General Flashcards
When should the mother expect milk to come in abunduntly?
3-5 days post delivery
Describe physiologic jaundice:
- why it happens
- when it’s mostly seen
- bilirubin levels
Physiologic jaundice:
- newborn’s liver is unable to process the RBC load from the birth experience, as this was previously the job of the placenta.
- most notable at 2-4 days. Gone by 2 weeks.
- indirect bilirubin: 12 or less
Describe pathologic jaundice
- why it happens
- when it occurs
Pathologic jaundice: AKA direct hyperbilirubinemia
- caused by sepsis, ABO incompatibility, toxoplasmosis, or occult hemorrhage
- appears at 24 hours of life
When should a clinician worry about jaundice?
1 Major risk factor + High Bhutani score
Known FHx of inherited disorder
Presentation varies widely from typical
Infant is not responding to phototherapy
What are the major risk factors of jaundice? (6)
- High bilirubin levels
- Jaundice within first 24 hours
- Gestational age 35-36 weeks
- Previous sibling treated with phototherapy
- Bruising
- Exclusive breastfeeding
Describe breast milk jaundice:
- when it occurs
- bilirubin levels
- how long it lasts
Breast milk jaundice: AKA indirect hyperbilirubinemia
- occurs after 7 days of life and peaks between 2-3 weeks of life
- indirect bilirubin: 15-17 or less
- lasts 1+ months
What child characteristics puts a child at risk for abuse?
- Prematurity
- Physical / developmental disabilities
- < 4 years old
What is the single most common presentation of child physical abuse?
Bruising
Bruises are rare in children of what age?
Less than 6 months as they are not mobile at this time.
“No cruise, no bruise”
What patterns of bruising in childhood are suggestive of abuse?
- away from bony prominences
- MC: head, neck, face (excluding forehead)
- buttocks, trunk (excluding spinous processes), arms
- large, multiple, and clustered
- patterned
What is the MC cause of death from abuse?
Head trauma due to a direct blow and/or shaking
A toddler presents with posterior rib fractures and no altered mental status. Does this warrant a head CT?
Yes – neurologically asymptomatic kids with rib fractures, multiple fractures, facial injury, and anyone less than 6 months of age with suspicious injury require a head CT/MRI.
Additionally, all patients with neurological symptoms and with concerns of child physical abuse require a head CT/MRI.
An 18 month old comes in with bruising and abdominal trauma. What is your next best step in management?
Skeletal survey.
All children <2 years of age with concerns of physical abuse require a skeletal survey.
Skeletal surveys have little value in those >5 yo.
Who needs screening for occult abdominal injury and when would you consider an abdominal CT?
Children less than 5 years old and suspected victim of physical abuse.
Screening test – AST and ALT
- if AST or ALT >80, obtain abdominal CT.
Drowning is the process of experiencing respiratory impairment through submersion or immersion. Describe the difference between submersion and immersion.
Submersion: airway under water
Immersion: significant amount of water enters oropharynx through splashing
Drowning has a higher chance of having a fatal outcome before coming to the hospital under what conditions?
No supervision
Age <2
Under water for >5 minutes or unknown
What are the best preventative methods one should utilize to prevent drowning?
Pool fencing - BEST
Life jackets
Swim lessons (1+ yo)
Supervision
Lifeguards
What are the most common scenarios of drowning by age group - babies, toddlers, teens?
Babies - bathtubs and buckets
Toddlers - swimming pools
Teens - freshwater
What is first line treatment for drowning?
Initiate CPR (respiratory first, then cardiac) at the scene, call EMS
Prioritize respiratory support
No need to stabilize C-spine
Under which drowning conditions would you observe a patient for 4-8 hours? What are you looking for in those 4-8 hours?
Conscious with no respiratory distress
Looking for:
- Cough, tachypnea
- Vomiting
- Mental status changes
In order for a child to be defined as having a febrile seizure, they must have what?
Be 6 months to 60 months (5 yo)
Have a temperature of >38 C (100 F)
No known intracranial, metabolic cause or history of afebrile convulsions
For a seizure to be defined as a simple febrile seizure, what characteristics must it have?
Lasts less than 15 min
Generalized tonic-clonic activity
No recurrence within 24hrs
No underlying neurologic disease
For a seizure to be defined as a complex febrile seizure, what characteristics must it have?
Last more than 15 mins
Focal
Recur within 24hrs
Associated with postictal neurological abnormalities
Under what conditions is a lumbar puncture warranted in those who have a simple febrile seizure?
If less than 6 months of age
If 6-12 months of age and immunizations are incomplete or unknown due to Hib or Strep. pneumo meningitis
If persistent lethargy (beyond typical post-ictal length), meningeal signs, or clinical suspicion
If a neonate has a fever, what diagnostic workup do you do? How would you treat?
Dx:
- CBC w/ diff
- U/A
- CSF
Tx: Ampicillin + Gentamycin until cultures are negative for 48 hours
When should you start checking BMI in office screenings?
2+ yo
What are the very toxic substances we worry about most for poisoning?
Prenatal vitamin supplements – due to iron content
Antidepressants – TCAs especially
Hydrocarbons – kerosene, lamp oils
What is considered a normal temperature in pediatrics?
96-100 F
At what age can you start introducing soft pureed foods once they sit with little support and have good head/neck control?
4-6 months
At what age can you introduce small soft pieces of foods that can be offered on a spoon or fork and they may start to self-feed with hands?
6-9 months
At what age can kids start eating a full variety of foods, may use a spoon or fork if food is on it, may try sippy cups or small open cups; small pieces of foods the rest of the family is eating?
9-12 months
At what age should the child be eating meals with families, small snacks in between, and transition to WHOLE milk and discontinue bottles/pacifiers?
12+ months
Define colic
An otherwise healthy 2-3 month old infant who seems to be in pain, cries for > 3 hours a day, for > 3 days a week, for > 3 weeks
Those with oppositional defiance disorder have a higher risk of what?
developing conduct disorder and suicide
Diagnostic criteria for oppositional defiant disorder includes what?
Must have at least four of the following and must last 6 months or longer with a negative impact on functioning:
- Angry and/or Irritable Mood
- Vindictive at least twice within past 6 months
- Argumentative and/or Defiant Behavior
- Often deliberately annoys others
- Often blames others for mistakes or misbehaviors
What screening tools are used to diagnose oppositional defiant disorder?
Conners and Vanderbilt screening tools (comorbid ADHD common)
A patient younger than 12 comes in presenting with oppositional defiant disorder. How would you treat them?
Cognitive behavioral therapy, peer group therapy, or family therapy.
Treat comorbid conditions.
Monitor for suicidal ideations.
Meds are NOT effective.
Which psych disorder is associated with developing antisocial disorder in adulthood?
Conduct Disorder
Diagnostic criteria for conduct disorder includes what?
3 of the criteria in past 12 months must be met + at least one criterion present in the past 6 months
- Aggression to People and Animals
- Destruction of Property
- Serious Violations of Rules - Often stays out at night despite parental prohibitions, beginning <13 years
- Deceitfulness or Theft
A patient comes in with conduct disorder. How would you treat them?
Cognitive behavioral therapy
Peer group therapy
Family therapy
Treat comorbid disorders
Monitor for suicidal ideation
Meds NOT effective
A patient comes in with breast engorgement. In your patient education, what do you tell the patient causes engorgement and how would you treat it?
Causes:
- Intrapartum fluids
- Increased blood flow
- Normal postpartum fluid shift
- Poor or infrequent feeding
Treatment:
- Breast massage
- Warmth before feeding & Cool compresses after feeding
- Brief period of expression prior to feeding to soften the areola and evert the nipple
- Reverse pressure softening
- Anti-inflammatories
A patient comes in with local tenderness and erythema on the L breast and a lump. She is afebrile. She notes that the pain radiates while she breastfeeds and complains of reduced milk supply. Upon further questioning, she notes that she has long sleep stretches overnight due to increased fatigue. What is the most likely diagnosis and how would you treat it?
Blocked Duct
Tx:
- WARMTH and massage
- FREQUENT BREAST EMPTYING
- Rest
- Change nursing positions
- Lecithin
Follow up if not resolved within 48 hrs
A patient comes in complaining of a white spot on her nipple. She notes it looks “creamy”. What is the most likely diagnosis and how would you treat it?
Bleb/Blocked nipple pore
Gentle compression
Keep the nipple well moisturized
Lecithin to prevent recurrent plugged ducts (1000 mg x4/day)
Steroid ointment to reduce inflammation (triamcinolone 0.1% Ointment, 3-4x/d)
F/U: Sterile de roofing if not resolved
A G1P1 patient comes in with fever, chills, and body aches 2 weeks postpartum. On PE, her R breast is red, swollen, hot, and tender to the touch. What is the most likely diagnosis and how would you treat it?
Mastitis
Breastmilk culture to r/o MRSA
Warm compresses, continue breastfeeding, & antibiotics
A patient comes in with mastitis for 2 months. What are you most concerned of it developing into and how would you treat it?
Abscess
Abscess tx:
- antibiotics
- drainage
Baby may continue to breastfeed/receive expressed milk so long as milk is not purulent
A G1P1 patient comes in complaining of itchy, chapped nipples that burn when breastfeeding. On PE, you notice fissures around the base of the nipple shaft. What is the most likely diagnosis and how would you treat it?
Candida
Topical nystatin ointment/clotrimazole
Oral Diflucan.
Clean everything that comes in contact with breasts, milk, baby’s mouth.
If you’re treating the mom or the infant, the other has to be treated.
A postpartum breastfeeding woman comes in complaining of her R nipple turning blue after breastfeeding or when she is exposed to cold temperatures. She notes associated pain, which lasts about 35 minutes. What is the most likely diagnosis, common causes, and how would you treat it?
Vasospam
Causes:
- poor latch/suck trauma
- baby biting
- autoimmune diseases: Reynauds or rheumatoid arthritis
Treatment:
- avoid the trauma, obvs
- Keep warm
A new mom comes in wanting to talk about breastfeeding. She asks about the benefits of breastfeeding compared to formula. In addition to talking about improved developmental outcomes and improved immune system of the baby, you also discuss reduced morbidity and mortality related to what?
SIDS & NEC
What can be accurately described as providing baby’s first immunization and how?
Colostrum - has high concentrations of antibodies, immune modulating factors, and anti-inflammatory substances.
This protects the infant while preparing the gut for mature milk feeding.
These protective factors function without causing inflammation or tissue damage in the baby.
How much milk is mom expected to produce and on what day?
Average production of 556-705 g/d on day 6 postpartum.
Onset of copious milk secretion: days 3-8 postpartum
What is/are the diagnostic criteria of gender dysphoria in prepubescent girls?
Dysphoria must be present for at least 6 months
Persistent and intense distress about being a girl, states desire to be a boy or insists is a boy
Assertion that she has or will grow a penis
Rejection of urination in a sitting position
Assertion that she does not want to grow breasts or menstruate
What is/are the diagnostic criteria of gender dysphoria in prepubescent boys?
Dysphoria must be present for a least 6 months
Persistent and intense distress about being a boy, states desire to be a girl or insists is a girl
Preoccupation with stereotypic female activities (cross-dressing or intense desire to participate in pass times of girls and rejection of stereotypical boy toys, games, and activities)
He will grow up to be a woman
His penis and testes are disgusting or will disappear
It would be better not to have a penis or testes
Antidote for Cyanide
Cyanide: sodium nitrite
Antidote for Iron
Iron: Deferoxamine
Antidote for Severe cyanosis
Severe cyanosis: Methylene blue 1%
Antidote for Acetaminophen
Acetaminophen: N-Acetylcysteine
Antidote for anticholinergics
Anticholinergics: Physostigmine
Antidote for Organophosphates
Organophosphates: Atropine or Pralidoxime
Antidote for Benzodiazepine
Benzodiazepine: Flumazenil
Antidote for Beta blockers
Beta Blockers: Glucagon
Antidote for TCAs
TCAs: NaHCO3
Antidote for Warfarin
Warfarin: Vitamin K
