CA powerpoint-- Adolescent Health and Diagnostics in Pediatrics Flashcards by Sasha Bonney

state & federal laws, HIPPA privacy act

examples of pitfalls

what about informed consent?

Confidentiality

•Pitfalls – eg, insurance, billing statements, record keeping

informed consent- varies by state

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Parental consent NOT needed for: (6)

substance abuse treatment
STI screening and treatment
pregnancy prevention and care
sometimes abortion
mental health care
emergency care

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Well child check in adolescence

Purpose of _____ ______ is to reduce serious morbidity & premature mortality, both during adolescence & in later years

preventive services

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Major componenets of WCC in adolescence visit (4)

•Major components of visit:

–Screening

–Counseling to reduce risk

–Providing immunizations

–Giving general health guidance

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Your List…

–School

–Mental health

–Nutrition & Development

–Oral health

–Safety

Teen’s List…

–Acne

–Fitting in

–Fitness & Weight

–Dating & Sex

–Drugs/alcohol

some hot topics

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leading causes of dealth in ages 10-24

unintentional injuries > suicide > other > homocie >cancer >heart disease …. and sooo on

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leading cause of dealth in over 65

heart disease >cacner

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•Mostly psychosocial & often correlate w/ poverty

–Unintended pregnancy

–STIs

–Substance abuse

–Smoking

–Dropping out of school

–Depression

–Homelessness

– Physical violence

Major Causes of Morbidity

******Early identification of at-risk teenager important!******

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Behave simply & honestly; do NOT overpower or intimidate
Recognize that teen’s outward appearance may not be accurate reflection of cognitive development
Recognizing that working w/ teens can be emotionally draining
High no-show rate is not unusual
Stated chief complaint often conceals teen’s real concern

Relating to the Adolescent Patient

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1 in 2 sexually acitve young peopel will get an STD by age ___. Most wont know it.

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Excessive sleeping; insomnia
Loss of self-esteem
Abandonment or loss of interested in favorite activities
Unexpected & dramatic declines in academic performance
Weight loss & loss of appetite (eating disorder)
Personality shifts & changes, such as aggressiveness & excess anger

Mental Health “Red Flags”

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Physical transition from childhood to adulthood

puberty

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onset of puberty AGE

male

female

FIRST SIGN ON PUBERTY IN WOMEN AND MEN

age 10 for girls
age 11.5 for boys

SIGNS:

WOMEN: BREASTS

MEN: TESTICLES

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–Growth spurt ends AGE:

age 14 for girls
age 17 for boys

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duration on puberty and stages?

Duration of puberty varies widely but stages follow same sequence (Tanner stages)

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Puberty marked by increase in ______ from hypothalamus. which stimulates secretion of FSH and LH from pituitary.

GnRH

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In girls, ____ stimulates growth of ovarian follicles and, in conjunction w/ LH, stimulates production of estradiol by the ovaries.

FSH

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______ in puberty, estradiol stimulates breast development and skeletal growth. ____ in puberty, estradiol leads to ovulation and menstruation.

Early

Later

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Puberty marked by increase in GnRH from hypothalamus. GnRH stimulates secretion of FSH and LH from pituitary. In boys, FSH stimulates growth of seminiferous tubules, leading to increase in testicular volume.

FSH also stimulates ______ cells of testes to produce inhibin B, which inhibits secretion of FSH.

Sertoli

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LH stimulates ______ cells of testes to produce testosterone, which induces growth of penis, deeping of voice, growth of facial/body hair, and increase in muscle mass.

Leydig

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what is this

Sexual Maturity Rating (Tanner stages)

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Issues Arising During Puberty

anemia
gynecomastia
acne
psychological changes
gynecologic issues
MSK injuries
Myopia
Scoliosis
STI’s

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–Girls; iron deficiency

anemia

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–Affects ½ of boys age 13

Gynecomastia

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–Open & closed comedones

•Acne

–Depression twice as common in girls –In teens, prefrontal cortex matures later than rest of brain (impulse control)

Psychological changes

–Anovulatory, AUB

Gynecologic issues

–Strains & sprains, sports-related; asynchronous growth of body parts

MSK injuries

–Caused by growth of the axial diameter of the eye

Myopia

–Accelerated progression due to growth in axial skeleton

Scoliosis

–High-risk group –↑ columnar epithelial cells on the exocervix (risk of infx)

STI's

* Absence or incomplete development of secondary sexual characteristics by an age at which 95% of children of that sex & culture have initiated sexual maturation * In U.S., this corresponds to an upper limit of: –12 years for girls (breast development being 1st sign) –14 years for boys (testicular enlargement being 1st sign)

Delayed Puberty

who will eventually progress spontaneously through puberty

Constitutional delay Referral to Peds and some objective findings you could do: sereal X-rays: growth plates should calcify

caused by variety of hypothalamic, pituitary, & gonadal disorders

pathologic delay in puberty

–Look at growth velocity (delayed vs “stalled”) –PE: Tanner stages (eg, serial measurements) –X-ray of L hand & wrist to check skeletal maturation –Additional tests: pelvic or testicular US, brain MRI, hormone testing (eg, FSH, LH, TSH, prolactin, estradiol or testosterone), & karyotyping

evaluation for delay in puberty

* 30 million children & adolescents participate in organized sports in U.S. * Most need pre-participation physical evaluation before season begins * Opportunity to promote health & fitness * Not designed to be comprehensive (but often substitute for annual WCC in most teens) * Print AAP Evaluation Form

down and dirty about sports physicals

* Maximize safe participation * Identify medical problems w/ risks of life-threatening complications during participation (eg, hypertrophic cardiomyopathy) * Identify conditions that require a treatment plan before/during participation (eg, asthma, DM) * Identify & rehab old MSK injuries * Remove unnecessary restrictions on participation (eg, Osgood-Schlatter disease)

Sports Physical: Goals

**•PMH** – chronic disease, prior surgery, hx heat-related illness, menstrual hx **•Injury history** – past injuries, LOC **•Cardiovascular history** – dyspnea, chest pain, syncope, palpitations, lightheadedness **•Family history** – sudden death, hypertrophic cardiomyopathy, Marfan syndrome, QT syndrome, pacemaker or defibrillator

Sports Physical: Targeted History

**•Vital signs** – BMI, BP, HR **•HEENT** – visual acuity, hearing **•Cardiac** – murmurs **•Lung** – wheezing, "good breath sounds" **•Abdomen** – organomegaly **•MSK** – “2-minute” screening exam –Look for weakness, limited ROM, evidence of previous injury (high-risk areas: shoulder, knee, ankle) **•Neuro** (hx concussion) **•Skin** – contagious infx?

Sports Physical: Examination

12 steps in the 2 minute sports physical...

1. Stand straight, facing forward 2. Move neck in all directions 3. Shrug shoulders against resistance 4. Hold arms out to side against resistance 5. Hold arms out to side w/ elbows bent 90˚; raise & lower arms 6. Hold arms out, completely bend & straighten elbows 7. Bend elbows 90˚, then pronate & supinate forearms 8. Make a fist, clench, then spread fingers 9. Squat & duck-walk for 4 steps forward 10. Stand straight, facing back 11. Bend forward w/ knees straight, touch toes 12. Stand on heels, then on tip-toes

* If normal exam, no laboratory testing indicated * After examination, athlete should be given: –Full clearance for participation –Clearance to participate w/ limitations –Exclusion from participating pending further evaluation •Noninvasive cardiac evaluation of athletes before participation is controversial; routine screening w/ ECG or ECHO is NOT recommended in U.S.

Sports Physical: Conclusion

•In female athletes, triad is combination of: –**eating disorder** w/ low caloric intake –menstrual dysfunction (usually **amenorrhea**) –low bone density (results in **osteoporosis**) * Associated sports – running, dance, gymnastics * Complications + Sports = –Pathologic fractures –Cardiac arrhythmias –Hypoglycemia –Seizures –Respiratory failure

“Female Athlete Triad”

* May be part of workup for acute infection * Typical finding early in infection (both bacterial & early viral) –

CBC **leukocytosis** w/ neutrophil response

CBC In **\_\_\_\_\_\_\_**, neutrophil response is transient, followed by ↑ lymphocytes

Viral Infection

CBC •In general, ___________ typically associated w/ greater neutrophil counts (“shift to the left” w/ increased # immature cells)

Bacterial infection

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ w/ increased neutrophil response – transient w/ viral infx, sustained w/ bacterial infx

“Shift to left”

* May be part of workup for chronic infection * Examples… –Eosinophilia for allergies –H+H for abnormal uterine bleeding –CBC w/ differential for cancer workup –H+H for preoperative evaluation –Hgb for anemia screening –Others?

Complete Blood Count

* Detects abnormalities in form and function * Confirmatory test (eg, leukemia, sickle cell disease) * Adjunct in evaluation of anemia

Peripheral Blood Smear

Normal – RBC w/ ~1/3 of central pallor

Normal

what are the three pictures of?

Top – **acute lymphoblastic leukemia** (most common childhood cancer, accounts for ~25% of cancers in children \<15) w/ increased blast cells (immature lymphocytes) Middle – **sickle cell anemia** Bottom – microcytic, hypochromic due to severe **iron deficiency anemia**

what is included in a Urinalysis? (9)

1. • pH 2. • Specific gravity 3. • Protein 4. • Glucose 5. • Nitrite 6. • Ketone 7. • Bilirubin 8. • Blood 9. • Leukocytes

•Gold standard for evaluation of CSF in suspected meningitis or encephalitis

Lumbar puncture

–Pressure: 70-200 mm H2O –Leukocytes: ≤5/mcL –Protein: 15-45 mg/dL

•Normal LP values:

* Pressure: ↑↑↑↑ * Leukocytes: 200-20,000 (mostly PMNs) * Protein: \>50

Acute bacterial meningitis Headache, fever, vomiting, rash (petechial, does not fade w/ glass pressed against it), photophobia, nuchal rigidity

* Pressure: normal or slightly ↑ * Leukocytes: 100-1,000 (mostly lymphocytes or monocytes) * Protein: normal or slightly ↑

Acute viral meningitis Headache, fever, vomiting, rash (petechial, does not fade w/ glass pressed against it), photophobia, nuchal rigidity

gold standard for UTI confirmation

culture Urine – w/ antibiotic sensitivities

sensitive & specific relating to cultures

blood cultures

•should be obtained w/ every LP, joint aspiration, I&D, biopsy, more…

other cultures

what type fo test is a rapid test when do we use it examples (3)

* Typically antigen tests * Useful for preliminary dx * Examples: –Strep [RADT for GAS]: **RADT** = rapid antigen detection test to check for group A strep –Influenza –Monospot

•Serologic tests look at ______ \_\_\_\_\_\_\_

Immune response

•Serologic tests look at immune response –Looks at the development of \_\_\_\_\_\_\_ examples:

antibodies –Examples: •Hepatitis, HIV, Lyme, HSV, many more…

•Molecular tests used to diagnosis ______ (unusual) diseases

genetic

•Molecular tests used to diagnosis genetic (unusual) diseases –looks at ______ sequencing via polymerase chain reaction (PCR) –can be used to determine genetic carrier status –more & more tests becoming available! –Examples: •CF, fragile X, Huntington disease, Tay-Sachs disease, Thalassemias, many more…

DNA

list the hormones (8)

1. •HCG 2. •FSH 3. •TSH 4. •Prolactin 5. •LH 6. •DHEA-S 7. •Estradiol 8. •Testosterone

QUESTION 1: •What are the views/options? \_\_\_\_\_\_\_\_\_ •# views depends on area (call x-ray, if questions) QUESTION 2: •Always examine joint \_\_\_\_&\_\_\_\_\_ QUESTION 3 •Know limitations of x-ray

1. views : –CXR –Neck –Abdominal “flat plate” –KUB –Joints/Limbs 2. joiint above and below 3. tissue tears and so on

what sign?

steeple sign CROUP

what sign is this?

thumbprint sign EPIGLOTITIS

4 types of ultrasounds

* Abdominal (eg, mass, appendicitis) * Pelvic (eg, PCOS) * Scrotal * Ultrasound-guided imaging

small ↑ lifetime cancer risk; usually takes seconds to perform; sedation rarely needed

•Primary modality in acute or emergent situations

noninvasive (no radiation); test of choice for CNS abnormalities (eg, brain tumor); sedation often required, time-consuming

MRI

Brain tumor (most common solid tumors of childhood, accounts for 25-30% of all childhood cancers) – classic triad of : 1. 2. 3. MRI – astrocytoma

morning HA, vomiting and papilledema

what to interperate on an ECG (5)

ECG interpretation: 1. Rate? 2. Rhythm? (NSR) 3. Axis? (I & aVF) 4. Intervals? (PR interval \<0.2 sec) 5. Ischemia or infarction

•Febrile infants \<1 mo need sepsis workup; initial diagnostic tests typically include: –CBC w/ diff –Blood culture –UA/UC –LP –± CXR * Toxic appearance? * Immunization status?

Fever workup!!!!

•Lab reference ranges may be \_\_\_/\_\_\_\_ dependent – always check

gender/age

•X-rays in infants & children can be difficult to read due to lack of ______ \_\_\_\_\_\_\_\_.

complete calcification

What is the age for adolescents

11-21 about

well child check is really to reduce?

morbidity and mortality

main reason for well child check in adolescents

help them not hurt themselves or others!

start perior 2.5 years after\_\_\_\_\_\_\_

start of breast development

testing for cardiomyopathy?

a lot do not require further testing but if kid as family history of unexplained dealth of mom and dad in early age but right now overall screening is not supported in the US

female athlete triad

–eating disorder w/ low caloric intake – amenorrhea – osteoporosis

CBC most often ordered

acute infection trying to figure out if bacteria or viral

what's this?

osteosarcoma

this?

middle lobe pneumonia

this?

fracture of fibula