve?
Face, hands, perineum, feet and not cross major joints or be circumferential and must be isolated (not inhalation injuries or high voltage injuries)
For burns, how do you calculate how much fluid to give?
Parkland formula: 4ml x weight (kg) x % total BSA. Give first half over 8 hrs and remainder over 16hrs
Or
Modified Brooke Formula: For children: 3mL x weight (kg) x % BSA. Give first half over 8 hours, remainder over 16 hours
For Lyme disease associated facial nerve neuropathy and meningitis, what is the treatment? I
Still ORAL doxycycline. It usually occurs 3-12 weeks after tick bite (could also do IV CTX, cefotaxime or PCN G)
How long should a pediatric patient be pre-oxygenated by Bag mask ventilation prior to intubation?
3 minutes. They are at more risk for hypoxemia due to lower tidal volumes, lower functional residual capacity, higher O2 metabolism
A boy with BP 180/100, HA, blurry vision, nausea/vomiting with normal head imaging is concerning for ____? And should be treated with _____
Acute severe hypertension (or accelerated hypertension or hypertensive crisis) and should be treated with IV labetalol
A child with acute severe hypertension, depressed consciousness, ataxia, seizures, and imaging findings is concerning for ____
Hypertensive encephalopathy = PRES
What is clonidine’s mechanism of action?
Central alpha adrenergic agonist
What test can be used to diagnose central Diabetes inspidius when the diagnosis is in question?
Water deprivation test
All infants born to HIV- infected mothers, regardless of viral load, should begin antiretroviral prophylaxis within 12 hours of birth
TRUE
What viral load for a pregnant patient with HIV is associated with a high risk of infection?
> 1000 copies/mL
If an HIV positive woman has < 1000 copies/mL viral load and she is on ARVs, she is a candidate for a vaginal delivery.
Yes
A patient classified as American Society of anesthesiologists class III or more, indicates severe systemic disease (e.g. acute wheezing and is generally an ABSOLUTE contraindication to procedural sedation
True
What’s the best way to unclog a G-tube
Insert warm water and then aspirate.
What size RPAs on CT should lead to prompt evaluation by ENT for possible surgical drainage?
> 2.5cm
A rapidly progressive acute cellulitis that developed within 24 hours of a cat bite is likely due to ______(what bacterium). Treat it with ____
Pasteurella multocida. Augmentin.
If a patient has sepsis or a gangrenous wound after dog bite, the bacterium is
Capnocytophaga canimorsus
What dose of naloxone reverses respiratory depression?
0.1mg/kg (max 2mg) IV
A boy with altered mental status and psychosis from illicit use of cough syrup dextrometorphan is experiencing which mechanism by he drug?
NMDA receptor inhibition
What makes a BRUE low risk?
All of the following have to be true.
Age > 60 days, gestational age >= 32 week and >= 45 weeks postconceptional age, only 1 occurrence, BRUE duration less than 1 min, no CPR by professional, no concerning history or physical exam findings
Post conceptional age is calculated as gestational age + chronologic age. For example a 4 week old, ex-24 weeker has a PCA of 28 weeks
What causes post strep glomerulonephritis?
What lab markers are usually decreased?
What should you expect to see on a UA?
Immune complex deposition within glomeruli after strep pharyngitis or impetigo.
Complement C3 levels and CH 50 are usually decreased.
Hematuria on UA (+/- proteinuria)
For a child with eczema with known colonization by MRSA, what has been shown to be most effective in decreasing colonization?
Bathing
What increases neural tube defect risks in pregnancy besides decreased folic acid?
Maternal obesity
NOT gestational diabetes but poorly controlled pre-gestational diabetes
A 20 month old boy admitted with 12 hours of emesis, diarrhea and poor PO presents with hypoglycemia, needs a D10 bolus to improve the glucose level and then again develops it. Insulin and C-peptide levels are undetectable. Beta hydroxybutyrate is elevated. What does he have? How is it treated?
He has idiopathic ketotic hypoglycemia. It’s treated with frequent protein and carb intake. Usually onsets in toddler years 18 months to 5 years and resolves by 8-9 years of age. Instead of the usual 30-36 hrs kids can fast without hypoglycemia, they can only fast 12-18hrs before developing hypoglycemia so are susceptible in acute illness. They usually have low plasma alanine
Because there are ketones, it is not a fatty acid oxidation disorder. Ketones are an end product of fatty acid oxidation.
What percentage of the body has to be involved for SJS to be concerning for TEN?
What laboratory findings would you expect besides the prodomal symptoms?
In addition, about half of patients have these laboratory abnormalities?
30% or more
Anemia and lymphopenia
About half have mild elevations in LFTs
What immune cell type is most present in human breastmilk in the first 2 months?
Macrophages. There also B/T lymphocytes in lower quantities.
What is an absolute contraindication to doing an LP in a neonate with HR90, RR 15, sat 85% with a bulging fontanelle. It’s not the fontanelle
Vital signs. Cardiopulmonary instability
If a patient with CF has rectal prolapse (which restore from frequent, large stools) OR meconium ileum what enzyme replacement therapy is indicated immediately?
Pancreatic enzyme replacement
In NRP with a baby who is apneic with HR 40, PPV is given and chest rise is not noted. What’s the best next step?
First take ventilation corrective steps (reapply mask, place head neutral or slightly extended, suction). If no chest rise noted, then pursue alternate airway (intubate) and after chest compressions.
What is the acronym for drug induced lupus?
HIPPS (hydralazine, isoniazid, procainamide, phenytoin, sulfonamides)
What disease process is characterized by bilateral, frontal-predominant regular 3Hz spike and wave discharges?
Absence seizures
What do you expect to see on EEG for infantile spams?
Hypsarrhythmia - chaotic interictal tracing with an electrodecremental response during episodes.
What is the treatment for infantile spasms?
High dose ACTH therapy (corticotropin), steroids, vigabatrin
Biphasic, focal centrotemporal spikes and slow waves are usually seen in which conditions?
Benign Rolandic seizures which are the most common partial epilepsy in childhood. Symptoms include unilateral facial sensory-motor symptoms including hypersalivation and speech arrest
Biphasic, focal centrotemporal spikes and slow waves are usually seen in which conditions?
Benign Rolandic seizures which are the most common partial epilepsy in childhood. Symptoms include unilateral facial sensory-motor symptoms including hypersalivation and speech arrest
Generalized 4-6Hz polyspike and slow wave discharge on EEG are seen in….
Juvenile myoclonic epilepsy. Symptoms are myoclonic jerks on awakening and GTCs.
What triad is suggestive of Aicardi syndrome?
Infantile spasms, agenesis of corpus callosum, retinal malformations.
Administration of what may improve outcomes or reduce BPD in preterm infants < 28 weeks
Caffeine
What is the target O2 sat for a preterm infant who requires oxygen?
90-95%
Maple syrup urine disease is characterized by LOW serum levels of ___
Its inheritance pattern is _____
There should be HIGH serum levels of ____
Alanine
Autosomal recessive
High levels of leucine, isoleucine, valine.
How long should patients in the ED be observed for possible biphasic reaction after anaphylaxis?
4 hours because 90% of biphasic reactions occur in the first 4 hours after presentation. After this, they can be discharged home with epi-pen, anaphylaxis action plan, referral to allergy if agent not yet identified.
What is a contributing factor for bone loss in anorexia nervosa?
Low levels of oxytocin
What is the fasting glucose cut off for Type 2 DM and what is the HgbA1c cut off?
HgbA1c >= 6.5% and fasting glucose greater than or equal to 126mg/dL OR plasma glucose >= 200mg/dL 2 hours after a glucose load in an OGT
What insulin marker is normal in Type 2 DM?
Normal levels of C-peptide. Type 2 DM is caused by peripheral insulin resistance and insulin production is not as affected or is just insufficient given that resistance.
What are the stages of LEWIN’s change management model?
Unfreeze, change, refreeze
Acceptance is a stage in the _________
Kubler Ross grief cycle
What is the treatment for pelvic inflammatory disease
Inpatient: Cefoxitin and docycline
OR
Clindamycin and gentamicin
Outpatient:
Ceftiaxone + doxycycline + metronidazole
If the patient has a tubo ovarian abscess, what should be prescribed?
Metronidazole or clindamycin
What can be administered if the patient is WITHIN 4 hours of a Tylenol ingestion?
Activated charcoal
What can be administered if the patient is WITHIN 4 hours of a Tylenol ingestion?
Activated charcoal
What nomogram provides guidance on initiating N-acetylcysteine for Tylenol ingestion? Above what level should the 21 hr IV treatment or 72hr oral treatment be started
Rumack-Matthew nomogram
Above 150mcg/mL
A girl presents with mucocutaneous bleeding and has a NORMAL CBC, PT, PTT, and VWF. What is the best next step?
Assess the peripheral smear for platelet count and then morphology. Bleeding time is no longer performed. It is an old test.
What are the most common causes of viral pneumonia in children under age 5?
After RSV, it’s influenza A/B not rhinovirus.
A 4 day old baby with hepatomegaly, jaundice, and rhinorrhea was born at full term to a mom with no prenatal care. The umbilical cord was edematous with spiral stripes of
Red, light blue, and white. What does he have?
Congenital syphilis
For a patient with Hypertrophic cardiomyopathy who presents with near syncope in gym class, what would be an indication for an implantable cardioverter-defibrillator?
Unexplained syncope OR
A ventricular wall-end diastolic dimension of >= 3cm
What are medical management options in symptomatic hypertrophic cardiomyopathy?
Beta blockers and calcium channel blockers
What demographic correlates best with a patient’s tracheal length for tracheostomy tube?
It’s weight NOT age
A 5 month old baby presents with increased work of breathing and poor oral intake with no URI symptoms. She is laying frog legged. When she takes a breath in, her chest contracts and her belly protrudes. What does she have and how should it be managed?
She has SMA - spinal muscular atrophy and should be managed with continuous positive airway ventilation with frequent suctioning.
What is the major antigen described in Hashimoto’s thyroiditis?
Thyroglobulin (also thyroperoxidase and TSH)
What is the gold standard for screening for suicidal ideation in adolescents?
The 30 question suicidal ideation questionnaire.
Toxicity with what substance causes nausea, emesis, tinnitus, fever, an anion-gap metabolic acidosis and a respiratory alkalosis?
Aspirin
Which of the following brain changes is associated with increased severity and early onset schizophrenia?
Decreased prefrontal cortext volume
What body system is the most common source of Group A strep bacteremia?
Skin and soft tissue accounts for 90% of the source of Group A strep bacteremia
The extent to which an observation accurately measures what it is intended to measure is???
Validity. This is NOT sensitivity.
How long should a submersion/near drowning injury patient be watched if they are not symptomatic?
8 hours
If the drowning/submersion patient is symptomatic, even with just tachypnea, the what is the right Disposition?
Admit for observation of respiratory status. They are at risk for bronchospasm, pulmonary edema, and acute respiratory distress syndrome. On chest X ray, if they developed ARDS, you would see bilateral alveolar opacities/ground glass appearance
A duration of submersion more than___ minutes is associated with a poor prognosis?
5 minutes
A 3 yr old boy who presents with nystagmus, hypoglycemia, metabolic acidosis and seizure is concerning for what toxicity?
Why does glucagon not work for the hypoglycemia?
Ethanol ingestion
He has exhausted his glucose stores. He needs IV dextrose
A 3 yr old presents with mildly elevated lipase, mildly elevated transaminases and a CT with a duodenal hematoma. This is most consistent with what mechanism of injury?
Inflicted injury
What medication should be used to manage delirium?
Olanzapine
What percentage of children with asthma will continue to have symptoms in adulthood?
50%
What are the signs/symptoms of a black widow spider bite (lactrodectus)?
Begins 1-8 hours after bite: abdominal cramping, nausea, vomiting, chills, urinary retention, priapism, respiratory distress. Antivenom reserved for severe cases.
Supportive care: opiates and benzodiazepines.
What is a Type 1 error in a study?
When you say there is an effect when there isn’t. This is related to your alpha (probability of committing a Type 1 error e.g. 0.05 = p value)
What is a Type 2 error?
Saying there is no effect when there is an effect. Relates to the beta value (typically 0.20). Power = 1- beta
What test do you use when you have two CONTINUOUS variables being compared to each other?
Pearson correlation coefficient
If you have ONE continuous variable and one categorical variable (yes/no - only with two values) what test would you use?
T-test
What test should you use if you have one continuous variable and one categorical variable where the categorical variable can take on more than 2 values?
First use ANOVA, then pairwise t-tests
If you are comparing two categorical variables, the test to use is?
Chi square test
If you have a time variable and a categorical variable (e.g. survival analysis), what test do you use?
Kaplan Meier curves and log-rank tests
If you have a continuous dependent variable (e.g days on HFNC) and want to see how many different variables influence that, what statistical test is needed?
Multivariate linear regression
If you have a categorical outcome (e.g HFNC or not) that you are trying determine the effect of multiple variables on (GA, virus they had etc) then the test to perform is
Logistic regression
If you have survival time and want to see how survival time is influenced by any variables, the test to perform is
Cox proportional hazards regression
What are the tools used in the plan phase of a PDSA cycle?
1) Process diagram - flow chart - helps identify factors.
2) Pareto chart - looking at different factors influencing the process interested in and sort from most influential to least influential and then can draw a line of the cumulative effect size. Helps to decide factor to focus on
3) Fish bone diagram - tries to identify every SINGLE factor that influences outcome - human factors, environmental factors, process factprs etc
From all the above, can create a Key Driver diagram which usually has the specific aim (goal to achieve) of your project on the left and on the right are secondary drivers (things I will do and intervene in). Middle are primary drivers (people and processes determining the phenomenon I am trying to change).
Failure mode analysis - what factors can lead to failure
What does a root cause analysis do?
It looks at how a past failure occurred
There are 3 primary measures in a QI project. What are they?
Outcome measure - exactly what you are trying to change
Process measure - whether or not the components of my change project are happening. Steps to achieve primary aim.
Balancing measure - Unintended outcomes
How do you study your data in a PDSA cycle?
Run chart
What is six sigma? (QI)
Sigma - deviation/variation. You want to keep every process at least 6 standard deviations from failure which corresponds to a failure rate of a couple per million.
The core is data collection, data analysis and tight statistical control and analyses.
What is the LEAN methodology?
This is focused on eliminating waste and done through value stream mapping.
What does the customer want and how do we go through to produce the steps a customer wants and how do we identify waste in each step.
A child with short stature, cafe au lait macules, petechiae and aplastic anemia is concerning for ?
Fanconi anemia which is also associated with hypoplastic or absent thumbs and VACTERL association. It is due to chromosomal breakage and is diagnosed by chromosomal breakage test followed by gene sequencing.
What are the CONTRAINDICATIONS to non invasive ventilation like CPAP/BiPAP or HFNC?
High aspiration risk, upper GI bleed, altered mental status, CPR, upper airway compromise (e.g. burns or epiglottitis)
How is heart failure classified?
What medications are indicated in each stage.
Stages A to D with A being the least affected (aka at risk of heart failure).
Stage B - abnormal cardiac morphology or function but no symptoms - past or present. Give ACE-inhibitor e.g enalapril.
Stage C - structural or functional heart disease with last or current symptoms - Give ace- inhibitor + oral diuretic PRN for fluid overload + low dose digoxin if needed for more symptom relief. After a few weeks of stability, add beta blocker.
Stage D - end stage heart failure - pharmacologic support and mechanical support and/or heart transplantation
Kids who ingest less than 20mg/kg of iron will likely have what symptoms?
Mild GI upset or be asymptomatic
Kids who ingest less than 20mg/kg of iron will likely have what symptoms?
Mild GI upset or be asymptomatic
Kids who ingest 40-60mg/kg of iron will typically develop what symptoms?
Anion gap metabolic acidosis, shock, altered mention, hepatic failure but signs may not develop until 12-24 hours after ingestion. An abdominal radiograph can show ingested iron quantities.
If iron is seen on radiograph, the measure serum electrolyte followed by serum iron level 4-6 hours after ingestion. Levels greater than 500 micrograms/dL usually indicate severe toxicity. These patients should get IV deferoxamine
Which newborns should be seen between 24 and 48 hrs of discharge?
Those with jaundice risk factors, those who had received phototherapy, late preterm or early term newborns, newborns with more than 8% weight loss at discharge.
What are Emanuel’s 4 guiding principles for the allocation of healthcare resources:
1) focus on improving health
2) patients should be informed
3) patients should have opportunity to consent.
4) * conflicts of interest should be minimized
What is the best study to diagnosis a peritonsillar abscess?
Intraoral ultrasound is preferred over neck CT with IV contrast because it reduces risk of thyroid gland irradiation.
Treat with 7-10 days antibiotics.
A 2 year old girl with dark urine for the past week, recent URI, fatigue and has jaundice with scleral icterus with a II/VI systolic ejection murmur best heard over the left sternal border likely has….
Autoimmune hemolytic anemia with a positive DAT/Coombs test.
Warm AIHA: Treatment is with treat the underlying cause, corticosteroids, immune suppression, splenectomy.
Cold AIHA: Treat underlying cause, warm patient, immunosuppression, plasmapheresis
What common complication in pregnancy besides prematurity, low birth weight, intrauterine infection and placental abruption is a risk factor for cerebral palsy?
Pre-eclampsia
Conflict of interest occurs when the validity of study results are influenced by…
Financial gain or personal relationships. Most important way to mitigate this is through disclosure.
How does baclofen work?
It acts centrally binding to GABA receptors.
How does diazepam work?
It centrally binds GABA-A receptors
How does dantrolene sodium work?
It blocks calcium release from the sarcoplasmic reticulum
How does tizanidine work?
It acts centrally as an alpha-2 adrenoreceptor agonist
If a child has HSP/IgA vasculitis with noted 1+ protein in the urine, what’s the most important next step?
Get a random urine protein/creatinine ratio to quantify urinary protein loss and monitor disease progression
Occurs in kids aged 3-15
In a child with spinal Bifida with 3rd febrile UTI, what should be initiated to minimize the risk of UTI?
Clean, intermittent catheterization for neurogenic bladder.
If a patient has a perforated appendicitis then it means that they have viscus rupture that has led to the presence of air in the peritoneal cavity.
True
A neutrophil count less than 500 is classified as ____
A neutrophil count less than 200 is classified as
Severe
Agranulocytosis.
A 4 yr old boy with fever, rash, and arthralgias presents with a prurituc maculopapular rash over the lateral aspects of his hands/feet, urticarial lesions on the flexural aspects of his knees and elbows, erythematous plaques on his lower extremities, some with central clearing. He was recently diagnosed with AOM and has taken amoxicillin for the past few days. What disease does he have? How should he be treated?
He has serum sickness like reaction. Type III hypersensitivity reaction. Onset 7-21 days after exposure or 12-36 hours after re-exposure.
Treat by stopping offending agent and giving NSAIDs, anti-histamines.
if persistent or severe symptoms, give glucorticoids usually tapered over 1 week unless symptoms reappear.
X-linked agammaglobulinemia or Bruton’s agammaglobulinemia is characterized by low B cells and low immunoglobulins which means affected patients are at risk of
Encapsulated bacteria (pneumococcus, pseudomonas, meningococcus, h.flu, staph) and bloodborne viruses (enterovirus family - polio, coxsackie, echovirus)
Treat with IVIG. No live vaccines.
Diagnosis via BTK gene testing. 40% have a family history.
They can have small or absent tonsils.
What is a risk factor for Type 2 DM developing in children?
Low birthweight
How is type 2 diabetes diagnosed?
Symptomatic with random plasma glucose >= 200
Asymptomatic
HgA1c >= 6.5%
Fasting glucose >= 126
Plasma glucose >= 200 after 75g glucose load in OGTT
First line: metformin
A 3 year old with low risk head trauma by PECARN unfortunately gets head CT (normal) and is transferred to a pediatric center for observation. What has occurred.
Overuse
A patient with Crohn’s who is s/p small bowel resection is ready for enteral feed initiation, how is it started?
Continuous NG tube feeds
What is the recommended HgbA1c target to keep kids with T1DM with no risk factors (for hypoglycemia) under?
Less than 7%
In Atrial fibrillation and atrial flutter, you have a narrow complex QRS on EKG but the rhythm is _____
Irregular. Giving adenosine only temporarily switches this to sinus rhythm. Either synchronized cardio version or rate controlling drugs are needed for treatment.
A REGULAR narrow complex tachycardia can only be either ____ or ______
What is the treatment for:
For stable patients
Unstable patients
Atrioventricular re-entrant tachycardia (HR > 180-200 with no p waves) or sinus tachycardia.
Stable patients: vagal maneuvers (valsalva, ice to face, gag). Then adenosine, procainamide, amiodarone or beta blockers.
Unstable patient: adenosine 0.1/kg, synchronized cardioversion 0.5-1.0J/kg
In what age group is acute cerebellar ataxia most common?
1-3 years old
In what age group is acute cerebellar ataxia most common?
1-3 years old
When can a dog bite wound undergo closure with sutures?
When it’s been less than 12hrs anywhere on the body or less than 24 hours on face. (Same as other wounds that can be closed on the body).
When should a cat bite undergo primary closure with sutures?
NEVER for a cat bit wound on body. Can consider primary closure for cat and dog bite if on face. Other wounds that should never be closed by primary closure: puncture wounds, wounds on hands/feet, crush injuries, wounds in immunocompromised children or those with venous stasis. Allow to close by secondary intention (dress it, irrigate it etc)
A platelet dysfunction disorder presents with epistaxis, petechiae, giant platelets and platelets aggregate in the presence of ADP, epinephrine, collagen but NOT ristocetin. Condition is___
Bernard soulier syndrome and results from deficiency of glycoprotein 1B in the platelet membrane. Autosomal recessive. Diagnosis is made by flow cytometry of missing glycoprotein.
What platelet disorder would present with a NORMAL platelet count and would be due to platelet glycoprotein IIb/IIIa fibrinogen complex. Platelet aggregation studies are not affected.
Glanzmann thrombasthenia.
What is the treatment for PSGN?
Supportive. Fluid and sodium restriction. Sometimes thiazide and loop diuretics are needed for fluid overload.
Testing/exam shows: (microscopic or gross) hematuria, hypertension, edema. Low C3 and CH50
Usually occurs 1 to 2 weeks after strep pharyngitis or 3-6 weeks after cutaneous infection.
What form of therapy is best for bulimia?
What medications are best for bulimia?
CBT
Fluoxetine, tricyclic antidepressants, topiramate
In epidermolysis bullosa, what besides dressing changes is recommended to decrease the bacterial colonization burden?
Bleach baths
What has the most significant influence on the yield of a bacterial pathogen from a blood culture specimen?
The amount/volume of blood in the culture bottle
What is the preferred test for an infant born to a HIV positive mother?
HIV qualitative RNA test
A newborn infant is found to have low platelets of 21,000 after persistent bleeding from a heel stick. The diagnosis is neonatal alloimmune thrombocytopenia. What is the management?
Platelet transfusion (and/or IVIG)
In neonatal alloimmune thrombocytopenia, fetus inherits a platelet antigen (1a) from his or her father and mom has antibodies to it. Risks include ICH. Patients who have less than 50K platelets and are symptomatic with bleeding or those with less than 30K platelets who are symptomatic or not should get a platelet transfusion.
If a child is being prescribed a ventilator for home, the home should be …
Inspected for safety and layout as a key part of discharge planning
If a child is being prescribed a ventilator for home, the home should be …
Inspected for safety and layout as a key part of discharge planning. Also TWO caregivers minimum need to be trained on the ventilator.
A 15 yo girl visits the hospital for 2nd opinion RLE pain. Started after an ankle sprain injury and has persisted since then. MRI normal. Evaluated previously by ortho, neuro, rheumatologist. What is the best next step?
Refer to physical or occupational therapy. Her symptoms are concerning for complex regional pain syndrome (cprs).
What’s the acronym for complex regional pain syndrome.
STAMP. S is sensory (allodynia, hypo or hyperalgesia, hypo/hyperesthesia). Trophic changes (skin, hair, nails). Autonomic (swelling, edema, sweating). Motor (weakened, contractures, atrophy). Pain
What are the most common bacterial causes of septic arthritis in an under 3 month old?
Staph aureus, Group B strep, gram negative bacilli and neisseria gonorrhea
At which temp does the basal metabolic rate fall to 50%
Less than 82F
What are the principles of adult learning theory?
Self-directed learning
Transformative learning - refers to the cognitive processes of adults and relies on past experience. Learning goes beyond knowledge and can include a change in perspective or belief.
It does NOT include experiential learning theory (task-driven learning) or social learning theory (observing others).
Though adult learning principles include being self-directed, experienced, ready to learn, being internally motivated, and problem-oriented.
What is the new name for conversion disorder?
What is the treatment?
Functional neurological symptom disorder
First, education about conversion disorder. If that doesn’t work, second line treatment is cognitive behavioral therapy
Which drug is FDA approved to treat agitation in children with autism?
Risperidone (and abilify)
How frequently does binging and purging need to occur to be one of the contributing factors to a diagnosis of bulimia?
At least once a week for 3 weeks
How frequently does binging and purging need to occur to be one of the contributing factors to a diagnosis of bulimia?
At least once a week for 3 weeks
What is the treatment for neuroleptic malignant syndrome? (Can consider in a child recently started on risperidone, reglan or promethazine).
What are symptoms and signs of the illness?
What laboratory abnormalities are present?
Cooling measures and dantrolene. Can also use benzodiazepines or bromocriptine
Fever, altered mental status, muscular rigidity, hypertension
Elevated CK, LDH, LFTs, myoglobin, and leukocytes
If a woman whose pregnancy records are unknown delivers in the hospital, what should be done for the baby with regards to Hepatitis B protection depending on baby’s weight?
Baby should get Hep B vaccine within 12 hours of birth and mom’s hep b surface antigen status should be checked. HBIG is not yet indicated because it should ideally be given in the first 7 days after an infant is born to a hepatitis b surface antigen positive mom.
If baby has a birthweight above 2kg, the above is true.
If the baby has a birthweight below 2kg then HBIG is indicated along with Hepatitis B vaccine within 12 hours if maternal status is unknown.
If a patient who develops lip swelling, hypoxia to 89%, and scratchy throat is given epinephrine and oxygen and recovers, what’s the best next step?
Observation for a biphasic reaction.
If a patient who develops lip swelling, hypoxia to 89%, and scratchy throat is given epinephrine and oxygen and recovers, what’s the best next step?
Observation for a biphasic reaction.
If a patient who develops lip swelling, hypoxia to 89%, and scratchy throat is given epinephrine and oxygen and recovers, what’s the best next step?
Observation for a biphasic reaction.
Is absence of a crematoric reflex always indicative of testicular torsion?
No. Some people have it absent at baseline.
What is the treatment for an isolated diaphyseal femur fracture in children aged 5-11 years?
Flexible intramedullary nailing is recommended FOR DIAPHYSEAL femur fractures in kids aged 5-11.
For younger children aged 5 months to 6 years, spica casting would be an option
Is a 1 month old, ex 37 weeker who experiences a BRUE high risk or low risk?
High risk.
Low risk = normal history and PE, gestational age >= 32 weeks, age > 60 days, post conceptional age > = 45 weeks. Episode less than 1 min and no CPR by a trained professional.
What is the initial management of ITP with non life threatening bleeding?
Glucocorticoids, IVIG, anti-D Ig
What is the initial management of ITP with NON-life threatening bleeding?
Glucocorticoids, IVIG, anti-D Ig
What is the initial management of ITP with NON-life threatening bleeding?
Glucocorticoids, IVIG, anti-D Ig
If bleeding were life threatening, a combination of platelet transfusion, glucocorticoids, and IVIG are used
What is the initial management of ITP with NON-life threatening bleeding?
Glucocorticoids, IVIG, anti-D Ig
If bleeding were life threatening, a combination of platelet transfusion, glucocorticoids, and IVIG are used
In what clinical scenario is fresh frozen plasma transfusion indicated?
Coagulopathy NOT isolated thrombocytopenia
In what clinical scenario is fresh frozen plasma transfusion indicated?
Coagulopathy NOT isolated thrombocytopenia
In what clinical scenario is fresh frozen plasma transfusion indicated?
Coagulopathy NOT isolated thrombocytopenia
A 20 day old infant who underwent a neonatal sepsis rule and had prelim negative cultures at 48hrs, starts to have a blood culture grow at 73 hrs when he is home. He has remained in good health after hospitalization. What are best next steps?
Await speciation and observe.
A 20 day old infant who underwent a neonatal sepsis rule and had prelim negative cultures at 48hrs, starts to have a blood culture grow at 73 hrs when he is home. He has remained in good health after hospitalization. What are best next steps?
Await speciation and observe.
What is most likely to decrease implicit bias in healthcare workers?
Practicing mindfulness. NOT working with diverse population and NOT training on cultural competence or health equity
What is most likely to decrease implicit bias in healthcare workers?
Practicing mindfulness. NOT working with diverse population and NOT training on cultural competence or health equity
What is most likely to decrease implicit bias in healthcare workers?
Practicing mindfulness. NOT working with diverse population and NOT training on cultural competence or health equity
What is most likely to decrease implicit bias in healthcare workers?
Practicing mindfulness. NOT working with diverse population and NOT training on cultural competence or health equity
What is most indicative of SBI in a febrile infant? temp 38.6C or CRP 15mg/L?
CRP 15mg/L is actually normal (it’s reported in a diff unit so above 20 is abnormal).
Temp > 38.5C is a more sensitive marker
Is the RDW high, low, or normal in thalassemia?
How about the red blood cell count?
It is normal.
The RDW is high in iron deficiency
In thalassemia, the RBC count is usually high
Do patients with secondary (central) adrenal insufficiency require mineralocorticoid replacement?
No because their RAAS system is functioning normally
But patients with primary adrenal insufficiency do need it in addition to hydrocortisone, they need fludrocortisone
High IgE levels, eosinophilia, eczema and recurrent bacterial skin infections and/or sinopulmonary infections, and coarse facial features is concerning for
Hyper IgE or Job syndrome. Autosomal dominant. Failure in JAK-STAT pathway which leads to poor neutrophil chemotaxis and poor helper T cell function. They get ‘cold abscesses’ - still infected but lacking usually overt signs
For a febrile NON hemolytic transfusion reaction where patients increase temp by less than 1 degree Celsius, is a blood culture indicated?
No. Just give supportive care with Tylenol and CONTINUE transfusion
When is the risk of VP shunt INFECTION highest?
WITHIN first 6 months of placement
For an emancipated minor who is emancipated by marriage, what evidence must be seen by the clinician in an emergency situation to utilize her medical decision making?
None. She can consent to all procedures on her own.
What type of catheter has the lowest risk of infection among the following: central venous catheter, UE PICC, LE PICC, peripheral inserted midline catheter
Peripheral inserted midline catheter
Glycopyrrolate or Robinul is an anticholinergic drug and can be associated with urinary retention.
Yes. True.
Can treatment of an adolescent for an STI in a pediatric clinic remain confidential?
Not necessarily as it may be revealed on parent’s insurance and will be reported to public health.
But reproductive planning in a Title X funded clinic can remain COMPLETELY confidential
A 9 year old child is burned on her anterior trunk, anterior LUE and posterior RUE. What’s the body surface area percentage that should be used in the parkland formula?
Trunk (anterior or posterior side) = 13% in all ages
Arm (upper - 4% and lower arm - 3%) = 7% in all ages
Lower extremity: One full Thigh (8%) + Leg (5.5%)
Foot - 3.5% in all ages
Infant head (one side) = 9.5%
Adult head (one side) = 4.5%
Palm = 1%
Buttocks = 5% (each buttock is 2.5%)
A 10 year old boy recently immigrated from Guatemala with symptoms of abdominal pain and diarrhea for 2 months has microscopic stool examination with barrel-shaped eggs with smooth, thick walk and hyaline plug on each end. What’s the infection?
Trichuris trichiura - human whipworm. Soil transmitted helminth. Trichuris dysentery can cause IBD like symptoms and present with severe abdominal pain, bloody diarrhea, tenesmus and rectal prolapse. Treatment is albendazole or mebendazole.
What is the official name for pinworms (that cause anal itching symptoms)
Enterobius vermicularis
Voluntary consent is essential for human research is in what document?
Nuremberg code
What does the Belmont Report focus on?
Maximization of possible benefits and minimization of possible harms - respect for persons, beneficence and justice
What product is best for dressing a pressure sore?
Transparent polyurethane film
What acid-base derangement does aspirin cause?
It causes a PRIMARY respiratory alkalosis in the 0-4 hour mark followed by a metabolic gap acidosis
What is metformin intentional ingestion characterized by?
Lactic acidosis (gap metabolic acidosis). Treatment is primarily supportive. Most times, the ingestion is NOT associated with hypoglycemia
A hospital team is trying to decrease their length of stay for healthy febrile infants less than 60 days with a normal preliminary evaluation by 12 hours since their length of stay is above the national
Average. They also want to balance their efforts with the risk of infants with remission for cultures that turn positive. What’s the outcome measure? What’s the balancing measure?
Outcome measure = length of stay
Balancing measure = hospital remission rate
What is transformative learning theory?
It is use of critical reflection to challenge a learner’s beliefs
A 5 yr old patient with poor weight gain and short stature, neutropenia (ANC 600), bony abnormalities, with steatorrhea (pancreatic insufficiency) and recurrent bacterial ear and skin infections is concerning for…
Schwachman-Diamond syndrome. Autosomal recessive inheritance.
What does the nasal nitric oxide test evaluate?
If your cilia are functioning normally in your airways
What is the maximum suction depth for a tracheostomy tube?
No more than 5 mm past the tip of the tracheostomy tube
A child presents with a limp in the setting of thigh pain 2 days ago and it has worsened since. Today he developed a fever and has point tenderness in the proximal femur. What’s his diagnosis?
Osteomyelitis
For my learning: what studies are not accurate from an IO?
WBC, potassium, ionized calcium, AST, ALT, blood oxygenation
For my learning: what studies are not accurate from an IO?
WBC, potassium, ionized calcium, AST, ALT, blood oxygenation
What anticholinergic drug can by used to treat bradycardia?
Atropine
What anticholinergic drug can by used to treat bradycardia?
Atropine
What drug is used to treat SVT if vagal maneuvers fail?
Adenosine
For a medically complex child who has been admitted several times recently for G-tube dysfunction, what could help in preventing readmissions?
Home based services
What is the triad of HUS? What is the treatment?
MAHA, thrombocytopenia and acute kidney injury.
Supportive: IV fluids without overloading, correcting electrolyte abnormalities, transfusing for anemia and initiating dialysis with progression of kidney injury. If there is CNS involvement, can give eculizumab
What are the indications to start dialysis? BUN equal to or greater than 80-100, severe fluid overload and Anuria, as we electrolyte derangements
If a QI committee is planning to downgrade the certainty level of the quality of evidence behind hypertonic saline nebs in bronchiolitis because some studies have shown benefit and others have not, what is the reason
Inconsistency — heterogenous results for the outcome of interest
What does imprecision refer to in studies or QI guidelines grading framework?
It refers to uncertainty about the effects observed in A STUDY. Meaning a very wide confidence interval.
What concept refers to studies that may not be generalizable to the intended patient population?
Indirectness
Under the age of 2, what is a risk factor for poor weight gain? (hint it causes a microcytic anemia).
What is the treatment?
Lead poisoning
Treatment: Oral succimer OR IV EDTA (given after dimercaprol)
What is the cut off of activity for Factor 8 or 9 to have a diagnosis of hemophilia? What coagulation study should be elevated in hemophilia?
What is its inheritance pattern?
Less than 40% activity
Coagulation study: PTT
X-linked recessive
What factors does PT (prothrombin time) measure?
II, V, VII, X, and fibrinogen (I)
What seizure drugs if administered to a patient with seizure disorder can cause phenobarbital TOXICITY?
Valproate OR fosphenytoin OR phenytoin
They decrease the metabolism of phenobarbital leading to increased serum concentrations.
What are the laboratory findings in MAS?
What’s the treatment?
High ferritin, LDH, LFTs, triglycerides
Low ESR, pancytopenia, low fibrinogen
High dose glucocorticoids and cyclosporine/immunosuppressants
A patient with hemophilia doesn’t present until age 11. What does this mean?
They just have a milder factor deficiency
What is the average circulating blood volume in a peds patient?
70-80mL/kg
A 4 yr old boy, 1 week after diagnosis of influenza comes to the ED with fever 39C, stridor, and voice hoarseness. What disease does he have and what bacteria is responsible?
What is the management?
He has bacterial tracheitis (exudative, invasive infection of trachea that occurs in kids under 6 after viral illness), and Staph aureus is the most common
Usually a toxic appearing child. Treat as an airway emergency in OR and use Brad spectrum abx
An 8 year old boy is being treated for hypothermia. At what temperature should IV fluids be administered?
T104F to T111F
An 8 year old boy with bilateral sensorineural hearing loss presents to the ED after syncope that occurred during a fireworks show. His grandfather had hearing loss and had a sudden death. What condition does he have and what is the expected EKG abnormality.
EKG abnormality = long QT interval. The condition is Jervell and Lange-Nielsen syndrome that includes congenital long QT and sensorineural hearing loss. Autosomal recessive.
99%ile for QT for pre-pubertal children is 460ms
A 4yr old girl with CP has R sided hemiplegia and uses a R wrist orthosis but has minimal incorporation of her R hand into coloring and drawing. What intervention would be helpful?
Constraint-induced movement therapy
What are the EKG changes seen with hyperkalemia?
Peaked T wave, widened QRS complex, dropped P wave.
What are the EKG changes seen with hyperkalemia?
Peaked T wave, widened QRS complex, dropped P wave.
A 2 year old boy presents to the ED with 2 days of bloody diarrhea. Family eats raw milk and stool culture show spiral-shaped, curved organisms in a gull-wing formation.
What is the treatment?
Campylobacter Jejuni. Treat with antibiotics (fluoroquinolones or azithromycin) only in SEVERE disease. Most cases are treated with supportive care.
What neurologic medication that is used as an anticonvulsant, can cause kidney stones?
Topiramate - weak carbonic anhydrase inhibitor. Leads to mild metabolic acidosis. This causes decreased citrate in urine which leads to stones.
Other meds like lasix and steroids can also lead to kidney stone formation.
ARDS is characterized by what pathophysiology?
Surfactant inactivation
A periapical ABSCESS (type of dental abscess) is treated with
Antibiotic management and tooth extraction (or antibiotic management and root canal)
Below what grade level should patient education materials be written?
Below 5th grade level (completion of elementary school)
The steps define, measure, analyze, improve and control are part of which QI technique?
Six sigma
A patient who presents with 2 days of paraparesis with urinary incontinence, constipation, can’t move lower extremities, has brisk reflexes in lower extremities and has lost pain/pin prick sensation below the level of T10 has what illness? What’s the imaging modality and treatment?
Transverse myelitis. Spine MRI with and without contrast. Treatment: high dose steroids for 3-5days. If no improvement, can do plasma exchange, IVIG, or immunosuppressants.
What inherited condition is a CONTRAINDICATION to phototherapy?
Porphyria
In what inheritance pattern is hereditary spherocytosis usually inherited? What is seen on smear?
Autosomal dominant
Spherocytes and Howell-jolly body (signify absent or dysfunctional spleen)
Hypoxemia and diffuse pulmonary infiltrates during or within 6 hours of a blood transfusion is concerning for____. Hypotension and fever can also be present.
What’s the mechanism?
Transfusion associated lung injury.
Neutrophil activation against the pulmonary vascular and also, pulmonary edema. No circulatory overload.
Kawasaki disease usually occurs in a child under age 5 years old. In a child who is 6 years old and has had an affected sibling, what is the greatest risk factor?
Family history. Having an affected family member results in 10x likelihood of being affected compared to general public. Twins have a 13% concordance.
What are some antibodies to test for strep?
Anti-DNAaseB antibody, anti-streptomycin antibody, anti-streptokinase antibody, anti-hyaluronidase antibody, anti-nicotinamide adenine dinucleotidase antibody
A SGA infant with microcephaly, hearing loss, salt and pepper retinopathy (pigmentary retinopathy), and hepatosplenomegaly is concerning for?
What is the next step?
Congenital rubella syndrome. Next step: Obtain a CBC to assess for thrombocytopenia and hemolytic anemia. (also LFTs, LP, bone XR). They can also have cataracts or glaucoma.
It can affected any organ system. Some have CHD. Later in life, they have endocrine disease like thyroid disease and DM
What findings do infants with congenital CMV present with?
SGA, microcephaly, hearing loss, hepatosplenomegaly but they present with a CHORIORETINITIS
In most states, what age would a child be considered a mature minor such that they could consent to a transfusion their parents refused?
14 years - but varies state by state and in some states requires judicial determination.
Does scheduled anti-pyretic reduce the risk of febrile seizures in future illnesses?
No. It may make patient feel better.
Which condition has the highest likelihood of developing paroxysmal sympathetic hyperactivity (dysautonomia) after recovery?
Cardiac arrest (> than CNS dx or injury)
What is the main mechanism by which heat is dissipated from the human body?
Evaporation via perspiration
Is Keppra (levetiracetam) associated with SJS/TEN?
yes, but less common. Phenobarbital is more common.
A pt with IVH and GDD, BPD, pulm HTN, AI, and feeding difficulties is admitted for post-op monitoring after G-tube placement. He received stress dose steroids prior to procedure. He suddenly develops hypoxia, hypotension, mild tachycardia and tachypnea. What is the most important med to get him?
Oxygen. He is having a pulm hypertension crisis. Adrenal insufficiency does NOT cause hypoxia.
What are the fetal heart tracing categories? I, II, III
I - Normal
II - intermediate, needs further eval and continued surveillance. reduced or marked variability, tachycardia or bradycardia. Occasional late variable or late decels.
III - requires immediate eval. bradycardia, no variability, recurrent late or variable decels, sinusoidal pattern.
Lyme arthritis is characterized by:
invasion of the synovium inducing a cytokine-mediated pro-inflammatory response.
In a patient with acute osteomyelitis, what should normalize before the transition from IV to oral antibiotics
Absence of fever. (It is not the labs)
A patient is going to require a G-tube. What would favor an endoscopic over a surgical approach?
Respiratory instability with high general anesthesia risk
What do patients with an acute cholecystitis present with?
Fever, RUQ pain, and LEUKOCYTOSIS.
Because the obstruction is confined to the gallbladder, do not present with elevated bilirubin or alk phos. Only biliary duct obstruction presents with that.
In a symptomatic teen (nausea, constipation, weakness, anorexia) with a serum Ca of 14.5, what’s the best next step.
Administer isotonic fluids for Ca >14. Then for long-term therapy: use bisphosphonates because they outlast calcitonin.
Most likely due to hyperparathyroidism or neoplasm.
A 5 month old with dysmorphic features and FTT, develops sat 88% while falling asleep as his overnight feeds are started. He has decreased breath sounds in the R middle and lower lung zones. What is the right next step?
Stop feeds and obtain a STAT CXR to confirm NGT placement.
What is the treatment for an asymptomatic child with hypocalcemia due to hypoparathyroidism?
Oral calcium and Vitamin D. Not PTH replacement hormone therapy (that’s a next step that is not always successful).
What is anti-DNAase antibody associated with?
Recent strep infection
What is anti-smooth muscle antibody associated with?
Auto-immune hepatitis
Anti-dsDNA antibody and anti-Smith antibody are associated with ____?
lupus
What is the acronym for drug-induced Lupus?
HIPPS - hydralazine, INH, Procainamide, phenytoin, sulfonamides
What is the maximal 100% oxygen flow that can be delivered by a low-flow concentration?
5L/min
What are signs of benadryl ingestion?
Flushing, tachycardia, delirium
For tylenol ingestion, what is the threshold at the 4hr mark, where hepatotoxicity is likely to occur – i.e. N-AC is indicated.
Above 150mcg/mL
What prenatal aortic feature predisposes to developing aortic coarctation?
Increased collagen
What is the most common inheritance pattern of SCID?
X-linked recessive or autosomal recessive
An infant who is exclusively formula fed, becomes extremely lethargic, hyperammonemic (93) and has hypoglycemia (38) after 48 hrs from birth. What condition does the infant have and what’s the best next step in treatment?
The mental status change in 48 hrs points to an organic acidemia or urea cycle defect.
In organic acidemia, aberrant breakdown of amino acids leads to an anion gap metabolic acidosis and the metabolites can mildly overwhelm the urea cycle leading to a mildly high ammonia level (i.e. hypoglycemia, acidosis, and mild elev ammonia). Dextrose infusion is the treatment in this condition.
In a primary urea cycle defect, ammonia is usually >100 and the priority is aggressive fluid resuscitation.
In both cases oral feeding should be stopped and protein in particular should be withheld.
What risk factor is associated with avascular necrosis of the femoral head (legg-calve-perthes) disease?
Male sex (4x more likely), usual age is 5-7 years
How does mumps usually present?
URI and unilateral parotitis (edema, erythema but NO discharge), then later, it will be bilateral. Treat with supportive care and expectant mgmt. Symptoms usually resolve over 5-7 days.
A child develops multiple non-blanching macules on his bilateral lower extremities and then his arms and his trunk. His CBC shows normal WBC and Hgb but plt low at 7. He had bleeding gums and a prolonged nosebleed. What is his condition?
ITP
What are Late preterm infants at increased risk of compared to term infants?
Apnea, resp distress, IVH, cerebral palsy. NOT seizures.
What is a normal WBC count for synovial fluid?
<150 - normal
>3000 Inflammatory
>25000-50000 - septic; with >75% PMNs
What is the definition of a high-reliability organization?
An organization that operates in complex, high-hazard domains for extended periods of time without a serious accident or catastrophic failure.
An organization that implements a complex, adaptive system that emphasizes how outcomes emerge from the complexity of the clinical environment is a …
an organization practicing resilience engineering
An organization whose internal data and experience are systematically integrated with external evidence and applies this knowledge into practice is a …
Learning health system
After a seizure and agitation due to cocaine, what’s a good treatment?
Diazepam
What is first-line treatment in managing Crohn’s disease
anti-tumor necrosis factor-alpha medications
What are examples of immunomodulators?
Methotrexate and azathioprine NOT corticosteroids
In a sickle cell patient with evidence of embolic stroke, even with Hgb >7, what should be done?
An RBC tranfusion while awaiting the gold standard which is an exchange transfusion. Aim to raise Hgb level to ~10mg/dL
There is no role for tPA in patients under 18yrs and it may lead to hemorrhagic conversion.
What are the two shockable rhythms in ACLS
pulseless V tach and V Fib
What adverse effect is hydroxychloroquine/plaquenil associated with?
Vision impairment including retinal deposits (pts should get annual opthto exams when on plaquenil)
Hep A vaccine is indicated in kids over 12 months of age as prevention and within 2 wks of exposure as post exposure prophylaxis.
Can do 6 months of age min if traveling internationally.
True
If subspecialist consults at community hospitals are delayed and causing increased LOS etc, what QI tool would be helpful if the hospitalists wanted to brainstorm all the factors that contribute to consultation delays?
Cause and effect diagram (also known as Fishbone or ishikawa diagram)
You can group things under materials, methods, equipment, environment, people
What is the appropriate work-up for a household contact (e.g. sibling) of a child diagnosis with child physical abuse?
If <2, physical exam and skeletal survey.
If >2, history and physical exam
In a study, what is a Type 1 (alpha) error?
One where the null hypothesis is rejected when it is true.
In a study, what is a Type 2 (beta) error?
One where the null hypothesis is not rejected when it is false.
On a receiver operating characteristic curve, what is the y-axis? what is the x-axis?
y axis = sensitivity (true positive)
x axis = 1 - specificity (false positive)
Depersonalization is an aspect of burnout that is characterized by…
Negative or cynical emotions towards patients and families
Emotional exhaustion is an aspect pf burnout when…
There is a perceived depletion of emotional reserve within the physician e.g. no compassion left to give
Pharyngoconjunctival fever is associated with adenovirus and characterized by…
follicular conjunctivitis, fever, pharyngitis, cervical adenitis
What is the antibiotic regimen for PID and when do they need a retest?
ceftriaxone, doxycycline, flagyl and they need a retest in 3 months. 14 days of treatment of doxy/flagyl
OR clinda/gent
or cefoxitin/ceftotetan + doxy
DIHS or drug induced hypersensitivity reaction is DRESS (drug reaction with eosinophilia and systemic symptoms). occurs 2-8 wks after exposure. Associated with fever, LN, rash, organ dysfunction (esp cholestasis and hepatic injury) and eosinophilia. It’s a severe, T-cell mediated drug reaction to AEDs, allopurinol, and antibiotics. Treatment is immune suppression.
Yes
What is the treatment for maple syrup urine disease?
Low protein diet. The amino acids that are elevated are usually leucine, isoleucine, and valine (branched amino acids) and alloisoleucine. Ketones are present in their urine. First step is to give hydration then low protein diet.
A low mixed venous O2 sat should increase concern for in a patient with tachycardia and hypotension is concerning for what type of shock …
Cardiogenic shock. Give a small fluid bolus of 5-10ml/kg and start epinephrine gtt.
