Exam 2 Flashcards
What are some symptoms of an mTBI according to the CDC?
Concussion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for 24 hours and neurological abnormalities such as focal seizures, and GCS of 13-15
What should your initial exam include for children suspected of a TBI?
Mental status
Cognition
Balance
Strength
Scalp or skull abnormalities
Any signs of neurological deterioration
What indication would prompt admission of a patient for a TBI?
-Any signs of intracranial injury
-Fluctuating or deteriorating neuro, cognitive, or symptom eval
-Safety better served by observation in hospital than at home
-Severe symptoms
Should healthcare providers use imaging to help diagnose mTBI in children?
No, HCPs should use validated clinical decision rules to decide if imaging is warranted
What are the categories of mTBI S&S?
- Somatic
- Cognitive
- Affective
- Sleep
What should an on-field exam include for sports if mTBI is suspected?
- ABCs
- Neuro assessment
- Determine initial disposition
Should a sports player return to field same day after injury and suspected mTBI?
No, never if an mTBI is suspected, even if they say they are OK**
How long do the majority of pediatric patients need to refrain from physical and cognitive activities after an mTBI?
2-3 days
When is the return to activity process complete after mTBI?
When the patient is able to perform all normal activity without symptoms
How should a healthcare provider instruct an athlete to return to sports after an mTBI?
Use the 6-Step approach:
1. Back to regular activities (school)
2. Light aerobic exercise (walking)
3. Sport-specific exercise
4. Non-contact training drills
5. Full contact practice
6. Return to sports (normal game play)
What should the athlete do if symptoms return during the step approach to returning to sports?
-Stop activity
-After 24 hours of no symptoms, the athlete can start again at the previous step
When should the HCP refer a patient with a concussion to a concussion specialist?
-If no improvement in symptoms or persistent symptoms after 10-14 days
What is the most common cause of mTBIs in children?
Falls
What is CTE or chronic traumatic encephalopathy?
A neurodegenerative disease that is believed to be caused from repetitive head impacts; this can be caused even in absence of concussion
How long should the provider tell patients to use a rear-facing car-seat?
Till 2 years old**
What vaccine is given at birth?
Hepatitis B
What are the recommendations for a child’s first flu vaccine?
-Can give at 6 months, then annually
-First time (no matter the age): give a half dose, then a half dose one month later**
What Piaget stage is characterized by egocentric thinking?
Pre-operational, age 2-5
What Erickson stage is characterized by making things and playing?
Initiative vs. Guilt, age 3-6
What is the average weight gain for infants during physical development?
-0-3 mo: 14 to 28 grams per day or 0.5-1 ounce
-4-5 mo: 5 oz per week
-5-8 mo: 3-5 oz per week
-11-12 mo: 1 pound per month
When do anterior and posterior fontanelles close?
Posterior- 2 months
Anterior- 18 months - 2 years**
What position is best for SIDS prevention?
Back**
What are the benefits of breastfeeding for the baby?
-Increased immunity
-Decreased incidence of bacterial infections such as otitis media
-Decreased incidence of asthma, diabetes, excessive weight gain, SIDS
-Bonding with mother
What are the guidelines for screen time for children?
Less than an 1-2 hours per day**
What is the “Ages and Stages” screening tool and what is it used for?
ASQ is a screening for children’s development including gross motor, fine motor, problem solving, and social skills**
Describe the difference between morbidity and mortality
Mortality- death
Morbidity- illness or disease
A 17-yr-old child presents to clinic without a parent. Can you legally see him?
No, not unless it is for an STI or suicidal ideation
What is the leading cause of death in children?
MVCs
What are the common causes of infant mortality?
-Congenital malformations
-Low-birth weight complications
-SIDS
-Complications from pregnancy
-Newborns with birth complications
What are common causes of infant morbidity?
-Falls
-Getting stuck or trapped
-Animal bites
What is a common cause of child mortality for a child from 1-4 years old?
Drowning
What are some common causes of child morbidity?
-Bike injuries
-Poisonings**
-Playground accidents/falls
-Obesity
What are some anticipatory guidance to prevent child morbidities?
-Helmets
-Seatbelts
-Gates and pools
-Lock up chemicals and meds
-Healthy eating
-Exercise
-Playground safety
Name some common causes of adolescent mortality
-Firearm injury
-MVAs
-Poisoning
What are some risk-taking behaviors that lead to morbidity in adolescents?
Tobacco, alcohol, drugs, falls
A breastfeeding mother must supplement breastmilk with what to meat the infant’s nutritional needs?
Vitamin D (always)** and iron (sometimes)
When should a child develop the pincer grasp?
9-12 months
When should an infant’s Babinski reflex disappear?
18-24 months
What are some common etiologies of developmental delays?
CNS dysfunction, mental health problems, chronic disease, child abuse/neglect, parental stress, genetics, ADHD, autism
When should a boy’s testicals be descended by?
6 months
What maneuvers should the provider use to assess for hip dysplasia in infants?
Barlow maneuver and Ortolani maneuver
Name and describe some common skin abnormalities in the infant
-Infantile eczema
-Lesions
-Bruising or burns: Mongolian spots are normal and can be present at birth or develop within the first few weeks
Instructions for parents on infant regurgitation and spitting-up
-Acid reflux is prevalent d/t sphincters being immature
-Break up feeding after 15 mLs, burp child and return to feeding
-Coming out of nose is normal
What are the weight and height gaining expectations for toddlers?
-Weight gain 4-6 pounds per year
-Height gain 3 inches per year
What is the expected visual acuity for a toddler?
20/40
What are the weight and height gaining expectations for school-aged children?
-Preschoolers: 5 lbs, 2-3 inches per year
-After preschool: 4-6 pounds per year, height increases 2 inches per year
Describe the respiratory development in a toddler
Respiratory tract is rapidly developing, but still anatomically much smaller
Describe physical development in school-aged children
-Skeletal lengthening and fat decreases
-Increased strength
-Losing teeth and development of permanent teeth
-GI system, cardiovascular system becomes that of an adult
-Bones become harder than at early ages
Describe the physical development of adolescence
-Extremities grow faster than trunk and head
-Nose and chin enlarge first
-Pelvis enlarges in females
-Shoulders enlarge in male
-SQ fat increases
-Increased function of sweat and sebaceous glands
At what age should a baby be cooing and making gurgling noise?
3 months
At what age should a baby roll front to back? And sit up without support?
6 months**, 9 months
Describe the 9-month milestones for infants
-Pincer grasp (fine motor)
-Play pat a cake and peek-a-boo
-May be afraid of strangers
-Can stand holding on
-Says “good-bye”
Describe the 1 year milestones for children
-Supports own weight & walks with hands held
-Parallel play
-Separation anxiety
-Can “cruise” and climb stairs
Describe the 2 year milestones for children
-Walks/Runs
-Climbs stairs using handrails
-Speech mostly understood
-Follows 2-3 step instructions
-Copies a line of speech
Describe 3-year milestones for children
-Speaks 3-4 word sentences and is understood by strangers
-Copies a circle with a crayon or pencil
-Rides tricycle
-Builds tower of more thana 6 blocks
-Runs and climbs
Describes 4-year milestones for children
-Draw a cross and a person with three body parts
-Plays house
-Hops and stands on one foot up to 2 seconds
-Cooperates with other children
-Name colors and numbers
Describe 5-year milestones for children
-Can draw a person with 6 body parts
-Counts 10 or more things
-Aware of gender
-Speaks clearly
What is the most sensitive information to obtain during a sports physical in children?
Cardiac history and family history: this is more sensitive than the physical exam in detecting conditions that could prohibit sports participation
What is the most common cause of death among athletes less than 35 years of age?
Hypertrophic cardiomyopathy**
Information to gather during sports physical about cardiac history
-Congenital heart disease
-Acquired heart disease
-HTN
-Murmurs
What are contraindications for clearance during a sports physical?
-Congenital cardiac anomalies
-Chest pain while exercising, new murmurs, HTN
-Family Hx of sudden death under 50 while playing sports
-Exertional syncope
-Symptoms or diagnosis of Marfan syndrome
-HTN >135/85
-Coarctation of aorta indicated by decreased intensity of pulse in femoral pulse
What findings would need follow-up for clearance in a sports physical?
-Hx of cardiac anomalies
-Family cardiac history
-History of concussions
-History of injuries
-Hernia
-Murmur, irregular HR
-Deformity, asymmetry
-Poor visual acuity
-Liver or spleen enlargement
-Contagious skin conditions
What is the primary symptom of hypertrophic cardiomyopathy?
Systolic ejection murmur that intensifies with standing or Valsalva maneuver
What are some symptoms of Marfan’s syndrome?
–Aortic insufficiency (decrescendo diastolic murmur)
-Mitral insufficiency (holosystolic murmur)
-Arm span longer than height
-Girls taller than 5.10, boys taller than 6.0
-Kyphoscoliosis
-Pectus excavatum
-Myopia
Describe the Tanner stages for boys
Stage 1: Pre-pubescent; no pubic hair or enlargement
Stage 2: Puberty starts (Age 11-13), increased testicular size with more textured scrotum; scant, lightly pigmented pubic hair
Stage 3: Lengthening of penis and larger testes and increasing pubic hair and pigment (age 13-14)
Stage 4: Testicular and penis growth, voice changes, acne (age 14-15)
Stage 5: Mature genital size & pubic hair (Age 15-16)
What age/Tanner stage does a male’s voice change? When does the male develop acne?
Tanner stage 4, age 14-15
How are girls tanner staging rated?
Based on breast maturation and pubic hair growth
Describe the Tanner stages for females
Stage 1: Pre-pubertal; no pubic hair, breast papilla elevated above breast wall
Stage 2: Puberty starts with breast bud forming a small mound, areola increases in diameter, scant pubic hair with light pigment**
Stage 3: The breast and areola and nipples grow together in one mound, pubic hair becomes more abundant & pigmented
Stage 4: Secondary breast mound formed w/ 2 distinct mounds for areola and nipple, pubic hair is abundant but covering smaller area; period begins
Stage 5: Nipple projects and areola becomes part of contour of breast; hair is adult in appearance; mature
In what tanner stage does a girl start her menstrual cycle?
Stage 4
Name and describe a screening tool for psychosocial history in adolescents
HEADSS assessment:
H- Home
E- Education and employment
A- Activities
D- Drugs
S- Sexuality
S- Suicide and depression
Until what age will you assess head circumference in children??
Until 2 years old
At what age do you start performing eye exams and blood pressure on children?
3 years old
Anticapatory guidance for 12 month well-child visit
-Use discipline and time-outs, praise good behaviors
-Family time is important
-Consistent routines
-Nap once daily
-Teeth brushing routine and first dental checkup
-Stay within arm’s reach when in water, lock up chemicals, use stair gates
Anticaptory guidance for 2.5 year well-child visit
-Use simple words, read together
-Encourage play with other children
-Build independence by offering 2 acceptable options
-Consider group child care, preschool, organized playdates, encourage toilet training
Recommended counseling for parents on healthy weight and techniques to prevent obesity in children
-Consume at least 5 servings of fruits and vegetables per day
-Remove televisions from children’s rooms
-No TV before 2 years
-Be physically active at least 1 hour per day
-Limit consumption of sugar-sweetened beverages
Feeding and nutrition recommendations for infants
-Solids at 6 months, begin with rice cereal
-Introduce one food at a time
-Limit juice to 2-4 oz per day and dilute
-Avoid peanuts, hot dogs, raisins, grapes, popcorn, and large chopped pieces of fruit and veggies
-No cow’s milk till 12 months
Name some anticipatory guidance recommendations about teething for infants and young toddlers
-Do not put to bed with a bottle of formula or juice
-First teeth usually come at 5-6 months, lower, central, sizers
-All teeth by 2.5 years
-Can be up to 12 months before first tooth erupts
What are some red flags for anorexia in adolescents?
-Skipping meals, making excuses for not eating
-Eating only a few certain “safe foods”
-Rigid meal or eating rituals (cutting foot into tiny pieces)
-Cooking elaborate meals for others but refusing to eat
-Frequent checking in the mirror for flaws
-C/O being fat
-Not wanting to eat in public
What is the leading cause of injury and death for adolescents?
MVAs involving alcohol
What is the second leading cause of death in adolescents?
Homicide, usually involving firearms
What percentage of teenagers have attempted suicide?
8%
S&S of depression in adolescents
Sadness, change in sleep patterns, pessimism and indifference, lack of energy, withdrawal from family and friends, inability to concentrate, weight loss or gain, suicidal ideation, aches and pains with unknown medical cause
5 leading causes of infant death and guidance to prevent them
-Congenital malformations: prenatal care, vitamin supplements and folic acid
-Low-birth weight complications: manage preexisting conditions, prenatal care, proper nutrition
-SIDS: back to sleep, no co-sleeping, no smoke-exposure
-Complications from pregnancy: prenatal care and testing
-Birth complications
What is Erickson’s theory?
Describes that each stage is characterized by a central problem that we all work to resolve or master to move to the next stage. If problem is not solved, it would continue to present as a problem throughout the next stages
Name and describe each of Erickson’s stages
-Trust vs. Mistrust: to get, to give in return (0-12 mo)**
-Autonomy vs. Shame: to hold on, to let go (12-36 mo)
-Initiative vs. guilt: to make things, to play (3-6 yrs)
-Industry vs. inferiority: to make things- to complete (6-11 yrs)
-Identity vs role confusion: to be oneself and find out about oneself (12-17)
-Intimacy vs. isolation: to lose and find oneself in another (17-30 yrs)
-Generativity vs. stagnation: production & care (30-70 yrs)
-Ego-integrity vs. despair: 70+
Name and describe each of Piaget’s stages of development theory
-Sensorimotor: Understands through senses and actions (birth -2 years)
-Pre-operational: Understands world through language and mental images (2-7 years)
-Concrete operational: Understands world through logical thinking and categories (7-12 yrs)**
-Formal operation: Understands world through hypothetical thinking and scientific reasoning (12 & up)
What are the key concepts of Piaget’s sensorimotor stage (birth-2 years)
-Object permanence, spatial relationships, goal-directed behaviors; focus is on self
1 pound in kilogram
2.2 kg**
1 tbsp in mL
15 mLs
Pediatric medication calc problem:
Giving 20 mg/kg PO daily
Available drug: 1 gram in 10 mL
Child weights 110 lbs
How many tsp will you give?
-2 tsp
How does absorption of medication differ in infants?
-Rates of drug absorption in the infant are lower than absorption rates in children and adults
-Prolonged gastric transit time and variable gastric pH lead to diminished absorption
How is distribution of drugs in the infant different from a child or adult’s?
-Drugs are more available in circulation due to low concentration of plasma proteins
-Rapid access of drugs in CNS
-Higher doses of water soluble drugs bay be needed due to increased total body water
How is an infant’s excretion of a drug by the kidneys different from an adult’s?
-Higher resistance and lower GFR
-Drugs are secreted more slowly, causing an increased risk of drug accumulation and thus increasing drug toxicity
What popular sweetener should not be given to children under 1 year?
Honey- has toxins that can cause botulism in the infant
Medications to use caution with in first 2 years of life
-Ibuprofen- shouldn’t be given if less than 6 months
-Benadryl, guaifenesin, and pseudophedrine- no younger than 18 months
-Loratadine- no younger than 2 years
What vaccines are combined in the pediarix vaccine?
-Dtap
-IPV
-Hep B
-Given at 6 months
When to start the influenza vaccine and how do you give the first dose?
-Injection for 6 months and up; must get 2 immunizations at least one month apart if under 8 years old**
Infants must learn pincer grasp before they learn what important task for independent feeding?
Hand to mouth
When should children first receive the TDAP vaccination?
-10-12 years of age
-Can give off-label as early as age 7 years for children that need catch-up
-Required for all 7th graders in MO
What disease is prevalent in adolescents greater than age 15 and also vaccine-preventable with a conjugate vaccine?
Meningococcal disease
Guidelines for administration of Miningococcal vaccine
-Routine with MCV-4 for children age 11-12 with booster at 16 yrs
-If vaccine received at 13-15 years, booster needed 3-5 years after first dose
-If first dose after 16 yrs, no booster needed
-College freshmen up to 21 years that live in dorms should receive this if not received after 16 yrs
Name and describe guidelines for HPV vaccine
-Gardasil
-Series of 3 injections: new exception if they have received 2 by 16 yrs, no need for 3rd dose***
-Schedule: Initial, 2 months, 6 months
What is the vaccination schedule for Hep B?
3 doses:
-Birth
-2 months
-6 months
What is the vaccination schedule for DTAP?
5 doses:
-2 months
-4 months
-6 months
-15 months
-4-6 years
What is the vaccination schedule for rotavirus?
3 doses:
-2 months
-4 months
-6 months
What is the vaccination schedule for Hib?
4 doses:
-2 months
-4 months
-6 months
-12 months
What is the vaccination schedule for PCV?
4 doses:
-2 months
-4 months
-6 months
-12 months
What is the vaccination schedule for IPV?
4 doses:
-2 months
-4 months
-6 months
-4-6 years
What is the vaccination schedule for MMR and varicella?
Both given in 2 doses at:
-12 months
-4-6 years
What is the vaccination schedule for Hep A?
2 doses:
-12 months
-18 months
What vaccines are given at the 6 month well child visit?
-Hep B
-DTAP
-HIB
-PCV
-IPV
-Rota
-Flu (annual and repeat 4 weeks later)
What vaccines are given at the 9 month well child visit?
None, unless needs catch up
What vaccines are combined in the Pentacel vaccine?
-Dtap
-IPV
-Hib
What vaccines are combined in the ProQuad vaccine?
-Varicella
-MMR
What vaccines are combined in the Kinrix vaccine?
-Dtap
-IPV
How many mLs in 1 teaspoon?
5 mLs**
What is the main goal of a sports physical exam?
To ensure safe participation in an appropriate physical activity
What is the most common cause of sudden death in athletes?
Congenital cardiac anomalies
What are some important aspects of the cardiac exam for a sports physical?
-Palpate the PMI for increased intensity and displacement that would suggest hypertrophy and failure
-Auscultate with patient supine and again standing and straining with the Valsalva maneuver
-Evaluate femoral pulse equality
-Blood pressure
Tips and tricks for communicating with toddlers and preschoolers during exam
-Let the child see and touch the examination tools
-Don’t ask if you can do something that you are going to do anyway
-Have the parent nearby or the child in the parent’s lap
-Make a game out of anything you can “let’s see how big your tongue is”
What findings would warrant weight checks in the newborn?
-Lost more than 6% of birth weight
-Not back to birth weight by 2 weeks
Important aspects of the HEENT exam in the newborn
-Fontanel size
-Eye alignment
-Red reflex- symmetry of the light reflex
Important aspects of the musculoskeletal exam in the newborn
-Leg fold symmetry
-Hip abduction
-Foot shape and flexibility
What is the moro reflex and when should it disappear?
-Sudden loud noise will cause symmetric abduction and extension of arms followed by adduction and flexion
-Disappears by 3-4 months
Describe fine motor development in the newborn
-Grasping reflex at 3-4 months
-Crude pincer grasp 7-8 months
-Neat pincer by 11-12 months
Injury and illness prevention for infants
-Hot water thermostat <120 degrees
-Small parts/toys
-Poison prevention
-Safety locks
-Stair gates
-No standing water
Milestones for 6-9 month well-child visit
-No head lag
-Sits with support
-Rolls over in both directions
-bears weight when standing
-Stands with support
-Responds to name
-Knows meaning of some words
What are some red flags at the 6-9 month well-child visit?
Not sitting, poor head control, persistence of primitive reflexes, inability to localize sound
Normal order for development of walking
-Roll
-Sit
-Scoot
-Crawl
-Walk
When would you start to be concerned about a child not walking?
-18 months
What are some etiologies of developmental delays?
-CNS dysfunction
-ADHD
-Autism
-Abuse/neglect
-Chronic disease
-Mental health problem
Developmental milestomes for baby 3 months old
-Holds head upright
-Smiles
-Moro reflex disappears
Developmental milestones for baby that is 6 months old
-Rolls over
-Sits upright with pelvic support
Developmental milestones for 7-9 months
-Sits alone with back straight
-Pincer grasp by 12 months
-Stranger anxiety
-Crawling (by 13 months)
Developmental milestones for 15 months
-Walks!
What vaccines are live vaccines?
Varicella and MMR
What are some risk factors what would prompt lead screening?
-PICA
-Child lives near a lead smelter or battery recycling center
-Family member works with lead-based materials
-Family uses folk remedies
-Family home built before 1960s**
What is the screening recommendations for lead?
Screen at 1-2 years of age or if signs or symptoms of lead toxicity
Recommended screening for Hgb
-12 months and as needed thereafter if risk factors present
What is a contraindication for a live vaccine?
-Being immunocompromised (leukemia, low T-cell count)
