Exam 4 Flashcards
Disequilibrium, unsteadiness (can be uni-/bilateral)
Vertigo, nausea
Vestibular Ataxia
Patho of Vestibular Ataxia
Drugs & Alcohol are most common
Menieres Disease: unilateral symptoms
Wide-base steps
Drunk appearance
Truncal or gait ataxia (vermic cerebellar lesions)
Dysmetria (poor judge of distance-finger nose test)
Dysdiadochokinesia (deficit in patterned movements - clap/slap test)
Variation in speech (amplitude, speed)
Appendicular Ataxia
hemispheric cerebellar lesions
Postural instability
Impaired eye movement control
Vestibulocerebellar (flocculonodular) Ataxia
Patho of Cerebellar Ataxia
Stroke, deymyelination, tumors, genes, and SUDs can all be causes
Inability to stand with eyes closed (negative Romberg sign)
Stumble in the dark
Sensory Ataxia (proprioceptive deficit)
Patho of Sensory Ataxia
Inflammation, deymyelenation, vitamin deficiencies, infections, inherited disorders
Hypotonia w/ hx of birth depression, seizures, or encephalopathy
Fisting past 3 months
CNS lesion in the newborn
Hyptonia w/
Hx of Breech presentation
Global Developmental Delay
Early Handedness
Upper motor neuron lesion
Hypotonia
Weakness
Age-Appropriate Cognition
Peripheral nervous deficit
Multiorgan involvement Feeding issues Breathing issues Family history Dysmorphic features
Points of assessment useful in diagnosing Hypotonia, when Neuromuscular presentation is vague
Leg scissoring in vertical suspension
Lower Motor Neuron Lesion
Sensory-level hypotonia w/ bladder/sphincter abnormalities
Spinal cord lesion
Depressed/absent DTRs
Peripheral lesion
Fasciculations
Motor unit lesion
Primitive reflex deficit
PNS deficit
Causes of IICP
Trauma
Tumors
Severe URI/Gastric Infections (Meningitis)
Irritability, feeding problems, and/or inconsolable and/or high-pitched crying, tense/bulging fontanels, separated sutures, setting sun sign, bulging scalp veins
IICP presentation in infants
Best circumstance under which to assess fontanels/sutures
Calm baby, or between sobs of a crying baby
Irritability, hands on head, vomiting w/ or w/o nausea
Headache presentation in toddlers
Headache, vomiting w/ or w/o nausea, diplopia/blurred, inability to follow instructions, somnolence seizure activity
IICP presentation in toddlers/young children
Headache:
Wakens from sleep
Vomiting w/o nausea
Pain increases w/ pressure: Strain, Sneeze, Cough
Occipital/neck pain
Cognitive, personality, behavioral changes
Sz
Instability of thought (schizoid behavior)
Red Flags for Tumor or Pathology
Triad of headache, N/V, imbalance
+ early morning vomiting
Posterior fossa tumor
Papilledema Nystagmus Gait, motor changes Arrest of pubescence/growth 1. Abrupt onset, severe HA Pattern changes to chronic progressive
Indications for imaging in patients with headache
1. Emergency, send to ER
Migraine Prevention
Lifestyle: hydration, exercise, sleep, diet, and stress management
Hydration for Migraine Prevention
1 oz/lb max 100; no artificial sweeteners
Exercise for Migraine Prevention
3+ days/week x 30 minutes
Sleep for Migraine Prevention
11-12 hours for infant & young
10-11 for school-age
8-10 for teens, regularity is key
Pharmacological Treatment of Migraine
High-dose: 10 mg/kg up to 800 mg ibuprofen Q6 oral, take at first sign of migraine or aura;
Goal: abort
NSAIDs, NOT acetaminophen, especially Tylenol
Imitrax (sumatriptan) intranasally (5-10) or PO (11+)
Prophylaxis: Topamax, Elavil, Periactin, propranolol (not if asthmatic)
Daily, non-progressive headaches (chronic daily headaches) with intermittent spikes between periods of complete normalcy
moderate to severe
Worsened by activity
Throbbing
Migraine
Chronic daily, "tight" or "pressure" mild-moderate headaches: without spikes possible vision changes do not respond to triptans Not worsened by activity Non-throbbing 1. Bilateral, vague presentation 2. Ipsilateral, focal presentation Photophobia, phonophobia, or neither, not both
- Tension headaches*
1. adolescents & adults
2. children
Sudden onset headaches followed by chronic daily recurrence is likely due to
Viral infections (meningitis, encephalitis, etc) or Injury (SAH, SDH, concussion, etc)
Headache with tender sinuses on exam
Sinusitis/sinus headache
Sharp recurrent pain localized to the orbital region
Cluster headache
Types of disability brought on by IM or CDH
Intermittent Migraines or Chronic Daily Headaches:
Absenteeism: School, Summer activities
Presenteeism: Drop in grades; There, not participating
Treatment plans for pediatric migraines
One for home, and one for school; involve teachers/school nurse staff
Imitrax (sumatriptan) intranasally (5-10) or PO (11+)
Prescribe with adherence in mind, who is administering meds?
Migraine Prophylaxis
Journal: patterns to inform need for/effectiveness of prophylaxis (even if just a week)
Topamax, Elavil, Periactin, propranolol (not if asthmatic)
OTC: K, Mg(O), B2, melatonin
Migraine Referral
Imaging is needed
6 mo. persistence through standard treatment (LSM & abortive)
Worsening disability (ab-/presenteeism)
CDH Management
Imaging? (Pattern changed to CD) ID subpattern (TM, CTT, new daily persistent) Stop overused meds Healthy habits/non-pharm School connection Pharm (abortive) Psych assessment/Tx Need for referral?
- Paroxysmal abdominal crampy/dull pain lasting 1+ hours, ages 7-12, lasting up to 72 hours; hx of motion sickness; resolves with sleep. Repeated episodes (2+) separated by weeks-months. 2+ of headache, photophobia, N/V, loss of appetite, pallor
- Sudden vertigo in toddlers/young children; pallor; irritability; wide, unstable gait; nystagmus, vomiting; resolves with sleep; normal ECG
- Recurrent vomiting (6/hour; 25 total on average), discreet, hours-days, can be assoc. with 1; 2.5-3 years old; exhaustion/fatigue, pallor, abdominal pain
All with symptom-free intervals, and possibly alongside headache
Migraine Variants in Children, History of Migraine is at least supportive if not necessary for diagnosis
- Abdominal migraine
- Benign Paroxysmal Vertigo
- Cyclic Vomiting Syndrome
When to refer for CVS
Severe dehydration/electrolyte imbalance
Hematemesis
Weight loss
What history questions are relevant to a child presenting with a headache?
Onset time of HAs? Location on head? Duration of HAs? Characteristics of pain? Alleviation of HA? Aggravation/triggers? Related symptoms: nausea, light/sound sensitivity, Sz? Temporal pattern, frequency? Prodrome? Present in AM Severity: wakens you from sleep?
Headache types:
Chronic, recurrent, frontal, throbbing, anytime, varied frequency, hours-days, nausea w/o vomiting, aura, photophobia & phonophobia
or
> 6 mo, daily, temporal, squeezing, anytime, varied frequency, hours-days, nausea w/ vomiting, aura, photophobia w/o phonophobia
vs
Primary headache
Subacute, progressive, posterior, pressure-type pain, waking, constant, nausea w/ vomiting, diplopia, phonophobia w/o photophobia
OR
Acute, progressive, posterior, pressure-type pain, early-morning, constant, vomiting w/o nausea, and diplopia
Secondary headache
Management of Anaphylaxis
Remove/discontinue trigger
1: 1000 epinephrine solution
- 0.01 mg/kg; max: 0.5 mg
- Autoinjector:
- > <25 kg children - 0.15 mg dose
- > >25 kg: 0.3 mg dose
Diphenhydramine 1-2mg/kg up to 50 PO, IM, IV
Bronchodialators (albuterol 0.5 jet neb) if wheezing
Serum Tryptase positive after three hours, only test if diagnosis is in question
Biphasic Reaction Treatment notes
Carry 2 doses of the autoinjector: suboptimal reponse/progressing symptoms take second dose
Preferred over adjunctive therapies
local redness/erythema abd tenderness watery eyes hives (wheezing)
Wasp/Bee Sting - Severe
Wasp/Bee Sting - Severe - Treatment
Anaphylaxis management
Epinephrine IM immediately
Oral diphenhydramine
Bronchodialators (albuterol 0.5 jet neb) if wheezing
Animal bite concerns
1. open, gaping, evolving
- Irrigate (animal or human) w/ >5 psi NS
Early Lyme/Late Lyme Disease Diagnostics, Treatment
Serum Lyme Ab Assay, Amoxicillin or Doxycycline (late: consult with ID)
Lyme Arthritis w/o evidence of CNS involvement treatment
- Joint swelling or persistant
- Second line treatment
doxy, amox, cefuroxime PO x 2 weeks
- 4 weeks
- 2-4 weeks IV ceftriaxone
ITP patho
Bleeding disorder: platelets < 100,000 w/ otherwise WDL CBC
Follows viral infection
Autoimmune destruction of platelets (spleen)
Bruising, petechiae; negative for splenomegaly or hepatomegaly
ITP
Purpura w/o thrombocytopenia abdominal pain arthritis GI Bleed [orchitis, nephritis, preceded by URI, Low fever (<38), recurrent]
HSP
HSP Treatment
Most: self-limiting, supportive symptom treatment only
Iron Deficiency Anemia Prevention, Treatment, and Follow-up
Exclusive breastfeeding: 1mg/kg/day of supplemental iron STARTING AT 4 MONTHS until iron foods given
Treatment of pathological IDA: FeSO4 3mg/kg for 2-3 months, +2-4 months to replace stores
not necessary to monitor asympomatic children
Therapeutic Hgb: (over 11 g/dL), should rise >1g/dL in 2-4 weeks depending on severity (under 9 vs. under 11)
Therapeutic Retic count: back to 0.5-1.5% after 1 week (predates Hgb, predicts recovery)
Microcytic Hypochromic anemia, hx of inadequate iron intake, or excessive milk intake
Dx
Iron deficiency anemia
CBC w/ diff, retic count, ferritin level, TIBC, serum iron
Malaria
more common in culturally diverse urban areas (esp. w/ international travellers)
high fever, diphoresis, rigor, HA as symptoms
TRAVEL HISTORY
COVID exposure
Antihistamines for 6+ mo. children
These are approved: Zyrtec (cetirizine), Clarinex (desloratadine), Allegra (fexofenadine)
DO NOT DELAY EPINEPHRINE esp. in favor of antihistamines, not an alternative, an adjunct
Allergic rhinoconjunctivitis symptoms
Mucus secretion or discharge, sneezing, irritation, and swelling (periorbital edema, cyanosis: allergic shiner)
Itching of the nose (paroxysmal sneezing and epistaxis), eyes, palate, or pharynx and loss of smell or taste
- irritability, lethargy, or poor feeding, a-/febrile, vomiting
Later: bulging / tense fontanel (IICP), high-pitched cry, seizures
Less likely to see + Brudzinski / Kernig
signs - Fever, chills, headache, vomiting; nuchal rigidity (stiff neck), seizures; +/- Purpuric rash (50%); Altered mental status, extremely irritable; Photophobia
Meningitis
- in infants
- in children/adolescents
Brudzinski: Bend the knee
Kernig: Krick the neck
Sudden fever, headache (3-12 days after tick bite)
Purpuric rash, petichiae 2-4 days later; wrists/ankles/soles spreads to trunk
RMSF
Pseudopurpura, petichiae
RMSF Tx
Immediate treatment with doxycycline (treat before you confirm, deadly disease
Wasp/Bee/Ant Stings
Systemic reactions from venom
IgE-mediated allergic reaction/anaphylaxis
Symptoms can DIFFER
Snake bite
AMBULANCE, esp. w/ edema, intense pain
Especially if snake species is unknown/copperhead/around a body of water
Then, intermediary assessment
Lyme disease prevention education
Tick Sprays: OTC, use for children - DEET, picaridin, IR3535, Oil of Lemon Eucalyptus (OLE), para-menthane-diol (PMD), or 2-undecanone
DO NOT use products containing OLE or PMD on children UNDER 3 years old.
Treat clothes with a 0.5% permethrin spray
When do S/S of Malaria appear?
Usually >14 days, as early as 7 days, as late as several months
Cyclic paroxysms of fever, chills, malaise, and headache
Abdominal pain, nausea, vomiting
1. Recurrent fever, irritability, poor feeding, vomiting, jaundice, and splenomegaly
2. Splenomegaly and mild pallor
Malaria S/S
- in infants
- In some uncomplicated cases
Tick bite, asymptomatic, no tick present
Educate parents as to S/S
No prophylaxis if type of tick is unknown
Zika virus transmission and sequelae
Transmitted by Aedes mosquitos (same vector as dengue and chikungunya), sexual intercourse, and vertically (mother-to-child) during pregnancy.
Vertical transmission to fetus during pregnancy may result in congenital Zika syndrome.
Usually mild rash, fever, and conjunctivitis
Zika, Dengue, Chikungunya infections
Infantile dietary concerns for:
- Vegetarian diet
- Goat’s milk
- Cow’s milk
1 & 2. Iron, folate, b12 deficiency
3. Iron deficiency (cow’s milk iron is lower, less absorbable)
HPV Vaccine details
9-valent (covers for vaginal/vulvar/cervical, penile, oral, and anal cancer - 7 types; and female/male genital warts - types 6 & 11)
2 doses before 15, 3 after, 5 months apart minimum
15 minutes of rest to avoid most common side effect: syncope
Bacterial Meningitis is always an
EMERGENCY
The most common cause of meningitis < 5
S. pneumoniae; (Hib was before vaccination)
1 month + w/ meningitis, the organism is likely
1. if immunocompromised
N. meningitidis
1. Listeria
0-28 days old, the most common causes of meningitis are
- Group B Strep
2. E. coli is second
Meningococcal Prevention
Vaccines: Hib, prevnar, PCV13, Pneumovax for high-risk groups, ACWY: age 11 (+1; same product!); B: age 16
Chemoprophylaxis: Rifampin to any contact if 4-year-old in their house (not immunized against Hib), w/in 24 hours
Important meningitis complications for primary care
Deafness and developmental delay; close monitoring required
[Cough, headache, sore throat], followed by a few days of URI symptoms, fever (38.5+), chills; malaise, weakness, myalgia, HA, N/V, arthralgia
[Prodrome of] vague meningococcemia symptoms
Pallor, mottling –> short-lived erythematous or maculopapular rash (face –> body) –> non-blanching red or brown petechiae/purpura
Rash progression specific to meningococcemia
A febrile child who has had purpura or petechiae for fewer than 12 hours should be
managed as medical
emergency sent to the hospital
What are the most common infectious causes of Aseptic meningitis?
- Enteroviruses and Parechoviruses account for most of all known cases.
- Arboviruses (especially West Nile virus and La Crosse virus - Mosquitoes)
- Borrelia burgdorferi (Lyme Disease - ticks)
Highest incidence of aseptic meningitis is when and in whom?
In Summer & Fall in those under 4 years of age
Noninfectious causes include
Medications, autoimmune and auto-inflammatory diseases, and neoplasms.
Herpes simplex virus (HSV) is a cause of life-threatening meningeal infection in
Neonates
- Direct coagulation of skin and subcutaneous
fat; microvascular vasoconstriction and thrombosis in peripheral tissue; necrosis - Response to a complex array of changes and insults, which can include neurohormonal changes, fluid loss, hypoproteinemia, and hypotension
2a. High fever and multi-organ dysfunction without infection
- Local and 2. systemic physiologic changes caused by
burns
2a. Large Burns
Essential components of outpatient care of small burns
Assessment: “A Second Degree Concern”
assess integrity of the Airway
organized Secondary survey - wound size (rule of 9s only applies to adults) & depth
Debridement (clean technique/saline & thin blister removal/soap & water): analgesics/anxiolytics, distraction, tetanus update
Compartment syndrome risk assessment
Dressings: 1st & 2nd degree - abx ointment/silver dressing x up to 72 hours - repeat exam
Maintenance of cleanliness (family, outpatient services PRN)
Heal within 3 weeks
Long-term physical and emotional outcomes can be enhanced through participation in burn aftercare programs that include…
…scar management, burn-specific physical and
occupational therapy, ready access to burn reconstruction, emotional
counseling, and family and peer support.
PT, Counseling, Family/Peer Support, OT, Reconstruction, Management = PC FORM
Referring children with ___ to pediatric burn centers
enhances survival.
large burns (>20% of the total body surface area [TBSA])
Nonburn conditions commonly treated in
burn units
TEN (med reaction) Staph scalded skin syndrome Purpura fulminans (sepsis) Tar/Chemical/Electrical/Crush/Blast Injuries Frostbite Soft Tissue Infections
Epidemiology of human and animal bites in children
250,000 human bites, 400,000 cat bites, and 4.5 million dog bites (1 to 3 per 1,000 children per year; peak incidence in 5- to 9-year-olds) occur each year in the United States in adults and children.
Common etiologic pathogens associated with 1. human and 2. animal bite wound infections
Usually polymicrobial; strep & staph; fusobacterium spp., prevotella spp.
- E. corrodens, Haemophilus spp., peptostrep, veillonella
- Both: Pasteurella spp.; Bacteroides, Porphyromonas, Propionobacterium. Dog: C. canimorsus, peptostrep. Cat: Moraxella spp.
Strategies to prevent bite wound infections and to decrease the risk of fatal infections such as: 1. rabies or 2. tetanus
Prophylactic antibiotics (Augmentin) if:
✓ Immunocompromised or asplenic
✓ Moderate to severe puncture wounds
✓ Injuries to the bone/joint/tendons
✓ Wounds in the face/hand/genitals
1. Assess rabies immunization/prophylaxis indication: mainly risk/vaccination status of animal; call public health PRN
2. Tetanus immunization status: < 3 or unknown = TIG & age appropriate Tvax; 3+ = nothing if last Tvax w/in 5 y; booster if not
Manage bite wounds
Irrigate wounds other than puncture using splashguards with 250+ mL of normal saline
Imaging?
Debridement and removal of foreign material
Cultures if evaluation occurs >8 h after the event or if the wound has signs of infection
Early closure if: face/neck wound, not hand (surgeon), signs of infection or at risk for infection
No SubQ sutures
Recheck in 48 hours regardless of treatment
Education and anticipatory guidance to children and their caregivers regarding safety with pets and animal contact
Use AAP resources/handouts
Include school-age or older children in conversation
No non-traditional pets in house with children
Ticks typically bite humans in the seasons of ___ because this is when they are in the ___ stage of their lifecycle
Late spring & summer; nymph (egg, larvae, nymph, adult)
The four main diseases transmitted by ticks
Lyme disease, ehrlichiosis, tularemia, & RMSF
Labs for Lyme Disease
Serology not useful for several weeks (IgM: 2-4 weeks; IgG 4-6 weeks)
Serum ELISA at 2 weeks –> IgM/IgG Western blot if symptoms persist beyond 30 days
Malaria Treatment
Early, three-day atovaquone-proguanil or artemether-lumefantrine regimen
If either was used for prophylaxis use the other (it wasn’t effective against the plasmodium sp. which is causing the active infection)
Intensely pruritic, erythematous papules associated with excoriations, vesiculations, and serous exudate
Chronically relapsing course
Infants: face, scalp, and extensor surfaces of the extremities
Atopic Dermatitis
- Recent viral infection
Wheals with reflex erythema that are pruritic and transient (hours) w//w/o concurrent asymmetrical, nonpitting edema not occurring predominantly in dependent areas
Urticaria & Angioedema
1. Acute (6- weeks)
Urticaria & Angioedema Management
Avoid triggers, treat any underlying/exacerbating infection
IgE if allergic origin is suspected to confirm, direct treatment
2nd-gen PO H1-antihistamine (ongoing); up to 4 x dose as secondary
Omalizumab - effective for antihistamine-refractory urticaria
Hx of rapid onset of urticaria/angioedema, respiratory compromise, hypotension, and/or GI symptoms after exposure to a common trigger
Anaphylaxis
Atopic Dermatitis Management
- Trigger Avoidance
- Hydration
- Moisturization (lotions, creams, ointments)
- Topical Corticosteroids (desonide/fluticasone approved down to 3 mo. old x 28 days)
- Severe: Tacrolimus and pimecrolimus (topical calcineurin inhibitors) - caution for photosensitivity
Concerning patients for Eligibility for Contraceptive Use
Gastric bypass/malabsorptive; rifampin/rifabutin; severe hypertension (160+/100+): no combo or progestin pill
Anticonvulsant therapy: 30+mcg of estrogen if pill
Lamotrigine, migraines w/ aura, gallstones or hormone related cholestasis, moderate hypertension (<159/99): no combo
The Shot - frequency with which it must be administered/changed
Every three months
The Implant - frequency with which it must be administered/changed
Every 5 years
The Patch - frequency with which it must be administered/changed
Q3 wk x 3 wk, skip a week
Oral Estrogen-Progestin - frequency with which it must be administered/changed
Daily as prescribed
Jaya is a 16-year-old female in for her well-check. During the history, she reveals that she is using a progestin-only oral contraceptive (which she has finished), and mother is supportive. She mentions that she is having trouble taking the pill every day and would like to try the Progestin implant. The first day of her LMP was a little under two weeks ago, and she has had unprotected sex since then. Her urine pregnancy test is negative. What is the next step to determine whether she can get her implant?
Determine whether she will bridge on the pill, or if she wants to get the implant today despite the risk of early pregnancy
3 mainstays of treatment for emergency contraception
copper IUD, ulipristal acetate, and levonorgesterel
Copper IUD emergent contraception time frame, efficacy, BMI limit
The copper IUD is the most efficacious form of emergency contraception. It can be used up to 5 days after unprotected sex to prevent pregnancy, and it works for patients of all BMIs.
Ulipristal emergent contraception MOA, time frame, counseling
Ulipristal Acetate mimics and blocks progestin, thereby delaying ovulation; it can be used for emergency contraception up to 5 days after unprotected sex.
Clinicians should counsel patients that starting hormonal contraception immediately after taking ulipristal acetate may make both medications less effective.
Levonorgestrel, emergent contraception: reasons to recommend
Levonorgestrel does NOT require a prescription and is available over-the-counter for people of all ages.
Screening for cervical cancer includes:
Routine Pap Test only
Screening for Trich includes:
Asymptomatic screening: Polys, MSMs, Hx of STI, HIV +, and those who present to STD clinics.
Symptomatic screening: women with vaginal discharge
Treatment for Trich includes:
Metronidazole (2g-500mg); (albicans: clotrimazole cream)
Herpes treatment
Acyclovir (400-400), valacyclovir (1g-500), or famciclovir (250-125)
Screening for 1. Chlamydia and 2. Gonorrhea includes:
Annual screening of all sexually active women younger than 25 years
Annual screening is recommended for men presenting to clinical settings with a high prevalence of patients with chlamydia, and in MSM (genital and rectal)
- Pregnant women younger than 25 years, screening
should be performed in the first and third trimesters - Annually in HIV-positive individuals
- Men with eurethritis
Treatment for 1. Chlamydia and 2. Gonorrhea are primarily
azithromycin 1 g x 1
2. ceftriaxone 250 mg IM; 1 g if conjunctivitis
