Exam 3 Flashcards
Neonate
Birth to 29 days
Infant
29 days to 1 year
Term infant
37-42 weeks
Birth weights
<10th percentile is too small
> 90th is large
APGAR
Appearance (color) Pulse Grimace (reflex response to bulb syringe) Activity (muscle tone) Respiratory effort
1 and 5 minute interval
APGAR scoring
8 is normal
5-6 is mild depression
3-4 need resuscitative measures
Ballard assessment is…
Calculates GA of child within 1 week
Neurological and physical components evaluated
When do you aspirate stomach contents in an infant?
Meconium stained amniotic fluid
C section babies
Failure to pass NG tube, think…
Esophageal atresia associated with tracheoesophageal fistula
High frequency tremors normal until…
4 days old
If >4, consider CNS, PNS
Pulse of infant
115-140
<90 or >180 is a concern
Physiologic jaundice
3-4th day of life
96 hours, self limited
Erythroblastosis fetalis
Jaundice in first 24hours of life, can cause kernicterus
Vernix caseosa
Normal finding at birth, peely white skin/residue
Acrocyanosis
Benign, hands/feet cyanotic
Central cyanosis
Tongue and gum mucosa blue, not normal
Milia
Pinhead smooth, white raised areas
Miliaria rubra
Heat rash
Caused by obstructed sweat glands, vesicles with erythematous base
Resolves in 1-2 weeks
Erythema toxicum
Baby acne
2-3rd day of life
Red macules with central urticarial wheals
Spontaneously resolves in a week
Angel kisses
On forehead
Stork beak
On back of neck
Salmon patches
Small and pink, fade over time
Port wine stains/nevus flammeus
Most often on face, unlikely to go away and may get darker
Sturge Weber syndrome
Trigeminal V1, seizures, hemiparesis, mental retardation, glaucoma
Orbit, upper eyelid and forehead
Large posterior fontanelle, think…
Congenital hypothyroidism
Caput succedaneum
Crosses suture lines
Swelling/edema
Cephalhematoma
Bleeding, doesn’t cross suture lines
Macrocephaly and microcephalic
> 2 standard deviations above the mean
3 standard deviations below the mean
Pupils constricted for…
First 3 weeks of life
Nasolacrimal duct obstruction
Tears begin 2-3 months, not fully patent until 5-7 months
Parent complains of chronic tearing
Ocular motility
4 weeks- following in an arc
8 weeks- follow past midline with coordinated head movements
3 months- follow an object
Nystagmus common in infants…
Immediately after birth
After a few days, consider blindness
Doll’s eyes for infants…
First 10 days
Blue sclera in infants…
After 6 months its abnormal
Sucking reflex until…
9-12 months of age
Micrognathia
Pierre robin syndrome
Breathing problems, glossoptosis
Epstein pearls
On palate, white spots
Teeth in infants
First set at about 6 months, bottom front teeth
By 10 months, what teeth ?
Two upper, two lower central incisors
4 teeth added every…
4 months. 8 teeth by 14 months
Apnea definition
> 20 seconds
Shrill, high pitched cry
ICP, narcotic addiction
Hoarse cry
Hypocalcemic tetany, congenital hypothyroidism
Expiratory stridor
Airway obstruction, polyp, tracheomalacia
Absence of cry
Severe illness, vocal chord paralysis, profound brain damage
Femoral pulses in infant
Check 24-48 hours after birth to assess strong pulses after closure of PDA
Weakness- consider coarctation of aorta
Heart lie in infant
More horizontally, apex is higher
PMI of infant
4th ICS, left of MCL until age 7
Auscultating infants
PVCs more common
Louder sounds
S2 split sometimes
Systolic II/VI or less until…
PDA and PFO close in the first 48 hours
Transposition of great vessels
Must have additional heart defect to survive
Not compatible with life without intervention
Tetralogy of fallot
Pulmonary stenosis
Thickened right ventricle
Ventricular septal defect
Overriding aorta (over septal defect)
Tet PE findings
Parasternal heave
Systolic ejection murmur over third intercostal space
Radiation to left side of neck
Atrial septal defect
Systolic ejection murmur over pulmonic area
Loud, high pitched, harsh
Thrill and parasternal thrust possible
Ventricular septal defect
Holosystolic murmur
Best heard at left sternal border in 3rd to 5th intercostal spaces
Loud, coarse, high pitched
PDA
Dilated and pulsatile neck vessels
Harsh, loud, continuous murmur
1st to 3rd intercostal spaces and lower sternal border
Kawasaki disease
Inflammation of. Small and medium arteries, including coronary arteries
High fever
Conjunctivitis
Strawberry tongue
Rash, polymorphous and erythematous
Umbilical stump
Falls off in 10-14 days
Umbilical hernia
Typically resolves spontaneously by age 2
Duodenal atresia
Double bubble sign
Ambiguous genitalia
Congenital adrenal hyperplasia is MCC
Concave abdomen
Diaphragmatic hernia
Bladder percussed at level of…
Umbilicus
Pyloric stenosis
Inspect during feeding in supine position
Olive mass
Projectile vomiting
Intussusception
Drawing up knees
Vomiting bile
Sausage mass
Obstruction
High pitch/frequency bowel sounds
Omphalocele
Incomplete closure of abdominal wall, midline defect with spleen, liver and stomach
Hypotensive baby, large exposed bowel, risk for sepsis
Hirschsprung’s disease
Congenital megacolon
Midline suprapubic mass
Failure to pass meconium
Colic
Excessive crying
>3 hours a day, >3 days a week for >3 weeks
Sudden onset, same time of day
First month, resolves by 3 months but may persist
High pitched intense crying, flushed face, furrowed brow
Metatarsus varus
Pigeon toe
Forefoot is adducted in relation to hindfoot
Resolves spontaneously in first few years of life
Talipes equinovarus
Club foot
Entire foot is deviated midline- forefoot adduction, fixed hindfoot inversion, Achilles’ tendon is foreshortened
Clavicle fx
Distal 1/3, crepitus
Ortolani
Index finger on greater trochanter, thumbs on lesser trochanter
Abduct hips, hear clicks or feel clunks
Barlow
Index fingers on greater troachanters and thumbs medially over lesser trochanter
Thumb presses backward and outward to feel for slip, index finger move forward and inward
Instability
Only test sensory in infant if…
Palsy or spina bifida expected
Meningiomyelocele
Severe spina bifida, massive and obvious
Spinal chord and nerves in the outpouching
Abdominal reflexes absent until…
6 months old
Rooting
Until 3-4 months
Touching mouth or cheek and head will turn to that side
Blinking/dazzle reflex
Eyelids close in response to light
1 year
Acoustic blink/cochleopalpebral reflex
Both eyes blink at sharp noise
Palmar grasp
3-5 months lasts
Hand will grasp finger
Moro startle reflex
Intact CNS, dead drops a few centimeters and arms spread wide
Disappears after 3-5 months
Gallant’s
One side of back stroked 1 cm from the midline, and lateral curving to the stroked side
Disappears after 2-3 months
Perez’s reflex
Thumb on sacrum and extend to head, causes flexion of knees and extension of neck, emptying bladder
Disappears after 2-3 months
Tonic neck reflex/fencing
Turn head to one side, holding jaw over babies shoulder
Arm and leg extend on the side the head turns, other side is flexed
Disappears at 6 months
Placing response
Foot lightly allowed to place on table
Hip and knee flex and then put their foot down
Disappears at 2-5 months
Test at 4-5 days of life
Stepping response
Both feet placed and should see alternate movement
Disappears at 2-5 months, test 4-5 days of life
Water less than…
120 degrees
Breast milk or formula only for…
First 4 months
Transient tachypnea of newborn and retained fetal lung fluid
Tachypnea, grunting, flaring, retracting
Excess fetal lung fluid from delayed clearance in C section
Klumpke’s paralysis
Brachial plexus trauma of wrist and hands
Erb’s palsy
Brachial plexus trauma at birth
Length of pregnancy
40 weeks
Nagele’s rule
9 months plus 7 days from last menstrual period
1-200 risk at age…
35
1-20 risk at age…
44
Over 5 parity increases risk for…
Placenta previa or accreta
Quickening
Around 20 weeks
8th week breast changes
Increased pigmentation and size of Arellano and nipple
Nipple more erect, Montgomery tubercles more prominent
16th week breast changes
Colostrum produced, may be expressed
Chadwick’s sign
Bluish/violet color change of vagina
Ph in pregnancy of vagina
More acidic
Uterus increases in weight from…
2 ounces to 2 pounds over 40 weeks
12-14 weeks, uterus shifts from…
Pelvic organ to abdominal organ
Hegar’s sign
6-8 weeks, softening of the isthmus
Cervical signs in pregnancy
Red velvet mucosa at cervical os
Goodel’s sign
Softening of cervix at 4-6 weeks
HTN after 24 weeks
PIH
What kinds of murmurs are not uncommon in pregnancy?
Soft, blowing murmurs
How many weeks to get fundal height same as GA
20 weeks
HR location
Midline/lower abdomen at 12-18 weeks
Heart rate of baby
160s early pregnancy
120-140s nearing term
When do you begin Leopold maneuvers?
28 weeks GA
Attitude
Fetal head when it is presenting
Flexed, hyperextended, etc.
Station
Presenting part and relationship to ischial spine
At ischial spine is zero, above or below, below is positive numbers
Effacement
Thinning, shortening and drawing up of cervix, measured in percentage from 0-100%
Documented in centimeters
Bishop score
Pre labor score to determine if induction of labor is necessary
Low BMI <19.8 weight gain
28-40 lbs
Obese BMI weight gain
Around 15 pounds
Early pregnancy bleeding
Implantation
Ectopic
Threatened abortion
Late pregnancy bleeding
Cervical changes
Placenta previa
Placenta acreata
Placental abruption
PIH
HTN after 24 weeks pregnanct
Pre eclampsia
HTN plus protein in the urine!!
Plus edema
Eclampsia
Pre eclampsia plus seizures
Can lead to death and HELLP syndrome
Placenta previa
Placenta lies low in uterus and partially or completely covers cervix
Painless bleeding in third trimester
Placental abruption
Most common pathological cause of bleeding in late pregnancy
Painful bleeding
0-3 scale
Premature rupture of membranes
High risk if it occurs preterm or if labor does not begin within 12 hours
Passage of fluid, nitrazine paper and fern leaf pattern
Ectopic pregnancy
Bleeding, pain on one side
If rupture- tachycardia, hypotension
Tenderness, adnexal mass, CMT
Myomas
Heavy menses, pelvic discomfort, can effect bowel patterns
Nodules on uterus, can prevent implantation and growth of an embryo
Geriatric
Over the age of 65
ADL versus IADL
Activities of daily living are more relevant like dressing, bathing, eating, walking
IADL are things they want to do, like housework, take meds, drive, laundry, shopping, cooking
Urge incontinence
Need to urinate comes quickly and can’t defer it
Stoke, MS, spinal chord injury
Overflow incontinence
Dripping of urine
Bladder obstruction, BPH
Stress incontinence
Leaking of urine with increased pressure, like laughing or running
Incompetent sphincter
Functional incontinence
Normal control but issues physically making it to the bathroom
Medications in elderly key points
Have them bring the bottles
Know prescription versus OTC
Leading cause of injury related to death in elderly?
Falls !
Temp in elderly
May not elevate in infection
BP inelderly
Systolic HTN, diastolic can level off between 50-60
Weight loss in elderly
If 5-10% in 12 months, work it up
Senile purpura
Purple/blue coloring on hands in elderly
Actinic keratosis
Face, neck, trunk and hands
Can develop into squamous cell carcinoma
Seborrheic keratosis
Face, chest, shoulders and back
Waxy, scaly and slightly elevated
MCC non cancerous lesion in elderly
Solar lentigines
Back of hands, forearms
Sun exposed areas, light brown to light flat macules
Sebaceous gland hyperplasia
Forehead or nose
3 mm with central pore andyellowish in color
Decubitus ulcers
Prolonged pressure over a bony prominence
Decubitus ulcers staging
1- nonblacnhing erythema of intact skin
2- partial thickness skin loss of epidermis
3- full thickness skin loss, damage or necrosis to subQ
4- significant damage or necrosis with muscle and or bone involvement
Headaches in elderly
Temporal arteritis (70) HTN
Eyes in elderly
Presbyopia- common vision changes with age, lens starts to harden
Need readers to focus on near objects
Senile ptosis
Drooping of eyelid, usually bilateral
Arcus senilis
Common over age of 60
Blue, grey, white
Disposition of lipids
Macular degeneration
Central vision loss
Progressive and painless
Amsler grid to evaluate
Cataracts
Opacities of lens, cloudy look
Medications contributing to hearing loss
Furosemide
Salicylate
Gentamicin
Aminoglycoside S
Cerumen impaction
Conductive hearing loss
MCC of hearing loss in elderly
More sudden
Presbycusis
50% of patients over 75
Slow, progressive hearing loss, sensorineural
Bilateral, high frequency sound
Otosclerosis
Gradual conductive hearing loss
Initially low pitched sounds and whispers
Hardening of bony growth of stapes
Xerostomia
Dry mouth
Oral cancer
> 40
Tobacco abuse
Leukoplakia and erythroplakia are pre malignancy
Colonoscopy
50-75 for USPSTF, every 10 years
50 every 10 years for ACS, annual guiac
Diverticulosis
Predisposed for diverticulitis
Fever, LLQ pain, guarding
UTI symptoms in elderly
Atypical, can be dementia
Osteoarthritis
Crepitus Asymmetrical Joint stiffness in morning andimproves within 30 minutes DIP joints, heberden nodes (women) Degenerative loss of cartilage
Polymyalgia rheumatica
Symmetric pain worse in the morning
Neck, shoulders, lower back, pelvic girdle
UE and pelvis are tender with palpation
Taste diminished…
Bitter and sour first
Analogies
Similarities and differences
Abstract reasoning
Shapes and patterns
Calculations
Serial 7s
Situational judgement
What if’s
