Final Exam: Lectures (Mod 6/7) Flashcards
Theory of development:
Children gradually acquire the ability to understand the world around them through active engagement with it
Piaget’s theory/intellectual development
Theory of development:
Development occurs as a series of stages influenced by interpersonal connections
Freud and Erikson
Definition:
Repertoire of traits with which a child is born
Temperament
Can temperament be changes or adjusted?
Yes it can be modified by the interaction with caregivers, peers, their environment
-Biological influences
-Psychosocial factors
-Family history
-Genetics
-Effects of parental depression
-Stressful life events
-Childhood maltreatment
-Peer and/or sibling influences
Risk factors for the development of childhood mental health disorders
Child, parent, teachers, care providers, medical records, neuropsychological testing
Sources for gathering information about the child’s well-being
Most common disorder of childhood
Boys > girls
Generally diagnosed prior to age 7
S/S occurring for at least 6 months
Increased risk of conduct disorder, anxiety, depression, learning disabilities
ADHD
Symptoms:
Attention problems
Distractibility
Impulsive behaviors
Hyperactivity
ADHD
6 y/o M presents to the office today with his father. Dad reports ongoing concern for inconsistency with homework, trouble concentrating during baseball practice, and often having to repeat instructions to the child to get him to complete a task. The child’s last report card noted the child is talkative in class and is often needing to be reminded to sit in his seat and not talk when the teacher is talking. Dad initially thought this was just “boys being boys” but wants to confirm. You complete a Vanderbilt Rating Scale with concern for:
ADHD
6 y/o M presents to the office today with his father. Dad reports ongoing concern for inconsistency with homework, trouble concentrating during baseball practice, and often having to repeat instructions to the child to get him to complete a task. The child’s last report card noted the child is talkative in class and is often needing to be reminded to sit in his seat and not talk when the teacher is talking. Dad initially thought this was just “boys being boys” but wants to confirm. A tool you can have dad complete today and send a copy home with the family to be filled out by the child’s teacher is:
Conner’s Parent/Teacher Rating Scales
After investigation, you diagnose the 6 y/o M with ADHD. What are next steps that are appropriate in his management?
Educating the parents on behavior management
Referral to therapy for the child
504 plan for school
Medications: Ritalin, Concerta, Adderral, Strattera
You prescribe the 6 y/o M Ritalin XR to be taken once a day. When educating dad on administration, what is an appropriate frequency for this mediction?
Every day before school with breaks on weekends and during school holiday
The 6 y/o M is to start Ritalin XR tomorrow prior to school. When would you like to see him back in the office for follow up?
In 2-4 weeks from initiation of medication. If he is stable at that visit, then change to every 3 months.
At the follow-up appointment at 3 weeks, the 6 y/o M presents with mom. She states that he is doing better in school, but the first few days he was not interested in eating much and coming home most days with a full lunchbox. What will you advise mom on?
Anorexia is a side effect of the stimulant medication. The extended release should diminish this side effect, if it persists can seek alternative medication options.
-Anorexia with weight loss
-Insomnia
-Headaches
-Abdominal pain
-Nervousness, jittery feelings
-Dizziness, HTN, tachycardia
-Skin rashes
-Abnormal LFTs
-Urinary retention
Side effects of ADHD stimulant medications
You are considering starting your patient with newly diagnosed ADHD on a stimulant medication. What diagnostic would you run prior to starting medication?
EKG
Males > Females
Possible genetic connection
Generally presents by age 3
Autism Spectrum Disorder
Symptoms:
-Delayed or not met developmental milestones
-Parental concern for development
-Language and communication deficits
-Lack of eye contact or facial expression
-Lacking social relationship development (with peers or others)
-Tolerance of non-goal directed behaviors
-Rocking, hand-flapping, self-injury, sleeping/eating problems, sensory impairments
Autism Spectrum Disorder
RED FLAGS:
-Failure to meet developmental milestones
-No eye contact
-No single words by 16 months
-No babbling, pointing or gesturing by 12 months
-No spontaneous 2 word phrases by 24 months
-Loss of language or social skills at any age
Autism Spectrum Disorder
When considering a diagnosis of Autism in a child with lack of language skills, you should consider auditory studies for what reason?
Language is developed primarily through sound interaction, if the child cannot hear they may have a delay in language skills
A newly 3 y/o F comes into the office today for her annual well-child appointment. She has been in day care since she was 6 months old, both her parents work full-time, and she has 2 older brothers who developed typically. Mom is concerned that over the past 2 months, the patient has become less social with her peers that she had previously interacted with. Prior to this visit, she has met all her milestones and has had no hearing impairments noted. She can repeat single words, only uses 1-2 word phrases and points to indicate what she would like. When assessing her, you note that she will track you in the room, but does not want to make eye contact when you address her specifically. She has previously not been a shy child. What is a leading differential to consider?
Autism Spectrum Disorder
You have a 3 y/o M with PMH Autism Spectrum Disorder presenting today with his father. Dad wants to get the child into a childcare setting. What is a program you can refer them to?
Birth to 3 through the State of CT
When caring for a child with Autism, who are some interdisciplinary team members that can be helpful?
Neuro
Psychiatry/LCSW
Parental support groups
Care coordinators
Community social worker
Incidence increases with age
Girls > boys after puberty
Low rate of patients who actually seek treatment
RF: FH, female, stressful events, loss, substance use, chronic illness, trauma, abuse, neglect, ADHD, anxiety, cigarette smoking
Depression
Symptoms:
-Irritable mood, sad expression
-Anxiety, somatic complaints
-Unusual behaviors, disinterest in play/normal daily activities they find enjoyable
-Impairment in overall function
Depression
14 y/o F comes in for her annual well-care visit today. As she is an adolescent you speak to her without her parent present at which time she reveals that she does not enjoy going to school, finds it difficult to wake up in the morning, and wants to quit soccer, but her mom won’t let her. When you speak to the parent separately, they state they have noticed a decline in her grades, a lack of interest in social interactions with her peers, and more time napping and watching Netflix alone. What is the next step you would initiate in this patient’s care?
Screen her for depression using Children’s Depression Inventory and a PHQ-9 as well as assess suicidiality
You have a 2 y/o F who presents with dad. She appears very thin and only speaks in 2 word phrases. When speaking, she does stares at the ground, does not look at you or her father. She does not smile or giggle when you attempt to interact with her with a toy. Her dad notes that this is her normal and is concerned with her lack of attachment to her parents when dropping her off at school and her general expressionless face with interactions. What is a lead diagnosis for this child?
Depression
A 4 y/o M comes in with mom after being kicked out of preschool for being aggressive with other students. He has a history of encopresis, well controlled on a stool softener for the past 3 months. Mom notes that at home he seems to be destructive of his toys and is fixated on everyone dying. What is a lead diagnosis for this child?
Depression
-Depressed mood most or nearly everyday
-Marked disinterest in pleasure
-Weight loss >5% in 1 month
-Insomnia or hypersomnia
-Psychomotor agitation or retardation
-Fatigue, loss of energy
-Feelings of worthlessness, excessive guilt
-Poor concentration/indecisiveness
-Recurrent thoughts of death, SI, suicide attempt or plan
Depression criteria per the DSM V
You have a 15 y/o M with a diagnosis of depression being treated with CBT. He states he still has low energy and disinterest in activities he previously enjoyed. He wants to know if there is something he can take to help his mood. You would start with prescribing him…
SSRI
You start your 15 y/o M patient on Celexa once a day. You educate him on the risk for SI and provide him with a crisis hotline number in case these feelings arise and he cannot get in touch with the office. You want to see him back for follow up when?
In 4 weeks. You want to continue ongoing assessment for suicidality at this appointment as the SSRI can improve energy and increase SI and/or attempt
You have a 17 y/o F who comes in for her pre-college physical assessment. She has been on Lexapro for a year for depression. She has been doing well with CBT and denies S/S of depression for over 6 months. She is wondering if she can stop taking her Lexapro prior to leaving for college. You advise:
She with tapering her dose over 6-8 weeks
Girls > boys
Primarily accompanied by depression
Persistent worry or fear for months that impair the person’s age-appropriate functioning
Anxiety
Symptoms:
-Very self-conscious
-Need for reassurance
-Somatic complaints
-Excessive worry or fear
Anxiety
You have a 16 y/o F presenting with feelings of constant worry, racing thoughts, insomnia, and fatigue. She feels that she can’t “turn my brain off” at night from the worry. You screen her with the GAD-7 and she scores for moderate anxiety. In addition to therapy, what medication would you consider?
Zoloft 25 mg PO daily
or any SSRI
You have a 15 y/o M come in for hypersomnia. When you ask him why he is here today, he states “my mom made me come, she thinks I sleep too much, but I’m just a teenager”. When speaking with his mom she notes increased mood swings varying from staying up all night playing video games, spending excessive amounts of money on video games, and having lack of interest in school work followed by hypersomnia and lack of interest in interacting with others or playing video games a week later. The patient’s parents are divorced with little contact with the father due to his lack of desire to seek treatment for bipolar disorder. Mom is concerned the 15 y/o patient has a similar diagnosis. What is your next step?
Reassure mom and refer to psychiatry to further workup of a mood disorder, specifically BP1.
DIG FAST for bipolar:
Distractibility
Insomnia
Grandiosity
Flight of ideas
Activities
Speech (pressured, hypersexual talk)
Toughtlessness
When considering bullying in relation to children today, where does this most commonly take place?
Social media
What is the teen suicide rate?
12-25%
Emotional or behavioral reaction to a stressful event that is maladaptive within 3 months of said event
Adjustment disorder
How would you treat adjustment disorder?
Refer to CBT
Symptoms:
-Uncooperative
-Defiant
-Irritable
-Negative and annoying behaviors toward parents, friends, teachers, and authority figures
Defiant disorder
When treating a patient with defiant disorder, what is the primary treatment?
Counseling, therapy, early intervention is key
RED FLAGS:
-Change or loss of interest in usual activities or appearance
-Withdrawn
-Acting out
-Running away
-Feelings of wanting to die
-Preoccupation with death
-Lack of response to praise
-Giving or throwing away important belongings
-Threatening action/plan
Suicide red flags
Primarily onset in late adolescence-20’s
Male > female
Disturbances of memory or concentration
Changes in emotional response and decreased sense of connectedness
Schizophrenia
Who primarily treats schizophrenia?
Psychiatry
A 17 y/o F comes in today with her mom. Mom has noticed her slapping herself when she needs to focus on school accompanied by nail biting. The patient admits to burning herself with a lighter when no one is around. You are concerned for self-injurious behavior and want to refer the patient to therapy. The patient is concerns about being admitted to the hospital for SI. You screen her for SI and her screen is negative. Mom is concerned about taking her daughter home safely. You educate mom on:
Self-injurous behavior is normally an act of harm with the absence of intent to die. The daughter denies SI and is safe to bring home with assistance from therapy to work on her coping skills
True/False:
Every child, every visit should be screened for child abuse especially with concern
True
You have a patient come in who is noted to have a loss of milestones. What system are you concerned about and where are you referring?
Concern for neurologic development with referral to neurology
5 y/o F presents with multiple light brown spots on her back and abdomen. They appear to you as cafe au lait spots. What is the next step?
Refer to genetics for concern for neurofibromatosis
You have a 15 y/o M presenting with intermittent headaches. He describes them as unilateral, above his L eye, and like someone is squeezing his head when they occur. He takes Tylenol with good effect when they occur. He has noticed that they happen most prior to an exam in a class when he hasn’t been eating to increase his study time. What would you educate him on?
Importance of not skipping meals as this can trigger headaches especially when under stress
Primary or secondary headache concerns:
-Worse in the morning
-Wakens child from sleep
-Vomiting not precipitated by nausea
-Increased pain with straining, sneezing, and/or coughing
-Occipital or neck pain
-Mental, personality, or behavioral changes
-Seizure
-Unsteady/dramatic behavior change
-Fever
-FH of neuro disorder
-PMH: VP shunt, hydrocephaly
Secondary headache concerns
FH migraines
Rapid onset of attack lasting seconds-minutes
Daily attacks in clusters over several days
Acute unsteadiness, nystagmus, N/V, pale appearance, frightened appearance, lethargy, drowsy, normal neuro
BPPV
When completing a BPPV workup, MRI is indicated for what reason?
Rule out a tumor
Symptoms:
-Unilateral or bilateral coordinated motor activity
-Occurs only when observed
-Does not interrupt play
-Pupils normally reactive to light
-Situation specific
-No associated injuries
-No incontinence
-Abrupt recovery with no postictal phase
Pseudoseizures
History:
-PMH: CNS infection, birth trauma
-SH: toxin or drug exposure
-Recent head injury
-FH: seizure
Physical:
-Focal abnormalities/weakness
-HTN
-Systemic disease
-CV disease
-Neurocutaneous disease
-Signs of head trauma
-Transillumination of the skull
Seizure disorder presentation
Diagnostics in seizure disorders are helpful for:
Guiding management plan
A 6 y/o M comes to the office today for his annual well-child visit. He has a witnessed seizure 2 months prior and is being followed by pediatric neurology for his management. Summer is coming up and the patient is excited for summer camp. He really wants to swim at camp this summer and mom is concerned about the safety. In conjunction with his neurologist, what is the best action plan for this child?
Neurology is primary for the stability of his disorder on medications
The child should wear a medical alert bracelet at all times
If cleared by neurology, he can swim at camp with a 1:1 supervision in the water at all times
You have a 5 y/o F coming in for her pre-kindergarten visit. She is due for her DTap at this visit. She was diagnosed with epilepsy at 4 years old and has been stable on her regimen. You have already discussed her plan with her neurologist. Can you administer the DTap at this visit?
Yes, DTap is safe as long as the epilepsy is stable and verified with neurology
Most common seizure type in children
Brief, generalized
Concurrent with an illness
Febrile seizures
The mother of a 13 month old calls you saying she went to the ED yesterday with the child after the child was thrashing and unresponsive. The child felt very warm at the time and was noted to have a temperature of 104F when EMS arrived. In the ED they treated the fever and underlying illness. She is concerned if the child needs a neurology workup for seizures. There is not FH of seizure disorder. This is the first episode for this child. What would you recommend?
Counsel and educate mom on febrile seizures
No need for referral to neurology at this time
You’re assessing a 1 month old. When picked up, the infant droops over your hand and is almost “floppy” appearing. Who would you refer this child to?
Genetics
Sudden, acute onset unilateral paralysis/weakening of facial nerve without sensory loss
Recent viral infection
Bells Palsy
Caudal end of the spinal cord fixed at or below L2 with noted neurologic deterioration is:
Tethered cord
Normally associated with spina bifida
Are murmurs common in children?
Yes, 80% have a functional murmur
Murmur that comes and goes
Usually louder at times of anxiety, fear, exercise, or pain
Functional/innocent murmur
ASD, VSD, PDA
Acyanotic
L to R shunting
TOF
Cyanotic
R to L Shunting
Murmur noted at the pulmonic area
End systolic murmur of L 2nd or 3rd intercostal space
Murmur associated with ASD
Symptoms:
-Generally asymptomatic
-R atrial enlargement
-L 2nd/3rd intercostal end-systolic murmur
-Possibly heave or thrill
-Fatigues easily with exertion
ASD
What is the medical management for ASD?
Diuretics, rate control, anticoagulation if in A. Fib
Do ASD’s ever close on their own?
Yes, small ones generally close spontaneously
Murmur that begins around 2-8 weeks of age d/t pulmonary vascular resistance falling resulting in CHF
Harsh pansystolic murmur with a thrill at L lateral sternal border
VSD
You have a 4 week old brought in for their well-child appointment. Dad has noticed increasing “puffiness” of the extremities and sweating when the baby feeds. On exam you note a murmur, what is the concern for this child?
VSD
Symptoms:
-Murmur at 2-8 weeks old
-Poor weight gain
-Increased RR
-Diaphoresis with feeding
-Recurrent pulmonary infections
-Crackles
-Harsh pansystolic murmur with a thrill at L lateral sternal border
VSD
You are concerned that the 4 week old has VSD after assessment. What is the next step?
Refer to pedi cards for further management
Soft murmur at the LSB radiating to the back
PDA
Symptoms:
-Soft murmur at the L sternal border to the back
-Machinery murmur later in life
-CHF symptoms
PDA
VSD, pulmonary stenosis, dextroposition of the aorta, R ventricular hypertrophy
Tets
Ejection systolic murmur with normal first sound, single second sound and systolic thrill
Sometimes noted an aortic ejection “click”
Tets
Symptoms:
-Dyspnea on exertion
-Cyanosis, generally resolved with squatting or knees-to-chest
-Clubbing
-Systolic thrill
-Normal first sound, single second sound, ejection systolic murmur
Tets
Why does squatting help with cyanosis in Tets?
It reduces the R to L shunting of the blood
Narrowing of the aorta most commonly seen in Turners with S/S of HTN, increased WOB, anorexia, fainting, headaches, fatigue, poor peripheral pulses
Coarctation of the aorta
Fever for at least 5 days and:
-Changes in extremities (edema, erythema, desquamation)
-Polymorphous exanthema (truncal)
-Conjunctival injection
-Erythema and/or fissuring of lips and oral cavity
-Cervical lymphadenopathy
Kawasaki’s Disease
Symptoms:
-Rhinorrhea, cough, pulm infiltrate
-Murmur
-Diarrhea, vomiting, ab pain, hydrops of gallbladder, jaundice
-Myositis, arthralgia, arthritis
-Irritability, aseptic meningitis, facial palsy, hearing loss
Kawasaki’s disease
You have a patient that you suspect Kawasaki’s in, what is your next step?
Send to ED and refer to cardiology for management
Child who needs scholastic support and specialized settings for scholastic achievement need what kind of plan in school?
IEP
Child who needs no change to the curriculum but additional scholastic support needs what kind of plan in school?
504 Plan
When attempting to achieve behavior modification in a child, what is key in promoting this management?
Family involvement in behavior management promotes the most success
Fetal loss <20 weeks
or
Delivery of fetus < 500g
Spontaneous abortion (SA)
Uterine bleeding w/o cervical dilation or passage of tissue
Threatened SA
> /= 3 spontaneous pregnancy losses before week 20
Recurrent or habitual SA
Bleeding with cervical dilation without passage of tissue
Inevitable SA
IUFD without passage of tissue
Missed SA
Partial passage of fetal tissue through partially dilated cervix
Incomplete SA
When do most miscarriages occur?
80% in 1st trimester
In a patient with SA, who is primarily treating this?
OB
Opening or relaxing of the cervix prior to the time of delivery
Incompetent cervix
You are concerned you patient has an incompetent cervix, what is the next step?
Place on bedrest and refer to OB for management
Amenorrhea
Abnormal uterine bleeding
Abdominal, back, or pelvic pain
Hemodynamic changes
Concern for ectopic pregnancy
Ectopic pregnancy is treated by the PCP by:
referring to ED or OB for management
Excessive vomiting in pregnancy with noted tiredness, dizziness, dehydration, malnutrition, poor weight gain and acidosis
Hyperemesis gravidarum
How is HG treated?
Support dietary recommendations
Encourage fluid intake
Can try Vitamin B6, doxylamine, or anti-emetics
If signs of severe dehydration, refer to ED for IV fluids
At an initial prenatal visit you obtain labwork and discover your patient is Rh-. You test her husband who is Rh+. What would your concern be moving forward?
Rh Isoimmunization between mom and baby, would need RhoGAM at 28 weeks to prevent this
-Tightening of the entire uterus (may be felt in the back or low abdomen)
-Duration of contractions become progressively longer
-Contractions become stronger in intensity
-Contractions become closer together
-Contractions are regular
-Changing activity or position does not stop the contractions from occurring
-Walking may make contractions stronger
True labor
If you suspect your patient is in preterm labor, what is the next step?
Send to L&D at the hospital for management
What is the most accurate diagnostic to confirm PROM?
Postive ferning test
IUFD is most commonly caused by
Genetic/chromosomal abnormalities
If you have a patient that you suspect IUFD, what should you do?
Refer to OB and provide patient support
-History of C-section delivery
-PROM
-Frequent cervical examinations
-Internal fetal monitoring
-Preexisting pelvic infection
-Diabetes
-Poor nutrition status
-Obesity
Risk factors for PP complications
Most common infection PP:
Endometritis
Symptoms:
Fever
Soft/tender uterus
Endometritis
30 y/o F PP week 1 presents for 3 days of low grade fever, foul smelling lochia, and mild lower abdominal tenderness. She delivered a healthy baby boy at 38 weeks via C-section. On exam, her temp is 101F, lower abdominal tenderness to palpation with a soft uterus noted. You are concerned for endometritis. You prescribe her…
Doxycycline or Clindamycin
25 y/o F, G1P1, PP week 3 comes into the office for R breast tenderness. She has increased pain and erythema of the R breast with fever 101.2F at home (treated with Tylenol) and chills. When assessed, her R breast is hard, swollen with mild enlargement of her R axillary lymph nodes. You suspect what?
Mastitis
25 y/o F, G1P1, PP week 3 comes into the office for R breast tenderness. She has increased pain and erythema of the R breast with fever 101.2F at home (treated with Tylenol) and chills. When assessed, her R breast is hard, swollen with mild enlargement of her R axillary lymph nodes. How would you treat her?
Antibiotics
Warm packs
Encourage to continue breastfeeding on that side to open up the blocked duct
Most common VTE in PP:
Superficial venous thrombosis
Most common VTE in pregnancy:
DVT
Treatment of a DVT in pregnancy is with:
Heparin or Lovenox (low-molecular weight heparin)
Treatment of superficial venous thrombosis
Monitoring, Rest, NSAIDs (if PP, not in pregnancy), compression stockings, elevated legs
Goodell’s sign
Chadwick’s sign
Hegar’s sign
Leukorrhea
Breast enlargement
FHT
1st trimester signs of pregnancy
Fetal movements (18-20 weeks)
Striae (possibly)
Fundus palpable
Leopold’s maneuvers possible
2nd trimester pregnancy signs
Colostrum may begin to leak (28 weeks)
Lightening 3-4 weeks prior to labor
Loss of mucus plug
Braxton-Hicks contractions
3rd trimester pregnancy symptoms
31 y/o F presents to her PCP with CC: LMP 5 weeks ago. Pt has history of normal cycles varying from 21-28 days. She has mild breast tenderness, mild increase in vaginal discharge, no nausea. On exam you note a blue/purple coloration of the cervix. Your next step would be?
Urine hCG test for pregnancy in office
31 y/o F presents to her PCP with CC: LMP 5 weeks ago. Pt has history of normal cycles varying from 21-28 days. She has mild breast tenderness, mild increase in vaginal discharge, no nausea. On exam you note a blue/purple coloration of the cervix. Her urine hCG in office comes back positive. What is your next step?
Refer to OB
Crown-rump length is done for what purpose?
Gestational age
Who can complete genetic carrier testing?
Any women who would like it per ACOG
Nuchal translucency on ultrasound is concerning for:
Trisomy 21, 18, 13 or Turner’s syndrome
UA, Urine culture
CBC
ABO/Rh
Antibody screening
Rubella titer
HBsAg
Syphilis testing
HIV screen
PAP smear
Cervical cultures
1st trimester/initial prenatal testing
Triple or Quad screen (16-20 weeks)
Anatomy scan
1 hour OGTT
2nd trimester testing
Can you administer the polio vaccine in pregnancy?
Yes, it is safe in pregnancy
Varicella
MMR
Live virus vaccines, contraindicated in pregnancy
Flu
Hep B series
Can be given and encouraged during pregnancy (if not already immune for HBsAg)
What is the reasoning behind no soft cheese, unpasteurized milk products, undercooked meats, deli meat in pregnacy
Risk for listeria that can lead to miscarriage, newborn illness
If a pregnant women has a cat, what must she do in caring for her pet?
Do not clean the litter box due to toxoplasmosis and if this cannot be avoided, wear gloves and wash hands thoroughly
Is there a standard for weight gain for pregnant women?
No it is person dependent
0-27 weeks, prenatal appointments are:
Every 4 weeks
28-35 weeks, prenatal appointments are:
Every 2 weeks
36-40 weeks, prenatal appointments are:
Weekly
Past 40 weeks, prenatal appointments are:
2x/week
-Recurrent pregnancy loss/IUFD
-FH of genetic anomalies
-Rh sensitization
-Hemoglobinopathies
-Thrombocytopenia
-Multiple gestation
-Abnormal triple screen
-HIV
-Uterine bleeding
-Previous PTL/preterm delivery
-Polyhydramnios/oligohydramnios
-PROM
-IUGR
-GDM or diabetes in pregnancy
Refer for consult due to high risk
Bluish/purplish discoloration of the cervix and vagina d/t vascular congestion of the area
Chadwick’s sign
Softening and cyanosis of cervix also r/t increased vascularity
Goodell’s sign
Softening and widening of the isthmus area, resulting in compressibility of the isthmus on bimanual examination
Hegar’s sign
32 y/o G2P1 comes in c/o urinary frequency. She is 21 weeks. What would you do for her?
Rule out UTI, obtain urine sample and PVR if possible
RED FLAGS:
-Dark, cloudy urine
-Hematuria
-Dysuria
-Polydipsia, polyuria, polyphagia
-Acute onset fever >102.2F
-Flank pain
-CVA tenderness
-N/V
Red flags for pyelonephritis
33 y/o F, 18 weeks, G3P3 presents with fever 102.4F, back pain, dysuria, dark urine x1 day. She has tried Tylenol for fever with no effect. On exam you illicit CVA tenderness. Her urine dipstick is dark with positive trace protein. You’re concerned for pyelonephritis. What is your next step?
Refer to hospital for acute management with IVF and IV abx
22 y/o F, G1P0, 12 weeks pregnant comes to the office with complaints of intermittent N/V. She says it is mildly improving, but she thought it would be gone now that she is almost in her 2nd trimester. Her physical exam is normal, no signs of distress or dehydration. What is your management plan?
Encourage continued adequate dietary intake and fluid hydration
She can try Vitamin B6 + doxylamine (OTC)
24 y/o F, G1P0, 22 3/7 weeks, with known FH of HG comes in with continued N/V unresolved throughout her pregnancy. She has been to the ED 2x this pregnancy for dehydration. Today, she endorses feeling mildly better then prior. Her exam shows mildly prolonged skin turgor, poor weight gain in her pregnancy, and her urine is positive for ketones. What is your next step?
Send to ED for IVF
Your patient c/o poor sleep in their pregnancy. This is concerning to you because:
Poor sleep is linked with a pro-inflammatory states that can increase risk of gestational HTN and GDM
What effects on the fetus can poor sleep have?
Low birth weight, IUGR, PTL or birth, C-section delivery
If you need to treat depression in pregnancy with medications, what are the first line treatment options?
Sertraline and Fluoxetine
36 y/o F, G5P2, 13 weeks, comes in c/o central discoloring of her face. She is concerned because this did not happen in her prior pregnancies. She wants to know if this is normal. After assessing her, you establish this is melasma and educate on her what?
This is a cosmetic change in pregnancy that generally resolves PP. Try to stay out of the sun and wear sunscreen if in the sun to reduce darkening of this area.
16 y/o F, G1P0, 30 weeks comes in today concerned for her “ugly stretch marks”. She wants to know if there is anything to do to fix them. You inform her:
There is no cure, they will fade over time. Keeping the area moisturized with lotions or emollients may help with irritation and itching.
29 y/o F, G2P2, PP week 4 comes in for follow up today. She is concerned that she has been noticing a significant amount of hair loss when brushing her hair. She doesn’t remember this from her prior pregnancy and PP, but that was “all a blur”. She is wondering if this is normal. You inform her:
Hair loss PP is very common and can last up to 6 months with hair growth returning to pre-pregnancy volume by 1 year PP
33 y/o F, G1P0, 34 weeks comes in with new onset red, excoriated papules in her abdominal striae. She states they itch and she is confused as to why they aren’t near her belly button. On exam, she appears to have PUPP. What is your next step?
Treat her with antihistamines, topical steroids, or an anti-pruritic
27 y/o F, G1P0, 38 weeks pregnant with known vulvar varicosities comes c/o anxiety r/t her birth plan. She would like to have her baby as “naturally as possible”, but is concerned her vulvar varicosities will prevent this. Are vulvar varicosities a contraindication to vaginal birth?
No they are not
25 y/o F, G3P2, 20 weeks comes in for her routine visit. She is 5’2”, her partner is 6’0”. Her previous babies with AGA when born. On exam, you check her fundal height and she is measuring at 17 weeks. What is your next step?
Refer to OB for a biometric US and further workup
In a child older then 6y/o diagnosed with ADHD, what is the first line treatment?
Behavioral therapy
Which medication class is first line for ADHD?
Stimulants
For children not responsive to a stimulant, what are the non-stimulant alternatives?
Atomextine (Selective Noradrenergic Inhibitor)
Guanfacine or Clonidine (Central alpha2 agonist)
