Aquifer 2 Flashcards
1
Q
List the general components of a well-child visit.
A
- Interval history
- Diet history
- Family history
- Social history
- Physical exam, including measurements and vision and hearing screenings (growth chart)
- Assessment of behavior and development
- Immunizations and lab screening
- Anticipatory guidance
2
Q
What developmental screening recommendations does the AAP make?
A
Developmental screening with a validated tool at 9-months, 18-months, and 30-months; specific autism screening is recommended at 18-months and 24-months
3
Q
If exclusively or partially breastfeeding, what supplementation should be given soon after birth?
A
400 IU vitamin D
4
Q
Caloric requirements for 1-2 month olds (term, preterm, very preterm).
A
Term - 100-120 cal/kg/day; average daily weight gain is 20-30g
Preterm - 115-130 cal/kg/day
Very preterm (<32 weeks) - up to 150 cal/kg/day
5
Q
Discuss car seat safety.
A
- Face rearward until age 2; after age 2/outgrowing weight/height limits on their car seats should be in a forward-facing car seat in the back seat
- Stay in a booster until 4’9”; children under 13 should not sit in the front seat
- Most effective car seat restraint is a 5-point harness
6
Q
Most healthy infants will double their birth weight by ___ and triple it by ___. Most children will reach double their birth length by ___.
A
4-5 months; 1 year; 4 years
7
Q
DDx - RUQ mass and pallor in a 9-month-old infant
A
Hepatic neoplasm, hydronephrosis, neuroblastoma, teratoma, Wilms’ tumor (nephroblastoma)
8
Q
What is the most frequently diagnosed neoplasm in infants?
A
Neuroblastoma (50+% present before age 2)
9
Q
Neuroblastoma may present as a painless mass in what areas of the body? Presenting symptoms also include fever, pallor, and weight loss.
A
Neck, chest, or abdomen
10
Q
When is a neuroblastoma a likely diagnosis in an infant younger than 1?
A
Asymptomatic RUQ abdominal mass and pallor, and no jaundice
11
Q
Median age of diagnosis of Wilms’ tumor?
A
3 years
12
Q
Presentation of Wilms’ tumor?
A
Asymptomatic RUQ abdominal mass (generally smooth, rarely crosses the midline), no lymphadenopathy or jaundice; associated symptoms occur in 50% of patients (abdominal pain, N/V, hypertension)
13
Q
Purpose of a CBC with differential in working up an abdominal mass?
A
Anemia, cytopenia (BM infiltration)
14
Q
What lab test is highly specific and sensitive for neuroblastoma?
A
Catecholamine metabolites (VMA and HVA)
15
Q
What is the best choice for a first imaging study working up an abdominal mass?
A
Ultrasound - can identify a mass, show organ of origin, and determine if a mass is solid, cystic, or both
16
Q
If a lesion is purely cystic, what lab test is not needed?
A
CT
17
Q
What is the prognosis of stage 4S neuroblastoma?
A
In infants less than 1 year of age, these tumors may spontaneously regress due to the unique nature of this tumor derived from embryonal cell lines
18
Q
Is neuroblastoma a familial illness?
A
There are familial forms, but this accounts for only ~1% of cases (AD and low penetrance); most cases are due to somatic mutations
19
Q
Describe the timing of vision and hearing screening in children.
A
Hearing - newborn, audiometry at age 4
Vision - screening with chart at 3
Between birth and 3, ask parents about concerns
20
Q
What is sometimes referred to as “the itch that rashes”?
A
Cycle of irritation that leads to scratching, leading to rash
21
Q
DDx for eczema (atopic dermatitis)?
A
Psoriasis (rare in young children, often precipitated by a strep infection)
Seborrhea
22
Q
How is eczema treated in young children?
A
Protect skin by lubricating extensively, use anti-inflammatories in short bursts, treat associated skin infections aggressively
23
Q
Medications used to treat eczema?
A
- Steroids (topical, alternate high and low potency); OTC inadequate
- Topical anti-inflammatories (calcineurin inhibitors) - second-line due to safety concerns with long-term use
- Antihistamines - can help with itch; use non-sedating
24
Q
Define weight age and height age.
A
Weight age - age at which the patient’s weight would plot at the 50th percentile (ditto for height)
25
List topics for anticipatory guidance at the 2-month visit.
1. Solid foods (4-6 months)
2. Vitamin D (400 U/day up to 12 months)
3. Child care
4. Sleep - most babies sleep through the night by 4-6 months; sleep on back in crib on a firm surface without soft objects in parent's room for first year of life
5. Safety (avoid smoking around the infant, chocking/suffocation hazards, etc.)
26
List topics for anticipatory guidance at the 6-month visit.
1. Toddler-proofing the house (crawling and walking)
2. Car seat placement (back seat, rear-facing)
3. Use of walkers - AAP does not recommend
4. Dietary - introduce new foods one at a time; babies do not need juice; solid foods should be soft and easy to swallow
27
List topics for anticipatory guidance at the 5-year visit.
1. Nutrition
2. Physical activity - 60 minutes of physical activity/day; limit screen time to 2 hrs/day
3. Oral health
4. Sexuality education - expect normal curiosity of genitalia and sex, explain good touch/bad touch and that certain body parts are private
28
Why is iron critical to normal development?
Due to its role as a CNS co-catalyst
29
Recommend that parents discontinue a bottle by age ___.
12-15 months
30
Core symptoms of ADHD?
Inattention, hyperactivity, impulsivity
31
Prevalence of ADHD?
8-10%; most common neurobehavioral disorder of children in the US
32
ADHD is not usually diagnosed until a child is at least ___ years old.
6
33
Describe how to elicit the cremasteric reflex.
Lightly stroking or pinching the superior medial aspect of the thigh leading to brisk ipsilateral testicular retraction
34
What does absence of the cremasteric reflex indicate?
Sensitive but non-specific finding for testicular torsion (can be absent in normal testes)
35
What is the blue dot sign and what does it indicate?
Small blue discoloration over an area of tenderness of the upper pole of the testis; suggests APPENDICEAL torsion of the testes
36
What is the Prehn sign and what does it indicate?
Physical lifting of the testicles; if it relieves pain (positive), it suggests epididymitis. If not, it suggests testicular torsion
37
List 4 possible causes of testicular torsion.
1. Congenital anomaly
2. Undescended testes
3. Recent trauma or vigorous exercise
4. No apparent reason
38
What is a bell clapper deformity?
A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis, leading to free swinging/rotating of the testis within the tunica vaginalis of the scrotum and possible torsion
39
Discuss the viability of a testis in torsion based on the duration of torsion.
6 hours - 90%
>12 hours - 50%
>24 hours - 10%
40
What is the most common cancer affecting males age 15-35?
Testicular cancer
41
What are some presenting symptoms of testicular cancer?
Nodule, painless swelling of the testicle, dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum area; acute pain (10% of cases)
42
What is the most common testicular tumor?
Germ cell tumor
43
What genetic disease is associated with a higher incidence of germ cell tumors?
Klinefelter's syndrome (47XXY)
44
Patients with cryptorchidism have a ___ increased risk compared with their normal counterparts.
20-40x
45
True or false - prior trauma, elevated scrotal temperatures, and recurrent activities like horseback riding are related to the development of testicular tumors.
False
46
List the three types of testicular tumors.
1. Germ cell tumors
2. Non-germ cell tumors
3. Extragonadal tumors
47
What is the most common type of testicular tumor and how are they classified?
Germ cell tumors (95%)
Seminomas (45%)
Nonseminomatous (50%)
48
List the types of nonseminomatous germ cell tumors.
1. Embryonal cell tumor (pure-cell) - 20%
2. Mixed GCTs - 40%
3. Teratomas and teratocarcinomas - 30%
4. Yolk sac tumors
5. Choriocarcinoma - 1%
49
What are the most common prepubertal germ cell tumors?
Yolk sac tumors (endodermal sinus tumors)
50
List the types of non-germ cell tumors.
Leydig cell tumors and Sertoli cell tumors
51
What are the most common malignancies to metastasize to the testicle?
Lymphoma, leukemia, melanoma
52
What are the three general steps of a scrotal exam?
1. Inspection (erythema, swelling, discoloration, skin integrity, position)
2. Palpation
3. Transillumination
53
If testicular torsion is manually corrected, what must still be performed and why?
Orchiopexy to fix the testes to prevent retorsion
54
What are the two methods used to diagnose testicular torsion and how do they compare?
1. Color Doppler U/S - 88% sensitivity, 90% specificity; faster, more available
2. Radionuclide scintigraphy - 100% sensitivity
55
DDx - Groin Pain in an Adolescent
Most likely - trauma, testicular torsion, torsion of the appendages, epididymitis
Less likely - inguinal hernia, hydrocele, HSP, testicular tumor, varicocele, referred pain
56
Presentation of testicular trauma?
Acute pain and swelling of the scrotum and its contents
57
The majority of cases of testicular torsion occur between what ages?
12-18 years
58
Presentation of testicular torsion?
Scrotal, inguinal, or lower abdominal pain which usually begins abruptly; pain is severe
PE - swollen, tender scrotum; absent cremasteric reflex
Can occur several hours after vigorous physical activity or minor testicular trauma
May have associated N/V
59
Torsion of the testicular appendages (small vestigial structure, remnant of Mullerian duct located on the anterosuperior aspect of the testis) occurs most commonly in what age group?
Younger patients, age 7-14 years
60
Presentation of torsion of the testicular appendages?
Abrupt onset of pain typically less severe than in torsion, localized to the region of the appendix testis without any tenderness in the remaining areas; may have a blue dot sign
61
What is the most frequent cause of sudden scrotal pain in adults?
Epididymitis
62
Presentation of epipidymitis?
Slowly progressive symptoms over several days; patient may appear comfortable except when examined; severe swelling and exquisite pain on the involved side, often accompanied by high fevers, rigors, and irritative voiding symptoms; may have had preceding symptoms suggestive of a UTI or STD
Cremasteric reflex is usually present; testes is in its normal location and position
63
Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on exam may be suffering from ___.
Referred pain to the scrotum
64
What three somatic nerves cause scrotal pain?
Genitofemoral, ilioinguinal, posterior scrotal nerves
65
Why do varicoceles occur more commonly on the left side (85-95%)?
The left spermatic vein enters the left renal vein at a 90 degree angle; the right drains at a more obtuse angle directly into the IVC, facilitating more continuous flow
66
Varicocele is associated with ___.
Infertility (1/3 of all males presenting to an infertility clinic have a varicocele)
67
What is the most common cause of painless scrotal swelling?
Hydrocele
68
An indirect inguinal hernia develops as a result of a persistent ___. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located midway between the pubic symphysis and the anterior iliac spine. It courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.
Process vaginalis;
69
A direct inguinal hernia usually occurs due to a defect or weakness in the ___ area of the Hesselbach triangle.
Trasversalis fascia
70
What are the components of the Hesselbach triangle?
Inferiorly - inguinal ligament
Laterally - inferior epigastric arteries
Medially - conjoint tendon
71
An inguinal hernia is a painless swelling in the inguinal region, which can be enhanced by maneuvers that do what?
Raise intra-abdominal pressure (cough, Valsalva maneuver)
72
What are the ages at which developmental milestones are assessed?
```
2 months
4 months
6 months
9 months
12 months
15 months
18 months
24 months
3 years
4 years
5 years
```
73
What are the 4 domains in which developmental milestones are assessed?
1. Gross motor
2. Fine motor
3. Communication/social
4. Cognitive/adaptive
74
What are the developmental milestones for a 2-month-old?
1. Gross motor: lifts head/chest when prone
2. Fine motor: eyes track past the midline
3. Communication/social: social (reciprocal) smile, alerts to sound
4. Cognitive/adaptive: recognizes parent
75
What are the developmental milestones for a 4-month-old?
1. Gross motor: rolls front to back
2. Fine motor: grasps a rattle
3. Communication/social: laughs, soothed by a parent's voice
4. Cognitive/adaptive: orients head to direction of a voice
76
What are the developmental milestones for a 6-month-old?
1. Gross motor: sits with no/little support [no head lag when pulled to sit from supine]
2. Fine motor: reaches with one hand, transfers objects [looks for dropped items]
3. Communication/social: babbles, developing stranger anxiety
4. Cognitive/adaptive: feeds self
77
What are the developmental milestones for a 9-month-old?
1. Gross motor: pulls to stand
2. Fine motor: developing immature pincer grasps, bangs 2 objects together
3. Communication/social: says "mama" and "dada" indiscriminately, waves bye-bye
4. Cognitive/adaptive: plays gesture games (pat-a-cake)
78
What are the developmental milestones for a 12-month-old?
1. Gross motor: stands/walks alone
2. Fine motor: fine pincer grasps
3. Communication/social: mama/dada + 1 word, follows one-step commands with a gesture
4. Cognitive/adaptive: points to get a desired object [hands parent a book, plays ball with examiner]
79
What are the developmental milestones for a 15-month-old?
1. Gross motor: stoops and recovers
2. Fine motor: scribbles in imitation
3. Communication/social: uses 3-5 words
4. Cognitive/adaptive: uses a spoon and a cup, turns pages in a book
80
What are the developmental milestones for an 18-month-old?
1. Gross motor: runs well
2. Fine motor: builds a tower of 3 cubes
3. Communication/social: points to 1-3 body parts
4. Cognitive/adaptive: "helps" in the house
81
What are the developmental milestones for a 24-month-old?
1. Gross motor: throws a ball overhand, kicks a ball
2. Fine motor: copies drawing a line with a crayon
3. Communication/social: speaks in 2-word combinations; 50+ word vocab, parallel play
4. Cognitive/adaptive: removes an article of clothing
82
What are the developmental milestones for a 3-year-old?
1. Gross motor: pedals a tricycle
2. Fine motor: copies a circle [builds tower of 6-8 cubes]
3. Communication/social: 75% of speech is intelligible to a stranger; 3-word sentences
4. Cognitive/adaptive: brushes teeth with help
83
What are the developmental milestones for a 4-year-old?
1. Gross motor: hops [on one foot, balances for 2 seconds, pours/cuts/mashes own food]
2. Fine motor: copies a square or cross
3. Communication/social: 100% of speech intelligible to a stranger, plays cooperatively with a group [knows gender and age, friendly to other children, plays with toys, engages in fantasy play, states first and last name, sings a song, plays board games]
4. Cognitive/adaptive: knows 4 colors
84
What are the developmental milestones for a 5-year-old?
1. Gross motor: skips [balances on one foot, ties a know, mature pencil grasp]
2. Fine motor: copies a triangle [draw a person with >6 body parts, print some letters and numbers]
3. Communication/social: defines simple words [listens and attends, can tell the difference between real and make-believe, shows sympathy/concern for others, articulates well, uses appropriate tenses/pronouns, counts to 10, follows simple directions]
4. Cognitive/adaptive: dresses self
85
List the gross motor developmental milestones for all ages.
```
2 months - lifts head/chest when prone
4 months - rolls front to back
6 months - sits with no/little support
9 months - pulls to stand
12 months - stands/walks alone
15 months - stoops and recovers
18 months - runs well
24 months - throws a ball overhand, kicks a ball
3 years - pedals a tricycle
4 years - hops
5 years - skips
```
86
List the fine motor developmental milestones for all ages.
2 months - eyes track past midline
4 months - grasps a rattle
6 months - reaches with one hand, transfers objects
9 months - developing immature pincer grasps, bangs 2 objects together
12 months - fine pincer graps
15 months - scribbles in imitation
18 months - builds a tower of 3 cubes
24 months - copies drawing a line with a crayon
3 years - copies a circle
4 years - copies a square or cross
5 years - copies a triangle
87
List the communication/social developmental milestones for all ages.
2 months - social (reciprocal) smile, alerts to sound
4 months - laughs, soothed by a parent's voice
6 months - babbles, developing stranger anxiety
9 months - says "mama"/"dada" indiscriminately, waves bye-bye
12 months - 1 word other than mama/dada, follows one-step commands with a gesture
15 months - uses 3-5 words
18 months - points to 1-3 body parts
24 months - speaks in 2-word combinations; 50+ word vocab, parallel play
3 years - 75% of speech intelligible to a stranger, 3-word sentences
4 years - 100% of speech intelligible to a stranger, plays cooperatively with a group
5 years - defines simple words, uses 5-word sentences
88
List the cognitive/adaptive milestones for all ages.
2 months - recognizes parent
4 months - orients head to direction of a voice
6 months - feeds self
9 months - plays gesture games
12 months - points to get desired objects
15 months - uses a cup and a spoon, turns pages in a book
18 months - "helps" in the house
24 months - removes an article of clothing
3 years - brushes teeth with help
4 years - knows 4 colors
5 years - dresses self
89
What is the most common gait variation in toddlers?
Intoeing caused by tibial torsion in toddlers (patella faces straight ahead, foot turns inward, resolves naturally with weight bearing by 4); caused by femoral anteversion in preschool/school-aged children (both feet and knees turn inwards, usually resolves by 8-12 years)
90
True or false - absorption of lead is higher in younger children than older children and adults.
True
91
True or false - iron deficiency decreases lead absorption.
False - it increases lead absorption
92
List common sources of exposure to lead
House paint used before 1978 and especially before 1960
Soil, plumbing/pipes, hobbies/occupational exposures, imported toys/ceramics/candy/cosmetics, folk remedies
93
What are the recommendations for screening children for lead poisoning?
All children 12-24 months old in areas where >25% of housing was built before 1960 or where the prevalence of blood lead levels are >5 mcg/dL in children is 5+%, individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated in the past 6 motns
94
Which children should be screened for anemia?
Age 12 months, at preschool/kindergarten entry (period when diet is often in flux) + any risk factors
95
True or false - signs and symptoms of primary pulmonary TB in most children are few to none.
True (>50% of infants/children with radiographic evidence of disease have no physical findings)
96
Who should get an annual TB skin test?
Those infected with HIV, incarcerated adolescents
97
Most common side effect of ADHD medicine?
Appetite suppression; weight loss, if any, is typically minor
(Insomnia is another common side effect; dose-related; typically worse in the first few days)
98
Is there a concern for decreased growth velocity as an AE of ADHD medication?
Slight decrease in the range of 1-2cm may occur, particularly in children who were on higher and more consistent doses; effects diminished by the 3rd year of treatment
99
DDx - school failure
Sensory impairment, sleep disorder, mood disorder, learning disability, conduct disorder
100
Patients with ADHD often have poor sleep hygiene, but typically do not seem ___.
Overtired
101
What is a learning disability?
Disorder of cognition which manifests itself as a problem involving academic skills
102
List some red flags for a learning disability.
History of maternal illness or substance abuse during pregnancy, complications at delivery, history of meningitis/other serious illness/serious head trauma, parental history of learning disabilities/difficulty at school
103
What psychiatric condition has the highest comorbidity rates with ADHD?
Conduct disorder
104
The probability of childhood obesity persisting into adulthood increases from ___% at age 4 to ___% by adolescence.
20; 80
105
What are the BMI categories for children?
Healthy weight - 5th to <85th percentile for age
Overweight - 85th to <95th percentile for age
Obese - >95th percentile for age
106
List some complications of obesity in children and adolescents.
1. Sleep apnea
2. Dyslipidemia
3. HTN
4. Slipped capital femoral epiphysis (SCFE) and Blount's disease (bowing of the legs)
5. Diabetes mellitus type 2
6. Steatohepatitis, steatosis, gallbladder disease
7. Metabolic syndrome
107
What is the recommended screening for hypercholesterolemia in children/adolescents?
Check a fasting lipid profile on every child with a BMI of >85% or those with a family history of high cholesterol
108
What is the goal total cholesterol and LDL for children?
Total - 170
| LDL - 130
109
When should children be treated with medication for hypercholesterolemia?
LDL>190 or >160 with risk factors + children >10 years and who are in Tanner stage 2 or have achieved menarche
110
What are the guidelines for screening children for DM2?
Beginning at age 10 or onset of puberty (whichever is earlier)
Screen if overweight + any of the following 2 factors:
Family history of DM2 in a first or second degree relative, race/ethnicity (non-white), signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, PCOS, HTN, dyslipidemia), or maternal history of DM or gestational DM during the child's gestation
OR
Obese without risk factors
Screen every 2-3 years
111
What is the first stage of pediatric weight management?
Prevention plus - if no improvement after 3-6 months, use 5-2-1-0 counseling: 5 servings of fruits and vegetables, 2 hours of screen time, 1 hour of physical activity, 0 sugar-sweetened beverages + family meals, healthy breakfast, allow children to self-regulate meals
112
What is the second stage of pediatric weight management (for children who have had no improvement on prevention plus/after 3-6 months if no improvement for all children with BMI >95)
Prevention plus + the following:
Reduce energy-dense foods
Structured meals (plan 3 meals a day and 1-2 healthy snacks and no other food)
1 hour of screen time
Diet and activity monitoring for 3-6 months
Monthly office visits
Additional support by dietitian, counselor, exercise therapist as needed
113
What is the third stage of pediatric weight management for children ages 2-5 (>95th %) or 6-18 (95-99th %)?
Steps 1+2 + referral to multidisciplinary obesity care team and behavioral modification
114
What is the fourth stage of pediatric weight management for children ages 6-18?
Steps 1, 2, 3 + referral to pediatric tertiary weight management center
115
What are the classifications of hypertension in children?
Normal - BP in <90th %
Prehypertension - BP in 90-95th %
Stage 1 HTN - BP in 95-99th % + 5 mmHg
Stage 2 HTN - BP >99th % + 5 mmHg
116
When should children be screened for secondary HTN?
1. History of umbilical arterial or venous access during the perinatal period may predispose to renal vascular disease
2. UTI - leading cause of HTN and renal insufficiency later in life due to scarring
3. Catecholamine excess (pheochromocytoma or NB) - may present with flushing, sweating, palpitations
4. Family history of renal disease (HTN, kidney disease, dialysis)
5. Coarctation of the aorta
117
When should an endocrine disorder be suspected as the cause of weight gain in chidlren?
When growth is limited, leading to short stature (only 1% of overweight patients have endocrine problems) - in most cases, obesity stimulates statural growth, leading to tall stature
118
DDx - fussy infant
Colic, pyloric stenosis, intussusception, allergy to breast milk, gastroesophageal reflux, infection, failure to thrive
119
___% of all infants experience colic. Symptoms begin around ___ weeks, peak at ___ weeks, and gradually improve until ___ weeks, by which point most are symptom free.
20-25
2, 6, 12
120
What is the most common cause of non-bilious vomiting (may be projectile) in infants?
Pyloric stenosis
121
When does pyloric stenosis tend to present?
After 3 weeks of age and up to 5 months; may present in the first week
122
Where is the pyloric mass of pyloric stenosis typically palpated?
Above and to the right of the umbilicus in the mid-epigastrium beneath the liver edge
123
In intussusception, which segment is most often the site of telescoping?
Ileocolic
124
What is the most common cause of intestinal obstruction in infants between 3 months and 6 years?
Intussusception
125
How does intussusception present?
Sudden onset of severe, paroxysmal, colicky pain, recurring at frequent intervals; may develop progressive lethargy, weakness, fever, and shock if not diagnosed/treated
126
How does gastroesophageal reflux present in infants?
Effortless dribbling of milk out of an infant's mouth; happy during and following episodes, no evidence of distress
127
When should an infant be evaluated for sepsis?
Under 2 months with documented fever >100.4 F
128
How does FTT usually present?
Later in life with genuine failure to gain weight or weight loss/falling of the growth curve
129
What is the Rule of Three (Wessel definition) of colic?
Unexplained paroxysmal bouts of fussing and crying that last at least 3 hours a day at least 3 times a week for longer than 3 weeks
130
Healthy infant crying behavior at 2 weeks, 6 weeks, and 3 months?
2 weeks - 2 hrs/day
6 weeks - 3 hrs/day
3 months - 1 hr/day
