Exam 2 Flashcards
What are 6 risk factors associated with increased risk of CHD?
Prematurity
Family History (first degree relative with CHD)
Genetic Syndromes
Maternal Factors (medical hx, drug use, smoking and Alcohol use)
Fertility treatments
In utero Infection
What are 7 in utero infections associated with CHD?
Rubella
Influenza
CMV
Coxsackie
Toxoplasmosis
Roseola
Fifth’s Disease
What 2 types of CHD are linked to fertility treatment?
Septal defects
Cyanotic CHD
What are the 2 most common causes of CHD?
Cyanotic
Acyanotic
Is a right to left shunt cyanotic or acyanotic?
cyanotic
*dangerous
*pressure + volume overload
–>deoxygenated blood –>oxygenated blood –> body
–>pulm –>systemic –> body
What is the most common Acyonotic CHD?
Ventral Septal Defect
What are the 5 types of cyanotic CHD?
Truncus arteriosis (1 vessel)
*Transposition of the Great Vessels (2 vessels switched)
*Tricuspid valve atresia (3 valve cusps)
**Tetralogy of Fallot (4 components)
*Total Anomalous Pulmonary Venous Return (5 words)
Also;
pulmonary and tricuspid atresia
you will also see in ARDS
acronym TPT (tet of fallot, pulm + tricuspid atresia)
What are 4 types of Acyanotic CHD?
VSD (25% of most cases; most common CHD surgical repair)
*ASD
*PDA (patent ductus arteriosus)
*Coarctation of the aorta
acronym “VAP” for VSD, ASD, PDA
Right to left shunt is indicative of which type of CHD?
Cyanotic
Left to right shunt is indicative of which type of CHD?
Acyanotic
This is when the pressure in the left side of the heart is greater than the pressure in the right side
not as dangerous as right to left shunt
–>oxygenated blood –>deoxygenated blood –>lungs
systemic –> pulmonary –>lungs
What happens during a TET spell (tetrology of fallot)?
-cyanosis
-hypoxemia (65% - 85%)
-clubbing
-polycythemia (report hgb over 22g/d)
Tetrology of fallot interventions
-knees to chest (infant)
-squatting (older kids)
-do NOT interrupt sleep
-provide a calm, quiet environment upon waking
-pacifier during sleep
-small frequent feedings
-swaddle
What is the definition of CHD?
Structural abnormalities of the heart and or great vessels occurring during fetal development.
What is the definition of Cyanotic CHD?
Heart defect in which less than normal oxygen levels are delivered to the body.
What is the definition of Acyanotic CHD?
Heart defect in which oxygen levels delivered to the body typically remain normal.
True or False In some infants with CHD, murmurs may not be heard during the initial examination but
may be detected at or beyond the age of six weeks.
True
What is the universal newborn screening for CHD?
Pulse oximetry
Pulse ox screening will diagnose which type of CHD?
R to L shunt
Cyanosis
How is the pulse ox screening performed?
Pulse ox on right hand and either foot.
List 3 criteria for a positive pulse ox screening in CHD?
Any sat less than 90%
Sat less than 95% in both extremities on 3 measures, each separated by an hour.
More than 3% absolute difference in sat between the right hand and foot on 3 measure each separated by one hour.
Is a positive pulse ox screening for CHD passing or failing?
Failing
What are some PE findings that suggest
CHD?
Abnormal HR: obtain ECG
* Abnormal BP in 4 extremities (i.e.: blood pressure ≥10 mmHg higher in the arms
than legs)
* Abnormal S2 splitting
* Abnormal extra heart sounds
* Abnormal precordial activity
* Pathologic murmurs (>3 intensity)
* Hepatomegaly
* Diminished pulses in lower extremities
* Extracardiac anomalies (in latest reports, noted in about 20% of children with CHD)
Name 8 associated history finding in cyanotic CHD.
Irritability or decreased level of activity
Diaphoresis and crying w/feedings.
Decreased amount of formula per feed
Hx of longer time per breast feeding
Poor weight gain
Fast and or irregular breathing
Bluish or purple discoloration of the skin or mucous membrane
Older children may present with exercise intolerance including dyspnea, diaphoresis, cyanosis, or palpations during exercise.
Name 10 physical exam findings for cyanotic CHD.
Cyanosis
* Tachypnea
* Increased work of breathing
* Pulmonary edema
* Tachycardia
* Heart murmur
* Hepatomegaly (Liver edge located more than 2.5 cm below the right costal margin)
* Weak femoral pulses
* Signs of poor perfusion or shock
* Lethargy
List 5 reasons to refer to cardiology for CHD.
+ Positive NB pulse oximetry screening
+ Signs or symptoms concerning for CHD, including cyanosis, respiratory symptoms, difficulty feeding, or poor weight gain
+ Physical examination findings suggestive of CHD
+ Genetic disorder or extracardiac abnormality associated with cardiovascular malformations
+ Abnormal CXR or ECG
Is it safe to give live vaccines to a patient on the transplant list?
NO
What are 6 roles of the primary care provider when treating pediatric patients with CHD?
- Close collaboration with cardiac team
- Routine immunizations given (careful consideration for live
vaccines in patients who are candidates for heart transplants) - Prophylaxis with Synagis for respiratory syncytial virus
- Subacute bacterial endocarditis prophylaxis for dental procedures
- Treatment of iron deficiency anemia
- Counseling parents regarding probability of cardiac malformation
occurring in subsequent children
What are the 3 most common pathogens in infective endocarditis?
Streptococcus Viridians
Staphylococcus Species
Enterococcus Species
True or False Patients with CHD are cured of their disease after successful treatment in childhood?
False
What percentage of newborns with Down Syndrome have CHD?
50%
What are the 4 most common heart defects?
- Atrioventricular septal defect
- Ventricular septal defect
- Patent ductus arteriosus
- Tetralogy of Fallot
Name 6 characteristics of Innocent Murmurs.
- Asymptomatic
- Grade ≤2 intensity
- Short systolic duration (i.e., not holosystolic and not diastolic)
- Minimal radiation
- Musical or vibratory quality
- Softer intensity when the patient is sitting compared with when the
patient is supine. - Usually resolves by early adolescence
For children 13 years old and older what is considered a normal BP?
Systolic <120
Diastolic <80
Dx of persistent childhood HTN is made when?
Repeat BP’s on three separate visits are > 95th percentile for age, sex, height of patient OR >/= 130/80.
Childhood hypertension remains a major risk factor for the development of?
Acquired heart disease in adulthood.
What are 6 modifiable risk factors in CHD?
- Obesity
- OSA
- Sodium intake
- Tobacco exposure
- Breastfeeding
- Childhood adversity
What are 3 non-modifiable risk factors in CHD?
- Sex
- Race
- Family hx
Which is more common in children Primary or Secondary HTN?
Primary
In pediatrics with stage 1 primary HTN without evidence of end-organ damage or CVD risk factors what is the initial intervention?
Nonpharmacologic therapy
In pediatrics with stage 1 primary HTN if BP target goals are not met within four to six months after nonpharmacologic initial therapy (BP below the 90th percentile) what is the next step?
Refer to a pediatric cardiologist for pharmacologic therapy.
When is Emergent treatment needed with pediatric HTN?
Stage 2 HTN and neurological symptoms
True or False Pt’s with Stage 2 HTN (140/90) should be restricted from high-static sports until BP is in normal range after lifestyle modification.
True
What 2 conditions warrant both pharm and nonpharmacological
interventions for any child with elevated BP or HTN?
Patients with CKD and/or diabetes
What are some causes for secondary HTN in children?
- Renal disease- most common (i.e., glomerulonephritis after strep, renal scarring after pyelonephritis, chronic renal disease, etc.)
- Endocrine disease (i.e., catecholamine excess- pheochromocytoma; corticosteroid
excess- Cushing syndrome or exogenous use)
*Cardiac disease (coarctation of aorta is primary cardiac cause)
*Drugs and toxins (cocaine, steroid use, OCP, arsenic, cyclosporine, tacrolimus)
True or False In children with secondary HTN, the underlying disorder may be curable with complete resolution of HTN?
True
Many of the antihypertensive agents available for adult use may also be used to manage hypertensive children and adolescents, even though only limited data are available to support this practice. Which 3 have the strongest data to support their use in pediatric patients?
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers (ARBs)
Calcium-channel blockers
Remember to refer for management!
Seven S’s: mneumonic for identifying murmurs in children:
Soft
Systolic
Small area of involvement on precordium
Short duration (typically early systolic or mid-systolic sounds)
Single (without clicks or snaps)
Sweet (not harsh)
Sensitive (to standing and respiratory variations).
Define what Stage A HF is.
At risk for HF but without symptoms, structural heart
disease, or cardiac biomarkers of stretch or injury (e.g.,
patients with hypertension, atherosclerotic CVD,
diabetes, metabolic syndrome and obesity, exposure to
cardiotoxic agents, genetic variant for cardiomyopathy,
or positive family history of cardiomyopathy).
Define what Stage C HF is:
Symptomatic HF
Structural heart disease with current or previous symptoms of HF
Define what Stage B HF is:
No symptoms or signs of HF and evidence of 1 of the
following:
Structural heart disease
-Reduced left or right ventricular systolic function o
Reduced ejection fraction, reduced strain
-Ventricular hypertrophy
-Chamber enlargement
-Wall motion abnormalities
-Valvular heart disease
Evidence for increased filling pressures
-By invasive hemodynamic measurements
-By noninvasive imaging suggesting elevated filling pressures
(e.g., Doppler echocardiography)
Patients with risk factors and
-Increased levels of BNPs*
-Persistently elevated cardiac troponin in the absence of
competing diagnoses resulting in such biomarker elevations
such as acute coronary syndrome, CKD, pulmonary embolus,
or myopericarditis
Define what Stage D HF is:
Advanced HF
Marked HF symptoms that interfere with daily life and with
recurrent hospitalizations despite attempts to optimize
GDMT.
Thyroid (T4) replacement medications and usual dose range?
Synthroid (brand)
Levoxyl
Levothyroid
Unithiroid
generic levothyroxine for all
75-125mcg of levothyroxine
Replacement dosing;
-adults 1.6mcg/kg/day
—titrate 12.5 to 25 mcg increments as needed
-adults at risk for afib or underlying cardiac disease
—lower starting dose (less than 1.6mcg/kg/day). titrate dose every 6 to 8 weeks as needed
-geriatric patients
—lower starting dose (less than 1.6mcg/kg/day)
Low TSH High T4
Hyperthyroidism
High TSH low T4
Primary Hypothyroidism
Low TSH Low T4
Secondary Hypothyroidism
What is the criteria for HFrEF (HF with reduced EF)?
Left Ventricular EF < or = to 40%
What is the criteria for HFimpEF (HF with improved EF)?
Initial Left Ventricular EF < or = to 40% with follow up greater than 40%.
What is the criteria for HFmrEF (HF with mildly reduced EF)?
EF 41%-49%
What is the criteria for HFpEF (HF with preserved EF)?
Greater than or = to 50%
Give 4 examples of clinical presentation for HF?
Dyspnea on Exertion (DOE)
Unexplained fatigue
Lower extremity edema
Unexplained weight gain
What is one of the most common reasons for acute care hospital admissions?
Acute exasperation of HF
What are 9 physical exam findings in a pt with HF?
Crackles over lung bases
Wheezing
Frothy blood-tinged sputum
S3
Tachycardia
Diaphoresis
Pallor
Peripheral cyanosis
Liver engorgement
What are 10 diagnostic test to order to dx HF?
CBC
U/A
CMP
Lipids
LFTs
TSH
BNP (?)
ECG
CXR
ECHO
Give 4 examples of differential dx when working a pt up for HF?
Renal Disease
Liver Disease
Asthma
COPD
What are 5 treatment goals for a pt dx with HF?
Relieve symptoms
Slow progression
Improve quality of life
Help patients live longer
Decrease hospitalizations
What are 5 classifications of medications for HF?
ACE or ARN inhibitors (Lotensin, Zestril, Cozaar,
Entresto)
Mineralocorticoid antagonists (Aldactone)
Beta blockers (Coreg)
Diuretics (Bumex, Lasix)
SGLT2 (Jardiance)
What are 9 lifestyle changes for a pt with HF?
Dietary-low sodium and fat
Smoking cessation
Limit alcohol and caffeine
Maintain a healthy weight
Exercise
Stress reduction
Report weight gain
Track symptoms
Regular follow-up
How can peripheral artery disease (PAD) be defined?
An atherosclerotic disease of the lower extremities associated with high cardiovascular mortality.
What is another term for PAD?
Chronic arterial insufficiency (CAI)
What are 8 risk factors for PAD?
Smoking
Hyperlipidemia (elevated LDL, Cholesterol and
Triglycerides)
DM
HTN
HIV
BMI > 30
Age > 50
Family Hx of CV Disease
What are 3 complications in PAD?
Critical limb ischemia and amputation
Stroke
MI
What is a classic symptom in PAD presentation?
Claudication
How can claudication be described?
Exercise-induced cramping w/fatigue, weakness & pressure
Not uncommon to deny pain, ask about discomfort with walking
Exacerbated by leg elevation,
Paresthesias, weakness and cool extremities
What are 3 criteria for a patient with Critical Limb Ischemia?
Pain at rest
Nonhealing wounds or ulcers
Gangrene in one or both legs.
Name 4 other clinical presentations for PAD.
Decreased or absent pulses distal to the obstruction
Presence of bruits over artery narrowing
Atrophic skin with hair loss, brittle nails
Pallor on elevation of legs, rubor on dependence
What is an Ankle Brachial Index (ABI)
A doppler study used to determine the ratio of ankle systolic blood pressure to arm systolic BP.
How do you calculate ABI?
Calculated by dividing the highest pressure for each foot by the highest brachial pressure. Should be greater in the affected extremity.
What is the ranges for the Ankle Brachial Index (ABI)?
>1 Normal
0.9-1.0 Minimal disease-nl.
0.5-<0.9 arterial occlusive disease, often have exercise claudication
<0.5 Severe disease, pain at rest
What would be a good medication to give a pt who has HF and DM?
SGLT2 (Jardiance)
What is seen in mild claudication?
Patient has pulses, exercises, loses pulses
Management for PAD includes?
Risk factor modification
tobacco cessation-nicotine patch therapy & Zyban
Exercise Therapy
30-45 sessions, 4 to 5 times a week for 12 weeks
Treat HTN (less than 140/90 non-DM, 130/80 DM),
DM (HgA1c <7%)
& Lipids
Is it ok to tell a pt with PAD that cutting down on smoking is enough?
NO THEY MUST QUIT!
What is the pharmacologic management for intermittent claudication in PAD?
Cilostazol (Pletal)
Naftidrofuryl (Nafronyl)
ASA Daily
What is the pharmacologic management for Cholesterol Reduction in PAD?
High Intensity Statins
Simvastatin (limbic and systemic complications)
Ezetimide (very high risk pts)
PCSK9 (evolocumab) –LDL>70
What is the pharmacologic management for Antiplatelet Therapy in PAD?
ASA 100 mg
clopidogrel-(Plavix)
Ticagrelor (Brilinta)
What is the pharmacologic management for Anticoagulation therapy in PAD?
warfarin
rivaroxaban (Xarelto)
Apixaban (Eliquis)
What is the pharmacologic management for BP in PAD?
ACE & ARB
What are 7 complications that can be seen in PAD?
Acute coronary syndrome
Stroke
Nonhealing Ulcer
Gangrene
Amputation
DVT
Erectile Dysfunction
What are the BP goals with the general population?
<60 years old <140/90
> or = 60 years old < 150/90
In the general population non-black and non-black with diabetes w/o CKD what are your first line treatment for HTN?
Thiazide
Ace Inhibitor
ARB
Calcium Channel Blocker
Alone or in Combination
What 2 blood pressure medications should not be used in combination?
ACE & ARBs
In all populations despite comorbidities if the 1st. line treatment for HTN is not working what is your next step?
Reinforce lifestyle and adherence
Titrate meds to max doses or consider adding another med (Thiazide, Ace Inhibitor, ARB, Calcium Channel Blocker)
In all populations despite comorbidities if the 2nd. line treatment for HTN is not working what is your next step?
Reinforce lifestyle and adherence
Add a class of drug not already selected ie. Beta blocker, Aldosterone antagonist and titrate 1st line drugs to max.
In all populations despite comorbidities if the 3rd. line treatment for HTN is not working what is your next step?
Reinforce lifestyle and adherence
Titrate meds to max doses
Add another med
Refer to hypertension specialist
In the general population for blacks what are your first line treatment for HTN?
Thiazide or CCB alone or in combination
For all ages and patients with diabetes but no CKD what is our BP goal?
< 140/90
For all patients with CKD with or W/O DM what is our BP goal?
< 140/90
For all patients with CKD with or W/O DM what is our 1st line treatment for HTN?
Initiate ACE or ARB alone or in combination of another class
If a patient presents with BP greater than 20/10 mm Hg above goal what would the initial treatment be?
Initiation of 2 drugs at the same time.
What is the pharmacologic treatment for HF w/HTN?
ACE/ARB + BB + diuretic + Spironolactone
What is the pharmacologic treatment for MI/Clinical CAD w/HTN?
ACE/ARB and BB
What is the pharmacologic treatment for CAD w/HTN?
ACE, BB, diuretic, CCB
What is the pharmacologic treatment for Diabetes w/HTN?
ACE/ARB, CCB, diuretic
What is the pharmacologic treatment for CKD w/HTN?
ACE/ARB
What is the pharmacologic treatment for recurrent stroke prevention w/HTN?
ACE, diuretic
What is the pharmacologic treatment for Pregnancy w/HTN?
labetolol (first line), nifedipine, methyldopa
What are 4 BB that are safer to use in pts with COPD, Asthma, DM, and PVD?
Metoprolol
Bisoprolol
Betaxolol
Acebutolol
What is the dosing range for HCTZ?
HCTZ 12.5-50mg
What is the dosing range for Spironolactone
25-50 mg
What is the dosing range for furosemide?
20-80 mg BID
What is the dosing range for lisinopril?
10-40 mg
What is the dosing range for valsartan?
80-320 mg
What is the dosing range for losartan?
50-100 mg
What is the dosing range for metoprolol?
50-100 mg BID
What is the dosing range for propranolol?
40-120 BID
What is the dosing range for carvedilol?
6.25-25 mg BID
What is the dosing range for labetalol?
100-300 mg BID
What is the dosing range for amlodipine?
5-10 mg
What is the dosing range for nefedipine ER?
30-90 mg
What is the dosing range for Diltiazem ER?
180-360 mg
What is the dosing range for Verapamil?
80-120 mg TID or ER 240-480 mg
What is the dosing range for hydralazine?
25-100 mg BID
What is the dosing range for terazosin?
1-5 mg at bedtime
What is the dosing range for clonidine?
0.1-0.2 mg BID
What is the dosing range for Methyldopa?
250-500 mg BID
What is the dosing range for guanfacine?
1-3 mg
What is a consideration for someone taking diuretics?
Monitor for hypokalemia
Most SE are metabolic in nature
Most effective when combined w/ ACEI
Loop diuretics may be needed when GFR <40mL/min
What are 2 considerations when taking Spironolactone?
gynecomastia and hyperkalemia
What is a consideration for someone taking ACE/ARBs?
SE: Cough (ACEI only), angioedema (more with ACEI),
hyperkalemia
Losartan lowers uric acid levels
What is a consideration for someone taking BB?
Not first line agents – reserve for post-MI/CHF
Cause fatigue and decreased heart rate
Adversely affect glucose; mask hypoglycemic awareness
What is a consideration for someone taking CCB?
Can cause Edema
amlodipine and nifedipine may be safely combined w/ B-blocker
verapamil and diltiazem reduce heart rate and proteinuria
What is a consideration for someone taking Vasodilators?
Hydralazine may cause reflex tachycardia and fluid retention – usually require diuretic + B-blocker
Alpha-blockers may cause orthostatic hypotension
How is HTN diagnosed?
2 separate elevated readings on 2 separate visits at least 1 week apart.
What is Primary enuresis?
Primary enuresis is defined as the patient never having been dry at night
What is Secondary enuresis?
Secondary enuresis is defined as the patient having had a period of being dry(at least 6 months) and then starting to wet
What is the most important screening test is diagnosing enuresis?
Urinalysis
What is the preferred medication for treating children with enuresis?
Desmopressin acetate (synthetic analogue of ADH)
What is a serious adverse effect from taking Desmopressin?
The only serious adverse effect reported in patients with enuresis treated with desmopressin is the development of seizure or other central nervous system (CNS) symptoms due to water intoxication. It stops the ability to urinate.
Early symptoms of water intoxication include?
Headache
Nausea
Vomiting
What is a Inflammatory-immune cause for hematuria?
Henoch-Schonlein purpura nephritis (HSP)
What are the renal manifestations of HSP?
- Hematuria with minimal proteinuria is the most common renal manifestation
- Nephrotic range proteinuria & elevated serum creatinine
- Hypertension may also be seen
When monitoring Henoch-Schonlein purpura nephritis (HSP), when is it necessary to refer to Nephrology?
Warranted when accompanying factors are present that increase the risk for renal parenchymal disease or significant resulting morbidity.
Includes the presence of hypertension, which may signify the presence of glomerulonephritis.
How is Chronic Kidney Disease (CKD) defined?
As the presence of structural or functional kidney damage that persists over a minimum of three months.
Functional damage from CKD is characterized by?
By a sustained reduction of estimated glomerular filtration rate (eGFR), a persistent elevation of urinary protein excretion, or both.
Can the GFF classification system be used in patients under 2 years old, why or why not?
No, because they normally have a low GFR even when corrected for BSA.
What is the criteria for category G1 on the GFR scale?
Greater than or equal to 90 is normal or high.
What is the criteria for category G2 on the GFR scale?
60-89 mildly decreased
What is the criteria for category G3a on the GFR scale?
45-59 mildly to moderately decreased
What is the criteria for category G3b on the GFR scale?
30-44 moderately to severely decreased
What is the criteria for category G4 on the GFR scale?
15-29 severely decreased
What is the criteria for category G5 on the GFR scale?
Less than 15 kidney failure
What are 7 causes of kidney disease in children?
Birth defects
Hereditary disease
Infection
Nephrotic Syndrome
Systemic diseases
Trauma
Urinary blockage or reflux
In children from birth to age 4 what are the 2 leading causes of kidney failure?
Birth defects
Hereditary diseases
What is a priority in the management of kidney disease in children?
Routine health maintenance
What are 3 additional management strategies of kidney disease in children?
Prevent or slow the progression of kidney disease.
Prevent or treat the complications of CKD.
Preparation for kidney replacement therapy when approaching kidney failure.
As CKD progresses in children they are at risk for these 6 complications
Poor growth
HTN
DLD
Anemia
Vit D deficiency
Electrolyte abnormalities
What are 6 screenings performed in routine health maintenance in a child with CKD?
Growth
Nutritional status
BP
Neurodevelopment assessment
Lab test
Immunizations
Why is protein restriction not recommended in children with CKD?
It has not been shown to influence the decrease in kidney function in children with CKD and may impair growth.
What is nephrotic syndrome?
A group of symptoms that indicate the kidneys are not working properly (proteinuria, hypoalbuminemia, edema, hyperlipidemia). Usually happens when glomeruli are damaged, which allows too much protein to leak from the blood into the urine.
What are 4 PE or Lab findings associated with nephrotic syndrome?
Proteinuria
Hypoalbuminemia
Edema
HLD
In nephrotic syndrome the glomeruli are damaged, what does this lead to?
To much protein leaks from the blood into the urine.
What is the most common sign of nephrotic syndrome in children?
Swelling around the eyes worse in the morning and may be confused with seasonal allergies.
What are 8 lesser common S/S of nephrotic syndrome in children?
Swelling in other parts of the body
Foamy urine
Fatigue
Hematuria
Loss of Appetite
Muscle cramps
Diarrhea
Nausea
What are the 2 main categories of Nephrotic Syndrome?
Minimal Change Disease (MCD) MOST COMMON
Focal sclerosis
Who manages a child with CKD or suspected nephrotic syndrome?
A nephrologist
If you have a child with CKD what nutritional needs would you monitor?
Fluids
Protein
Phosphorus
Sodium
Potassium
What is Vesicoureteral reflux (VUR)?
The retrograde passage of urine from the bladder into the upper urinary tract
What is the PCP’s role in the management of VUR?
Mandatory UA and urine cultures whenever urinary s/s or unexplained fever.
What are four autoantibody markers of beta cell autoimmunity in type 1 diabetes?
acronym - “PIGI” (pronounce piggy)
antibodies to protein tyrosine P hosphatase
I slet cell antibodies
antibodies to G lutamic acid decarboxylase
I nsulin autoantibodies
What are some complications of kidney disease in children?
-anemia
-heart disease
-electrolyte imbalances in the blood (especially potassium)
-growth problems
-htn
-infection
-metabolic acidosis
-mineral and bone disorder
-cognitive issues
-urine incontinence
What is a major risk in antibiotic management of VUR for long term prophylaxis?
Antibiotic resistance
Antibiotic treatment for VUR for patients > 2 months of age, use single daily dose of:
TMP-SMX (Bactrim) or TMP (Primsol) alone – Dosing is based on TMP at 2 mg/kg
Nitrofurantoin – 1 to 2 mg/kg
Antibiotic treatment for VUR for patients < 2 months of age, use single daily dose of:
Cephalexin 10mg/kg
Ampicillin 20mg/kg
Amoxicillin 10 mg/kg
Sulfonamides and nitrofurantoin are associated w/ increased neonatal hyperbilirubinemia
Phimosis is defined as the:
Inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis
What are the 2 forms of phimosis?
Physiologic
Pathologic
What is physiologic phimosis?
Children are born with tight foreskin at birth and separation occurs naturally over time.
This form is normal on uncircumcised children
What is pathologic phimosis?
Phimosis that occurs due to scarring, infection or inflammation.
What antibiotics do you want to try to avoid when treating children >2 with VUR due to the increased likelihood of resistant organisms?
Amoxicillin
Ampicillin
Cephalosporins
What are 3 initial presentations in Type 1 Diabetes in Children?
Classic new onset of polydipsia, polyuria, and weight loss with hyperglycemia and ketonemia (or ketonuria).
Diabetic ketoacidosis (DKA).
Silent (asymptomatic) incidental discovery
What are 3 other presentations in Type 1 Diabetes in Children? (not the initial presentations)
Perineal candidiasis
Acute visual disturbances (due to changes of osmotic milieu in the lens)
Cataracts (more common in females and patients with higher A1C)
What are some risk factors for type 1 diabetes in children?
Lifetime risk is significantly increased in close relatives of a patient with T1DM
Ethic differences
Environmental influences (perinatal factors, viruses, cow’s milk- although Vit D is protective, introducing cereals too early, higher nitrate concentration in water)
Age of presentation of childhood-onset T1DM has a bimodal distribution it peaks at different ages. What are the 3 age ranges?
One peak at four to six years of age
Second peak in early puberty (10 to 14 years of age)
Approximately 45 percent of children present before 10 years of age
How many stages and what are they in Type 1 diabetes in children?
Four stages:
Stage 1 – Beta cell autoimmunity (≥2 islet autoantibodies), normal blood glucose, and presymptomatic
Stage 2 – Beta cell autoimmunity (≥2 islet autoantibodies), raised blood glucose (dysglycemia), and presymptomatic
Stage 3 – Beta cell autoimmunity, raised blood glucose (dysglycemia), and symptomatic
Stage 4 – Longstanding T1DM
Diagnosis of DM in children is based on 1 of 4 signs, what are the signs?
Fasting plasma glucose ≥126 mg/dL on more than one occasion
Random venous plasma glucose ≥200 mg/dL in a patient with classic symptoms of hyperglycemia
Plasma glucose ≥200 mg/dL on a glucose tolerance test
Most children and adolescents are symptomatic and have
plasma glucose concentrations well above ≥200 mg/dL
(11.1 mmol/L); thus, an oral glucose tolerance test is seldom necessary to diagnose T1DM
Hemoglobin (A1C) ≥6.5 percent
This criterion should be confirmed by another measure of
hyperglycemia
How is type 1 DM primarily characterized?
Insulin deficiency
How is type 2 DM primarily characterized?
Insulin resistance with relative insulin deficiency
Differentiating between type 1 and type 2 DM is based on?
Clinical presentation and history
What lab studies can be done to help differentiate between type 1 and type 2 diabetes?
Pancreatic autoantibodies
indicates autoimmune destruction of pancreatic beta
cells- seen with T1
Insulin and C-peptide levels
high fasting insulin and C-peptide levels suggest T2
High fasting insulin and C-peptide levels suggest which type of DM?
Type 2 DM
Autoimmune destruction of pancreatic beta cells is seen with which type of diabetes?
Type 1 DM
A treatment goal for a preschool-age child with controlled type 1 diabetes is to have a glycohemoglobin of less than or equal to?
7.5%
What are 6 risk factors for type 2 DM?
Ethnicity (African American, Hispanic, Native American, Pacific Islanders, Asian Americans)
1st degree family history
Obesity
LBW
Mom with gestational diabetes
Female
T3 Increased
T4 Normal
TSH Decreased
What condition could this be?
T3 Toxicosis
T3 Normal
T4 Increased
TSH Decreased
What condition could this be?
T4 Toxicosis
What is the treatment of choice for adolescents and adults with Graves disease?
Radioactive Iodine (Sodium iodide, I131,
Iodotope)
What are the HgbA1C values for non-diabetic, pre-diabetic, and diabetic?
non-diabetic <5.7
prediabetic 5.7-6.4
diabetic > or = to 6.5
What are the FBS values for non-diabetic, pre-diabetic, and diabetic?
non-diabetic <100
prediabetic 100-125
diabetic > or = 126
What are the 2 hour glucose tolerance test values for non-diabetic, pre-diabetic, and diabetic?
non-diabetic <140
prediabetic 140-199
diabetic > or = 200
What is the random blood sugar for diabetic?
> or = 200
What should always be done in a clinical assessment for a Diabetic patient?
HEENT - especially the eyes check for hemorrhages, cotton wool patches
Dental exam
Skin - ALWAYS look at the feet and check sensation, check for lesions, acanthosis nigricans.
Heart and lungs
Neurological/Musculoskeletal
Abdomen
What are the goals of therapy for a diabetic patient?
– Stabilize glucose to maintain glycemic goals
– Prevent/minimize hypoglycemia (3am hypoglycemia
may result in death in diabetics; often falls <50)
– Minimize weight gain and promote weight loss
– Identify current comorbidities (microscopic and
macroscopic), manage them and prevent worsening
developments
What disease is a common cause of hyperthyroidism?
Graves Disease
Excess circulating thyroid hormone originating from any source is known as?
Thyrotoxicosis
A rare hypermetabolic state induced by excessive release of thyroid hormones that is acute, severe, and life threatening is known as?
Thyroid Storm
Thyroid stimulating hormone is released by the:
Anterior lobe of the pituitary
Condition in which serum thyroid levels are not sufficient
to maintain intracellular hormone function?
Hypothyroidism
What groups are at risk for hypothyroidism?
Newborns
Strong Family History
New moms (Postpartum)
people over 65
People with autoimmune diseases
Name 6 early symptoms of Hypothyroidism:
Fatigue
dry skin
slight weight gain
cold intolerance
constipation
heavy menses
Name 9 later symptoms of Hypothyroidism:
very dry skin
yellow skin
coarse hair
hair loss of eyebrows
slight alopecia
hoarseness
weight gain
impaired mentation
depression
What are 4 conditions that untreated Graves disease lead to?
atrial fibrillation
congestive heart failure
angina
osteoporosis
The #1 consideration in the management of enuresis is?
Behavior modification
What are 2 risk factors for enuresis?
Family history of enuresis
Being a male
In a pt with HSP what is the recommended length of monitoring?
In ALL patients, need to monitor for renal involvement for 6 months after presentation even if initial urinalysis results were normal
Children who have demonstrated renal manifestations in the acute phase and continue to have hematuria or proteinuria should be examined every 3-6 months because renal failure or hypertension can develop up to 10 years after disease onset
What is treatment for Minimal change disease in children?
Steroids
Who is responsible for managing and prescribing prophylactic antibiotic in a child with VUR?
Urology
What 3 antibiotics do you want to avoid in children >2 months and why?
Amoxicillin
Ampicillin
Cephalosporin
To decrease the likelihood of resistance
What are the 5 types of urinary incontinence?
Detrusor instability or Overactivity (Urge)
Sphincter or Pelvic Incompetence (Stress)
Reflex incontinence
Detrusor hypotonia (Overflow)
Functional Incontinence
Name 3 medications that can be used for Urinary Incontinence:
Oxybutynin (Ditropan)
Tolteridine- Detrol
Solifenacin- Vesicare
What is a screening tool for urinary incontinence mainly used to differentiate stress and urge?
Questionnaire for Urinary Incontinence Diagnosis (QUID)
What are 6 symptoms of BPH?
Frequency
Urgency
Trouble starting a stream
A weak or interrupted stream
Dribbling
Nocturia
When preforming a digital rectal exam on a person with BPH how would the prostate feel?
Boggy
How is the urinary flow affected in BPH?
The prostate is enlarged and strangles the urethra therefore decreasing and restricting the flow of urine.
What are the 3 classifications including mechanism of actions of meds used to treat BPH?
aBlockers-
Doxazosin (Cardura) reduce smooth muscle tone
Tamsulosin (Flomax) reduce prostatic muscle tone
5aBlockers-
Finasteride (Proscar) block conversion of testosterone/ decrease size of prostate by20%/1yr
Phosphodiesterase Type 5 (5PDE) inhibitors
Tadalafil (Cialis) reduction in symptoms
Meds may cause sexual dysfunction
What BPH medication is contraindicated in a pt having cataract surgery and why?
Tamsulosin (Flomax)
***This drug may make the cataract surgery more difficult as it interferes with pupillary dilation and makes it harder to safely remove the cataract. Notify the surgeon if you take or EVER took Flomax before surgery!
What are 4 surgical options for BPH?
Prostatectomy
TURP-transurethral prostatectomy
TUMT-transurethral microwave thermotherapy
TUNA-transurethral needle ablation
What is a reason that a PSA could be falsely elevated?
Infection ie. prostatitis or epididymitis
What is an acceptable PSA level?
<4
What is the #1 management of BPH?
Watchful waiting
What are 2 examples of medications used to treat erectile disfunction (ED)?
phosphodiesterase type 5 (PDE5)
Sildenafil-Viagra
Tadalafil-Cialis
How do phosphodiesterase type 5 (PDE5) medications work for treatment of ED?
They induce smooth muscle relaxation and increase the blood flow to the penis leading to an erection.
What 3 classifications of medications are contraindicated to take with PDE5 and why?
Alfa blockers
Blood thinners
Nitrate medications
They can result in fatal hypotension
What drink is contraindicated with PDE5 meds?
Grapefruit juice
What lab value would you want to check in a patient with ED and what are the ranges?
Testosterone
males 240-950
females 8-60
What are 2 drug classes that are helpful for pts with premature ejaculation?
Tricyclics
SSRI’s
What are some drugs that frequently interfere with sexual function?
SSRI
Betablockers
Benzos
Anti-lipids
Antihypertensives
Opioids
Digoxin
Alcohol
Cocaine
When should eye exams and foot exams be started in a child with DM?
5 years after diagnosis
age 10 or after puberty whichever comes first
What are the three parameters measured for 2-20 years?
Weight
Height
BMI
What are the three parameters measured for 0-2 years?
Weight
Length
Head Circumference
If your patient has a fall out of 2 of the 3 measurements for growth what would this be considered?
Failure to thrive
What are 4 clinical presentations of a patient in DKA?
Vomiting
Polyuria
Dehydration
Kussmaul Respirations
In assessing a patient for PAD what would you expect to see on elevation of leg vs leg dependent?
Pallor on elevation
Rubor on dependence
What are the 4 antibodies that are markers of B-cell autoimmunity in type 1 DM?
Islet cell antibodies (ICA)
Antibodies to glutamic acid decarboxylase (Anti-GAD)
Insulin autoantibodies (IAA)
Antibodies to protein tyrosine phosphatase
What medications does Synthroid interact with?
-tricyclic antidepressants
-beta blockers
-diabetes drugs
-corticosteroids
-birth control pills
-iron, calcium, aluminum hydroxide
-PPIs
-bile-acid binding agents
Acanthosis Nigrans is a sign of which type of diabetes?
T2 DM
What is the preferred diagnostic study for PAD?
Ankle brachial index
What are 5 diseases/comorbidities that increase risk of heart failure?
M - Metabolic syndrome
A - Atherosclerotic disease
D - Diabetes
H - Hypertension
O - Obesity
