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B
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V
100
Give an example of an indication for ordering a food allergy panel.
Trick questions: NONE!
Only order IgE for foods a child has had hives to.
Don't ever order IgE on a food a child is tolerating. +IgE can show "sensitization" and they could develop and allergy if they stop getting exposed.
Of note: cashew and pistachio have a high cross-reactivity, as do walnut and pecan
100
What percent of NAAT tests for strep are positive in asymptomatic kids?
Throat culture?
20%
12.5%
Don't test unless there is reason to test
UK, Belgium, Netherlands don't test
100
What is the difference between Irritant contact dermatitis and Allergic contact dermatitis?
Irritatant contact derm: Non-specific skin irritation,
Anyone is susceptible.
Repeated exposure to soaps, saliva (babies, lip lickers), friction from clothes/diapers, etc.
Allergic contact derm: type 4 delayed hypersensitivity
Only occurs in susceptible people.
Commonly nickel, adhesive, latex, lotions, plants (lines of blisters).
100
What is the most dangerous FB? What is the special finding on x-ray? What can you tell families to do at home (while rushing to the hospital) for kids >1yo?
Button Battery; double ring; give honey
Esophagus- emergent removal
Stomach and symptomatic- emergent removal
Past the stomach- will pass w/in 3 days
100
What is astigmatism/what is the underlying mechanism of astigmatism?
In astigmatism, the eyeball has an oblong shape, like a football, as opposed to a round shape.
100
What foot fractures do not need to be referred to Ortho?
Salter I, II, or avulsion fx of distal fibula. Brace or Boot (better than casting)
100
What are the 4 stages of a migraine HA?
What is the best tx for migraines if ibuprofen does not work?
What is the best prophylactic medication for migraines?
Prodrome (3 hr-days); Aura (5-60 minutes); HA (4-72 hours); Postdrome (1-2d)
Triptans (>5yo Rizatriptan, >11yo any triptan, zolmitriptan disintegrating tablets)
Anything! Nothing better than placebo, but need to use something (low dose cyproheptadine, nutraceuticals- coenzyme q10, mag, riboflavin)
*Migraine Action Plan
100
What inhaler should kids over 11 years old use for:
rescue? maintenance?
ICS-formoterol (not any other LABA)
100
What physical device enables 57% of kids to wean off medication for constipation?
DPMD- defecation posture modification device aka potty stool--> slightly flexed at the hips instead of 90 degrees.
100
What is estrogen's and what is progesterone's effect on the uterus in the menstrual cycle?
Estrogen increases the lining of the uterus
Progesterone stabilizes the lining.
200
After an episode of anaphylaxis, in the ER what are 2 medications might a child appropriately receive in their management and 1 medication commonly used which is never appropriate?
Another dose of IM epinephrine.
Albuterol for wheezing, 02 for resp distress
Antihistamines can treat ONLY skin sx (hives or angioedema)
Oral steroids are never appropriate.
F/U: what percentage of kids need another dose epi?
200
Why do we treat for Group A Strep?
How effective are treatments?
Decrease transmission: 80-90% effective in 24 hours?
Reduce sx: reduces sx by 1-2 days. (sx generally resolve within 3-5 days without tx)
Reduce risk of Rheumatic fever by 67% (IM PCN is the preferred tx to prevent ARF)
-The yearly incidence of ARF in school aged children in the US is <2/100,000 (poorer communities confers increased risk); India has an incidence of 51/100,000.
200
Why is general good skin care so important in vitiligo, psoriasis, warts and lichen planus?
The Koebner phenomenon- more lesions appear along lines of skin trauma
200
You get a call from a family who is out of town. They went to urgent care because the 2 year old swallowed a coin. They tell you they got an xray.
What do you tell them if the coin is in the esophagus? intestines?
If a coin is in the esophagus and the child is symptomatic--> urgent removal.
If the coin is in the esophagus with mild sx--> observation x 12-24 hours (20-30% pass)
If the coin is past the stomach- it will pass.
200
You have a 7 year old child with ASD and ARFID. They complain that the light is hurting their eyes all the time (no h/o concussion). What is the diagnosis?
Vitamin A deficiency- xerophthalmia (severe eye dryness), aka "Night blindness"
200
Refer or don't refer:
Tibia fx
5th middle phalanx fx of finger
Pubis fx 2 cm
Buckle fracture
Yes- refer all tibia fractures
Yes- refer all finger fractures
No- surgery if >3 cm separation, o/w no need to see ortho
No- removable splint x 3 weeks, normal activity after 4 weeks. (Thick strong periosteum)
200
What is the most important advice to someone after a concussion/what is most associated with sooner recovery?
When are 50% of people recovered? After 4 weeks what percentage are asymptomatic?
Light aerobic exercise, 20-30 minutes per day - exercise bike, light on treadmill, jog, etc.
Sleep is also very important, but not a lot of naps.
50% sx free after 7-10d;
70-80% sx free after 4 weeks
DON'T use mild, moderate, severe
200
Per GINA (Global Initiative for Asthma)
6-11 years old, what inhaler should kids use for:
rescue? maintenance? if they have EIB?
ICS + albuterol
ICS
ICS + albuterol
Any time someone is using albuterol (SABA) they should also use ICS
200
FGID (functional GI disorder) is now known as DGBI.
What does DGBI stand for?
Disorder of the Gut Brain Interaction
200
What is the definition, based on menarchal age, of irregular menses?
When is primary amenorrhea abnormal?
Normal cycles:
<1 year MA: 90+ days between cycles
1-3 years: 12-45 day cycle
>3 years: 21-35 day cycle
Amenorrhea at 15 yo
Amenorrhea 3y post thelarche
300
You have a 9 mo with bad eczema. The eczema seems to get worse when they eat egg, she does not get hives. What do you advise them?
Be more vigilant with the eczema treatment, continue to give her egg (could develop an allergy)
300
A 4 yo presents with acute onset torticollis, drooling, and fever. What is the likely diagnosis?
Retropharyngeal abscess- airway compromise from an infection in a retropharyngeal LN (which involutes at 5yo).
Causes spasm in the muscle next to the LN.
IV abx vs drain the abscess
300
What to do for your 5 year old who just came back from vacation with this rash and why (bonus: what activity were they engaged in):
Phytophotodermatitis
No tx
Using something like limes to make their parents' margaritas.
300
FTT is now known as FW. What does FW stand for?
Instead of using BMI percentile, we should now use what when following FW (and why)?
Bonus: what is the best measurement to use to evaluate FW (that we never use and never will)?
Faltering Weight
Z score because it is better <1%ile and it is linear unlike BMI.
45%ile->35%ile ≠ 35%ile->25%, but
z score 3->2 = 2->1; 0=50%ile, 2=2SD away from the mean
Bonus: Mid upper arm circumference
300
A newborn comes in for their first visit and has this finding:
Infantile glaucoma (enlarged cloudy cornea).
Often with increased tearing, photophobia
300
14 year old football player (lineman) thinks he hurt his knee in a pile up last week. Has been limping for a week. He was seen at urgent care and had a normal x-ray of the knee. His knee exam is normal in the office.
What imaging reveals the diagnosis?
AP and frog leg x-ray of the hips.
SCFE- usually at the end of puberty (less periosteum so less support, but growth plate hasn't closed)
Tx- pinning to prevent avascular necrosis
300
9 yo comes in with his second episode of vomiting in the past 2 months. He could kind of tell it was going to come on. What in the family history helps with the diagnosis? What is the treatment?
FHx migraine.
Cyclic Vomiting Syndrome, N/V q4-6w.
Tx= ondansetron, can use ibuprofen
Prophy: cyproheptadine (or amitriptyline)
300
Per GINA (Global Initiative for Asthma)
≥12 years old, what inhaler should kids use for:
rescue? maintenance? if they have EIB?
ICS-formoterol (not any other LABA)
ICS-formoterol (not any other LABA)
ICS-formoterol (not any other LABA)
300
What would be a typical clean out for a 5 yo?
16 yo?
5 yo: 4 caps of miralax in 32 oz of pedialyte (consumed over 4 hours) and 2 tabs of senna x 2 days
16 yo: 7 caps of miralax in 32 oz of pedialyte or gatorade (consumed over 4 hours) and 2 tabs of bisacodyl QD x 2 days
Don't use red pedialyte/gatorade
*Constipation Action Plan
300
You have a 15 year old come in with vaginal bleeding for 3 weeks. 5-6 pads per day. Occasional tampons. In the office she looks ok, her hemoglobin is 10.5.
What is the treatment for the bleeding?
What do you need to counsel her about with tampons?
COC 1 pill q8 hours until the bleeding stops, then BID x 2 days then QD
(vs COC 1 BID until bleeding stops, then QD)
Don't leave tampons in for more than 4-6 hours due to risk of toxic shock.
400
A 10 year develops a maculopapular rash on day 6 of amoxicillin. There are no hives. What do you put in the chart/what is your next step in consideration of amoxicillin allergy with this child?
Do not consider this a allergy. Only diagnose an allergy with hives.
It is estimated that >90% of people dx'd with amox allergy are not allergic.
And there is no blood test for drug allergies.
400
What is the timing relationship between HFM and onychomadesis?
Nail shedding occurs 4-6 weeks after the infection.
400
In what way are seborrheic dermatitis and Pityriasis (Tinea) Versicolor similar?
Both caused by Malassezia, a yeast that loves sebum from inc androgens (young infant and peripubertal)
Pityriasis (Tinea) Versicolor isn't tinea- Tinea is caused by dermatophytes (more mold-like, as opposed to candida and malassezia which are yeasts)
400
What is the initial basic work up for a child with FW who is otherwise asymptomatic?
None. Base the work up on if there are symptoms (diarrhea, temperature intolerance, etc).
Work ups have a "trivial benefit"
400
What instructions should you give on how to administer inhaled corticosteroids?
What instructions should you give on how to use Neffy?
Angle toward the ipsilateral ear, do not inhale (the medication will then end up in the throat.
"Don't use it. It was tested on normal patients" (not in anaphylaxis, without rhinorrhea- many people have rhinorrhea- during anaphylaxis)
400
8 year old gymnast comes in with back pain at rest and with exercise. Thinks she has had a fever at home. She went to urgent care and had a normal x-ray.
+ localized pain
What is the likely diagnosis?
Osteomyelitis- one key is pain at rest
400
What are the most important micronutrient supplements for NICU premie grads?
What labs need to be done before weaning supplementation?
Iron: 2-3 mg/kg/d for 6-12m (monitor ferritin)
Vit D: 400 IU QD x 1yr (higher for ELBW <1kg)
Ca and Ph: check serum alk phos and Ph 1m after d/c, check qfew months.
Risk of osteopenia especially <32w, <1500g. Consider x-ray of wrist or long bone to eval)
OK to wean to BM (from fortified BM or premie formula) only if growing well, good labs.
400
Per GINA (Global Initiative for Asthma)
<6 years old, what inhaler should kids use for:
rescue? maintenance? if they have EIB?
Rescue: albuterol
Maintenance: ICS
EIB: doesn't really say (SABA + ICS)
400
For someone who won't take miralax, such as a child with autism, what is an alternative that is usually well tolerated?
Dulcolax Soft Chews Kids- give 1/2 chew (600 mg)
400
How many generations of OCPs are there?
What are each used for?
4 generations (based on different progestins and what receptors they bind to)
Use monophasic, minimum 30 mcg estradiol, ok not to menstruate
1st gen- prevent pregnancy [norethindrone]
2nd gen- for heavy periods [levnorgestrel]
3rd gen- for PCOS/acne [norgestimate]
4th gen- prevent pregnancy [drospirinone]
500
Around what percent of children in the US are estimated to have a peanut allergy?
What percentage of children test positive for IgE peanut?
What does it mean if you have Class 5 vs Class 2 level IgE to an allergen.
2.5% (1-5%)
10%
Not much- maybe the likelihood that it is a true allergy. Does not indicate level of possible allergic reaction.
500
What are two in-office tricks that can help distinguish between strabismus and pseudostrabismus?
Shine the light in the child's eyes- will hit the same part of the eyeball.
Squeeze the skin at the bridge of the nose
500
You have a 6 month old only child (not in day care) following up in your office for the 3rd episode of croup successfully treated with oral steroids.
What is the appropriate treatment for the underlying condition, or what physical finding helps with the diagnosis, or where do you refer them to for treatment, or what is the finding on imaging?
Subglottic hemangioma- off center steeple sign. Could find other hemangiomas.
Treated with propranolol by derm.
500
What are two techniques to get a FB out of a nose (other than just grabbing it which it often impossible)?
"Parent's kiss"- blow into mouth, occlude other nostril
Balloon tipped catheter- 5/6 Fr Foley, lubricate, go past the object, inflate slightly and pull out
500
What is the finding and diagnosis in this 7 year old?
Proptosis
Orbital Rhabdomyosarcoma- malignant soft tissue tumor of childhood, most commonly presents at 5-7 years old.
GU (22%), extremities (18%), parameningeal (16%), and head/neck (10%)
500
8 year old gymnast presents with back pain for a few weeks. Feels ok at rest, pain worst with hyperflexion. Doesn't remember a specific injury.
Spondylolysis- fx of vertebral pars interarticularis (a fatigue fracture from overuse, +/- acute injury)
Spondylolisthesis- slip of the vertebral body out of alignment, pressing on another vertebra
500
Name 3 important changes to make to decrease the exposure to plastic nanoparticles (pieces of plastic so small they can get across the blood brain barrier into the brain and across the placenta)?
What to do/not to do:
Do not microwave food/beverages in plastic.
Do not put hot liquids in plastics (including water bottles/baby bottles/sippy cups).
Use wood or bamboo cutting boards as opposed to plastic
Minimize single use plastic bottles.
Limit pouches as much as possible. Aim for maximum 2 per week?
Use as much glass, stainless steel or ceramics to store food.
Use glass or stainless steel water bottles as much as possible.
Tap water is better than bottled water.
When able hand wash plastics, or at least put them on the top rack of the dishwasher.
Avoid non-stick pans
Non-food plastics
If plastics cannot be avoided, especially on toys and food containers, check the symbol on the bottom of plastic containers and avoid the plastics marked 3 (PVC or Vinyl), 6 (Polystyrene), or 7 (Other - can contain BPA).
500
If miralax is not working well enough for a kid with constipation, what is your next step?
What are the best non-oral therapies?
ADD a stimulant laxative like bisacodyl (can't crush the tablets) or senna (plant derived, exlax, can crush/break up).
1) Bisacodyl suppository, 2) Fleets Mineral Oil Enema (there are lots of different kinds of enema, use mineral oil), 3) Transanal Irrigation (used in Europe, esp with spinach bifida)
500
You have a 7 year old with ASD and ARFID who is all of sudden cranky when they try to brush his teeth, doesn't want to walk, and presents with this rash on their legs:
Vitamin C deficiency- (scurvy)
Petechial rash, microcytic anemia, gingivitis, arthritis, mucosal bleeding.
Have every kid with eating issues take a MV with iron
Bonus: what is the best MV to give a kid like this?