CA powerpoint-- Adolescent Health and Diagnostics in Pediatrics Flashcards
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
Parental consent NOT needed for: (6)
- substance abuse treatment
- STI screening and treatment
- pregnancy prevention and care
- sometimes abortion
- mental health care
- emergency care
Well child check in adolescence
Purpose of _____ ______ is to reduce serious morbidity & premature mortality, both during adolescence & in later years
preventive services
Major componenets of WCC in adolescence visit (4)
•Major components of visit:
–Screening
–Counseling to reduce risk
–Providing immunizations
–Giving general health guidance
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
leading causes of dealth in ages 10-24
unintentional injuries > suicide > other > homocie >cancer >heart disease …. and sooo on
leading cause of dealth in over 65
heart disease >cacner
•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!******
- 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
1 in 2 sexually acitve young peopel will get an STD by age ___. Most wont know it.
25
- 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”
Physical transition from childhood to adulthood
puberty
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
–Growth spurt ends AGE:
- age 14 for girls
- age 17 for boys
duration on puberty and stages?
Duration of puberty varies widely but stages follow same sequence (Tanner stages)
Puberty marked by increase in ______ from hypothalamus. which stimulates secretion of FSH and LH from pituitary.
GnRH
In girls, ____ stimulates growth of ovarian follicles and, in conjunction w/ LH, stimulates production of estradiol by the ovaries.
FSH
______ in puberty, estradiol stimulates breast development and skeletal growth. ____ in puberty, estradiol leads to ovulation and menstruation.
Early
Later
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
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
what is this
Sexual Maturity Rating (Tanner stages)
Issues Arising During Puberty
- anemia
- gynecomastia
- acne
- psychological changes
- gynecologic issues
- MSK injuries
- Myopia
- Scoliosis
- STI’s
–Girls; iron deficiency
anemia
–Affects ½ of boys age 13
Gynecomastia
–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…
- Stand straight, facing forward
- Move neck in all directions
- Shrug shoulders against resistance
- Hold arms out to side against resistance
- Hold arms out to side w/ elbows bent 90˚; raise & lower arms
- Hold arms out, completely bend & straighten elbows
- Bend elbows 90˚, then pronate & supinate forearms
- Make a fist, clench, then spread fingers
- Squat & duck-walk for 4 steps forward
- Stand straight, facing back
- Bend forward w/ knees straight, touch toes
- 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)
- • pH
- • Specific gravity
- • Protein
- • Glucose
- • Nitrite
- • Ketone
- • Bilirubin
- • Blood
- • 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)
- •HCG
- •FSH
- •TSH
- •Prolactin
- •LH
- •DHEA-S
- •Estradiol
- •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
- views :
–CXR
–Neck
–Abdominal “flat plate”
–KUB
–Joints/Limbs
- joiint above and below
- 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
CT
•Primary modality in acute or emergent situations
CT
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:
- Rate?
- Rhythm? (NSR)
- Axis? (I & aVF)
- Intervals? (PR interval <0.2 sec)
- 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
