All subjects Flashcards
Common rash-first few days after birth
Small blotchy erythematous areas with a raised yellow/white center***
May be anywhere, including palms and soles, esp. on trunk
Usually in first week to ten days of life; up to 4 weeks ***
Dissipate without treatment in 5-7 days***
Cause is unknown
Harmless
Biopsy shows eosinophil’s
erythema toxicum
what is moniliasis
beefy red with satellite lesions
diaper rash
use nystatin ointment
3-5% of children 6 mo to 10 yr
Ill-defined, red, pruritic, papules/plaques
Diaper area spared***
Acute: erythema, scaly, vesicles, crusts
the itch that rashes
this is atopic dermatitis (eczema)
Chronic: scaly, lichenified, pigment changes
Cause: unknown; ? combo dry, irritated skin w/ malfunction of immune system; ?genetic basis ?food causes flare
treatment of atopic dermatitis
gets better with steroid cream (topical steroids)
Antihistamines for itching
After showers, moisturize with thick ointments QUICKLY afterwards, don’t wipe completely dry
Vaseline, Aquaphor, Cetaphil, Eucerin, Vanicream
Dove unscented
Abdominal pain, rash on legs (nonblanching and raised), arthritis in ankles
Laboratory tests are usually normal (platelets, complement level, and antinuclear antibodies) except for the urinalysis, which may be positive for blood or protein in 50% of the patients
Henoch shonlein purpura
HSP is a systemic vasculitis** of small** vessels characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks and extremities – palpable purpura***
Patients with HSP limited to the skin and joints can be managed as outpatients. Severe abdominvolvement inal pain, gastrointestinal hemorrhage, intussusception, and severe renal are indications for admission.
what is the most frequent and serious complication of HSP
Renal involvement is the most frequent and serious complication and usually occurs during the first month. It commonly manifests itself as acute glomerulonephritis. Hypertension is uncommon
Still’s murmur?
Still’s: low-pitched sounds heard at the lower left sternal area, “musical.” These most commonly occur between age 3 and adolescence. Low pitched - best heard with the bell of the stethoscope. Can change with alteration of position and then can decrease or disappear with the Valsalva maneuver (valsalve decreases preload) . No clicks are present.
Bounding pulse, murmur Tachypnea Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily poor growth
patent ductus arteriosus
Failure of closure of ductus arteriosus within a few days after birth
Girls>boys
More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions
Small PDAs usu. asymptomatic
5 T’s of cyanotic congenital heart disease
Tetralogy of Fallot
1. VSD 2. Overriding aorta 3. RV outflow obstruction 4. RV hypertrophy
Transposition of the Great Arteries
TAPVR- total anomalous pulmonary venous return
Truncus arteriosus
Tricuspid Atresia
steeple sign
most common cause of inspiratory stridor *** in peds at rest
viral in origin
laryngotracheobronchitis (croup)
subglottic narrowing of the trachea = steeple sign
Coryza 1-2d prior to croupy cough, hoarseness, & stridor
treat with inhaled epi and oral steroids
pt’s that have the bacterial form are WORSE and get intubated
Typically has an abrupt onset of symptoms Typically the school aged child Sore throat Fever Headache GI symptoms: abdominal pain, nausea, and vomiting Poor oral intake NO cough or rhinorrhea!!
strep pharyngitis (no viral symptoms)
Exudative pharyngitis or erythema of posterior orophayngeal mucosa
Enlarged tender anterior cervical lymph nodes
Palatal petechiae
Inflamed uvula
Scarlatiniform rash- little bumps all over
Pastia’s lines- AC fossa
Important cause of chronic cough in toddler***
foreign body
Nasal
Unilateral purulent drainage
Foul smelling
Lower respiratory tract
DDx: recurrent viral infections and asthma
PE and CXR may be unrevealing
Hyperlucency of right hemithorax & shift of mediastinal structures to left on expiration (foreign body in right mainstem bronchus).
Most common cause of diarrhea in young children throughout the world
rotavirus
there is a vaccine for this
how do you treat labial adhesions
Tx: mechanical separation then petroleum ointment to diminish irritation
use estrogen creams (Premarin)- causes atrophy of the tissue and makes it unfused
simple febrile seizure
Lasts a few seconds to 5-10 minutes
Followed by a period of drowsiness or confusion (30 minutes post-ictal)
complex febrile seizure
lasts longer than 15 minutes
In just one part of the body
Occurs again during the same illness.
gower maneuver
duchene’s muscular dystrophy
Progressive degeneration of skeletal muscle
1:3500 male births
X-linked recessive
Early onset, symmetrical, begins w/ pelvic/pectoral girdle involvement
Confined to wheelchair by adolescence
Death from cardioresp. Insufficiency by age 20
Traction apophysitis of tibial tubercle
PE: tenderness/swelling at tibial tuberosity
osgood schlatter disease
M>F
Cause:
Differential rates of osseous & soft tissues
Stress on apophyses by vigorous physical activity
Pain often relieved w/ rest
Duration: 6-24 months
Tx: rest, NSAIDS, cast/splint (if severe)
Steroid contraindicated***
Coxsackie A 16
Painful, shallow, yellow ulcers surrounded by red halos
Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars
Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks
hand foot mouth disease
At risk: preschoolers
Highly contagious
Incubation: 4-6 days
Prodrome: 1-2 days before rash
Low grade fever, anorexia, malaise, sore throat
Oral lesions without the exanthem = herpangina
At risk: school age children (4-10) Season: sporadic Incubation: 4-14 days Infectious: until the onset of the rash Rash on face is characteristic “slapped cheek” appearance***
Erythema infectiousum (5th disease) parvovirus B19
> 50% asymptomatic
Prodrome
Mild fever (15-30%), sore throat, malaise
Dangerous for pregnant women in 1st trimester
Can cause hydrops fetalis***
High fever for 3-4 days
Abrupt drop in fever with appearance of rash
Roseola infantum- human herpes virus 6,7
fussy baby not consolable
rule out meningitis
Begins distally (erythematous, blanching, fine, maculopapular)**
Spreads centripetally & becomes petechial
Often see conjunctival erythema, edema and photophobia w/ rash
Rocky mountain spotted fever
rickettsia
Must treat immediately if suspected
Doxycycline (in all children)
Maculopapular rash beginning on the face and spreading to the trunk and extremities***
meningococcemia
Maculopapular rash beginning on the face and spreading to the trunk and extremities***
meningococcemia
what is a full neuro exam
A “top to bottom” approach: the cortex to the brainstem, the cerebellum, the spinal cord, and the peripheral nerves
- Mental status examination
- Cranial nerves
- Cerebellum
- Strengths
- Deep tendon reflexes
- Sensory testing, as needed
- Gait, if possible
what are the components of a mental status exam
Level of consciousness
orientation
language
attention
memory
executive/intellectual function
non-dominant hemisphere
difference b/w LOC that is lethargic vs. stuporous
- LETHARGIC: Patient prefers to sleep, but will stay awake with minimal verbal or physical stimulation
- STUPOROUS: Patient requires repeated physical stimulation to stay awake
what are some causes of stupor or coma in a pt that was previously alert
something is seriously wrong
- The patient has had a new problem such as a decline in the function of an organ system: CNS, heart, lungs, kidneys, liver
- A new medication has produced an adverse effect
- The bacterial infection has spread to the blood: sepsis
- The patient’s hematocrit, glucose or partial pressure of oxygen has declined, or the partial pressure of carbon dioxide has risen
what is included in orientation
person, place , time
- Not always valuable in localizing brain disease, but traditionally tested in virtually all patients
- May be affected by any of the medical conditions that cause delirium or dementia
what does aphasia mean
• Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years
difference b/w broca’s and wernicke’s aphasia
- BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output
- WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding. No weakness
- Both have ANOMIA, or inability to name objects, and inability to repeat
- Both usually have limitations in writing, AGRAPHIA
what does dysarthria indicate
• DYSARTHRIA, or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth
what are the steps in testing language function
- First of all, listen to patients, beginning with your history taking
- Have patients REPEAT words or simple phrases
- Have patients READ a paragraph
- Have patients WRITE a sentence
- Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
- Have patients NAME some simple objects, such as a pen, a comb, a cup, etc.- dollar bill
- Anomia – inability to name simple things
what is apraxia and why does it occur
- Partial damage to the dominant lobe, resulting in the loss of complex, multi-step actions, such as combing the hair, brushing the teeth, shaving or putting on makeup, or even getting dressed
- Patients cannot carry out these tasks, even though they have sufficient motor and sensory functions to do them
- Likely due to damage to connections between different sites in the cerebral cortex
- Common in stroke survivors and in severely demented people
what is Gerstmann syndrome and what causes it
• Most patients with apraxia have a lesion of the dominant parietal lobe, leading Gerstmann to name a syndrome specifically found from damage to the angular gyrus of the dominant PARIETAL lobe:
- ACALCULIA: Inability to understand numbers or to calculate
- AGRAPHIA: Inability to write
- Inability to distinguish the left and right sides of the patient (or of the examiner)
- Inability to distinguish the individual fingers
how do you test attention
Three easy tests for attention (sometimes called concentration)
- Digit repetition, generally 7 forward and 5 backwards
- Serial sevens, subtracting seven starting from 100
- Read a series of letters, asking the patient to raise his hand when he hears the letter “A”
- Have the patient spell “WORLD” forwards and backwards
The disoriented patient, who can suddenly no longer give you his location or the approximate date or time…
OR:
The inattentive patient, who cannot stick to the subject at hand, fails to do serial sevens, or cannot spell a word forwards or backwards…
may have…
delirium
• Patients with delirium can not reliably be tested for any parts of the MSE beyond attention, or certainly not beyond language
what is delirium
- Now often called ACUTE CONFUSIONAL STATE, or ENCEPHALOPATHY
- There may be agitation (aggressive and dangerous behavior), sometimes hallucinations, tremors, wide fluctuations in blood pressure and pulse rate
- Usually there is hyper-reactivity to environmental stimulation, or at other times, extreme sleepiness
- Suggests in most cases a diffuse systemic problem is affecting large sections of the brain, such as both hemispheres or the entire brainstem
- Often due to serious infections sometimes with sepsis, new medications, impairment of respiration, hepatic or renal function, or a widespread stroke, infection or infections within the brain, or alcohol or narcotic withdrawal
- Localizes to widespread dysfunction of the entire brain
- Patients with delirium can not reliably be tested for any parts of the MSE beyond attention, or certainly not beyond language
- They are too inattentive to understand memory testing, and to recall the words they hear
- Very poor at executive functions, because of lack of concentration, and functions of the nondominant hemisphere
- The physician cannot conclude that a delirious patient has these other MSE abnormalities until the delirium clears
- However, patients with prior dementia are more vulnerable to delirium
anterograde
recent memory
recent memory, or the ability to store new information, up to a few days
retrograde
distant memory
including autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.). Less commonly lost
test by:
Less often tested, mostly for confirming a diagnosis of dementia
Examples:
• 1. When did you graduate from high school?
• 2. When did you get married?
• 3. How many children do you have?*
• 4. When did you retire?
• 5. When did the Vietnam War (or World War II) occur?
• 6. Can you name some recent presidents?
where does memory impairment stem from
• Localizes to BILATERAL medial temporal lobe damage, particularly the HIPPOCAMPUS
how do you test anterograde memory
• Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Memorize your OWN 3 words, and ask them in approximately 3 – 10 minutes. Some patients deserve a second try.
• Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic
Also tested by:
• 1. “How long have you been in the hospital?”
• 2. Giving a patient a brief story to remember, perhaps three or four sentences long
• 3. “What did you have for breakfast (or lunch, dinner)?”
• 4. Hide three objects in your examining room
how do you test executive intellectual function
Recent news events, recalling recent Presidents or the current governor of the state, general fund of knowledge (distances, geography), determining similarities of two objects, the interpretation of common proverbs
what is verbal fluency
testing of executive function
- Ask the patient to name as many members of a category as he can:
- Examples: animals, girls’ or boys’ names, states in the United States, cities in Colorado, things you can buy in a grocery store or an apartment store, or words beginning with the letter A, F, S, etc.
- Most healthy young patients can name 20 or more in one minute, while demented elderly patients will name less than TWELVE in one minute
what does abnormal executive function, judgment and abnormalities in nondominant hemisphere indicate
- These are the indicators of DEMENTIA;
- A more gradual, subtle loss of all of the higher cognitive abilities, which develops over months or years
- Unlike delirium, dementia is usually irreversible
- Patients will lose their memory in most types of dementia, their ability to do the activities of daily life, their social and occupational skills, and ultimately they will be unable to live independently
- As dementias progress over years, the earlier aspects of the mental status exam will also suffer, such as orientation and attention, language, and finally even level of consciousness
what is the non dominant hemisphere responsible for
parietal, temporal, occipital
visual-spatial and construction skills, neglect, music
• Some functions are partly or entirely localized to the right hemisphere:
- Parietal lobe: visual-spatial skills, constructions, awareness of one’s own body or the environment, especially to the left visual field
- Abnormalities suggest a new tumor, stroke or trauma, or part of dementia
- Temporal lobe: loss of musical abilities and a tendency to psychiatric disturbances such as psychosis, depression and bipolar disorder, anxiety
- Occipital lobe: left homonymous hemianopia and prosopagnosia, inability to recognize faces
what is • Anosognosia
the inability to recognize weakness in a patient’s left arm or left leg. If you hand the patient your left arm they will think it’s their arm.
how can you test a lack of constructional skils
- Again, a sign of nondominant (right) parietal lobe damage
- Can be tested by having the patient draw, or copy, simple and then increasingly complicated figures, such as a circle, a square, a cube, a house, or a clock with all of the numbers
- May also reveal hemispatial neglect
- Very much impaired in dementias such as Alzheimer’s Disease
pupil that does not react to light at all
may be caused by blindness, optic neuritis (sometimes due to multiple sclerosis), an optic nerve tumor, or when it is dilated and unreactive, due to Adie’s pupil (polyneuropathy, especially in diabetics)
unilateral significantly dilated pupil
• A unilateral significantly dilated pupil may be due to a lesion of CN III, including herniation of the ipsilateral cerebral hemisphere!
