NP619 Module 7 & 8

Question 1

Treatment of club feet

Answer 1

More common in boys
The cause is unknown
Serial casting is the treatment for 6-8 weeks with cast changes weekly
surgery possible between 3-18 months
OUR ROLE is to make sure that baby is growing and that someone is doing weight checks

Question 2

Metatarsus Adductus

Answer 2

can affect one or both feet
from position in utero
Ankle has full plantar and dorsiflexion
Do not x-ray
do not worry unless no resolution by 6 months

Question 3

Torticollis-Contracture of the sternocleidomastoid muscle

occur from position in birth canal, etc

Answer 3

Crook in the neck
What we consider after meningitis
TX: ROM, motrin, older children can maybe use some flexeril

Question 4

Subluxation of the elbow-Most common at ages 1-3

Answer 4

entrapment of the annular ligament
Dx by Hx: partial dislocation of the head of radius, arises from the sudden jerk or pull of a toddlers arm
Arm=motionless, slight flextion, pronation, adduction, radial head is tender

Question 5

Tx of the nursemaids elbow

Answer 5

Cup elbow
appl pressure over the radial head
thumb in the antecubital fossa
apply slight longitudinal traction by grasping the wrist
supinate (palm up) and flex (to 90 degrees) forearm
palpable click felt with reduction
child uses arm within 15 minutes
can use sling 1-2 days
if it does not work-do x-ray

Question 6

Scoliosis=lateral curve of 11 degrees or greater of spine

Answer 6

Long term consequences:
unpleasant deformities
back pain
social and psychological problems
limited job opportunities
Screening: inconclusive.  some states mandate! 
TX=bracing has limited effect.
maybe exercise, electrical stimulation and surgery if really severe

Question 7

Cobb angle

Answer 7

Used for scoliosis
Angle of 10 is minimum angulation to define scoliosis
Significant = 25-30 degrees
Severe=45-50 degrees

Question 8

Sport physicals

Answer 8

Who can participate
Used to meet legal and insurance requirements
counsel on health related issues
Do 6 weeks before pre-season
leading reasons for disqualifying from participation:rhythm and conduction abnormalities
systemic hypertension
valvular heart disease

Question 9

Sports

Answer 9

Red flags=asthma, mono, SOB w/exercise
palpitations
seizures
family hx of early heart disease
LOC
hx of fx. Strains, sprains, spec equipment

Question 10

Sports

Answer 10

ABSOLUTE NO=carditis
leading causes of sudden cardiac death are
hypertrophic cardiomyopathy, coronary artery anomalies, myocarditis, and aortic stenosis

Question 11

Pectus carinatum

Answer 11

The sternum is bowed
Usually does not present with problems
Cosmetic issues-may be fixed with surgery

Question 12

Pectus Excavatum

Answer 12

Funnel chest
1 in 500-1000
when moderate or severe it can cause abnormalities of the heart or lungs
can correct with surgery

Question 13

Osgood-Schlatter syndrome

Answer 13

Common in adolescents
(especially in athletes during growth spurts)
inflammation of anterior proximal tibial tuberosity PULL OF THE LARGE POWERFUL MUSCLWS IN THE FRONT OF THE THIGH
resolves in 6-12 months
knee looks normal but pain over patellar grooves no instability of the knee

Question 14

Genus varus-persistant bowing may be sign of underlying disruption of growth centers of the knee

Answer 14

Bowlegs
common in children under 2
By 2 they become knock kneed
be concerned if area between the knee is greater than 5-6 inches
Can be associated with Rickettes or Blount dx (early walking or obesity)

Question 15

Genus valgum (knock knees)

Answer 15

lateral angulation of the tibia relative to the femur in the coronal plane, persisting into adulthood
Normal in 30 month old and will generally show spontaneous correction
Excessive (5-6 inches between ankles) persisting in the older child 6-8 years old is abnormal
Tx = bracing

Question 16

Septic Arthritis=usually involves hip joint

Answer 16

source of infection can be anywhere
joint is hot, swollen, impaired mobility
complication=necrosis of femoral head
Dx features=younger than 3, HIGH fevers, ill appearing, refusing to walk

Question 17

Toxic or transient synovitis

Answer 17

limp associated with Upper respiratory dx
low grade fever
child refuses to walk, appears well, decreased internal rotation, normal WBC, ESR <25, blood culture, hip aspiration =neg, x-rays nge, ultrasound of hip = neg (more reliable in detecting fluid)
Tx: resolves in 3-7 days, give ibuprofen
complications 2% will develop Legg-Calve Perthes Disease
position for less pain

Question 18

Legg-Calve Perthes Disease

Answer 18

Develops over time
Usually 4-8 years old (white males)
DX= limp without hip pain, knee pain is referred, loss of internal rotation, loss of abduction, over all decreased ROM
x-ray shows flattening or deformity of femoral head leads to avascular necrosis
TX=decrease activity, surgery if severe
can lead to degenerative hip disease

Question 19

Salter-Harris System Criteria

Answer 19

Type I horizontal fracture through the physis
Type II Fx through the physis, extending into the metaphysis
Type III Fx throu the epiphysis, extending into the physis
Type IV Fx through the epiphysis, physis and metaphysis
Type V crush injury of the physis

Question 20

Salter-Harris

Answer 20

Greenstick=cortex broken on tension side but intact on compression side
Transverse=perpendicular to long axis of the bone
buckle=bone compression causes a buckle or bend rather than break
Spiral=zig-zag course around the bone
oblique=at an angle to long axis of the bone
comminuted=fx with 3 or more fragments

Question 21

RICEM

Answer 21

Rest
ice
compression
elevation
mobility

Question 22

Cerebral palsy

Answer 22

neurological brain disorder
life long condition
affects communication between brain and the muscles, causing permanent state of uncoordiated movement and posturing
result of an episode that cause lack of oxygen to the brain

Question 23

CP-establish and diagnose that motor deficits are static and nonprogressing (fine and gross motor skills not devleoping)
Can do an MRI or EEG

Answer 23

prenatal factors
infections, maternal anoxia, ABO incompatibility)
perinatal factors=anoxia, prolonged labor, resp. obstruction, and others stuff
POSTER: posturing, oropharyngeal problems, strabismus, tone, evolutional responses, reflexesCan be tx with BtA for spacisidy

Question 24

Muscular Dystrophy=genetic, x-linked autosomal recessive degeneration of muscles

Answer 24

babies=diminshed reflexes
flat affect
floppy
later they are clumsy, toe-walking
Need to look at their development

Question 25

MD-Creatinine Kinase is elevated

can do a muscle biopsy

Answer 25

Refer to Neuro
Referr to PT/OT
Refer to First Steps program

Question 26

Hip dysplasia=more common in girls

breech and familial

Answer 26

not sure when it displaces so must check FOR A FULL YEAR!!!!
If not caught it affects movility and abnormalities of the femoral head and the acetabelum
Get a plain frog leg view or ultrasound

Question 27

Ortolani= (click of entry) 90 degree hip abduction and feel if hip moves smoothly or do you feel a click or clunk
abduct the hips 90 with index finger palpate hip joint for clicks, clunks = dislocated femoral head reduced

Answer 27

Barlow=(click of exit) push down and see if you can put joint out of socket
one hip at a time-knee flexed and extended
Thigh back and out!!
Hips are adducted

Question 28

Ortolani and Barlow are used only 6-8 weeks

Answer 28

Galeazzi is noted with the observed discrepancy in knee heights when infant is supine. the sacrum is flat on the table and the knees and hips are bent

Question 29

Pavlik harness is used on infants

Answer 29

worn 3 mos by children 3 mos and younger
and older children 4 mos or older a period of double their age. Should be worn 23 hours a day
Traction or cast would be next.

Question 30

Refer to Ortho is clunk!!

Answer 30

Click may just be ligament

Question 31

Sports

Answer 31

Repetitive motion is the problem

Question 32

Craniosynostosis

Answer 32

The premature closing of suture lines
2 most common forms:
Scaphocephaly (boat head) long and narrow Sagittal suture fuses,
Most common. 54-58%
Brachycephaly is if the coronal sutures fuse too soon, the head is flattened. 18-29%

Question 33

Microcephaly - <2 standard deviations below norm
for age, gender and gestational
Premature closure of suture line
hypoxic encephalopathy
congenital infection

Answer 33

Macrocephaly>2 standard deviations above normal for age, gender and gestation
Hydrocephalis
enlarged ventricular system
megaencephaly-from metabolic conditions
97th percentile and higher

Question 34

Plagiocephaly-positional molding

occipital flattening

Answer 34

Ask if it was round at birth
teach parents to turn head
treat torticollis with stretching
orthotic device-helmet

Question 35

Meningitis- late winter, early spring

viral=summer and fall.

Answer 35

household or
close contacts (individuals who slept and ate in the same household with the
patient) and intimate nonhousehold contacts who have had mucosal exposure
to the patient’s secretions (such as a boyfriend or girlfriend). Individuals
who have had direct exposure to the patient’s secretions through
shared utensils or toothbrushes, kissing, and school/daycare contacts in
the prior seven days should receive chemoprophylaxis.four or more hours with the index case for 5-7 days before the illness

Question 36

meningitis types- Treat with Rifampin
Cipro or rocephin
rifampin
given in a 600 mg dose for adults, 10 mg/kg every dose for children older
than 1 month, 5 mg/kg every dose for neonates (age less than or equal to
30 days) orally every 12 hours for a total of four doses.

Answer 36

S. pneumoniae (47%), 
N meningitidis (25%),

Question 37

The article says

Answer 37

Close contact (for more than
eight hours) with someone with N. meningitidis infection
Contact with oral secretions of someone with N. meningitidis infection

Question 38

Kernig and Brudzinski signs

Answer 38

poorly sensitive but highly specific for bacterial meningitis.
K=patient supine flex knee and thigh to 90 degrees pain in the hamstring when leg is extended is a + sign
B=flex neck and reflex flexion of the hips is a + sign

Question 39

Meningitis in children-fever, petechial (nipple line & down) or purpural rash on trunk, legs, mucus membranes, flu-like symptoms, classic signs of HA, vomiting, photophobia, nuchal rigidity, full fontanel, poor feeding

Answer 39

A recent history of upper respiratory tract infection is common in children with bacterial meningitis; children are also more likely than adults to experience a seizure.12 The illness course varies, with progression over hours to several days.

Question 40

Suture lines close= 2-3 years
Anterior fontanel 15-18 mos
Posterior fontanel= 2 mos

Answer 40

Abuse-call CPS and police

ASK; who, what, where, when

Question 41

Primitive reflexes

Answer 41

Something wrong in the brain or CNS

Question 42

Shaken baby syndrome

Answer 42

Lethargy / decreased muscle tone
Extreme irritability
Decreased appetite, poor feeding or vomiting for no apparent reason
Grab-type bruises on arms or chest
No smiling or vocalization
Poor sucking or swallowing
Rigidity or posturing
 Difficulty breathing
 Seizures
 Head or forehead appears larger than usual or soft-spot on head appears to be bulging
 Inability to lift head
Inability of eyes to focus or track movement or unequal size of pupils

Question 43

`Closed head injuries

Answer 43

No LOC, minor head injury
normal mental status, no abnormal findings or focal findings on exam, including fundoscopic, no evidence of skull fx
THEN YOU CAN OBSERVE WITH NO CT/SKULL FILMS

Question 44

For LOC<1 minute and neg exam you can still observe or get a cranial CT scan. Skull films and MRI are not recommended

Answer 44

Helmets cut risk for head injury by 80% if worn properly

If worn wrong, then twice as likely to have a head injury

Question 45

Headaches

Answer 45

Tension-like a band around the head.
Migraine=pain, n/v, visual changes
common vs classic (aura)

Question 46

Brain tumors-Chronic recurrent headaches

Answer 46

worse on wakening
may improve with vomiting

Variables that predict a presence of a space-occupying lesion include:
HA of less than 1 month
absence of family hx of migraine
abnormal neurological findings on exam
gait abnormalities
occurrence of seizures

Question 47

Neuroimaging study on a routine basis is not recommended in children with recurrent headaches and a normal neurologic examination

Answer 47

Should only be considered with an abnormal neurologic exam or other physical findings that suggest CNS disease

Question 48

Treatment of migraines in children

Answer 48

>5 with features from below
lasts 1-72 hours
bilateral or uni (frontal or temporal)
pulsating
moderate to severe intensit
aggravated by routine physical activities
AND
n/v
photophobia

Question 49

Acetaminophen is probably effective

Answer 49

Children <6 ibuprofen is effective and acetaminophen
Work on triggers
Give antiemetic early for nausea
Child must be 12 for migraine triptans
A neurologist can give a triptan earlier if he wants.
You should refer for this if younger than 12

Question 50

Seizures

Answer 50

chronic that recur without any external disorder
REFER
Order lab tests based on historic or clinical findings such as vomiting dehydration, or failure to return to baseline alertness

Question 51

Consider toxicology if question of drug use or exposure

Answer 51

In the child with a NONFEBRILE first seizure, LP is of limited value. The EEG is recommended as part of the neurodiagnostic evaluation of the child with an apparent first unprovoked seizure.

Question 52

If a neuro-imaging study is obtained, MRI is the preferred modality.

Answer 52

Consider MRI with a signficant cognitive or motor impairment
unexplained abnormalities
a seizure of partial onset with or without secondary generalization
an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy
in children under 1 year of age

Question 53

Seiaures

Answer 53

medication is typically started after 2 unprovoked seizures
Involve neuro and peds
monotherapy is the gold standard
routine blood tests may actually lead to unnecessary changes and more problems in asymptomatic patients, BUT do if suspect toxicity
therapy maintained for two years of seizure free period and then d/c?

Question 54

Psuedo seizure vs true seizure

Answer 54

Psuedo=The EEG may be normal
Look for in children who have witnessed a seizure in another, who have seizures that occur in the same situations, does not decrease with anticonvulsants, and whose seizures appear “suggestable”
True -Seizure is like epilepsy. Brain activity depolarization of the neurons is widespread

Question 55

NPs and seizures

Answer 55

Discuss safety issues with the parents. Drowning, machinery, careful of being in high places,