Developmental + Others PNP-PC Part 1 Flashcards
Pulls a pull toy, walks forward and backwards, drinks from cup; holds utensils, some attempts to use
15-month-old
Aims and throws a ball; stacks up to six blocks; removes own socks; scribbles spontaneously
18-month-old
Turns a doorknob; kicks a ball; climbs up on furniture; turns pages one at a time
24-month-old
Walks on tiptoes; buttons large buttons; jumps with both feet; build a tower with nine cubes
30-month-old
Muscle weakness, ataxia, confusion, anorexia, tachycardia, and heart failure in infants
Thiamin/Vitamin B1 deficiency
Colic, gastroenteritis, viral illness, dietary protein allergy, UTI, intussusception, incarcerated hernia, testicular torsion
Infant Acute Abdominal Pain
Gastroenteritis, viral illness, constipation, pharyngitis, UTI, appendicitis, intussusception, pneumonia, trauma
Preschool Acute Abdominal Pain
Gastroenteritis, viral illness, pharyngitis, UTI, constipation, appendicitis, pneumonia, pancreatitis, trauma
School-Age Acute Abdominal Pain
Gastroenteritis, viral illness, UTI, constipation, appendicitis, pancreatitis, cholelithiasis, IBD
Adolescent Acute Abdominal Pain
PID, dysmenorrhea, ectopic pregnancy, ovarian cyst
Female Adolescent Acute Adominal Pain
What is the dose for a child 10-30 kg of polyethylene glycol 3350?
0.2-0.82 mg/kg/day
What is the dose for a child >30 kg of polyethylene glycol 3350?
17 g/day
When do you start weaning polyethylene glycol 3350?
After 2 months and all symptoms have resolved for 1 month
Which infections can intussusception follow?
Gastroenteritis, otitis media, URI, adenovirus
What is the recommended fiber daily?
Age + 5= grams/day
Abdominal discomfort/pain associated with 2 of the following: -improved with defecation; change in frequency of stool; change in the appearance of stool ALONG WITH no evidence of inflammatory anatomic metabolic or neoplastic process
Diagnosis of irritable bowel syndrome
Hx of chronic/intermittent diarrhea, persistent/unexplained GI symptoms, sudden or unexplained weight loss, prolonged fatigue
Celiac disease
Hx of abdominal pain, diarrhea, nausea, gas, bloating related to amount of lactose ingested
Lactose intolerance
What do you use to test for celiac disease?
Serologic (IgA tissue transglutaminase antibody, IgA endomysial antibody)
What do you use to test for cow’s protein intolerance and allergy?
Skin patch for true allergy; serum IgE, elimination diet
What do you use to test for lactose intolerance?
Lactose hydrogen breath test
Impaired growth, failure to thrive, unexplained iron anemia, abdominal distention, bloating/cramping pain
Celiac disease
Abdominal distention
Lactose intolerance
Nausea/vomiting, abdominal pain, diarrhea, bloody stool, GERD, eczema, failure to thrive
Cow’s protein intolerance and allergy
What is the expected weight gain from birth to 3 months?
25-30 g/day or 1 oz/day
What is the expected weight gain from 3-6 months?
15-20 g/day or 0.5 oz/day
What is the expected weight gain from 6-12 months?
10-15 g/day or 0.5 oz/day
What is the expected weight gain from 12+months?
5-10 g/day
Slow onset of pain that gradually worsens with dysuria, swollen/inflamed scrotum, and tenderness along the epididymis
Epididymitis
What is the treatment for epididymitis?
Cephalaxin 40 mg/kg/day for 14 days
Sudden onset of unilateral, unrelenting scrotal pain; swollen/inflamed scrotum (ipsilateral), can occur after physical exertion, trauma, or upon waking up
Testicular Torsion
Edematous, erythematous, and warm on ipsilateral scrotum; “blue dot” sign; cremasteric reflex is absent
Testicular Torsion
Jaundice, hypothermia, failure to thrive, sepsis, vomiting, diarrhea, cyanosis, abdominal distention, lethargy
Neonate UTI
What is the most common pathogen for UTI in neonates?
GBS
What is the most common pathogen for UTI in all ages?
E. coli
Malaise, irritability, difficulty feeding, poor weight gain, fever, vomiting, diarrhea, malodor, dribbling, abdominal pain, colic
Infant UTI
Altered voiding patterns, malodor, abdominal/flank pain, enuresis, vomiting/diarrhea, malaise, fever, diaper rash
Toddlers UTI
“Classic dysuria”, malodor, enuresis, abdominal/flank pain, fever/chills, vomiting/diarrhea, malaise
School-age UTI
At what age do you need to do a straight in-and-out catheter for UTI diagnosis?
Younger than 2 years of age
What will show up on urinalysis for a UTI?
Increase leukocytes (WBC), RBCs, and nitrates
If + nitrates without RBC on urinalysis, is that a UTI or not?
Considered UTI until cultures confirm
Any culture result of ______ for a single organism UTI in catheter, suprapubic, or clean catch?
> 100,000
Any culture result of ____-_____ for a single or multiple organism UTI in catheter, or suprapubic?
10,000-100,000
In a clean catch urine culture, a result of _____ - _____, means possible UTI?
10,000 - 100,000
Spotting, vaginal discharge, painful urination, mild abdominal pain, yellow discharge, postictal bleeding; males–thick, cloudy, penile discharge
Chlamydia
What is the treatment for chlamydia?
Azithromycin 1 g orally SINGLE or Doxycycline 100 mg twice daily for 7 days
When do you follow up for chlamydia?
3 months
Females–profuse thick, green discharge, labial pain/swelling, Skene/Bartholin gland abscess, bleeding between periods and painful periods; Males–dysuria, yellow-green penile discharge, testicular pain
Gonorrhea
What is the treatment for gonorrhea?
Ceftriaxone 250 mg IM SINGLE PLUS Azithromycin 1g PO SINGLE
Profuse vaginal discharge, frothy greenish/yellowish, fishy discharge, strawberry cervix that bleeds easily
Trichomonas
What is the treatment for trichomonas?
Metronidazole 2g SINGLE DOSE
Asymptomatic or painful warts/”rash”; cauliflower-like warts that occur 4-6 weeks after exposure
Human Papilloma Virus
What education do you provide for trichomonas treatment?
Do not take alcohol after metronidazole for 24 hours after the dose
When does acute post-streptococcal glomerulonephritis occur after strep infection?
Usually 1-2 weeks after an initial strep infection
Triad of anemia, thrombocytopenia, and renal failure
Hemolytic Uremic Syndrome
Pulse normal, systolic BP normal, respirations normal, tacky/slightly dry buccal mucosa, normal anterior fontanelle, normal eyes, normal skin turgor, normal skin, normal/slightly reduced urine output, increased thirst
Mild 3-5% dehydration
Rapid heartbeat, normal to low systolic BP, deep, slightly increased respirations, dry buccal mucosa, sunken anterior fontanelle, sunken eyes, reduced skin turgor, cool skin, markedly reduced urine output, and listlessness and irritability
Moderate 6-9% dehydration
Rapid and weak pulse or absent pulse; low systolic BP, deep tachypneic respirations or decreased respirations, parched buccal mucosa, markedly sunken anterior fontanelle, markedly sunken eyes, tenting skin turgor, cool mottled skin, anuria, grunting, lethargy, and coma
Severe > 10% dehydration
What is the age range of early adolescence?
11 to 14 years
What is the age range of middle adolescence?
15 to 17 years
What is the age range of late adolescence?
18 to 21 years
Characterized by a growth spurt and development of secondary sexual characteristics, cognitive skills may not keep up; *daydreaming is common with emerging reasoning skills; peers are more important and appear *“anti-adult”, *mood swings, conscious of bodies, *development of own value system; believe peers more than adults because adults don’t know what they are talking about
Early adolescence (11-14)
Development of separate identify from parents; increased concerns about attractiveness (more comparing occurs during this time); intellectual sophistication, creativity, reasoning, logic, decision-making skills; peer group but less anti-adult, dating, sexual experimentation, developing ego centrism increases, risky behavior
Middle adolescence (15-17)
Clearer self-concept and formed a distinct identity; well-formed opinions and ideas; physical development complete; adult reasoning skills, but brain is still developing; relate to family as adults, shaping of identity, committed partner relationships for many
Late adolescence (18-21)
Focus on pleasurable sensations and child seeks out stimulation and sexual satisfaction; lasts throughout adulthood; goal: to love and work well
Genital stage (Freud) in adolescence
When is the genital stage for Freud?
Adolescence
What is the age range for identity vs role confusion?
12-18
Development of self; struggle with questions who am I and what do I want with my life; along with trying on many different selves to see which one fits right; attempts to discover oneself; individual successful in this stage has a strong sense of identity and able to remain true to beliefs and values even in the face of problems; failure: develop a weak sense of self and experience role confusion and may be unsure of their identity and struggle with goal for future
Identity vs role confusion
What is the age range for intimacy vs isolation?
18-21
After developing a sense of self, they are ready to share their lives with others, but if they are not successful in finding identity and self-concept; they have had issues maintaining and developing relationships with others; must have a strong sense of self before developing successful, intimate relationship; may develop feelings of loneliness and isolation so may not develop relationships
Intimacy vs isolation
What age range is formal operational?
11 years to adulthood
Which theorist is formal operational?
Piaget
Develop the ability to think in abstract ways that enable the child to engage in problem-solving methods in developing hypothesis, can think of abstract concepts and combine two different concepts into a new one; by the end, they can use deductive reasoning and use hypothetical ideas and explain different concepts
Formal operational
What age groups are in post-conventional?
Adolescence
Which theorist is post-conventional?
Kohlberg
Standards that are beyond a certain group or authority figure; social contract orientation or universal ethical principle orientation or mystical/religious reflection
Post-conventional
What is the first physical sign of the onset of female puberty?
Breast buds
What is the first physical sign of the onset of male puberty?
Enlargement of testicles
What are the three components of sexual orientation?
Sexual imagery, sexual behavior responsiveness, self-identification (heterosexual, bisexual, homosexual)
How many kcal will an adolescent need daily?
45 kcal/kg/day
What are the average daily calories needed for adolescents?
2200-300 calories/day
What electrolytes and vitamins are really important for adolescents?
Calcium and vitamin D level
What might strict vegetarians be missing from their diet?
Protein. vitamin B12, zinc, iron
What sleep is recommended for adolescents?
8-9 hours
What is sports injury is higher in female athletes?
Anterior cruciate ligament
What fracture is more common with amenorrhea?
Stress fractures
What is the female athlete triad?
Low energy availability with or without disordered eating pattern; menstrual dysfunction; and low bone density
Flat, circumscribed change of skin; used for lesions <1 cm
Macule
What are examples of macule?
Tinea versicolor, small cafe au last spot, freckles
Flat, circumscribed lesion with color change that is >1 cm
Patch
What are examples of patch?
Mongolian spot, vitiligo, larger cafe au lait spots
Circumscribed, nonvesicular, nonpustular, elevated lesion that measures <1 cm
Papule
What are examples of papule?
Milia, molluscum contagiosum, acne
Broad, elevated, disk-like lesion that occupies more than >1 cm; formed by confluence of papules
Plaque
What are examples of plaque?
Tinea corporis, eczema, psoriasis
Circumscribed, elevated, 0.5-2 cm, that involves dermis with the greatest mass below the surface of the skin
Nodule
What are examples of nodules?
Furuncle, melanoma
Circumscribed elevation <1 cm in diameter that contains purulent exudate
Pustule
What are examples of pustule?
Folliculitis, acne
Circumscribed elevated lesion >1 cm in diameter, deeper component and filled with purulent material
Abscess
What are examples of abscess?
Staphylococcal abscess
Sharply circumscribed, elevated, fluid-containing, that measures <1 cm in diameter
Vesicle
What are examples of vesicle?
Chickenpox, impetigo, herpes simplex
Circumscribed, elevated, fluid-containing >1 cm
Bulla
What are examples of bulla?
Fixed drug eruption
Firm, edematous plaque
wheal
What are examples of wheal?
Hives, dermographism
Pearly, yellow, 1-3 mm papules on face, chin, and forehead; resolves during first month of life
Milia
Erythematous, 1-2 mm papules and pustules; can occur anywhere but mainly on forehead, upper trunk, and flexural or covered surfaces; may come and go; appears after the first week of life, but can be on SCALP; cooling skin and loosening clothes can cause resolution; “heat rash/prickly heat”
Miliaria Rubra
Multiple 1-2 mm yellow papules; clusters around *nose and cheeks; resolves within 4-6 months
Sebaceous gland hyperplasia
Barely elevated yellowish *papules/pustules, 1-3 mm, surrounding irregular macular flare or wheal of erythema; appear first on face and spread to trunk and extremities; usually between first 3 days of life and usually fades over 5- 7 days, “flea-bitten appearance”
Erythema toxicum
Multiple, tiny, monomorphous papulopustules on erythematous base; primarily on cheeks and extends on to the scalp, usually appears at 3 weeks of age and spontaneously within 1-3 months
Neonatal acne
Chapped, shiny, erythematous, parchment-like skin with possible erosions on convex surfaces, but *creases are spared; peak 9-12 months
Irritant contact dermatitis
How to treat irritant contact dermatitis?
Frequent diaper changes, gentle cleansing, barrier cream, air dry, 0.5-1% hydrocortisone
Shallow pustules; fiery red plaques on convex surfaces, inguinal folds, labia, and scrotum; *satellite lesions and common after recent antibiotic use or diarrhea
Candidiasis
Erythematous, denuded areas or fragile blisters, crusting, pustules in suprapubic areas and periumbilicus; usually occurs in newborns
Bacterial dermatitis
How to treat candidiasis?
Antifungal cream, frequent diaper changes, gentle cleansing, barrier cream, air dry
How to treat bacterial dermatitis?
Nystatin if yeast is present; mupirocin in minimal; augment/cephalexin if severe
Erythematous, flaky crusts of yellow, greasy scales on scalp, face, diaper area, mild flakes with dandruff, not pruritic
Seborrheic dermatitis
What causes bacterial dermatitis?
Staphylococcal or streptococcal
What is the treatment for seborrheic dermatitis?
Antifungal agents (-azole, selenium sulfide); anti-inflammatory agents (topical steroids, calcineurin inhibitors), keratolytic agents (salicylic acid, urea)
What causes scarlet fever?
Group A beta-hemolytic streptococcus
How does scarlet fever begin?
Fever and pharyngitis followed by enanthem and exanthem in 24-28 hours
Face appears flushed; tongue initially has white coating that fades by 4th day with *very erythematous tongue with prominent papillae underneath; cervical and submandibular lymphadenopathy; diffuse erythema with small-fine papules give *sandpaper-like quality that begins on neck and spreads rapidly to trunk and extremities; rash resolves in 4-5 days with *fine peeling of skin
Scarlet Fever
High fever, severe headache, malaise, myalgia, edema around eyes and back of hands, GI symptoms (N/V, anorexia)
Rocky Mountain Spotted Tick Fever
What is the incubation period for rocky mountain spotted tick fever?
3-12 days
Erythema migrans, malaise, headache, fever, myalgia, arthralgia, lymphadenopathy
Lyme Disease
What is the incubation period for Lyme disease?
3-30 days
Fever, chills, malaise, muscle pain, GI symptoms (N/V, diarrhea, anorexia), altered mental status, rash (more common)
Ehrlichiosis
What is the incubation period for ehrlichiosis?
5-14 days
Fever followed by rash on 4th day
Rocky Mountain Spotted Tick Fever
Small, flat, pink macules initially on wrists, forearms, and ankles that spreads to trunk and involves palms and soles within 2 days (early); petechiae not seen until day 6 or later (later); generalized *periorbital edema
Rocky Mountain Spotted Tick Fever
“Bull’s Eye” rash; red ring-like or homogenous expanding rash; flu-like symptoms; lymphadenopathy
Lyme disease
Fever, severe headache, malaise, and myalgia skin rash is not common feature
Ehrlichiosis
How to treat Rocky Mountain Spotted Tick Fever?
Doxycycline
How to treat Lyme disease?
amoxicillin for 14-21 days or doxycycline for 10-21 days
How to treat ehrlichiosis?
Doxycycline
How to diagnose Rocky Mountain Spotted Tick Fever?
Rocky Mountain Spotted Tick Fever IgG titer
How to diagnose Lyme disease?
Sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA)
How to diagnosis ehrlichiosis?
Detection of DNA by PCR
1-2 mm erythematous papules/pustules, progresses to vesicle or bullae which rupture–honey-colored crusts?
Non-bullous impetigo
Large, flaccid, thin-wall, superficial, annular or oval blisters/bullae
Bullous impetigo
How to treat superficial, nonbullous, localized impetigo?
Topical mupirocin
How to treat multiple, nonbullous, and widespread lesions of impetigo?
Augmentin, cephalexin, clindamycin, or dicloxacillin
Do they require being home from school with impetigo?
Yes, exclude from school/daycare until treated for 24 hours
Pruritis, follicular pustules, and follicular erythematous papules; discrete, erythematous 1-2 mm papules or pustules on inflamed base near follicle; pruritis papules/pustules, deep red/purple nodules in areas under swimsuit
Folliculitis
Where does s. aureus folliculitis occur?
Scalp and face
Where does p. aeruginosa folliculitis occur?
Usually below neck
When does hot tub folliculitis appear?
8-48 hours after exposure
Where is hot tub folliculitis normally appear?
Areas of swimsuit contact
Collection of pus within dermis and surrounding soft tissues
Furuncle/Abscess
Painful, tender, fluctuant, and erythematous nodules that eventually will have pustule; regional lymphadenopathy; deep red/purple nodules, painful; “boil”
Furuncle
What is the management for furuncle/abscess?
I&D alone
Erythematous, defined borders with central clearing
Tinea corporis
Annular, oval, circinate lesions with red, scaly borders; clear centrally; often prominent over hair follicles
Tinea capitis/corporis
What can occur during inflammatory stage of tinea capitis/corporis
Kerion
Pustular, boggy mass; diffuse scalping to scalp without much hair breakage around it
Kerion
How to treat kerion?
treat tinea capitis, but do not use steroids or antibiotics
What is the management for tinea capitis/corporis?
Topical antifungals until the lesion has resolved and then 2-3 days more, treat 1 inch beyond edge without covering the lesion with bandaid or gauze; griseofulvin for places where there is hair (treat for 4 weeks and give with fatty foods, but check CBC, LFTs every 4 weeks); treat contacts
Do you need to be excluded for tinea capitis/corporis?
Exclude until 24 hours
Multiple annular, scaling macules/patches, hypo/hyperpigmented, raindrop pattern, that occurs in warm, humid weather, occurs mostly on back and upper shoulders
Tinea versicolor
What is management for tinea versicolor?
Selenium sulfide lotion/shampoo; sun exposure can make pigmentation work; evidence of flaking means its been an effective treatment
Pruritis, dry skin, papules, vesicles, edema, serous discharge/crusts, lichenification, scratch marks, generalized dry skin
Eczema
What is management for eczema?
Moisturize!!! (vasoline, Cetaphil, Crisco, Aquaphor, eucerin); mild topical corticosteroids; antihistamines, wet wrap therapy, no topical antibiotics or systemic steroids
Widespread papulovesicular rash from repeat exposures to substance that child is already sensitized to
Id Reaction
Follicular plug, localized on face and trunk
Microcomedome
Papule; blockage at mouth of follicle; appears on face, upper back, shoulder, chest
Open comedome/Blackhead
Semisoft, precursor to inflammatory acne
Closed comedome/whitehead
Fewer than 20 whitehead/blackhead, fewer than 15 inflamed bumps or fewer than 30 total lesions
Mild Acne
Between 20 to 100 whiteheads or blackheads, 15 to 50 inflamed bumps, or 30-125 total lesions
Moderate Acne
Multiple inflamed cysts and nodules; acne may turn deep red or purple and leaves scars
Severe acne
Rash preceded by fever, cough, red eyes, Koplik’s spots; begins as pink then evolved to erythematous that starts on face, then chest and abdomen then arms and legs
Rubeola/Measles
Rose-pink, maculopapular rash begins on face spreads to trunk and extremities lasting less than 72 hours; malaise, joint pain, lymphadenopathy
Rubella/Three-day Measles
3 days of high fever with rapid decline then afterwards a diffuse, faint, blanchable, erythematous reticulated rash appears
Roseola Infantum/Herpesvirus 6
Fever, pharyngitis, malaise, coryza, then “slapped check” erythema then *lacy, reticulated, erythematous exanthem
Erythema infectiosum
Fever, malaise, headache, pharyngitis, or diarrhea; small gray-white vesicles and erosions with erythematous rings on hard palate, buccal mucosa, tongue, gingiva and then small oval vesicles with erythematous ring are seen on lateral aspects of hands and feet as well as palms and soles
Coxsackievirus
Progression of lesions from erythematous macules to papules of fluid-filled vesicles to crusted lesions and fever/malaise; pruritic crops of lesions appear on face, trunk, and scalp; “Dew on a rose”
Varicella
(Herald patch usually on trunk (2-5 cm ovoid lesion) and after that will see symmetric, small macular/papular pale pink lesions in *Christmas tree pattern
Pityriasis Rosea
Burning, stinging pain, hyperesthesia, tingling (itching may be more common than burning) that does not cross midline; 2-3 *clustered groups of macules/papules progressing to vesicles that last 7-10 days
Herpes Zoster
small, firm, pink-flesh-colored papules that become umbilicated with cheesy core/surrounding dermatitis; itching at the site
Molluscum contagiosum
What is management for warts/verruca vulgarism?
Salicylic acid and lactic acid
Solitary papule, irregular, rough; common around the cuticle of fingers and roes that can spread through trauma
Verruca vulgarus
Spiny projections from the skin with stalk on eyes, lips, nose, or eyelids
Filiform warts
Flat-topped, smooth surfaces that is skin or tan-colored; common on areas of trauma
Flat warts
Rough papule that disrupts dermal ridges; painful
Plantar warts
Cauliflower-like lesions; discrete or confluent papules with rough surface that can be on genitals, oral mucosa, respiratory tract
Condylomata acuminate/Venereal warts
3 linear, erythematous papules in a row; pruritic
Bed Bug Bites
May cause intense itching behind ears and at neck; “flakes” that do not wipe away easily; nits are small white/brown oval cases attached to the hair shaft
Pediculosis/Head Lice
What is the management for pediculosis?
Permethrin, then remove nits and cleanse environment; anything that cannot be washed needs to be placed in a plastic bag for 2 weeks
Itching; worse at night; progressively intense; multiple erythematous papules; s-shaped burrows, webs of fingers, sides of hands, folds of wrists; vesiculopustular lesion sin infants/young children
Scabies
What is the management for scabies?
Permethrin 5% applied from the neck down and rinse off in 8-14 hours and repeat in 1 week; treat close contacts and wash linens and clothing
Highest mortality rate of all mental health disorders
Anorexia Nervosa
Athletes are more likely to develop; depressed mood, social withdrawal, insomnia, OCD related to food, body shape, and weight; sometimes there is a family history of anorexia, alcoholism, or affective disorder
Anorexia Nervosa
Less than 85% of expected weight for age; BMI <17.5
Anorexia Nervosa
Weight is often average or overweight; binging and/or purging for at least once a week for more than 3 months; self-criticism; laxative use; vomit for gag reflex, diuretics, laxatives; may have family history of obesity
Bulimia Nervosa
What does the SCOFF questionnaire check for?
Anorexia and Bulimia
What are the components of SCOFF questionnaire?
Do you make yourself *sick because you feel full?
Do you worry that you have lost *control over what you eat?
Have you lost *over 10 lbs in the last 3 months?
Do you believe you are *fat when others say you are thin?
Would you say *food dominates your life?
What are the lab tests for anorexia and bulimia?
CBC, electrolytes, fasting glucose, LFTs, thyroid, FSH, LH, urinalysis, ECG
What is expected weight gain for refeeding?
1.1 lb (0.5 kg) per week
Markedly depressed/irritable mood or diminished interest in usual activities for a *period > 2 weeks
Major Depressive Disorder (MDD)
Depressed or irritable mood for majority of days in past 2 years *less intense but more chronic then depressed episodes
Dysthymic disorder
Occurs within 3 months of a major life stressor less severe symptoms usually *mild and brief
Adjustment Disorder with Depressed Mood
Sadness, irritability, impulsive, crying spells, loss of pleasure/interest in activities, somatic complaints, externalizing behaviors, comorbidity with anxiety is common, often misdiagnosed as ADHD
Major Depressive Disorder in School-Age
Sadness, hopelessness, self-hatred, anger, withdrawal, loss of pleasure/interest in activities, neurologic vegetative symptoms; decrease sleep, appetite, concentration; drug/alcohol use are common
Major Depressive Disorder in Adolescents
What is treatment for mild MDD?
Cognitive-behavioral therapy
What is treatment for moderate MDD?
Cognitive-behavioral therapy and possibly SSRIs
What is treatment for severe MDD?
Cognitive-behavioral therapy + SSRIs
What is are SSRIs that approved for children?
Fluoxetine/Prozac >8 years
Escitalopram/Lexapro >12 years
How long do children need to take SSRIs for MDD?
Should be used 1-year past resolution
What are the common side effects of SSRIs?
Excitation, agitation, n/v, diarrhea, dizziness, chills
What is the risk for SSRIs?
Serotonin Syndrome
Increase in body temperature, pupils are dilated, rapid heart rate, increasingly agitated, tremors, sweating that occurs within 8-10 days hours of ingestion of SSRI
Serotonin Syndrome
When is suicide risk at the greatest risk?
During the first 4 weeks of depressive episode
Which psychiatric disorder has the highest risk of suicide?
Bipolar disorder
Characteristic pattern fo manic episodes before or after major depressive episodes
Bipolar disorder
When does the onset of symptoms for bipolar disorder typically occur?
15-19 years
What are comorbid conditions with bipolar disorder?
Conduct disorder, substance abuse, ODD, disruptive disorder, personality disorders
When a child with depression begins to exhibit mild ADHD symptoms, what is the possible cause and what happens next?
Bipolar disorder; evaluation by a psychiatrist
What drugs should patients with bipolar disorder NOT take?
Antidepressants alone may cause manic response
Stimulants may worsen manic symptoms
“Worriers” and most prevalent psychiatric disorder; diagnosed most often ages 9-18; very hard on themselves; difficulty concentrating; muscle tension; unexplained fatigue
General Anxiety Disorder
What screening tools for you use for general anxiety disorder?
Spielberg State-Trait Anxiety Inventory for Children (STAC) for 9-12 years and Screen for Child Anxiety Related Disorders (SCARED) for 8-18 years
What is the management for general anxiety disorder?
Cognitive-Behavioral Therapy + parental education/training
What is the management for obsessive-compulsive disorder?
Mild to moderate use cognitive behavioral therapy
Moderate to severe use cognitive-behavioral therapy + SSRIs
What clinical findings separate PANDS from classic OCD?
Urinary frequency, hyperactivity, impulsivity, worsening handwriting
Visual hallucinations are more common in children; disorganized speech and behavior can occur; develops between late teens to mild 30x; onset can be abrupt or insidious and around 1/2 will have depressive symptoms
Schizophrenia
Unexplained injuries, bedwetting, fear of going home, changes in behavior, appetite changes, sleep disturbances, anxiety, self-harm, suicidal ideations
Post-Traumatic Stress Disorder
Acting out, nightmares, insomnia, extreme startling, social withdrawal, tears, anxiety, depression, panic attacks, anger/rage, internalizing, suicidal ideation, impaired concentration, impaired school performance
Adolescence with PTSD
Sleep problems, nightmares, development regression, repetitive themes in play, social withdrawal, new onset of anxiety/fears, panic attacks, impaired concentration, impaired school performance, avoidance symptoms, somatic complaints
School-age PTSD
Sleep problems, nightmares, developmental regression, aggression, extreme temper tantrums, anxiety symptoms, sudden worsening of fears, irritability, avoidance symptoms
Preschool PTSD
Feeding problems, FTT, sleep problems, irritability
Infancy PTSD
Formal diagnosis around age 7; associated with history of harsh discipline, abuse, neglect; high rate of comorbidity with depression leading to substance abuse and suicide; repetitive/persistent pattern of behavior in which rights of others and rules are violated
Conduct Disorder
Open defiance/non-compliance with authority; must persist minimum of 6 months; recurrent pattern of negative, defiant, disobedient, hostile behavior usually directed at family members, teachers, or peers known well to child
Oppositional Defiant Disorder
What is substance abuse most commonly comorbid with?
Conduct disorder, depression, anxiety
Excessive crying, poor feeding, failure to thrive, irritability, jitteriness, excessive lethargy, poor eye contact, sleep disorders
Substance abuse in infants and young children
Decreased school performance, lethargy, hyperactivity, hypervigilance, decreased attention, disinhibition, risk-taking behavior, repeated absences/suspensions, loss of interest in previously enjoyed activities, withdrawal from family and friends, exaggerated mood swings, hypersexuality, sleep disturbances
Substance abuse in older children and adolescents
What is the starting dose of fluoxetine/Prozac?
10-20 mg/day
What is the starting dose for escitalopram/Lexapro?
10 mg/day
If a child is born with trisomy 21, what is the most common heart defect?
AV canal defect
What are common heart defects with down syndrome/trisomy 21?
AV canal defect, ventricular septal defect, tetralogy of Fallot
You have a baby in the nursery who has poor pulses in the lower extremities who has a webbed neck and puffy hands and feet, what is the issue?
Coarctation of the aorta
What is the most common heart defect with Turner syndrome?
coarctation of the aorta
What are the common heart defects with Digeorge syndrome?
Interrupted aortic arch and tetralogy of fallot
What chromosome is affected with DiGeorge syndrome?
Chromosome 22
Where would the apical impulse be located with cardiomegaly?
Left mid-clavicular line between 4th and 5th intercostal space
If you feel a precordial thrill, what grade murmur does the child have?
At least Grade 4
Where is the aortic area for auscultation?
2nd Right Sternal Border
Where is the pulmonic area for auscultation?
2nd Left Sternal BOrder
Where is Erb’s Point located?
3rd Left Sternal Border
Where is the tricuspid area for auscultation?
4th Left Sternal Border
Where is the mitral area for auscultation?
4-5th Mid-clavicular line near apex
What does S1 heart sound correlate with?
Mitral and Tricuspid valve closing; heart best at left lower sternal border
What does S2 heart sound correlate with?
Aortic and Pulmonary valves; heard best at 2nd intercostal space near pulmonary area
What does the presence of S3 mean?
High output states (fever) or Congestive heart failure (Ken-tuck-y)
What does the presence of S4 mean?
Very bad congestive heart failure (Ten-nes-see)
What does a fixed S2 split mean?
Atrial Septal Defect or Pulmonic Stenosis
What heart sound will you hear with atrial septal defect?
Fixed S2 sound
Low-pitch, vibratory, twangy, systolic murmur heard loudest at LLSB or 2nd/3rd ICS when lying down or after exercise
Innocent Heart Murmur
You hear a murmur near the clavicle with a continuous bruit. When you turn the child’s head toward the murmur, it gets louder. When you turn the child’s head away from the murmur, it gets softer or disappears. What murmur does the child have?
Venous Hum
You hear a murmur at the left lower sternal border that is musical in nature, that occurs in mid-systole, grade II/VI, low to medium pitch. What murmur do you hear?
Still’s murmur
Murmurs that are heart loudest at the base of the heart, at least grade III or above, heard during diastole and does not change with positioning are usually what type of murmurs?
Pathologic heart murmurs
The most common congenital heart defect in children is:
Ventricular Septal Defect
What are the components of tetralogy of Fallot?
PROVe Pulmonic Stenosis Right Ventricular Hypertrophy Overriding Aorta Ventricular Septal Defect
A child has high BP in right upper extremity, lower BP in lower extremities, bounding pulses in the right upper extremity, and weak, absent/delayed pulses in lower extremities
Coarctation of aorta
What are the most common acyanotic lesions?
Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
The child has systolic ejection heartbeat heard best at LUSB with fixed S2 split
Atrial Septal Dect
The child has holosystolic murmur heard over LLSB and mitral region
Ventricular Septal Defect
The child is a premature infant with continuous machinery-like murmur without thrill heard over LUSB
Patent Ductus Arteriosus
A child has diastolic rumble on heart auscultation with upward slanting eyes, Brushfield spots, short neck, and low muscle tone. What heart defect is present?
AV Canal
Single artery comes from the heart giving origin to coronaries, pulmonary arteries, and aortic arch
Truncus Arterieosus
What kind of shunting occurs with acyanotic heart defects?
Left to right shunting
What kind of shunting occurs with cyanotic heart defects?
Right to left shunting
What are the most common cyanotic heart defects?
Tetrology of Fallot Transposition of the Great Vessels/Arteries Pulmonary Atresia TAPVR Single Ventricles
You hear a systolic ejection murmur over LUSB and the base of the heart that radiates to the lungs with a harsh quality. The intensity of murmur is increased with deep inspiration.
Pulmonic Stenosis
You hear a midsystolic ejection murmur over RUSB and the base of the heart that radiates to the neck or back with a harsh quality.
Aortic Stenosis
What is the treatment for transposition of the great arteries?
Requests prostaglandins and early surgery (Jatene)
What congestion occurs with right-sided heart failure?
Systemic Congestion
What congestion occurs with left-sided heart failure?
Pulmonary Congestion
Periorbital/facial edema, hepatomegaly, sudden weight gain, dependent edema, and ascites
Right-sided heart failure
Tachypnea, increased respiratory effort, grunting and nasal flaring, retractions, crackles
Left-sided heart failure
What are the nutritional requirements for congenital heart disease?
Small, frequent meals with increased calories (24 kcal or greater)
What is the daily kcal requirement for congenital heart disease?
120-150 kcal/kg/day
Which cardiac conditions require SBE (bacterial infectious endocarditis) prophylaxis?
Cyanotic congenital heart disease that has not been fully repaired, has a prosthetic material/device for 6 months after repair, or repaired heart which persistent leaks or abnormal flow
What is the most common causative agent of bacterial endocarditis?
Streptococcus viridans
Unexplained fever, splinter hemorrhages, and petechia on face and upper body
Bacterial Endocarditis
What are the major criteria for acute rheumatic fever (ARF)?
Migratory polyarthritis (Joints) Carditis (significant new mumur) Subcutaneous nodules Erythema marginatum Sydenham's chorea
What are the minor criteria for acute rheumatic fever (ARF)?
Fever Arthralgia Previous rheumatic fever Elevated acute phase reactants (increased ESR/CRP) Prolonged PR interval
Acute systemic vasculitis under age 5
Kawasaki Disease
A child has a history of mild upper respiratory illness but has become very irritability and has had a fever for more than 5 days with strawberry tongue, conjunctivitis without discharge, trunk rash, dry lips, flaking of the palms and soles of feet, swelling of hands and feet, and redness. The child is very irritable.
Kawasaki Disease
Fever/viral illness, lethargy, low-grade fever, exercise intolerance, palpitations, muffled heart sounds, weak pulses, hepatomegaly, pallor
Myocarditis and Cardiomyopathy
What do you need for hypertension in order to diagnose?
Three consecutive readings of high BP
Macular erythematous rash with pale center on trunk and extremities
Erythema marginatum
Homophonic wheeze, brassy cough, dyspnea, cyanosis
Tracheal Foreign Body
Rapid onset, chronic croupy cough, unilateral wheezing, recurrent pneumonia
Laryngeal Foreign body
Initial episodes of coughing, gagging, choking, with no signs of respiratory infection, limited chest expansion, decreased vocal fremitus, atelectasis, crackles, rhonchi, wheezes
Foreign body aspiration
Starts with cough and rhinorrhea and gradually develops respiratory distress (tachypnea, substernal/intercostal retractions), expiratory wheezing, fine/coarse crackles, decreased appetite
Bronchiolitis
What age range is typically affected by bronchiolitis?
Less than 24 months
What time of year does bronchiolitis typically occur?
Late fall through early spring
Inspiratory high pitched “whoop” that lasts up to 6-10 weeks; usually source for infants is adults that have an unrecognized infection
Pertussis
What is the incubation period for pertussis?
7-10 days (5-21 days)
What is the treatment for pertussis?
Azithromycin (macrolide antibiotics)
TMP-SMX can be alternative medication
Do family members and close contacts need to be treated for pertussis for chemoprophylaxis?
Yes!
Child has a history of mild URI, abrupt high fever, restlessness, shaking chills, apprehension, shortness of breath, malaise, pleuritic chest pain, vomiting
Pneumonia
What are the common causative agents for pneumonia in infants?
Group Beta Strep, Staph, E.coli
What are the common causative agents for pneumonia in children less than 5?
Strep pnuemonia, h. influenzae
What are the common causative agents for pneumonia in children older than 5?
Group A strep, mycoplasm, staph pneumonia
If you believe if it’s bacterial pneumonia, how would you treat it?
Amoxicillin 90 mg/kg/day BID
If you believe a child has atypical pneumonia (such as mycoplasm), how would you treat it?
Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg/day once daily for day 2-5
These are the radiographic findings for bacterial pneumonia with diffuse interstitial, alveolar, apical/upper lobe infiltrates with a “ground glass” appearance
Pneumocystis (PCP)
Prolonged expiratory phase, diminished breath sounds, increased work of breathing/signs of distress, decreased pulse oximetry, increased heart rate, increased respirate rate, wheezing, breathlessness
Asthma
Helps assess the severity and reversibility of airflow obstruction and severity of asthma
Peak flow measurement
Meconium ileus, prolonged jaundice, intestinal atresia
Cystic Fibrosis (neonatal)
Cough, colonization of bacteria in mucus, bacterial pneumonia, FTT, hypoproteinemia, abdominal distension, cholestasis, rectal prolapse, steatorrhea, distal intestinal obstruction syndrome, hemolytic anemia
Cystic Fibrosis (infancy)
Polyps, steatorrhea, rectal prolapse, distal intestinal obstruction syndrome, hemolytic anemia
Cystic Fibrosis (childhood)
Allergic bronchopulmonary aspergillosis, chronic pansinusitis, nasal polyposis, bronchiectasis, hemoptysis, idiopathic pancreatitis, osteoporosis
Cystic Fibrosis (adolescence)
