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ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
A 10 year old male presents with a 1 month history of fever, weight loss, fatigue and pain in his right thigh. On exam you note painful localized swelling in the area of his right midproximal femur. What is the most likely diagnosis?
A. Osteosarcoma
B. Legg-Calve Perthes Disease
C. Osgood-Schlater syndrome
D. Ewings Sarcoma - ANSWERS-Explanation: Answer C. Ewing's sarcoma tends to involve systemic symptoms such as fever, weight loss and fatigue. It is associated with an increased ESR. It usually involves the diaphyseal portion of the long bones. The most common sites are in the lower body including the midproximal femur and the bones of the pelvis.
Answer A. Legg-Calve-Perthes patients are usually younger (4-8 years)
Answer B. Osgood-Schlatter present with pain and swelling over the tibial tuberosity
Answer D. Osteosarcoma involves tumors in long bones (humerus, femur and tibia). Common in adolescents and young adults.
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QUESTION 2
Gastroenteritis associated with Escherichia coli is associated with which of the following complications?
A. Hemolytic Uremic Syndrome
B. Cholera
C. Failure to thrive
D.. Appendicitis - ANSWERS-Explanation: Answer C. Both Shigella dysenteriae and Escherichia coli (0157:H7) produce an enterotoxin associated with hemolytic uremic syndrome. This syndrome causes: hemolytic anemia, nephropathy and thrombocytopenia.
Answer A. Failure to thrive occurs with giardiasis.
Answer B. Cholera does not cause HUS
Answer D. Appendicitis does not cause HUS
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QUESTION 4
A 3 week old male infant present to the ED with a chief complaint of vomiting x 3- 4 days. His mother describes the vomiting as "shooting out of his mouth." The emesis is non-bilious and non-bloody. His vital signs are stable, his abdomen is slightly distended and he has a firm, small, movable mass below his xiphoid process. His lab work shows: Na 135, K3.5, Cl 86, Bicarb 37, glucose 69. As the PNP you interpret these labs as:
A. Hypochloremic alkalosis
B. Hyperchloremic acidosis
C. Moderate dehydration
D. Nephrotic syndrome - ANSWERS-Explanation: Answer A. Hypertrophic pyloric stenosis (HPS)
Males>females
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Non bilious vomiting - projectile
UGI - "string sign" olive shaped abdominal mass
Visual inspection of abdomen - peristaltic waves from left to right
Weight loss, FTT, dehydration
Labs - hypokalemia, hypochloremia, metabolic alkalosis
Treatment is Surgical consult - non emergent.
Stablilize infant, improve hemodynamics (IVF's) to correct the hypochloremic alkalosis. With vomiting hydrogen ion loss leads to an elevation of serum bicarbonate, followed by a derease in serum cholride and development of hyppochloremic alkalosis
NGT placement controversial - stimulates GI tract secretions
Post op - ready for DC when the infant can tolerate 60ml's x 2 feedings.
Answer B-Hyperchloremic acidosis occurs from a loss of bicarbonate with retention of chloride
Answer C. Moderate dehydration - sodium and potassium levels are within normal limits
Answer D. Nephrotic syndrome - usually diagnosed with serum and urine labs work and includes presence of protein in urine and low protein in the blood
QUESTION 5
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Answer A. If the patient needs surgery, you may offer information on direct blood donation
Answer B. Educate the parents on CHF and probable cause, however reassure them this can be reversed once the PDA is closed
Answer D. Educate the parents cardiac catheterization will only be necessary if the patient qualifies for transcatheter device closure of her PDA
QUESTION 6
What blood product do you administer for altered fibrinogen?
A. Cryoprecipitate
B. PRBC's
C. LR
D. Platelets - ANSWERS-Explanation: Answer B. Cryoprecipitate contains Fibrinogen and plasma
Answer A. PRBC's in packed red blood cells
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Answer C. LR is lactated ringers and is not a blood product
Answer D. Platelets are thrombocytes involved in hemostasis
QUESTION 7
Which of the following antibiotics are the best option for coverage of Pseudomonas aeruginosa positive pneumonia?
A. Ceftazidime
B. Penicillin G
C. Vancomycin
D. Ampicillin - ANSWERS-Explanation: Answer D. Ceftazidime is a third generation Cephalosporin which is active against pseudomonas, a Gram negative bacilli. Its use is indicated for the treatment of patients with infections caused by susceptible strains of Pseudomonas aeruginosa in the lower respiratory tract. It is a broad spectrum beta lactam antibiotic and administered IV. In patients with Cystic Fibrosis, pseudomonas can cause chronic lung infections and shorten their lifespan.
Answer A. Penicillin is effective on Gram + organisms. Pseudomonas is normally resistant to Pencillin
Answer B. Vancomycin in combination with a quinolone can be tried but not vancomycin alone
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B. Dysrhythmias
C. Bleeding especially in females
D. Anorexia - ANSWERS-Correct Answer: Dysrhythmias.
Hemodialysis can cause hypotension, muscle cramping and dysrhythmias during treatment
A, B, C are all examples of complications of peritoneal dialysis.
The difference in myocarditis and pericarditis is:
A. Myocarditis is diagnosed by a myocardial biopsy
B. Pericarditis is treated according to the cause and the type and extent of inflammation
C. Pericarditis is caused by endocarditis
D. Myocarditis requires pericardiocentesis - ANSWERS-A. Diagnostic procedures for pericarditis are similar to those for endocarditis and myocarditis. The age, size and condition of the patient with pericarditis also determine treatment which may include: analgesics, anti-inflammatory drugs, restriction of activity, corticosteroids, and surgical intervention including percardiocentesis
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B. Performing a myocardial biopsy in a patient with suspected myocarditis would allow diagnosis but the procedure is so high risk due to the friability of the myocardium, it is not recommended
C. Myocarditis may be a complication of endocarditis but is usually triggered by a viral infection such as influenza, coxsackie and HIV
D. Pericarditis may require surgical intervention such as pericardiocentesis or removing fluid from the pericardial sac to relieve increasing pressure and diagnose causative agents.
Acute tubular necrosis (ATN) occurs when a hypoxic condition causes renal ischemia that damages tubular cells of the glomeruli so they are unable to adequately filter the urine, leading to acute renal failure. Treatment of ATN includes:
A. Loop diuretics
B. Fluid restriction
C. Antibiotics
D. FFP for coagulopathy - ANSWERS-Correct Answer: Loop diuretics
Explanation: A. Adequate fluid balance is necessary to perfuse the kidneys. Identifying and treating underlying cause is key
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A. Hypospadius
B. Post urethral valve related issues
C. Undescended testes
D. Single kidney - ANSWERS-Explanation: C. Post urethral valve issues are the most common cause of bladder obstruction in pediatric male patients.
A, B, D. None of these GU or renal abnormalities cause bladder obstruction
When doing Pulmonary Function Tests (PFTs), the NP recalls:
A. Asthma is a form of restrictive lung disease
B. Forced expiration is the best indicator of obstructive airway disease
C. Forced expiration is the best indicator of restrictive airway disease
D. A value is considered abnormal if it is less than 50% of your predicted value - ANSWERS-Correct Answer: Forced expiration is the best indicator of obstructive airway disease
Explanation: A. In PFT's, forced expiration is the best indicator of obstructive airway disease. Obstructive disease make the lungs contain too much air and take longer to empty. Changes in lung volumes and capacities are generally consistent with the pattern of impairment. With obstructive lung disease total lung capacity,
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functional residual capacity and residual lung volume increase. With obstructive lung diseases, these decrease.
B. See explanation for A.
C. A value is considered abnormal if it is less than 80% of your predicted value
D. Asthma is a type of obstructive lung disease
A child in the emergency department has point tenderness over the proximal tibia and an appropriate history of trauma. The radiograph show a fracture through the growth plate that extends in to the epiphysis and joint space. This type of fracture would be characterized as:
A. Salter - Harris Type I
B. Salter - Harris Type II
C. Salter - Harris Type III
D. Salter - Harris Type IV - ANSWERS-Explanation: C. Salter - Harris type III is a fracture through the growth plate that extends into the epiphysis and into the joint space. They may require open reduction and fixation.
A. Salter - Harris type I occur along the growth plate
B. Salter - Harris Type II fractures extend into the metaphysis only
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A. Ketones in urine
B. Hypoglycemia
C. Hypercarbia
D. Decreased BUN - ANSWERS-Explanation: C. Diabetic ketoacidosis (DKA) usually exhibits with some combination of polyuria, polydipsia, fatigue, headache, nausea, emesis and abdominal pain. When DKA occurs, ketones are formed in the blood and cleared in the urine.
A. Hyperglycemia is usually present, not hypoglycemia
B. Primary metabolic acidosis with secondary respiratory alkalosis is noted (decreased pH and hypocarbia)
C. Dehydration results in an elevated BUN level. When DKA is present, the patient's total body potassium is depleted from significant potassium loss in the osmotic diuresis. However, serum potassium measurements at presentation may appear high, low or normal.
Your 2 year old patient is intubated and ventilated. He suddenly decompensates, dropping his saturations to 50% and becomes bradycardic to 60 bpm. What is your next course of action?
A. Remove patient from ventilator and hand bag with 100% FiO
B. Order a chest X-Ray
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C. Order a stat blood gas
D. Extubate and re-intubate - ANSWERS-Explanation: D. DOPE mnemonic - displaced, obstructed, placement and equipment. If the patient suddenly decompensates for no apparent reason, TREAT the Patient by using the DOPE mnemonic to ensure there is not equipment related or something obstructing the endotracheal tube.
A, B, C may all need to be done, however rule out mechanical causes of decompensation first.
Your are assessing a 5 year old whose parents say she is having "coughing fits" with a difficult time "catching her breath". She is up to date on her immunizations and has no other significant medical issues. Based on the parent's description of her cough, your differential diagnosis would include:
A. Mycoplasma pneumonia
B. Pneumocystis pneumonia
C. Croup
D. Strep pneumonia - ANSWERS-Explanation: A. A child who is up to date on their immunizations and present with a paroxysmal type cough (characteristic of pertussis), when treated with a macrolide antibiotic usually improve in 3-6 weeks.
B. A child who is not immunocompromised should not contract pneumocystis carinii pneumonia
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D. KUB (kidney, ureter and bladder) abdominal x-ray will not reveal active upper or lower GI bleeding.
A known Cystic Fibrosis patient may need which of the following medications for control of known Pseudomonas infection.
A. Antibiotics
B. Inhaled Tobramycin
C. Recombinant human deoxyribonuclease nebulized
D. Physical therapy and vigorous vibration exercises - ANSWERS-Correct Answer: Inhaled Tobramycin
Explanation: A. Alternating months of regular inhaled tobramycin may be indicated for patients infected with Pseudomonas
B. Nebulized recombinant human deoxyribonuclease breaks down thick DNA complexes present in mucus as a result of cell destruction and bacterial colonization
C. Physical therapy and vigorous vibration exercises are the most fundamental therapies used in CF therapy. These are helpful in mobilizing secretions
D. Antibiotics decrease the production of bacterial toxins, reduce inflammation and curb tissue destruction. Azithromycin has recently been added as a possible immune modifier
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Which of the following patients is at greatest risk for developing sepsis?
Incorrect
A. 5 year old requiring PICC for TPN secondary to ruptured appendix
B. 2 year old with a PICC placed 24 days ago
C. 5 year old patient with PIV placed for dehydration 72 hours ago
D. 2 month old with central line placed < 2 weeks ago - ANSWERS-Explanation: B. PICC's placed in a patient admitted to a PICU for greater than 21 days are at higher risk for developing a hospital acquired infection. The prolonged catheter dwell time can lead to catheter colonization and biofilm formation.
A. Although PIV's pose a risk for infection, short term use is not highly likely to lead to sepsis
C. Infants with central line placed less than 2 weeks are at risk for infection but not as high risk as patients admitted to PICU with PICC line in place greater than 21 days
D. Adolescents with ruptured appendix who need a central line (short term) for nutrition purposes are at risk but lower risk than a patient admitted to a PICU with a PICC in place for greater than 21 days
Two month old male presents with fever of 102F and fussiness. He has decreased urine output, but mild symptoms of dehydration. A full sepsis workup is completed and he needs to be started on antibiotics. Your orders include Ampicillin and
