Monday 26 January 2015
Monday 19 January 2015
How to survive residency in Pediatrics
Hmmm, how do I start this epistle...
I once hated Pediatrics... Yep.. As a medical student, I knew that I will never do my residency in Pediatrics. How can I? My patients don't talk! All they do is cry, eat, poo poo and the process repeats itself again. The older ones are no better since they can't even accurately tell you what is wrong with them... Aaaaaaahhhh!
But when I graduated, got married, gave birth to my first child and went back for my house job.. I decided to do my residency in an area with the least stress.. Pediatrics. You see, I quickly learnt that babies talk well in their own special way... I knew this for a fact because I understood my daughter's needs despite her not saying actual words. Each cry is different, each sound portraying a certain need. I quickly learnt that a baby's cry is much more tolerable than a pregnant woman in labour or a grown man crying from an unbearable pain. Better still, with the knowledge that I will gather in the specialty, I can take better care of my family.
Ladies and Gentlemen, with that noble thought and passion, I delved into to the world of Pediatrics.
MCQs in Growth/development/psychiatric disorders
Ok, I am preparing for my West African exams which will come up in 2 months time!!! Although, I must confess that I am relaxed because I was opportuned by God's special grace to pass my Nationals last year. So, this is my way of giving back, sort of.
All the questions here are from Nelson Pediatrics on the chapters: Growth, Development and Behaviour and Behavioural and Psychiatric Disorders. So, you can attempt to solve this while timing yourself and if you want the answers with explanations, then email me. Best of Luck!
1.Growth is an indicator of
a. Interpersonal stress
b. Chronic disease status
c. Psychological stress
d. Emotional well being
e. Overall well being
2. Choose the correct statement as regards growth and development
a. Neurogenesis in the subventricular zone of the lateral ventricles persists in adulthood
b. The plasticity of the brain continues into adolescence
c. Traumatic experiences can lead to enduring alterations in endocrine/neurotransmitter systems
d. Neurogenesis in portions of hippocampus persists till adulthood
e. At birth, each neuron develops an average of 15,000 synapses by 3 years of age
3. The biopsychosocial model when applied to a child's height includes all the following except
a. Personal eating habits
b. Parents' beliefs
c. Access to food
d. Quantity of food given
e. Genetic endowments
4. Which is a true statement on temperament
a. Personality changes largely result from shared environment
b. Stability of temperament is associated with genetic factors
c. It is relatively resistant to parents' attempt to modify
d. It is biologic or inherited
e. It helps parents understand child's behaviour without guilt
5.Behavioural states in the newborn include
a. Quiet and active sleep
b. Drowsy and alert states
c. Fussy and crying states
d. All of the above
e. Non of the above
6. The visual acuity of a newborn permits recognition of an object held at a distance of
a. 1-2 inches
b. 8-12 inches
c. 15-24 inches
d. 24-30 inches
e. 30-36 inches
7. Temperament
a. There are 9 dimensions
b. There are 3 commonconstellations
c. Genetic differences account for 20-60% of the variability
d. Genetic influences on temperament remains static throughout life
e. It influences parenting styles
8. The response to a ball dropped in front of a 2 month old child is
a. Eyes lowering as ball descends
b. Staring momentarily at the spot at which the ball was dropped
c. Persistence in searching for the ball
d. Crying when the ball hits the groud
e. Smiling at the game of hide and seek
Match the following according to age attained correctly
a. 8 months f. 22 months
b. 2 months g. 12 months
c. 9 months h. 13 months
d 15 months I. 15 months
e. 6 months j. 18 months
9. Build tower of 2 cubes
Object permanance
Thumb finger grasp
Bangs 2 cubes
Builds tower of 6 cubes
Turns pages of books
Speaks 4-6 words
Egocentric symbolic play
Speaks 10-15 words
Monosyllabic syllable
10. Early walking suggests
a. Preoccupation with objects
b. Advanced social development
c. Spasticity
d. Early neuronal maturation
e. Advanced language development
11. The probable age of a child who skips, names 4 colors, dresses and undresses is
a. 15 months
b. 48 months
c. 30 months
d. 18 months
e. 60 months
12. Preschoolers
a. Handedness is determined by the 2 year
b. The number of words of in a sentence is equal to a child's age in years
c. Receptive language varies less in rate of acquisition than expressive language
d. Expressive language has greater prognostic importance than Receptive language
e. Language plays a minimal role in behavioural regulation
13. Assessment of growth
a. Diagnosis of delayed tooth eruption is at 12 months of age (mean +3 SD)
b. The ration of 1 of Upper body to lower body segment occurs at 7 years of age
c. Skinfold thickness is a marker of total fat
d. <70% of ideal body weight is severe wasting
e. 110% of ideal body weight is overweight
14. The following causes delayed tooth eruption is
a. Familial
b. Idiopathic
c. Hypothyroidism
d. Mechanical crowding
e. Hypoparathyroidsm
15. Causes of early exfoliation
a. ALL0
b. AML
c. Histiocytosis
d. Rickets
e. Hypoparathryoidism
16. Which of the following is not true of M-CHAT
a. It is a screening tool for autism in school aged children
b. It may detect language impairment and learning disabilities
c. The AAP recommends screening at 18 months and 24-30 months.
d. It can be used as a sole developmental screen at a well child visit
e. It can detect intellectual disability in some cases
17. Bruxism
a. This is a common tic disorder
b. It begins in the first 5 yr of life
c. May be associated with nighttime anxiety.
d. Can manifest as TMJ pain
e. Treatment include praising the child
18. The following are habit disorder except
a. Breath holding
b. Teeth grinding
c. Stuttering
d. Nail biting
e. Thumb sucking
19. Choose the correct statement on Gilles de la Tourette syndrome
a. It occurs in 4-5 per 10, 000 persons
b. It is 3x more likely in girls than boys
c. It is often co-morbid with OCD and ADHD
d. It is characterised by motor tics and stuttering
e. Coprolalia is characteristically seen in most patient
20. Tics
a. Difficulty in controlling behaviour
b. Is a form of dyskinesia
c. Reduced during mental activity
d. Disappears during sleep
e. Possible occurrence following encephalitis
21. Tics
a. Normal EEG
b. Occurrence of brief transient amnesia after tic
c. Exacerbated by emotional stress
d. Can be inhibited uncounsciously
e. It is a habit disorder
22. The treatment of choice for childhood onset depression with mild functional impairment include all except
a. Monoamine oxidase inhibitors
b. Tricyclic antidepressants
c. Serotonin reuptake inhibitors
d. Benzodiazepines
e. Fluoxetine
23. The true statement is/are
a. Diurnal enuresis is defined as wetting both in the day/night
b. Diurnal enuresis is defined as wetting during the day only
c. Nocturnal enuresis is wetting during sleep only
d. Primary enuresis occurs in one who has never been consistently dry in both day and night
e. Monosymptomatic enuresis is more common than nonmonosymptomatic enuresis
Tis the season of Gastroenteritis
My last daughter just had gastroenteritis. It turned out that so many private outfits are all filled up with cases of gastroenteritis.
A 3 yr old Obese patient with Blount (Idiopathic Tibia Vara)
I was in the children's outpatient clinic when a slim man walked up with his son at my table. I couldn't help but notice how big the boy was. On further scrutiny, I noticed that he walked with a limp and had bow legs but with the left more affected. Suspecting Blount disease, the father gave me an xray having come for a follow up
x ray
Now convinced that he had blount
Sunday 11 January 2015
Respiratory distress syndrome
Not too long ago, we had a case of Respiratory distress syndrome in a VLBW baby which sadly didn't end well. On reviewing the case, I wondered what might have been done differently.
This was a 28 wk GA VLBW baby brought in about 2 hrs after birth with respiratory distress. The mother had not attended any antenatal services. Initially the mgt was geared towards managing a preterm baby and possibly sepsis, the usual, with oxygen instituted but after about a week or so on admission, was still in distress, even more so, with reducing oxygen saturation despite been on oxygen. At this point, we entertained RDS as a possible diagnosis.
We couldn't carry out any investigations since JOHESU are on strike. But then again, what possible investigation can one do to confirm RDS in our setting in a week old neonate? A CXR in that critical state to reveal a fine reticular granular appearance (ground glass) plus air bronchogram (cos of the aerated bronchioles meeting the collapsed alveoli) and poor expansion is not pathognomonic of it since a Gp B strep pneumonia will show a similar picture. We don't do blood gases to detect acidosis, low PaO2 and high PCO2 and already our pulse oximeter had showed a poor oxygen saturation earlier. So, we settled for clinical diagnosis evidenced by Progressive signs of respiratory distress and physical signs of prematurity. Now, coming to the management and the reason I shared this case scenario. Asides from carrying out the usual mgt of caring for a preterm ie taking care of hypothermia, hypoglycemia, electrolyte disturbances etc. It is advocated to give surfactant via an endotracheal tube a few hours after birth prophylactically or some days later as early rescue.
Sadly, since this is largely unavailable and expensive in our environs, the primary therapeutic modality for RDS in now tending towards Continuous Positive Airway Pressure(CPAP) to be specific BUBBLE CPAP for poor settings.
Bubble CPAP is appealing because of its simplicity and low cost. It is also associated with a decreased incidence of bronchopulmonary dysplasia (BPD) compared to mechanical ventilation. It has been demonstrated to lead to a marked reduction in respiratory distress syndrome mortality. CPAP keeps the alveoli open at the end of expiration, decreasing the right-to-left pulmonary shunt.
Tinea Versicolor
My daughter just recovered from tinea versicolor after about 3 WEEKS OF THERAPY! As I write this, the lesions are still there although repigmentation has begun. I am positive that in a matter of days, the lesions will disappear.
It all started when i noticed some hypopigmented annular skin lesions on the bridge of her nose with slightly raised borders and non-itchy.
I made a diagnosis of tinea versicolor.
So, having combed through the books on management, I gave oral itraconazole bd for 5 days first for convenience sake since I read that the topical therapy will need to be applied for about 3 weeks and I wanted to avoid that stress. I had deliberately avoided giving oral ketoconazole since I read again that it has been banned as an over the counter drug and first line therapy due to its predisposition to lead to hepatoxicity in susceptible patients. I remember this by noting that ketoconazole starts with k for kill.
The books say that oral itraconazole therapy given over 5 to 7 days will lead to a cure in over 90% of cases of course evidenced by the abscence of the typical meatball and spaghetti appearance after scraping and using the KOH preparation.....
Well, i was all too willing to "Believe" in the cure and wait for the repigmentation stage to begin after I was through with the oral therapy rather than go through the process of confirming the cure. 5 days later after treatment , I was still waiting for the repigmentation to begin and then I became concerned. On consulting the book and online sites yet again, I discovered that it can take weeks for the lesions to disappear... WEEKS!!!
Of course, despite giving lots of explanations to my family on why we need to wait, they wanted any kind of topical therapy to be instituted not believing that any cure had been achieved, who can blame them... I wasn't even sure myself. And so while researching on the go to topical therapy, I learnt that I can use selenium sulphide, the popular shampoo used for dandruff, topical terbinafine, itraconazole and ketoconazole. I opted for Nizoral( topical ketoconazole) and selenium sulphide.
I was worried dt it might spread to her siblings but that fear was allayed when I read that it wasn't contagious.
So, that was my ordeal with Tinea versicolor, a chronic skin condition, that is non-contagious, not associated with bad hygiene and might take weeks to heal despite obeying instructions.
Almost forgot, a concerned parent proceeded to tell me that it was poor hygiene that led to my child having the lesions and advised me to keep scrubbing at it to elicit a cure. Well, I thanked her and then educated her on what TINEA VERSICOLOR was all about...
