Exam 1: Lectures Flashcards
What is the high quality recommendation screening for perinatal and postpartum depression?
1, 2, 4, 6, and 9 month well-child visits
When should screening for developmental delays be conducted based on high-quality practice recommendations?
6, 9, 12, 18, 24, and 36 months
Based on high-quality recommendations, when would you screen for social-emotional problems?
4-months, 15 months, 24 or 30 months, and 36 months
When does autism spectrum disorder screening happen according to high-quality recommendations?
18 months and then 24 or 30 months
You have a newborn baby coming to you for this first visit to the practice. What is an important screening to complete?
Domestic violence screening
High-quality recommendations suggest screening for domestic violence at which visits?
1st encounter to the practice, 6 month visit, 18 month visit, 24 or 30 month, 36 months
Is juice recommended for children under the age of 6 months old?
No, it can lead to poor dental health outcomes
Your patient comes in for their 18 month well child visit. They have a few teeth and their mother is concerned about cavity prevention. She would like to know if she should be using toothpaste when brushing the child’s teeth. What do you recommend?
Toothpaste is not recommended for use until 24 month (2 y/o). Continue to brush the child’s teeth twice a day with a soft toothbrush.
How much toothpaste does a child 2-6 y/o need?
A pea-sized amount
When should BP monitoring begin in children?
3 y/o
Vision screenings should occur in children at what ages?
5, 6, 8, 10 and 12 y/o
You have a patient who is 6 y/o in office for their well child exam. Their 5 y/o vision screen was 20/30 and you suggested to repeat it in a year knowing that some children will not reach 20/20 vision until age 6. Today, their vision screening is 20/40. What would you do next?
Refer to ophthalmology
When should you repeat a hemoglobin level on an infant?
9-12 months
When should lead levels be checked?
9-12 months and then 18-24 months
According to the AAP, when do you screen lipid panels?
6 y/o, 8 y/o, annually at 10 y/o
According to USPSTF, when do you screen lipid panels in children?
It is not recommended to screen lipid panels in children according to USPSTF
What are the components of the newborn visit?
A thorough history including prenatal, birth, and current history
Complete physical and vital signs
Anticipatory guidance for the parents
Wrap-up
Height, weight, head circumference, pulse, RR, temp, newborn screening testing, growth chart beginning at birth are components of:
Newborn assessment
Skin texture, plantar creases, breast, eyes, ears, genitals, posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear help determine:
Gestational age
General appearance/temperament
Growth from birth
Skin integrity
Response to environment including muscle tone and symmetry of movement
Hearing/vision screening
Cardiac/Respiratory
Hip dysplasia or bone fractures
Cord healing and circumcision healing
Neurological defects
Abuse/neglect
Newborn physical assessment key aspects
Multiple, firm, pearly, opalescent white papules that exfoliate spontaneously
Milia
Yellow-white papultes generally over the nose, forehead, upper lip and cheeks
Sebaceous hyperplasia
Firm, yellow-white, 1-2 cm papule or pustules with surrounding erythematous flare that developed around 24-48 hours old
Erythema toxicum
Vesicopustules that rupture easily and leave a halo of white scales around a central macule of hyperpigmentation on the trunk, limbs, palms, and soles
Transient neonatal pustular melanosis
Scattered superficial bullae on the upper arms and lips
Sucking blister
Lacy, reticulated, red or blue vascular pattern
Cutis mermorata
Half of the baby’s coloring is red and the other half is pale
Harlequin color change
Yellow, hairless smooth plaque on the head or trunk
Nevus sebaceous
You have a patient that you diagnosis with nevus sebaceous. What would be your next step in the treatment plan for this patient?
Refer to pediatric dermatology as these lesions can develop into a secondary malignancy
If you see a preauricular skin tag or pit what are you concerned for?
Genetic disorders, especially those involving the kidneys
The child you are assessing has a loud diastolic murmur, what is your concern?
For a pathologic disorder
The child has a flow systolic murmur. What is the concern?
No concern, this is normal in infants
Moro, walking/stepping, rooting/sucking, tonic neck, palmar grasp, galant, seimming, and babinski’s are all:
Primitive reflexes seen in the newborn
What are management considerations for the preterm infant?
Additional vision and hearing screenings
Adjusted growth expectations
Supportive services for parent and baby based off of medical needs
Close medical surveillance
MISFITS acronym:
Metabolic disturbances
Inborn errors of metabolism
Sepsis
Formula dilution or over concentration
Intestinal catastrophes
Toxins
Seizures
MISFITS helps with DDx for which population?
Critically ill newborns
Newborns should have how many wet diapers/day?
6-8
G6PD deficiency, isoimmunization, extrvascular blood, polycythemia, sepsis, drugs, hypothyroidism, and bowel obstruction are all causes of what?
Pathologic etiology of hyperbilirubinemia seen with jaundice
The Rule of ‘3’ is helpful for remembering:
Colic
Onset by 3 weeks, gone by 3 months
Poor feeding/appetite or sucking
Fever >100.4
Inconsolable crying >3 hrs
Skin rash, red eyes, jaundice
Irritability, lethargy
Umbilical cord odor, drainage, or redness
Cough, vomiting (not spit-up), diarrhea, abdominal distention
Parents should:
Call the office immediately
Physical/Motor skills:
-Posterior fontanelle closure
-Step and grasp reflex begin to disappear
-Able to lift head to 45 degrees
2 month
Sensory/Cognitive markers:
-Looks at close objects
-Cry differentiates
-Coos, smiles
-Vocal response to familiar voices
2 months
Red flags:
-No startle
-Doll eyes
-Quiet
-Asymmetric movement
-Excessive irritability
2 months
Physical/Motor markers:
-Moro, tonic neck, and rooting reflexes fade
-Little to no head lag
-Able to sit straight if propped
-Raise head to 90 degrees on stomach
-Roll from front to back
-Reaches for objects with hands, can grasp with both hands, loves putting objects in mouth
4 months
Sensory/cognitive markers:
-Well-established close vision
-Starting hand-eye coordination
-Babbles, coos, laughs
-Anticipates feeding by visual cues
-Showing signs of memory development
-Attention seeking via fussing
-Recognize familiar voices and parental touch
4 months
Red flags:
-Lack of social smile
-Doesn’t track or turn to a voice
-No hand/mouth activity
-No attempt to raise head when prone
-Persistent fisting
4 months
Physical/Developmental markers:
-Doubled birth weight
-Vision 20/60
-Imitating sounds
-Enjoys hearing own voice, loves mirrors and toys
-Able to lift chest and head on stomach, bears weight on hands
-Rolls from back to stomach
-Able to grasp and pick up objects
6 months
Sensory/cognitive markers
-Vision 20/60
-Increasing complexity of sound stimulation
-Fear of strangers, recognizes parents
-All primitive reflexes except Babinski is gone
6 months
Red flags:
-No smiling or response to play
-No tracking, reaching, or looking for parents
-No grasping or babbling
-Head lag, no attempt to sit with support
-Persistent primitive reflexes
6 months
Physical/developmental markers:
-More regular elimination patterns
-Able to crawl, sit for prolonged periods of time, pulls self to standing
-Pincer grasp develops, can help feed self
-Throws and shakes objects
9 months
Sensory/cognitive markers:
-Developing depth perception and object permanence
-Responds to simple commands
-Knows their name
-Understands “no”
-May be afraid if left alone
-More interactive with play
9 months
Red flags:
-No eye contact or interactive play
-Does not sit in tripod
-No grasp, no visual/oral response to toys
-Asymmetric crawl
-No response to name
9 months
Physical/developmental markers:
-Triple birth weight, double birth length
-Head circumference = chest circumference
-6-8 teeth present
-Babinski reflex is gone
-Pulls to stand, may start cruising and walking with hand holding, attempting to walk independently
-Sits independently
-Turns pages, has a more precise pincer grasp
12 months (1 y/o)
Sensory/cognitive markers:
-Comprehends several words/simple commands
-“mama”, “dada”, a few other short words
-Imitates sounds and animal noises
-Can develop attachment to objects/toys
-Points to things, waves ‘bye’
-Separation anxiety, clingy to parents
12 months (1 y/o)
Emotional development for the toddler stage
Autonomy v. Shame/doubt
Cognitive development for the toddler stage
Piaget’s object permanence, visual displacement
Red flags/Health watch:
-Cannot walk by 18 month
-Fails to develop heel-toe walking pattern after several months of walking
-Less then 15 words by 18 months
-No two-word sentences
-No imitation of actions or words
-Cannot stack at least 6 blocks
-Doesn’t feed self
-Cannot follow simple instructions
2 y/o concerns
Emotional development: 3 y/o
Initiative v. Guilt
Intellectual development: 3 y/o
Egocentric
Health watch/red flags:
-Cannot throw ball, jump in place, ride a tricycle
-Cannot grasp crayon with thumb/fingers
-Difficulty scribbling
-Cannot stack 4 blocks
-Cries/clings to parents when they leave
-No interest in interactive play/ignores others
-Doesn’t engage with people outside family or fantasy play
-Resists dressing, sleeping, toileting
-Lashes out, angry outbursts, no self-control
-Cannot copy a circle
-Sentences <3 words, doesn’t use “me”/”you” correctly
3-4 y/o concerns, early intervention is key
Early childhood
5-7 y/o
Middle childhood
7-10 y/o
Late childhood
10-12 y/o
Developmental characteristics:
-Attached to opposite sex parent
-Sexual identity develops
-Growing social circle
-Learning to modulate behavior
-Development of consciousness
-Intuitive problem solving
-Magical thinking, egocentric
Early childhood
Developmental characteristics:
-Superego/conscious is internalized
-Acquiring cultural/social skills and incorporating family values/beliefs
-Appreciated individuals interests/skills
-Desire to be successful part of the group
-Logic becomes more apparent, more objective with problem solving
-Motivation to achieve and learn
Middle childhood
What is a key social developmental piece of information to assess in middle childhood?
Loss of learning motivation
Developmental characteristics:
-Reemergence of sexual impulses
-Socialization with others with development of hobbies and interests outside of school
-Concrete and formal operational levels develop for problem solving
Late childhood
Abstract thought process to conceptualized physical properties
Used to organized into a hierarchical system
Concerte operational
Abstract thinking, complex reasoning, flexibility, hypothesis
Formal operational
When does AAP recommend beginning screening for scoliosis?
8 y/o
When should children start to have privacy and time separate from their parents at their well child visits?
Adolescents (11/12+
SMR Pubic Hair (Males and females):
Absent hair
Stage 1
SMR Pubic Hair (Males and females):
Downy hair present
Stage 2
SMR Pubic Hair (Males and females):
Scant terminal hair present
Stage 3
SMR Pubic Hair (Males and females):
Terminal hair fills the whole triangle overlaying the pubic area
Stage 4
SMR Pubic Hair (Males and females):
Terminal hair extending beyond the inguinal crease onto the thigh area
Stage 5
SMR Breast Development:
No glandular breast tissue palpable
Stage 1
SMR Breast Development:
Breast bud palpable under the areola
Stage 2
SMR Breast Development:
Breast tissue palpable outside areola
No development of the areola
Stage 3
SMR Breast Development:
Areola elevated above the contour of the breast, forming a “double scoop” appearance
Stage 4
SMR Breast Development:
Areolar mound recedes into single breast contour along with hyperpigmentation of the areola, papillae development, and nipple protrusion
Stage 5
SMR External Genitalia (Male):
Testicular volume less than 4mL or long axis less than 2.5cm
Stage 1
SMR External Genitalia (Male):
4mL to 8mL or 2.5 to 3.3 cm long
Stage 2
SMR External Genitalia (Male):
9mL to 12 mL or 3.4 to 4.0cm long
Stage 3
SMR External Genitalia (Male):
15 mL to 20 mL or 4.1 to 4.5 cm long
Stage 4
SMR External Genitalia (Male):
> 20 mL or > 4.5 cm
Stage 5
When is the ideal time to complete a sports participation physical and why?
4-6 weeks prior to the start of the season to allow for ample time to condition prior to the season thus preventing injury
Dancing, running, strength training, swimming, tennis
Non-contact sports
Baseball, cheerleading, fencing, figure skating, gymnastics, skiing, softball
Limited contact sports
Basketball, field hockey, football, ice hockey, lacrosse, rugby, soccer, wrestling
High impact sports
You have a patient that is diagnosed today in office with mono. She plays field hockey for her high school. She wants to know when she will be able to return to play.
Minimum: 1 month d/t high risk for splenic rupture
Stress fractures and tendonitis are considered what type of injury?
Overuse
Ligamentous injuries and fractures are considered what type of injury?
Macrotrauma
You have a patient with Down Syndrome. They participate in Special Olympics events regularly. They are here today for their updated sports physical. What aspect is mandatory for assessment according the Special Olympics association for this athlete?
Cervical evaluation as atlantoaxial instability is associated with Down Syndrome.
What is always on the differentials for children with back pain as a CC?
Neoplasms
When do you treat pharyngitis/tonsillitis with antibiotics?
Group A Strep +
Age (5-17 y/o)
Season (late fall, winter, early spring)
Evidence of acute pharyngitis (erythema, edema, exudates)
Tender, enlarged anterior cervical lymph nodes
Middle grade fever (101-104)
Absence of S/S of viral URI
Six points to consider Group A Strep
Can GAS spontaneously resolve?
Yes, it generally spontaneously resolves in 3-5 days
You have an 8 y/o M with confirmed GAS + pharyngitis. He has NKA. What are you going to prescribe for his treatment?
Amoxicillin or PNC
Your patient comes in with sore throat and fever of 101.2 x2 days. She is 9 y/o and is diagnosed with GAS + tonsillitis. She is allergic to PNC with a reaction of severe hives. What do you prescribe to treat her?
Cephalexin
If concurrent allergy to cephalosporins: azithromycin or clindamycin
Your patient comes in with conjunctivitis x1 day with a fever of 103. You note on exam they also have mucositis, peripheral edema, a truncal rash and cervical adenopathy. What’s the lead on your differentials at this time.
Kawasaki disease
What is the most common cause of pharyngitis?
Viruses
What is the causative agent of enterovirus?
Coxsackie A
Small vesicles in the posterior pharynx
Usually seen in children 1-10 with mean age of 4 y/o
Enterovirus
Hand/foot/mouth disease is formally known as:
Adenovirus
Fever
Severe pharyngitis
Posterior AND anterior cervical lymphadenopathy
Can have hepatosplenomegaly
Commonly seen in adolescence
Mono
Order from shortest duration to longest:
Mononucleosis
Viral pharyngitis
Bacterial pharyngitis
Viral, bacterial, mono
What is the most common cause of sick visits for children?
Acute otitis media
What are the 3 most common bacteria that cause AOM?
Strep pneumoniae
H. influenzae
Moraxella catarrhalis
Which 2 vaccines given in infancy can help with protection against the bacteria that can cause AOM?
Hib and PCV13
Acute history of onset
S/S middle ear inflammation, bulging TM AND middle ear effusion
AOM diagnostic criteria per AAP
< 6 weeks old
Immunocompromised
Failure of antibiotics after 2-3 rounds
Fluid in middle ear > 12 weeks
Recurrent infections (>3 in 6 month period)
Hearing loss > 3 months
Reasons to refer for tympanocentesis
You are seeing a 3 y/o F for a sick visit. She has a mild fever, ear pain, and has been more irritable for the past 2 days. Mom reports she has noticed she a poor response when called from other rooms as well. She has NKA. When assessed, you note a bulging TM with moderate effusion and inflammation of the middle ear. You diagnose her with AOM. What will you prescribe for this patient?
Amoxicillin for 7 days
You have a 4 y/o M presenting for sick visit with mom. He has had increasing fatigue, low grade fever. He keeps asking his parents to repeat what they are saying and keeps pulling on his L ear saying it hurts. On exam you see middle ear inflammation, mild effusion, and a bulging TM. He is allergic to PNC. What do you treat him with?
Erythromycin/sulfasoxazole for 7 days
You prescribed 2 patients treatment for AOM on the same day. When would you like them to return for a follow up?
48 hours after initiation of medication
At the 48 hour mark, both your patients are improving with their AOM. When would you like to see them back?
10-14 days
Is testing necessary when diagnosing otitis externa?
No. You can culture the fluid if there is drainage or run labs if the patient is toxic appearing
What do you use to treat otitis externa?
Astringents
Acetic acid solutions
Ear wick
Ear drops
Most acute rhinosinusitis occurs in the:
Maxillary sinuses
When do the maxillary sinuses present
At birth with the ethmoid sinuses
When do the sphenoid sinuses pneumatize?
5 y/o
When can you begin assessing the frontal sinuses?
7 y/o, but don’t fully develop until adolescence
What are the 2 most common predisposing factors of sinusitis?
URI, allergic rhinitis
What is a common condition associated with asthma?
Chronic rhinitis (80% of people with asthma)
What is the treatment course length for acute rhinosinusitis?
14 days
What is your 1st line treatment for acute rhinosinusitis?
Amoxicillin
If PNC allergy: macrolide (Clarithromycin is best)
When can the fundoscopic exam begin?
5 y/o
Defective development of visual pathways needed to attain central vision, generally unilateral
Amblyopia
Deprivational ambylopia
Ptosis, cataract, nystagmus
Refractive amblyopia
Myopia, hyperopia, astigmatism, anisometropia
Treatment for amblyopia:
Corrective lenses by an ophthalmologist
Strabismus treatment:
Eye patching the “good eye”
Corrective lenses
Surgical intervention (not a 1st line)
Is nystagmus ever a normal finding?
Yes in the first few weeks of life, if persists the patient should be referred
Strabismus, decrease visual acuity, white pupil, abnormal red reflex, nystagmus, glaucoma, cellulitis, and photophobia are signs of:
Retinoblastoma
Insufficient breakdown of membrane that covers the nasolacrimal duct
Begins 2-6 weeks old and generally resolves spontaneously
Nasolacrimal duct obstruction
When should nasolacrimal duct obstructions be treated with eye drops?
When there is excessive mucuopurulent exudate
What is the recommended ages for audiometry testing?
3, 4, 5, 10, 12, 15, and 18 y/o
Permanent hearing loss most commonly associated w/ dysfunction of the inner ear
Sensorinerual hearing loss (SNHL)
Blocked transmission of sound waves from the external auditory canal to the inner ear
Conductive hearing loss
Abnormalities of the outer, middle, and inner ear
Mixed hearing loss
Nerves or nuclei of the CNS are impaired
Central hearing loss
Birth weight < 1500g
Apgar 0-3 in first 5 minutes, hypotonia up to 2 hr old
NICU admission > 2 days
Prolonged mechanical ventilation (>10 days)
Metabolic disorders
Hyperbilirubinemia with kernicterus or needing transfusion
Ototoxic drug use
RF for SNHL in newborns
Recurrent OME for > 3 months
Head trauma with LOC or skull fx
Bacterial meningitis
Ototoxic medications
DM
Kidney malformation
FH childhood hearing loss
Neurodegenerative disorders
Syndromes associated with progressive HL
Neurofibromatosis
Parental concern of delays
RF for SNHL in children 1 month-3 y/o
If there is cause for concern with vision, hearing, eye/ear abnormalities, what should the NP do?
Refer to the specialist
