Exam 1 Flashcards
urticaria - wheals on a erythematous base which is blanchable suggesting inflammation, may be pruritic, red, or skin-colored. May last a few minutes to 24 hours and may need antihistamine to alleviate the burning/itching.
Nonbullous impetigo - well-localized area of papules and pustules with surrounding erythema and thick, adherent, golden-colored crust located on the chin.
Diaper candidiasis - diffuse, confluent erythema with discrete erythematous papules and plaques, superficial scale and satellite lesions to the inguinal area
Miliaria Rubra: Scattered vesicles on an erythematous base, usually on the face and trunk
Result from obstruction of the sweat gland ducts
Disappears spontaneously within weeks
Malignant melanoma - think ABCDE-EFG - assymetry, irregular borders, different colors especially blue and red, diameter > 6 mm, evolving or changing, elevation, firm to palpation, growing rapidly over several weeks
squamous cell carcinoma - keratoacanthomas are SCCs that arise rapidly and have a crateriform center, often have a smooth but firm border, SCCs can become quite large if left untreated. Highest sites of metastasis are the scalp, lips and ears.
herpes zoster “shingles” - grouped vesicles on erythematous base usually in a dermatomal distribution that does not cross the midline (unilateral)
solar lentigo - happens on sun-exposed skin. Light brown and uniform in colr but may be assymetric
Slate blue patches: A dark or bluish pigmentation over the buttocks and lower lumbar regions
Common in newborns of African, Asian, and Mediterranean descent
Result from pigmented cells in the deep layers of the skin
They become less noticeable with age and usually disappear during childhood
Document these pigmented areas to avoid later concern about bruising
acanthosis nigricans - dark, velvety patches appearing in creases and folds of the body, i.e. axillae, neck, groin, occurring in people who are obese, have DM or metabolic syndrome. May be corrected with weight loss and resolution of underlying condition.
Coxsackie Virus (hand, foot, and mouth disease) - common in summer and fall, generally not painful and is contagious (person-to-person, touching of surfaces, droplet, touching fecal matter of infected individual). It happens mostly in children under 5 years of age but anyone can get it. It may consist of vesicles on a erythematous base on the soles and palms. The person may also have mouth sores, anorexia, sore throat, be fussy. It will go away with supportive treatment.
Seborrheic keratosis - often verrucous texture, appear like flattened ball of wax, may crumble or bleed if picked, may be erythematous if inflamed, common in older adults, non-cancerous and may appear as brown, black or skin-colored, appears on face, back, shoulders and chest
Molluscum contagiosum - caused by pox virus, pearly colored dome-shaped papules with umbilication, may appear in clusters or linear fashion (likely due to scratching)
Cutis marmorata - seen in normal children and and congenital hypothyroidism and Down syndrome. Vasomotor response to cooling or chronic exposure to radiant heat.
actinic keratosis - often easier to feel than see, superficial keratotic papules “come and go” on sun-damaged skin, pre-cursor to SCC
Dermal nevi - brown dome-shaped papule. Uniformly round and symmetric. Elevated and smooth, approximately 7 mm in diameter.
Tinea corporis of face: round, annular lesion with advancing red, scaly border noted on left cheek. Border is raised. Central hypopigmentation with red papules noted in center.
Café-au-lait spots: Pigmented light-brown lesions (<1 to 2 cm at birth)
Isolated lesions have no significance, but multiple lesions with sharp borders may suggest neurofibromatosis
plaque psoriasis - scattered erythmatous to bright pink well-circumscribed flat-topped plaques on extensor knees and elbows with overlying silvery scale
varicella “chicken pox” - dew drop on a rose petal appearance, now less common due to vaccinations. Lesions consist of a vesicle on erythematous base. Signs and symptoms include pruritis, fever, unwell symptoms.
Wild chicken pox (presently more common), is more virulent, lesions may become infected causing sepsis and death
basal cell carcinoma - pearly pink plaque with central depression and overlying arborizing telangiectasias on left cheek. It is the most common type of skin cancer, often appearing on sun-exposed areas.
Erythema infectiosum “fifth disease” - caused by parvovirus B19, starts with mild fever, rhinitis, headache (contagious) followed in 3-5 days with rash, no longer contagious. Appearance includes slapped cheek red rash on face and lacy rash on arms, legs and trunk.
acrocyanosis - a blue cast to the hands and feet when exposed to cold is very common in newborns for the first few days and may recur throughout early infancy. If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered.
Physiologic jaundice in newborn - may appear in days 2-3, peaks at day 5. Jaundice within 24 hours of birth is concerning for pathologic cause. Description is based on its extension which happens from head down, i.e. “jaundice to nipple line”
Erythema toxicum - Diffuse rash which happens only in newborns. Consists of erythematous macules with central pinpoint yellow or white pustules. It appears in first few days of life and disappears within a week. Can appear on face, chest, arms, legs but not on palms/soles.
Abnormally large head
macrocephaly due to hydrocephalus, subdural hematoma or rare causes like brain tumor or inherited syndromes
Acrocyanosis
Normally disappears after 8 hours or with warming. If not, then consider cyanotic congenital heart disease
activities of daily living
toileting, dressing, grooming, transferring, continence, feeding
adolescent (11-20 years) development
Onset of puberty avg age for girls 10, boys 11
Concrete to operational thinking, wide variability in cognitive development, increasing autonomy and peer influence, struggle for identity, independence, eventually intimacy leads to stress, health-related problems and often high-risk behaviors
Concrete to formal operational thinking: acquiring an ability to reason logically and abstractly and to consider future implications of current actions
adolescent (11-20 years) growth
girls growth spurt by age 14, boys by age 16
Alcohol in older adults
No more than 3 drinks per day or seven drinks per week
Apgar score
heart rate, respiratory effort, muscle tone, reflex irritability, color
Normal 1 min score: 8-10
Some nervous system depression score 5-7
Normal 5 min score: 8-10
High risk CNS and other organ dysfunction score 0-7
Ex. Skin, all blue, score = 0
pink trunk with blue hands/feet, score = 1
all pink, score = 2
Assess for aortic regurgitation
Patient sits, leans forward and exhales, use diaphragm over left sternal border at the apex (MCL at 5th ICS), listen for a soft diastolic decrescendo murmur
Assessing for mitral stenosis
Patient rolls to left side and listen with the bell of the stethoscope for S3 at apex (MCL at 5th ICS)
Assessment (SOAP)
analysis and interpretation
Auscultation
Use bell or diaphragm of stethoscope to detect heart, lung and bowel sounds
Basal cell carcinoma
translucent nodule that spreads and leaves a depressed center with a firm elevated border
Blood pressure in children
start measure at age 3, sooner if an issue is present
BMI
weight (kg)/height (m squared)
BMI in children
Measure in children older than 2
Bulla
Fluid-filled, > 1 cm
CAGE (for alcohol/drug use and abuse)
Concern/Cut
Apparent/Annoyed
Grave/Guilty
Evidence/Eye-opener
Causes of weight loss
GI disease, endocrine d/o, chronic infection, HIV/AIDS, malignancy, chronic cardiac/pulmonary or renal failure, depression, anorexia, bulima
Central cyanosis
concern for congenital heart disease; best place to check is tongue, oral mucosa
Chief complaint
Use quotes, use patient’s own words
coarctation of aorta and occlusive aortic disease
systolic hypertension in upper extremities and lower bp in legs, diminished or delayed femoral pulses referred as femoral delay
Common geriatric syndromes
falls, delirium, cognitive impairment, functional dependence, urinary incontinence
Cutis marmorata
prominent in premature infants and in infants with congenital hypothyroidism and Down syndrome
Diphtheria
Bacteria
S/S: Affects mucus membrane, insidious onset of pharyngitis, within 2-3 days membrane forms which can cause respiratory obstruction, fever usually not high but patient appears toxic
Dx: Culture of site, membrane formation, low-grade fever, toxic look of patient
Tx: Antitoxin, erythromycin/procaine PCN G
Vaccine: IM in DTaP, DT, Td, or Tdap
Schedule:
DTaP: 3 or 4 doses plus booster (entering school, under age 6)
Tdap: 11 or 12 yrs
Td or Tdap (preferred booster): q 10 years
Drugs associated with weight gain
TCA, insulin, sulfonylurea, contraceptives, glucocorticoids, progestational steroids, mirtazapine, paroxetine, gabapentin and valproate, propanolol
early childhood (1-4 years) development
walk by 15 months, run well by 2 yrs, pedal tricycle and jump by 4 years, sensorimotor learning, drive for independence, impulsive, poor self-regulation, temper tantrums, preoperation (lack of sustained, logical thought process)
early childhood (1-4 years) growth
physical growth slows by 50% growth of 3.5 inches and gain 4 pounds avg more leaner, muscular preschoolers
Extremely low birth weight
< 1000 grams (2.2 lbs)
Family History
Elaborate on HTN, CAD, elevated cholesterol, stroke, DM, thyroid/renal disease, arthritis, asthma, mental illness, suicide, substance abuse and allergies, cancer (ovarian, breast, colon, prostate), genetic disorders
Fatigue
non-specific, many causes, loss of energy, common symptom in anxiety and depression, also caused by other conditions such as infections, endocrine disorders and others.
Five critical domains of pediatric development
gross/fine motor, cognitive, communication, personal/social domains
Full description of symptoms
Begin with open-ended questions, then specific questions and finally yes/no questions
general survey
apparent state of health, LOC, signs of distress, skin color and lesions, dress, grooming, hygiene, facial expressions, body/breath odor, posture, gait, motor activity, ht, wt, BMI, waist circumference
gold standard
best measure of presence of disease
Haemophilus influenzae
Bacteria
S/s: Meningitis, epiglottitis, pneumonia, arthritis, and cellulitis
Dx: Culture in chocolate agar media, serotype using slide agglutination and real-time PCR
Tx: 3rd generation cephalosporin or chloramphenicol plus ampicillin
Vaccine: Hib
Schedule:
4-dose series at age 2,4,6, 12-15 months
3-dose series at age 2, 4, 12-15 months
Head circumference in children
Measure until age 24 months
Hepatitis A
RNA virus
S/s: Abrupt onset of fever, malaise, anorexia, nausea, abdominal discomfort, dark urine and jaundice
Dx: Serologic testing, detectable IgM anti-HAV 5-10 days before onset of symptoms and persist for up to 6 months
Tx: Supportive management, post-exposure prophylaxis with IVIg
Vaccine: IM Hepatitis A vaccine
Schedule:
2 doses, first age 12-23 months, 2nd dose 6 months later
Over 24 months, also receive 2 doses
Hepatitis B
double-shelled virus
S/S: Preicteric: insidious onset of malaise, anorexia, n/v, RUQ abdominal pain, fever, h/a, myalgia, skin rashes, arthralgia and arthritis and dark urine
Icteric: 1-3 weeks and c/b jaundice, light or gray stools, hepatic tenderness and hepatomegaly (splenomegaly is less common)
Dx: Serologic testing: HBsAg (infectious), anti-HBc (past infection), IgM anti-HBc (recent HBV infection), anti-HBs (vaccine)
Tx: Supportive in acute infection, for chronic HBV (interferon alpha) and nucleoside or nucleotide analogues: lamivudine, adefovir, entecavir telbivudine and tenofovir
Vaccine: IM hepatitis B
Schedule:
3 doses, booster not routinely recommended
Infants: birth, p 4 weeks (1-2 months), p 8 weeks (6-18 months)
herpes zoster (shingles)
vesicular lesions occurring in a dermatomal distribution
History of Present Illness
summary, OLDCART, relevant risk factors, symptom history, medications, allergies, tobacco/alcohol/drug use
Vaccine schedule: HPV
If first dose given at age 9-14 years, second dose at least 5 months apart
If first dose given 15 years +, 3 dose-series
1st dose
2nd dose: >=4 weeks from dose 1
3rd dose: 12 weeks from dose 2 and 5 months from dose 1
Human papillomavirus
small, double-stranded DNA virus
S/S: Anogenital warts, respiratory papillomatosis, cervical/anal/vaginal/vulvar/penile cancers
Dx: Pap tests (cervical cancer screening)
Tx: Supportive treatment of genital warts
Vaccine: HPV
Schedule:
Age 11-12 yrs, or females 13-26 yrs, males 13-21 yrs
(2-dose series if first given prior to age 15, 3-dose series if given if older than 15)
Hypertension
average of 2 readings on 2 separate occasions > 140/90
Immunization in older adults
influenza, pneumonia PPSV23 and PCV13, herpes zoster, tetanus/diphtheria and pertussis
Infant at 3 months
Able to lift head, clasp hands, coo
Infant at 6 months
able to roll over, reach for objects, turn to voices, babble and sit with support
Infant at 9 months
neat pincer grasp, indicate wants, developed “stranger danger”
Influenza
Helically-shaped RNA virus
S/S: Abrupt onset of fever, myalgia, sore throat, nonproductive cough and h/a
Dx: Clinical esp in context of community patterns, nasopharyngeal swabs within 3 days of onset of illness, serologic rise in influenza IgG (< 5 days of onset), hemagglutination inhibition test >= 4-fold rise in antibody titer
Tx: zanamivir, oseltamivir (given within 72 hours of onset of symptoms), otherwise supportive measures
Vaccine: inactivated (min age 6 months) or live attenuated vaccine (min age 2 years)
Schedule: 2-dose series for children under age 8, given 4 weeks apart
then annual, no live attenuated version after age 65
Influenza vaccine
Through age 8, first time and less than 2 years old - 2 doses of inactivated influenza vaccine (IIV), 4 weeks apart
LAIV has minimum age of 2 years old - also 2 doses prior to age 8
After age 8 - 1 annual dose
Live attenuated (intranasal) OK through age 50
Inspection
observing details in appearance, behavior, movement, gait, hygiene
instrumental activities of daily living
shopping, paying bills, cooking, using a telephone, doing laundry, transportation, taking medication and managing money
Interval between live vaccines
If not given on same day, minimum interval ins 4 weeks
LGA
> 90th percentile (usu. due to diabetic mothers, tall parents, genetic syndromes)
Common complications: hypoglycemia
Listening
single-most important part of health history, 90% of diagnosis comes from history
Live attenuated viral vaccines
Immune response resembles natural immunity
Usually require one vaccine
Can be given together with other live vaccines
If unable to give together must separate by at least 4 weeks
Examples of live vaccines: measles, mumps, rubella, vaccinia, varicella, zoster, yellow fever, rotavirus and intranasal influenza
Contraindicated in pregnancy, after age 65, immunocompromised
Live zoster virus vaccine
1 dose, after age 60
Separate from recombinant zoster vaccine by at least 2 months
Low birth weight
< 2500 grams (5.5 lbs)
Macule
flat, < 1 cm
Measles
paramyxovirus with a core of single-stranded RNA
S/S: Fever, onset of cough, coryza, conjunctivitis, Koplik spots, maculopapular eruption
Dx: Measles virus from urine, nasopharynx, blood, throat, rise measles IgG by any standard serologic assay, positive sero
Tx: Supportive, vitamin A to reduce complications
Vaccine: MMR/MMRV
Schedule:
2 doses
Infants: age 12-15 months, age 4-6 months (prior to attending school)
Additional dose for increased risk: college students, healthcare workers, international travelers
melanoma
dark, raised asymmetric lesion with irregular borders
Meningococcal disease
Bacteria
S/S: Sudden onset of fever, h/a, stiff neck, n/v, photophobia and AMS, petechial rash
Dx: Isolation of N. meningitidis from a normally sterile site (CSF)
Tx: Empiric therapy with broad-spectrum antibiotics, e.g. third-generation cephalosporin, vancomycin started promptly after cultures obtained, also penicillin
Vaccine: MenACWY (Menactra), MenB (both IM)
Schedule: 2 doses, 1st age 11-12, booster at 16
MenB, 1 dose at age 16-18 years
middle childhood (5-10 years) development
improvement of strength and coordination, concrete operation, school family and environment influence learning, self-efficacy, language more complex, more independent, guilt and self-esteem emerge, clear sense of right and wrong
middle childhood (5-10 years) growth
grow steadily but more slowly
MMRV in adults
1 dose if no evidence of immunity (titers are low) for non-pregnant women of childbearing age
2-dose series given at least 4 weeks apart for:
HIV (CD4>=200), ESRD, HCW, MSM, DM, asplenia, heart/lung disease, liver disease, ETOH
Contraindicated in pregnancy and severely immunocompromised (incl CD4<200), over age 65
Mononucleosis in adolescent
persistent fever, tonsillar pharyngitis, cervical lymphadenopathy
Mumps
Paramyxovirus
S/S: Myalgia, malaise, h/a, low-grade fever, orchitis, parotitis
Dx: Based on clinical manifestations and serum mumps IgM, rise in IgG antibody titer in acute and convalescent-phase positive mumps virus culture or detection of virus by rRT-PCR), specimens from parotid duct (preferred), salivary gland ducts (preferred), throat, urine and CSF
Tx: Supportive
Vaccine: MMR
Schedule:
At least 2 doses
Infants: 12-15 months of age
Children: age 4-6 years, prior to attending school (at which point MMRV is preferred)
Newborn development
habituation, attachment, state regulation, perception
Newborn growth: late preterm
34-36 weeks
Newborn growth: preterm # of months
< 34 weeks
OBGYN history
GPML (gravida, para, miscarriages, living) I am 4-3-1-3
Objective data
Signs Vital signs Physical exam findings Diagnostic tests
OLDCART
onset, location, duration, characteristics, aggravating/relieving factors, timing
Older adult: approach to primary care
observe for geriatric syndromes, be aware of community resources, review advanced directives, be familiar and reference Beers Criteria, adopt an evidence-based approach to health screening
Palpation
tactile pressure from fingers or fingerpads
Papule
Raised, < 1 cm
Parts of a comprehensive health history
Identifying Data, Reliability, Chief Complaint, Present illness, Past illnesses, Family history, Personal and social history, Review of systems
Past History
Childhood illnesses, medical, surgical, OBGYN, psychiatric, health maintenance
Patch
Flat, > 1 cm
Pediatric Growth: need further evaluation
variations more than 2 std dev for age, below 5% or above 95% percentile for ht/wt/head circumference, reduced growth velocity, drop > 2 quartiles in 6 months,
Pediatric health promotion and supervision (in general)
AAP guidelines, immunizations, age-specific screening, anticipatory guidance, development, discuss parental concerns, physical exam
Percussion
Striking plexor finger against pleximeter finger on chest, back, abdomen to elicit resonance or dullness
Personal and social history
occupation, education, home situation, significant other, religious/spiritual beliefs, ADLs, exercise, diet, safety, sexual orientation and practices, alternative health care practices
Pertussis
Gram-negative rod
S/S: Onset of coryza, low-grade fever, mild occasional cough which starts mild then more severe, paroxysmal cough, high-pitched whoop
Dx: Clinical history (cough > 2 weeks with whoop, paroxysms or posttussive vomiting), culture (gold standard), PCR (high false-positive rate)
Tx: Supportive, antibiotics are of some value, i.e. azithromycin, clarithromycin and erythromycin, SMZ-TMP can also be used.
Vaccine: DTaP, dTaP
Schedule:
DTaP: age 2 months, 4 months, 6 months, 15-18 months, 5th dose if 4th dose given before age 4
Tdap: age 11 years, in each pregnancy weeks 27-36, healthcare personnel, q10 year booster
Pityriasis rosea
oval lesions on trunk, in older children, often in a Christmas tree pattern, somteimes a herald patch (a large patch that appears first)
Plan (SOAP)
patient education, changes in meds, needed tests, referrals, return visits, patient response to plan
Plaque
Raised, > 1 cm
Pneumococcal disease
Bacteria
S/S: Abrupt onset of fever and chills/rigors, pleuritic chest pain
Dx: Isolation of organism in blood or otherwise sterile body sites, sputum specimens, urinary antigen test
Tx: Penicillin
Vaccine: PCV13, PPSV23
Schedule:
PCV13 - 3 doses age age 2,4,6 months, booster at age 12-15 months
adults age 65+
PPSV23 - 1 dose, 12 months from PCV13, revaccinate at least 5 years after 1st dose
Pneumococcal vaccine
If not vaccinated during childhood, give PCV13 first
then PPSV23, 12 months later
Never give them together
If PPSV23 given before age 65, revaccinate in 5+ years
In chronic medical conditions: PCV13 followed in 8 weeks with PPSV23, then PPSV23 in 5 years, after age 65, PPSV23 at least 5 years from last dose
In asplenia/functional asplenia - separate from meningococcal vaccine, give only after the youth series is finished
Poliomyelitis
RNA enterovirus
S/S: Most are asymptomatic, minor, nonspecific illness, stiff neck/back/legs, flaccid paralysis
Dx: Two specimens separated by 3 weeks, serology with four-fold rise in antibody titer, in poliovirus infection of CF, fluid will have increased WBC and mildly elevated protein
Tx: Supportive including physical therapy
Vaccine: IPV
Schedule: Infants - 3 doses @ age 2,4,6-18 months
Child- age 4-6 years
Problem List
List most active/serious first with date of onset
Pustule
small, palpable collection of neutrophils or keratin that appears white
Review of systems (ROS)
general, skin, HEENT, neck, breasts, respiratory, CV, GI, PV, urinary, genital, MSK, psychiatric, neurologic, hematologic, endocrine
Risks of postterm
increased risk for mortality/morbidity r/t asphyxia and meconium aspiration
Risks of preterm/late preterm
Many including respiratory, cardiovascular and neurodevelopmental
Rotavirus
Double-stranded RNA virus
S/S: Self-limited watery diarrhea, severe dehydrating diarrhea with fever, vomiting, fever > 102F
Dx: Rotavirus antigen in stool by EIA (preferred), also in serum 3-7 days after disease onset
Tx: Rehydration, replacement of electrolytes, supportive care
Vaccine: Rotavirus (oral)
Schedule: Infants max age 8 months,
3 doses @ age 2,4,6 months
Rubella
Togavirus
S/S: 1-5 day prodrome with low-grade fever, malaise, lymphadenopathy, URI symptoms, rash that is maculopapular and occurs 14-17 days after exposure, starts at face then progressing to feet, occasionally pruritic rash
Dx: Positive viral culture by PCR, presence of rubella-specific IgM antibody or significant rise in IgG antibody from paired acute- and convalescent-phase sera.
Tx: Supportive care
Vaccine: MMR/MMRV
Schedule: 2 doses
age 12-15 months, 4-6 years
Screening for alcohol use disorder
Men: <=4 drinks per day or 14 drinks per week
Women: <=3 drinks per day or 7 drinks per week
1 drink = 12 ounces of beer, 5 ounces of wine, 1.5 ounces of spirits
Screening questions for depression
- Over the past 2 weeks, have you felt down, depressed or hopeless? 2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?
sensitivity
probability person with a disease has a positive test (true positive rate)
SGA
< 10th percentile (usu. due to nutritional issues/smoking/illicit drug use and placental issues)
Skin findings components (#8)
Number, Size, Color, Shape, Texture, Primary lesion, Location, Configuration
Skin scraping with KOH
The skin lesion KOH (potassium hydroxide) exam is a simple test that helps doctors identify fungal infections on a person’s skin, hair, and nails. If negative, lesion is not due to fungus or may have to test again.
Small head size
from premature suture closure or microcephaly due to chromosomal abnormalities, congenital infections, maternal metabolic disorders and neurologic insults
SnNOUT
Sensitive test with negative result rules out disease
SOAP
subjective, objective, assessment, plan
specificity
probability non-diseased person has a negative test (true negative rate)
SpPIN
Specific test with positive result rules IN disease
squamous cell cancer
firm reddish-appearing lesion often emergin in a sun-exposed area
Subjective data
Symptoms, What the patient tells you, Data source/reliability, Chief complaint, History of present illness (HPI), Past history, Family history, Personal and social history, Review of systems
Tdap
given during pregnancy weeks 27-36 and child’s caregivers, given with injury/wounds and every 10 years
Telogen effluvium
Diagnosed after hair pull test - grab 50-60 strands of hair, using thumb and index finger pull away from scalp. If hair is removed and contains the bulb, test is positive for telogen effluvium
Temperature in infants
rectal temp most accurate in symptoms
Tetanus
Bacteria
S/S: Trismus or lockjaw, stiffness of neck, difficulty swallowing, abdominal muscle rigidity, elevated temp/bp, sweating, episodic rapid HR, spasms x 3-4 weeks
Dx: Clinical, may be recovered from wound in only 30% of cases
Tx: Wound care, supportive care and maintenance of adequate airway, tetanus immune globulin (TIG) to help remove unbound tetanus toxin (one IM dose, or IV)
Vaccine: DT, DTap, Tdap
DTaP @ ages 2,4,6, 15-18 months, 4-6 years,
DT/Td/Tdap: q10 boosters
Timing and spacing between vaccines and antibody
first vaccine, wait 2 weeks to give antibody
first antibody, wait 3 months to give vaccine
Exception is post-exposure such as tetanus/hep B/rabies antibody and vaccine can be given at same time
Vaccination @ 12 months
MMRV
Vaccination @ 1-1.5 years
MMR, Hepatitis A, DTap, Hib, PCV13, Varicella
Vaccination: @ 2 months
Hepatitis B, DTaP, Rotavirus, Hib, IPV, PCV13
Vaccination: @ 4 months
DTaP, Rotavirus, Hib, IPV, PCV13
Vaccination: @ birth
Hepatitis B
Vaccinations: 11-12 years
Tdap, HPV, Meningococcal
Vaccinations: 16-18 years
Meningococcal booster
Vaccinations: 4-6 years
Varicella, DTaP, IPV, MMR
Vaccinations: @ 6 months
Influenza, Hepatitis B, DTaP, Rotavirus, Hib, IPV, PCV13
Varicella zoster
DNA virus
S/S: Varicella: Mild prodrome may precede onset of vesicular rash which appears first on head, to trunk and then extremities, 1-4 mm, may rupture and crust, dew drop on rose petal appearance
Shingles: vesicular eruption in the distribution of a sensory nerve, involves trunk or 5th CN, 2-4 days prior to eruption, may have pain and paresthesia at involved area, few systemic symptoms
Dx: Clinical symptoms, Varicella virus from vesicular fluid, rapid virus identification using PCR or DFA, significant rise in varicella IgG by any standard serologic assay
Tx: Supportive care, if high-risk antiviral therapy such as oral valacyclovir or acyclovir
Vaccine: MMRV, V, zoster recombinant, live zoster
Schedule: MMRV - 2 doses, @age 12-15 months, 4-6 years
and in persons without proof of immunity, 2 doses separated by 4 weeks
Adults age 50+: 2 doses of zoster recombinant vaccine (2-6 months apart)
Age 60+: 1 dose live zoster vaccine
Very low birth weight
< 1500 grams (3.3 lbs)
Vesicle
Fluid-filled, < 1 cm
Weakness
Denotes demonstrable loss of muscle power
Weight and height at 12 months
Triple birth weight, 50% length
Weight loss
Pounds lost over a 6-month period
When is a comprehensive health assessment done?
new patients, in-depth knowledge of patient, provides a baseline for future visits, health promotion and education, comprehensive exam
When is a focus/problem-oriented health assessment done?
Appropriate for established patients, addresses focused concerns or symptoms, addresses symptoms related to specific body systems, focused exam utilizing specific techniques or maneuvers
Why should pneumococcal and meningococcal vaccines be separated in asplenia/functional asplenia?
In addition to being at increased risk for meningococcal disease, children with functional or anatomic asplenia are also at increased risk invasive disease caused by Streptococcus pneumoniae. Data show that the MenACWY-D may interfere with the immunologic response to PCV13 if these two vaccines are given too close together. So ACIP recommends that MenACWY-D not be administered until at least 4 weeks after completion of the age-appropriate PCV13 series. MenACWY-CRM (Menveo) does not affect the immune response to pneumococcal vaccine so can be given at any time before or after PCV13.
Zoster recombinant vaccine
2 doses, 2-6 months apart - after age 50
Passive immunity
Antibodies are transported across the placenta during the last 1–2 months of pregnancy. As a result, a full-term infant will have the same antibodies as its mother. These antibodies will protect the infant from certain diseases for up to a year. Protection is better against some diseases (e.g., measles, rubella, tetanus) than others (e.g., polio, pertussis).
Immunity from inactivated vaccines
Inactivated vaccines always require multiple doses. In general, the first dose does not produce protective immunity, but “primes” the immune system. A protective immune response develops after the second or third dose.
Sensitive interviewing re IPV
Begin with normalizing statements such as “Because abuse is common in many women’s lives, I’ve begun to ask about it routinely.”
Followed by probing questions and then in-depth questioning.
Boraching sensitive topics
The single most important rule is to be nonjudmental. Explain why you need to know certain infromation. Find opening questions for sensitive topics and learn the specific kinds of information needed for your shared assessment and plan.
Hypothyroidism
High TSH, low T3, T4
S/S: fatigue, bradycardia, thin hair, dry skin
Hyperthyroidism
Low TSH, high free T4, high free T3
S/S: increased basal metabolic rate, exophthalmos, restlessness, sweating, heat intolerance, weight loss, flushing of face and hands, smooth, moise and warm skin, fine, soft and thinned scalp hair
