Pediatrics: Block 1 Flashcards

1
Q

What two phases is the prenatal period divided into?

What period overlaps the Prenatal and Postnatal periods?

A

Embryonic- first 8wks
Fetal- after 8wks of gestation

Perinatal- 20-28wks of gestation through 1-4 weeks after birth

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2
Q

Define Perinatal Mortality

What are the two most common causes of it?

A

Fetal death between 20wks EGA through 28 day pos-delivery

Congenital abnormalities
Prematurity <37wks

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3
Q

What is the range for normal respiration for newborns?

What is the range for normal heart rates? What ranges are indicative of necessary interventions needed?

A

30-60/min

120-160
>100: routine care
60-99: ventilation
<60: ventilation and chest compressions

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4
Q

What is the correlation between pediatric age, HR, BP and R?

How many chest compression and compression/breath ratio during NRP?

A

As they get older HR and RR decreases, BP increases. “Adult-like” around 12 y/o

120bpm
3 compression : 1 respiration w/ two thumbs method (preferred) or two finger method

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5
Q

When placed supine on tables, what breathing position do babies take?

When administering O2 to newborns by blow by, how much is used?

A

Sniffing position

Blow by= 10L/min @ < 1/2” from face
BVM= sniffing position @ 40-60/min
Intubated= done if no chest rise/fall w/ BVM and allows for med delivery and preferred for transport

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6
Q

What is done for neonatal HOTN?

What drugs are given for HR?

What drugs are given for opioid use/abuse?

A

10mL/kg NS or LR

Epi 0.1-0.3mL/kg or 1 : 10,000 for IV/ETT for Asystole/Brady and unresponsive to O2

Narcan- narcotic/opioid reversal 0.1mg/kg IV/IM/ET

DONT if mom is addict/methadone, leads to withdrawal seizures
USE if mom received opioids/short term use during delivery

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7
Q

What type of issues are seen in Hemorrhagic Disease of Newborns?

A

Generalized echymosis
GI bleeds
Umbilical stump bleeding
Circumcision bleeding

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8
Q

If baby is bottle fed, what does the formula need to contain when 4-6mon of age is reached?

A

Fe- deficiency risk starts at 4mon,
Starting @6mon: 1mg/kg/day, max 15mg
Vit D- 400 IU/day for first days of life; deficiency= rickets, most common in first 2yrs of life

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9
Q

What are the results of rickets in babies?

A

Craniotabes- thin skull, fells like ping pong ball
Thickened wrists/ankles
Rachitic Rosary- costochondral junction enlargement
Enlarged anterior fontanelle/delayed closure
Bow leg/knock knees

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10
Q

During a newborn exam, what does an enlarged anterior fontanelle greater than 5cm suggests ? issue

Define Craniosynostosis

A

Hypothyroidism

Closed fontanelles

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11
Q

Define Leukocoria

During newborn exams, how would congenital heart d/os present?

A

White reflex in the eye
Can be cataract, retinoblastoma, chorioretinits, hyperplastic primary vitreous, retinopathy of prematurity

Systemic Sxs, murmur may not be heard

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12
Q

What are the negative, false result and positive screenings for pulse oximetry for newborn screening and what are the next steps?

A

All 3 done at 24hrs of life or shortly before discharge
95% or more on R hand/foot w/ 3% difference= negative screening, plan for discharge

90-94% and 3% or less difference= repeat screening in 1hr. If repeat results are in low range, repeat again in 1hr. 3 readings in this range need echo

<90% in R hand or foot= positive screening result, Echo

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13
Q
What do each of the following findings during a newborn exam indicate?
Weak pulse
Bounding pulse
Single second heart sound
Continuous harsh holosystolic murmur
Grade 3 or higher murmur
Hepatomegaly
A
Poor CO- aortic stenosis
High CO- PDA
Cyanotic HDz- truncus arteriosus, hypoplastic left heart
Pathologic
Pathologic
Pathologic
L HF
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14
Q

Newborn exam should show a soft and round abdomen, what does a scaphoid shape mean?

Define Barlow and Ortolani maneuvers

A

Diaphragm hernia

Hip dysplasia indicator test
Ortalani- clunk of hip relocating anteriorly

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15
Q

What are the risk factors of congenital hip dysplasia

How is it evaluated?

A

Female, FamHx, Breech, First born, Oligohydramnios, Post natal swaddling

US suspicious findings or risk factors @ 4-6wks old

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16
Q
When are the following reflexes gone by
Fencer/Asymmetric neck reflex
Trunk Incurvature/Galant
Placing
Rooting- turns cheek to stimulus
Moro
Grasp
Babinski
A
3mon
4mon
4-6mon
4-6mon
6mon
6mon
12-28mon
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17
Q

Define Caput Succedaneum

Define Cephalohematoma

A

Common boggy edematous swelling of scalp that crosses suture lines and resolved in 3 days

Less common swelling that doesn’t cross suture lines and resolves in wks/mon but can lead to jaundice

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18
Q

Define Subgaleal Hemorrhage

A

Rare subaponeurotic bleeding result of vacuum delivery that crosses suture lines and pushes ears anteriorly and increases risk of jandice; Tx by compression and resuscitation

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19
Q

Define Epstein Pearls

Define Vernix Caseosa

A

Keratin cysts, resolve in first weeks
Salivary tissue- Bohn nodules

Chalky white/gray mixture of epithelial cells, sebum, keratin and hair
Common in pre-terms
Thought to be protective/lubricant in womb

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20
Q

Define Milia

Define Milia Rubra

A

White smooth papules on face/scalp from epidermal occlusion of pores
Self limited and resolving

Overheated/febrile heat rash as erythematous papules
Tx by correcting over heating

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21
Q

Define Mongolian Spot

Define Cafe Au Lait Macules

A

Blue/black pigments on lower back/butt in AfAm/Asian/Indian infants that fades in life
Must be documented

Sharply defined oval macules/patches
6cm or larger Cafe or 5cm or larger diameter need further eval of neurofibromatosis, tuberous sclerosis, McCune-Albright Syndrome

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22
Q

Define Nevus Simplex

Define Nevus Flameus

A

AKA Salmon Patch
Stork bite- nape of neck
Angel kiss- forehead/eyelid
Transient and benign

Port wine stain from malformed capillary bed
Must consider Sturge-Weber Syndrome on face (trigeminal nerve distribution)

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23
Q

Define Erythema Toxicum Neonatorum

Define Neonatal Acne

A

Pustules w/ erythematous base appearing on back and trunk 24-48hrs after birth that lab results will show eosinophils and resolves in 2wks

Acne on cheeks/scalps in first few weeks of life from maternal estrogen

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24
Q

Define Cutis Marmorata

Define Cradle Cap

A

Mottling
Physiologic response to cold, resolves w/ warmth that decreases w/ age
If persistent: hypothyroid, vascular/congenital issue

Seborrheic Dermatitis
First sign of atopic dermatitis
Can treat resistant/persistant cases w/ mineral oil, white petrolatum emollient or medicated shampoo

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25
Define Umbilical Granuloma
``` Red papule from umbilical stumps and resolved w/ silver nitrate Distinguish from: Urachus- urinary d/c Meckels Vitelline Duct Talc granulomas ```
26
Define Metatarsus Adductus
Most common foot disorder in infants Medial deviation of mid and forefoot, can lead to hip dysplasia Dx- mid-heel bisector line should go between toe 2 and 3; V-finger should not gap at 5th MT Tx- most spontaneous, serial casting, bracing, surgery
27
Define Talipes Equinovarus
``` Clubfoot, Limp Hypoplasia Calf atrophy and foot shortening, half are bilateral Congenital- 75% of cases Teratological- myelomeningocele Positional from in utero Tx w/ serial cast or surgery ```
28
Define Spina Bifida
Lumbosacral neural tube defect, Cleft Spine Dx during 2nd trimester from maternal AFP and US Rachischisis- hair tuft Meningocele- meninges through neural arch Meningomyelocele- meninges and cord through arch Myeloschisis- open skin, cord exposed
29
How can spina bifida be prevented during pregnancy? Facial pasly after birth is indicative of ?
Folate Forcep delivery
30
Define Erb-Duchenne Palso
``` C5-6 and Phrenic nerve lesion + Grasp reflex - Bicep reflex Waiter tip palsy From difficulty delivery- shoulder dystocia Resolves w/ PT and observation ```
31
Define Klumpke's Palsy
``` C8-T1 lesion - Grasp reflex + bicep reflex Claw hand Ipsilateral Horner's Syndrome ```
32
What are the two types of hydrocephalus
Communicating- w/ subarachnoid Non-communicating- obstructed Tx w/ Ventriculoperitoneal shunt
33
What are the risk factors of neonatal sepsis
``` Prematurity- 6x greater Prolonged membrane rupture GBS Maternal fever Amnionitis Fetal tachycardia ```
34
What are the common etiologies of early onset neonatal sepsis What are the causes of late onset?
GBS, E Coli, Klebsiella, Listeria M., Salmonella, Mycoplasma H Influenzae, Staph, HSV, CMV, Enterovirus, S Pneumo, N. Meningitis
35
What is early onset neonatal sepsis What is late onset?
0-7 days old; fast onset and quick progression to severe Sxs: fever, hypothermia, HOTN, Resp Distress 8-28 days old; isidious onset w/ fever, poor feeding, lethargy, bulging fontanelle, poor muscle tone, seizures, direct hyperbilirubinemia; more likely associated w/ meningitis
36
What labs are ordered to evaluate neonatal sepsis?
CBC, Cultures x 2, UA, Urine culture, Blood glucose CXR LP for culture, stain, protein and glucose
37
How is neonatal sepsis treated?
``` IV Ampicillin and Gentamicin or; Ampicillin and Cefotaxamine Draw labs and continue until: - culture results Sepsis confirmed- 14 day Tx Meningitis confirmed= 21 days Tx ```
38
What two ABX can be added to neonatal sepsis treatment
Vancomycin- if late onset of miningitis is present Acyclovir- concern for HSV infection Support- IV fluid, nutrition
39
What are the 3 steps for GBS treatment of the mother?
1- infant Sxs; yes= full eval and empiric Tx 2- child <35wks EGA; yes= limited eval and 48hr observation 3- mother receive 2 ABX doses prior to delivery; yes= no eval or therapy, observe 48hrs
40
RDS is AKA and is what issue?
``` Hyaline Membraine Dz Insufficient surfactant production by Type 2 Pneumatocytes Commonly seen <34 wks EGA Ends w/ End-Expiration Atelectasis CXR shows bilateral ground glass ```
41
How can RDS be prevented prior to birth? How is it treated after birth?
Steroids at 32-34wks Intubation and respiratory support by artificial surfactants via ET tube
42
# Define PDA and what type of issue is it How is it treated?
L to R shunting from high to low press that becomes apparent 2-4 days of life but can result in HF, pulmonary edema or hepatomegaly Fluid restriction and diuretics Indomethacin or Ibuprofen
43
What causes Bronchopulmonary Dysplasis and how is it treated?
``` O2 toxicity/barotrauma Presents as required O2, Poor Growth, Hypercapnea, PHTN, R HF Inc risk in those who: O2 dependence at 36wks RDS fails to improve after 2wks Prolonged mechanical ventilation ```
44
What causes Retinopathy of Prematurity
Acute and Chronic effects of O2 toxicity | Leads to neovascularization, retinal detachments or fibrous proliferation behind lens
45
What are the 2 types and causes of Premature Apnea How is it treated
Central- medulla and pons don't stimulate phrenic nerve (majority but usually has peripheral component too) Peripheal- airway obstruction O2, Caffeine/Theophylline, Anemia Tx
46
Define Tracheomalacia
Weak/floppy tracheal cartilages Worsens: cry, cough, feed or URIs Possible high pitch/rattling noise
47
What 4 issues can develop into Meconium Aspiration Syndrome What delivery airway interventions are done?
Respiratory distress, Pneumonia, Pneumonitis, Pneumothorax Nonvigorous child= intubate and suction Vigorous- no routine intubation or suction
48
How does MAS look on CXR?
Coarse irregular infiltrates | Predisposed to chemical/bacterial pneumonia and pneumothorax
49
What causes Transient Tachypnea of Newborns?
Retained amniotic fluid causing mild hypoxia and resolves in 24hrs CXR shows fluid in fissures More common in C-Section or LGA infants since they don't get squeezed during delivery
50
What are the two types of PHTN
Primary- hypoxia w/out cardiac/pulmonary dz; normal CXR; inherited/autoimmune, drugs Non-Primary- result of other process PFO, PDA
51
What is the most common cause of neonatal anemia What test is done to assess anemia from maternal-fetal hemorrhage?
ABO incompatibility Kleihauer-Betke test
52
What is the most common cause of neonatal jaundice? Define Breastfeeding Jaundice Define Breast Milk Jaundice
Hemolytic Dz of newborns Insufficient milk production/ingestion Unknown milk factor that inhibits bilirubin conjugation or enzyme that enhances bilirubin absorption
53
Characteristics of Physiologic Pattern Jaundice Characteristics of Pathologic Patter
Evidence of jaundice starting when Bili levels get to 5-10; starts on face and moved to trunk, concerning if past umbilicus Term= 12 or less on day 3 Pre= 15 or less on day 5 Early /fast, >13mg/dl on day 1 (always pathologic), jaundice set in within 24hrs Hepatosplenomegaly and Anemia Inc of >0.5mg/dl/hr, onset within first 24hrs and peak over 12= abnormal
54
What can cause Physiologic Jaundice
``` Insufficient UDPGT activity= no conjugation Insufficient intestine bacteria Dec intestine motility Altitude- +3100m Race- Asian, Greek Premature Breast feeding ```
55
What causes Breast Milk Jaundice
Adequate intake Fatty acids displace bilirubin from albumin (unconjugates) Factor enhances intestinal bilirubin Occurs 7-10 days after birth Unconjugated hyperbilirubinemia w/out hemolysis Bilirubin rarely rises above 20mg/dL
56
What labs are ordered for Neonatal Jaundice
``` Total bili CBC, Blood type Coombs- tests for Abs on RBCs Peripheral smear Retic count Test G6PD deficiency ```
57
Define Kernicterus
Bilirubin Encephalopathy Lipid solube, unconjugated indirect bilirubin that accumulate and are CNS toxic Usually does NOT develop in term infants but are predisposed if other issues are present
58
How does Kernicterus manifest clinically
Early: Lethargy, Hypotonia, Irritable, Poor Moro response, Poor feeding, High pitch cry usually seen on day 4 of life Late: bulging fontanelle, opisthotonic posturing, pulmonary hemorrhage, fever, hypertonicicty, paralysis of upward gaze, seizure
59
How are different severity of neonatal jaudince treated?
Mild- lifestyle changes, increase feeding, sunlight Moderate- phototherapy Severe- transfusion (indirect Bili @ 20 in infants w/ hemolysis and weight +2000g; indirect Bili >25 in ASx infants w/ physiologic or breast milk jaundice
60
What are the adverse effects of neonatal phototherapy?
Short: Diarrhea, interfered bonding, intestinal hypomotility, temp instability Long: Childhood asthma, Type 1 DM
61
What are the timing intervals for jaundice evaluation of healthy term neonates post-hospital discharge
Discharged before: 24= 72hrs 24-47.9= 96hrs 48-72= 120hrs
62
What are the age ranges for Neonate, Infant, Toddler, Pre-Schooler, Child, and Adolescent?
``` N 0-28 days I 29-1y T 1-3y P 2-5y C 1-12y A 13-18y ```
63
What are the criteria for underweight, normal, overweight and obese
Under= <5th percentile Normal= 5-85th Over= 85-95th Obese- >95th
64
During childhood, what part of growth typically doesn't cross percentile lines? When does sigmoid shaped growth occur?
Height Adolescence, accounts for 15% of adult height
65
How does weight change from day of birth to first year of life
5-10% of birth weight lost in first few days Return to weight by day 14 Double 4-5mon Triple- 1yr Daily gain- 20-30g first 3-4mon; 15-20g for rest of first year
66
Average baby length is _in at birth and _in by 1st year and _in by 4yrs What is the average head circumference
20, 30; double birth length or 40in 35cm at birth Inc 1cm/mon for first year; 2cm/mon for first 3mon then dec
67
How long are head circumference serial measurements taken? When do abnormal growth patterns require action to be taken?
Until 2yrs old Infant <5% w/ no obvious cause Infant crosses two percentiles or major channels w/out cause Large discrepancy between head circumference, height, weight
68
In general, half of a child's growth occurs during ? Babies that are small for gestational age or are premature do catch up growth when?
First 2yrs of life and usually remains in the same channel First 6mon
69
What is the mid parental method of height prediction equations? What is the 2 year x 2 method equation: What is the most accurate method
Male: Dad + Mon/2 + 2.5 Female: same but -2.5 Inches at 2 x 2 Bone age- xray of hand
70
What are the 5 developmental areas assessed during ASQs? When is DDST-II used?
Communication, Gross motor, Fine motor, Problem solving, Personal-Social 0-6yrs, assesses 4 areas: Personal-Social, Fine motor-adaptive, Language, Gross motor
71
What is the M-CHAT
Modified Checklist for Autism in Toddlers Autism Screening done at 18-24mon that checks 23 behaviors >2 predictive or >3 total behaviors require additional assessment
72
What milestones are seen at 2wks old?
Gross motor: moves head side to side Personal social: regards face Language: alerts to bell
73
What milestones are seen at 2mon old?
Gross motor: lifts shoulder when prone Fine motor: tracks past midline Personal social: smiles responsively Language: cooing, searches w/ eyes
74
What milestones are seen at 4mon old?
Gross motor: lifts up on hands, rolls f-to-b, no head lag Fine motor: reaches, raking grasping Personal social: looks at hands, works towards toys Language: laughs and squeals
75
What milestones are seen at 6mon?
Gross motor: sits alone Fine motor: transfers objects in hands Personal social: feeds self, Language: babbles
76
What milestones are seen at 9mon?
Gross motor: pulls to stand, seating postion Fine motor: pincer grab, bangs blocks together Personal social: waves by, plays patty cake Language: says non-specific two syllable words
77
What milestones are seen at 12mon?
Gross motor: walks, stoops and stands Fine motor: puts blocks into cups Personal social: drinks from cups, initiates others Language: says mom/dad and one/two other words
78
What milestones are seen at 15mon?
Gross motor: walks backwards Fine motor: scribbles, stacks blocks Personal social: uses spoon/fork, helps in housework Language: says 3-6 words, follows commands
79
What milestones are seen at 18mon?
Gross motor: runs Fine motor: kicks ball, stacks 4 blocks Personal social: removes clothes, feeds dolls Language: says 6 words
80
What milestones are seen at 24mon?
``` Gross motor: goes up and down stairs Fine motor: stacks 6 blocks Personal social: washes/dries hands Language: puts two words together Other cognitive: understands concept of 'today' ```
81
What are the red flags of gross motors are concerning if seen at certain time frames?
Rolling prior to 3mon= increased tone Poor head control by 5mon= hypotonia Lack of sitting by 7mon= hypotonia Hand dominance before 18mon= contralateral neuromotor abnormality
82
What are the red flags of language development?
``` 1st think hearing Failure to vary voice pitch by 4mon Lack of babble/localizing sound by 6mon No true words/gestures by 15mon No protodeclarative pointing by 18mon Less that 50% intelligible speech by 2yrs ```
83
All kids with speech delay get what series of exams? Visual exams are performed at every visit until what age?
Tympanometry, Audiometry- Auditory Brain Stem Response to r/o peripheral hearing loss 2y/o
84
When do general exams occur in peds lives? Normal development should show what type of BP by 3yrs old?
3-5 days, 2wks Mon= 2 4 6 9 12 1 5 18 24 then annual ``` SBP= 80 + (age x 2) DBP= 2/3 of SBP ```
85
What is one growth marker/assessment that is conducted at every appointment? What screening tests are performed on kids?
Obesity Metabolic, Hgb Electrophoresis, Hearing eval
86
When are anemia screenings conducted? How much lead does it take to cause learning issues?
12mon if healthy, 4mons if at high risk 5-10 ug/dL, screened at 12 and 24mon Screening questions from 6mon-6yrs, may be required prior to starting Kindergarten
87
When is TB screening conducted? When are kids lipid panels assessed?
After 12mon 9-11yrs and 17-21yrs If parents have Cholesterol >240 or premature CAD, start at 2y/o Normal total cholesterol <170
88
How often are STI screenings done and what is tested for? When are Paps and HPV done?
Annually after any form of intercourse G/C, syphilis, Hep B and HIV 21y/o
89
# Define Active Immunity Define Passive Immunity
Induces immunity from vaccine/toxoid (inactivated toxin) Induces transplacental transfer of maternal Abs and administration of Ab (immunoglobulin or monoclonal Ab)- breast feeding
90
How often are premature babies vaccinated?
Regardless of weight, same chronologic age/schedule as full term kids ONE exception- Hep B for <2000g; if mother is Hep B surgace Ag negative then give at 1mon instead of birth
91
When are adolescents given vaccines? Which vaccine has mercury and why is it of concern?
11-12yrs of age w/ completion of series by 13-18yrs N Meningitides booster at 16yrs Thimerosal- trace amounts found in flu vaccine but was banned in 2001 and autism cases have increased
92
What is the Hep B series
3 doses, 1st dose at birth/within 24hrs | Exception, underweight <2000gm
93
What is the DTap Series
5 doses given at 2 4 6 and 15-18mon and 4-6yrs old | 1 adult dose at 11-12y/o
94
What does the HIB series prevent? What was the IPV series discontinued?
Reduces risk of meningitis and epiglottis Only known cases of vax-induced polio in US
95
What is MMR given? When is MCV4 (Menactra) given?
Mumps- resurgence in adolescents Rubella- prevent fetal malformation Measles- from overseas Meningococcal, given 11-2y/o or prior to college Consider at 2-10 if splenc disfunction/immunocompromised
96
When is Hep A given? How old do kids need to be before influenza vaccine is given?
2 shots between 1-2yrs 6mons or more
97
What does Prevnar vaccine prevent? Why is Varicella used?
Pneumoccocal Secondary cellulitis and pneumonia, reduces shingles
98
When is the HPV series given? Facts of Rotavirus
9-26y/o Given prior to exposure, protects 75% from cervical CA and 90% of genital warts Live attentuated cow rotavirus; first dose MUST be at 15wks, final dose NLT 8mon
99
When are vaccines contraindicated? Which vaccines are 'live" vaccines?
Anaphylaxis No live vaccines in immunocompromised or pregnant PTs MMR, Rota, Smallpox, Varicella/Chicken Pox, Yellow fever and Nasal influenza
100
What are the basic guidelines for doing Peds exams when they're from birth to 6mon? What about 6-36mon? 36mon and older?
No stranger fear, easily comforted by parents, easily distracted Fearful of adults/strangers Harder to restrain Moody Less fear, more interaction
101
What recommendations are offered to providers when examining Peds that may be difficult? How long are kids recommended to sit in car seats?
Sit at distance, observe interaction w/ parents, start w/ heart/lungs and save ears/mouth for last Until 2yrs or reach weight/height limit of seat
102
How long are kids recommended to sit in booster seats? Define SIDS
Until 4' 9" and 8-12yrs <13 should be in back seat and w/ seat belts Unexpected death of infant under 1y/o after autopsy, investigation and review of clinical Hx- Dx of Exclusion
103
What are the stats associated w/ SIDS? What position do babies sleep in and what can be offered that are beneficial
3rd leading cause of infant death in US, most common cause of death in ages 1mon-1yr On back, Pacifier
104
Kids exposed to tobacco smoke are at risk for ? How does tobacco cessation rank among quitting?
LBW, SIDS, Respiratory illness, Otitis media, Asthma Harder than alcohol, heroin or cocaine
105
Define Plagiocephaly
Asymmetric head shape Risks: first born, premature, limited tummy time, no position changes during sleep If normal= no x-ray, improves in 2-3mon Tx: supervised tummy time, treat torticollis If unresolved after 4-6mon, refer
106
What predicts adult stature and some health outcomes for Peds? What are the major risk periods for growth stunting?
Nutrition and growth in first 3 yrs 4-24mon
107
Mothers taking anti-thyroid drugs are recommended to take ? ones if breast feeding? What pediatric issues are contraindications of breast feeding? Pumped breast milk needs to be refrigerated and used with ? hrs
Propylithiouracil preferred over methimazole Galactosemia, PKU 48hrs or frozen and stored for up to 6mon Once thawed, use in 24hrs NEVER microwave
108
What type of formula is used when absorption/digestion is a medical problem? If kids are allergic to cows milk they may also be allergic to ?
Casein Hydrolysate Protein in soy formula
109
Why are no formulation substitutions before 12mon old recommended? What are the criteria of peanut/food allergy?
Scurvy, anemia or nutritional deficits ``` 1= severe eczema, egg allergy or both, earliest attempt at 4-6mon 2= mild/mod, attempt at 6mon 3= no eczema or allergy, attempt as age appropriate ```
110
Limit cow milk intake in toddlers to what amount? What is defined as child obesity?
<24oz/day, can reduce intake of food diversity 95th percentile or higher
111
Fluffy kids don't need to be on diets before what age When are mother's screened for post-partum
3yrs Edinburgh Post natal scale for 1st 6mon; increase activity, decrease sedentary life
112
How much TV/day? When should toilet training occur? Home water heaters should max out at what temp?
Nothing before 2yrs, no more than 2hrs/day Between 2-3y/o 120*
113
If kids have delayed teeth eruption, what needs to be checked? When do permanent teeth show?
``` TSH and Ca (hypo thyroid, hypo pituitary, rickets) Osteoporosis Gaucher Dz Down Syndrome Celidocranial dysplasia ``` Begin 6yrs, end 12yrs 3rd molar @ 18y/o
114
Sequence of primary teeth eruption
Slide 98 Lect 2
115
How is infant oral hygience accomplished Don't use fluoride toothpaste before what age? When are dental visits started?
Rubbing gums w/ wet washcloth/infant toothbrush 2y/o, community water w/ 2ppm is effective 1y/o, cleanings q6mon
116
What are the most psychological damaging comments parents can make to kids? What kinds of disciplines threats are appropriate
Leave/give up kids Mild loss of privileges
117
# Define Extinction discipline How much time out is used?
Eliminates frequent/annoying and harmless behavior through ignoring the kids actions One minute per year of life
118
What is the definition of FTT
Weight <3rd percentile Weight decreases, crosses two major percentile lines Weight <80% of median weight for height
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What are the 3 types of FTT
Wasting- deficient weight gain from malnutrition Shunting- deficiency in linear growth but head circumference is spared Symmetric- proportional weight, height and head from long malnutrition, chromosome abnormalities, infections/exposures
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What is the cause of FTT What do patterns of FTT mean?
Insufficient usable nutrition at the cell level Dec weight after certain age= infection, endocrine, environment Body asymmetry= epiphyseal, chromosome issue
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If a Peds PT is hospitalized for FTT, what results can be seen and what do they mean?
Feeds fine/gains weight= poor home feeding Feeds normal, doesn't gain weight= malabsorption, endocrine, metabolic dz Infants that feed poorly in hospital= neuromuscluar, poor intake or frequent regurg
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What Hx ?s are asked during a FTT issue? What are the parts of a FTT physical?
Hx on prenatal, birth, medical, family, nutritional/stool and social VS, Ht, Wt, HC Impression Full head to toe exam
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What labs are ordered in FTT visit? How is premature FTT weight calculated?
CBC, Fe, UA w/ culture, Serum E+, PPD, LFTs, HIV, Stool culture, lead and TSH Adjusted until 24mon HT correction until 40mon HC correction until 18mon Birth age - # of wks premature
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Bone age > chronological age is seen in ? issues Bone < chronological age can mean ? If bone age = chronological age and no other abnormal findings are seen then ?
CAH, Premature adrenarche, excess sex steroids, overweight insufficient GH, hypo thyroid or constitutional growth delay Probably hereditary short stature
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How is FTT treated? When are FTT PTs admitted for in patient care?
Increase calorie/protein intake by >1.5x Severe, underlying Dx requiring hospitalization, safety is jeopardized or failed out patient
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Why does Refeeding Sydrome cause death?
New food sitmulates glycogen/fat/protein synthesis which requires E+ that are already depleted leading to deficiencies: Loss of fluid/E+ homeostasis causing loss of phosphorous, Mg, and K and causing fluid retention leading to cardiac, pulmonary and neurological p
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What type of genetic issues are most common at birth? What are examples of autosomal dominant inheritance issues
Multifactorial defect Achodroplasia, Neurofibromatosis, Huntington,s Marfans, Polycystic Kidney
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What are examples of autosomal recessive Dzs? What are X-linked issues?
CF, PKU, CAH, SS, Fragile X, Muscular Dystrophy, Hemophilia A, G6PD, Color blindness
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Autosomal dominant= ? Autosomal recessive= ?
Hetero or homozygous expression from one gene, both sexes equally effected Homozygous expression from two genes, usually born to unaffected parents
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X chromo carries ? genes while Y carries ? genes
X= 500 Y= 50 Males more common, all daughters of affected males will be affected, no father-son transmission and may skip genes
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# Define Genotype Define Phenotype
Type of genes Physical characteristics
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``` These AKAs are for ? Dz Trisomy 21 Excessive base repeats 45XO 47XXY Autosomal dominant CT d/o ```
``` Downs- mongoloid previous term no longer used Fragile X Turner Klinefelter Marfan ```
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Facts of Downs Syndrome
Method of inheritance= Increased risk w/ maternal age and parents genetics (maternal nondisjunction) All kids need genetic studies, if translocation is present= parents need screening
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What are the 3 types of TS21?
3 copies- mos common, from maternal nondisjunction Translocation- carrier state w/ higher baseline maternal nondisjunction rate Mosaicism- phenotypically normal
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What is the take away from Down's maternal age and incidence?
Incidence higher in older women | Downs kids are born more commonly to younger women due to more births
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What are the phenotypical features of Downs
``` Hypotonia, decreased Moro reflex Small head Up slanting fissures- opening between eye lids Epicanthal folds Midface hypoplasia Dyspastic pinna- small ears Macroglossia ```
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What are the phenotypical features of Down's extremities
Single palmar crease- don't use term 'simian" Shortened 5th finger Widened firs toe space Shortened/stubby fingers
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What medical conditions are Down's PTs more susceptible to?
``` Development delay Hearing/eye loss GI/Cardiac abnormalities- ASD, VSD, Eisenmengers Hypothyroidism- life long issue Polycythemia Leukemia ```
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What types of hearing losses do Down's suffer from?
Sensorinueral- issues w/ CN8 Conductive from dysplasia of ossicles and scarring from ear infections Hearing screening q6mon until 3y/o then annual
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What eye defects are seen in Down's
``` Ophthalmology exam by 6mon Brushfield spots- white/gray spots on periphery of iris Cataracts Ectopic lens Refractice errors Strabismus- cross eyed ```
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What is the first Sx to be seen suggesting Down's PT is suffering from R sided HF? What is the 'double bubble' sign seen in these PTs?
Clubbing, cyanosis in lips Echo done routinely Esophageal/duodenal atresia
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What type of cervical issues do Down's have? What labs are drawn/tested annually?
Atlantoaxial instability C-spine x-ray by 3-5y/o TSH, CBC, Celiac
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Fetal alcohol syndrome is the severe manifestation of ?
Fetal Alcohol Spectrum D/o
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What is the most common cause of preventable development and intellectual delays? Kids living in what 3 areas are more susceptible?
FASDs Poverty, American Indian, Foster care
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What are the common physical characteristics of FAS? What are the less common features
Short palpebral fissures Smooth philtrum Thin upper lip Rail road track ears Ptosis Microcephaly Epicanthal folds
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What extremity, cardiac and developmental abnormalities are seen in FAS PTs?
Clinodactyly Hockey stick crease VSD, ASD Retardation, fine motor delay, ADHD
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Mothers are referred to therapy to prevent FAS if how much is consumed? FAS Tx is a multi-specialty team effort including?
>7 drinks/wk Multiple periods of >3 drinks/wk ADHD, Anxiety, Speech, SpecEd
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What chromosomal issue causes Fragile X Syndrome What neurological problems appear?
Excess CGG base triplet repeats at 5' end of FMR1 gene on the X chromosome Hyper arousal/anxiety Epilepsy Autism spectrum d/o
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What physical attributes are related w/ Fragile X How is it officially Dx?
Large head, oblong face Macro-orchidism Joint laxity Hypotonia DNA amplification w/ direct analysis
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How is Fragile X treated?
Genetic counseling, Spec Ed Autism eval Neuro referral
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What are the 3 variants of Turner Syndrome
50% lack X 25% have abnormal X 25% are mosaic Phenotypic female w/ absent/dysfunctional X chromosome
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What mental development issue and increase is seen in Turner's? What cardiac issues are seen?
Normal development, poor visual/spacial skills Superior verbal skills Coarctation, bicuspid aorta, early HTN
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What endocrine issues are seen in Turners How is Turners Dx
Amenorrhea/infertile Hypo thyroid DM Type 1 Osteoporosis ``` Direct Karyotyping Barr body (inactive X chrom) analysis not recommended due to high % of mosaics ```
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How is Turner's treated? What labs are tested annually?
Cardio consult at Dx for Echo, MRI and ECG Endo referral for GH Start estrogen replacement at 14y/o TSH, Chem 7, UA
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What d/o is phenotypically normal prior to puberty What dangerous issue can be seen rarely?
Klinefelter Synd 15% have mosaic variants- multi-X or multi-Yx= irregular features, violence, retardation
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Klinefelter Barr Test is same as ? Klinefeltor Sxs are related to an issue of ?
XX Female Testosterone deficiency
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How is Klinefelter Dx How is it Tx?
Direct karyotyping Inc LH and FSH w/ dec testosterone Testosterone replacement to treat hypogonadism and cause virulization
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Marfan Synd is an issue at what molecular level? What pos thumb/wrist sign is seen?
AutoDom mutation in Fibrilin 1 gene on Chrom 15 Arachnodactyly Thumb AKA Steinberg Sign Wrist AKA Walker-Murdoch Both needed for Arach. Dx
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Marfans manifests in what 3 body systems? How is it Dx?
Cardiac, skeletal, Ophthalamic Clinical criteria but confirmed w/ FISH (Fluorescent In-Situ Hybridization)
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When are infant crying louder and more intense? Premature infants cry little before __wks but cry more than term infants at _wks
Hunger and Pain 40wks; 6wks
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How much crying should babies be crying at 2wks, 6wks, 12wks How much fussing is seen?
2: little 6: 2/hrs day 12: 1hr/day 6wks: 10 episodes/24hrs
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Corrected age equation How long is it used for?
Chron age - wks premature Until 24mon
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# Define Colic What is Wessels rule of 3
Difficult/fussy child that has paroxysmal crying w/ facial grimace, leg flexion and flatus Crying >3hrs/day Crying 3 days/wk Crying more than 3wks Usually resolves around 3mon
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What has been shown to be an excellent soother of colic babies? What is more likely to be seen when colic babies are present?
Car rides White noise- vacuums Post Partum depression in mother
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What is the most commonly reported pediatric behavioral problem What are triggers?
Temper tantrum- terrible twos Tired, Hungry, Ill, Transition
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How can temper tantrums be prevented? How are breath holding spells treated
Parent education at 12-18mon Ignore
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What is the goal of therapy in special needs Peds What do parents experience after child is Dx w/ Special Needs
Maximize potential for adult function Kubler Ross stages of grief
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How are special needs kids best managed? Define Intellectual Disability
Medical Home D/os with common deficits of adaptive and intellectual function and an age onset before maturity is reached IQ <70
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Criteria of Mild ID Criteria of Severe ID
IQ 50-70, higher association w/ environment and highest risk among low socioeconomic status IQ <50, linked to biological/genetic causes
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What developmental delay is common in PTs w/ ID? What needs to be considered if abnormal facial features, hypotonia, FTT are seen at birth?
Hearing and Speech delays Syndromes or Genetic Abnormalities
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What labs are ordered for ID PTs? What is the school screening used to ID students needing help?
UA, Metabolism (PKU, TSH), Hypo thyroid, EEG, Chromosomes Parent's Evaluation of Developmental Status
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ID Tx is dependent on ? What environmental risk factors increase chances of autism?
Stanford Binet scores, IQ doesn't equal functional ability ``` Advanced age Premature birth Maternal obesity Short interval from prior pregnancy Infections ```
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Autism often coexists w/ what other issue? How does Autism clinically present?
ID Deficit in social communication/interaction Restricted/repetitive actions of behavior/activities Inflexible adherence to routines Hyper/hypo reactive to sensory input
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Most Autism PTs have what comorbid condition What meds are used?
Sleeping problem ``` Antipsychotic SSRIs Antiepileptics Gi meds- esp constipation Sleep hygiene ```
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# Define Cerebral Palsy What is a huge risk for CP?
D/o of movement and posture limiting activity 80% antenatal factors leading to abnormal brain development Multiple pregnancy Infertility treatments
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If child only walks on tip toes they have? What other neuro S/Sxs may be seen
Spastic Hemiplegia Ankle Clonus, Babinski, Inc DTRs
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What is the imaging modality preferred for CP?
MRI, inc sensitivity
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If child is continuously army crawling, they have ? What other Neuro S/Sxs are seen?
Spastic diplegia Damage to immature white matter Brisk reflexes, ankle clonus and bilateral Babinksi
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What is the most common neuropathic finding in spastic diplegia?
Periventricular leukomalacia
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# Define Spastic Quadriplegia What will be seen on neuro exam?
Motor impairment of all extremities High risk of ID and seizure, pneumonia and growth failure Inc spasticity, dec spontaneous movement, brisk reflexes, plantar extensor responses Athetosis is common
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Define Athetoid CP
Choreoathetoid, Extrapyrimidal, Dyskinetic Hoptonic, poor head control, head lag and isolated more to upper extremeties Slurred speech
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What causes Athetoid CP What labs/rads are ordered?
``` Birth asphyxia Kernicterus Lesion in basal ganglia/thalmus Genetic metabolic d/o Mitochondrial d/o ``` MRI and metabolic panel
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What labs/rads are ordered to Dx Cerebral Palsy What meds can be used for spasticity
Hx, Clinical, MRI, Vision/Hearing, EEG, UA Genetics Botox, Benzo, PO MRs, Baclofen
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Difference in ADHD appearance in m/f How is it Dx?
M- hyper active and impulsive F- inattentive <16= 6 inattention or 6 hyperactive/impulse Sxs >17= 5 inattention or 5 hyperactive/impulse Sxs For 6mon In 2 or more environments
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How is ADHD Tx?
Behavior management- core Stimulants- first line NE reuptake inhibitor- Atomoxatine A-agonist- Clonidine/Guanfacine
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Signs of ODD Signs of CD/o
Angry/irritable Argumentative and vindictiveness Aggression, destruction and deceitfulness/theft Serious violations of rules
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How are ODD/CD/o screened for What meds are used for both?
Vanderbilt Stimulants Atypical antipsychotics
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Define Early, Mid and Late Adolescence
Early- Concrete, body/attention focused, ambivalent to independence Mid- abstract, concern w/ identity, risky behavior, independence Late- formal operational, marriage/job, commitments, re-emergence of unresolved separation anxiety Failure to launch
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# Define identity confusion Define Role Confusion
Search for commitment before identity roles are formed- experimentation Reluctant to make commitment and develops avoidance
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What is the acronym for doing adolescent interviews
``` HEADDSS Home/friends Education Alcohol Drugs Diet Sex Suicide/depression ```
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Series of events that lead to sex hormone production Interference with this process can be caused by ? and lead to early puberty
Hypothalamus inc GnRH Ant Pit releases FSH/LH (pulse generator) Hormones triggered CNS d/o, tumor
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First part of female development is ? What is second?
Estrogen, Breasts Adrenal- androgen
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What are the Tanner stages of breast development
``` 1- preadolescent 2- buds 3- enlargement of breast/areola 4- areola and papilla mound 5- mature ```
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What are the Tanner stages of female pubic hair?
``` 1- none 2- sparse along labia 3- dark/coarse over pubes 4- covers but not to thighs 5- covers to thighs Peak growth 3-4 ```
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When do female menarche begin?
2.5-3yrs after breast development Tanner 4 breast Physiologic leukorrhea 3-6mon prior 2-3yrs post-thelarche Avg- 4/2yrs
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What is the first part of male development?
Testosterone, inc testes size | SMR 2
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What are the Tanner stages for male pubic hair
``` 1- childhood 2-testes enlarge 3- penile length 4- penile breadth 5- adult ```
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What are the Tanner stages of
``` 1- none 2- sparse, base of penis 3- darker, coarse, curled 4- covered but not thighs 5- thighs Avg- 2.5-5yrs ```
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# Define Leukorrhea When do gynecomastia cases need to be referred to Endo?
Tanner stage 3 event- vaginal discharge of clear/non-odorous due to estrogen stimulation of uterus/vagina >3cm Persists after 2yrs Past age 16yrs Tanner 1, 2, 5
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DDx of premature Thelarche Male testes should not enlarge before ? age, and if the do ?
Estrogen excess- soy, legumes, flax seed, tofu Prior to 9, brain MRI
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# Define Adrenarche What are DDx
Odor, hair, acne F: <8 M: <9 Cushings, Tumor, Adrenal hyperplasia
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What can be given for obvious gynecomastia? How long are female cycles? How long does each last? How much is normal flow?
Androgens, Aromatase inhibitors, Estrogen antagonists Past 18-24mon- surgery 21-45 for first 3yrs 21-35 after Lasts 7 days or less 6 or fewer pads/tampons
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What type of abnormal cycle needs further eval? What are the two types of Amenorrhea What are the 3 caveats
2 or more abnormal cycles or skipped period for more than 3 consecutive cycles Primary- 15y/o or no period 3yrs after puberty onset Secondary- no menstruation for 3 cycles in post-menarchal PT Lacks puberty signs by 13 Sexually active Early breast development
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What are the first line evaluations for amenorrhea? What are the S/Sxs of PCOS
TSH, Prolactin, FSH, HCG, US if primary Hperandrogenism, obesity, insulin resistance
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PCOS can be Dx with two of what findings?
Infrequent bleeding Secondary amenorrhea Hyperandrogenism US showing morphology
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How is PCOS anovulation manages? How is hypothalamic amenorrhea treated?
Cyclic Prog/PO OCs Est/prog combo
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What drugs are used for androgen excess in PCOS PTs? What is the most common cause of abnormal uterine bleeding in adolescents?
Combo Est/Prog Sprinolactone helps hirsutism Metformin Anovulation
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Why are combo Est/Prog used for abnormal uterine bleeding cases?
Regulates menstruation Allow hypothalamic-pituitary-gonad axis maturity Pts w/ bleeding d/o (Von Willebrand)
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What causes the pain of 1* Dysmenorrhea
Prostaglandins/Leukotriens from declining progesterone levels increase uterine tone and contractions
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Menstruation pain w/ pelvic pathology is most frequently caused by ? If outlet obstruction is suspected, what imaging is used?
Endometriosis or PID US
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When are MRIs used for dysmenorrhea evals? How is endometriosis Dx?
Complex reproductive tract abnormalities Laparoscopy PID in Tx failure
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What are the red flags of Enometriosis/Adenomyosis, Mullerian, and PID
E/Ad- increasing dsymenorrhea despite therapy M= pain at/shortly after menses w/ known renal tract abnormality PID- vaginal d/c
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How is dysmenorrhea treated?
Prevent/dec prostaglandins w/ NSAIDs If unsuccessful, hormones If hormones fail after 4mon, re-eval and reconsider Dx
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Sex identity is self perceived with what 4 components Define Gender Identity
Sex at birth, Gender Identity, Expression, Orientation Basic sense of man/woman (PRESENTATION)
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# Define Gender Expression Define Gender Non-Conforming
Characteristics, need to distinguish from gender identity Fem boy/masculine girl
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# Define sexual orientation Define Sexual behavior
Attraction/attachments to men/women Activity for pleasure
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What is the difference between trans, cross dresser and drag?
Trans- live in other gender Cross- crosses over but reverts back to assigned Drag- impersonator
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# Define nonbinary Define Gender Fluid
Neither Not fixed but changing
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When is gender identity formed? Whats the difference between Gender Constancy and Consistency
2-3yrs Const- stable over time Consis- permanent
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What part of gender identity is normal and part of life? Define Gender Dysphoria
Nonconformity Distress from inconsistency on thoughts/feelings of gender More often in male kids but even in adolescence
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Can medical professionals tell coaches a Ped PT isn't cleared for sports and not violate HIPPA? What two cardiac findings during sports physicals are bad?
Yes, but can't tell why Murmur that gets louder w/ Valsalva or standin
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Can kids play sports with seizure history? What is a disqualifier?
Yes as long as it's controlled Stage 2 HTN or poorly controoled (S/DP >99 percentile for age +5mmHg)
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Can kids play sports w/ Mono? How many calories do male/female adolescents need?
Restricted for 28 days to dec risk of spleen trauma F: 1800-2400 M: 2000-3200
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What is the Ca+ requirement for adolescents How is adolescent BMI calculated? What is over, obese
1300mg/day ``` BMI= kgs/height in meters^2 >120% IBW obese >200 IBW morbid 85-95% BMI= overweight >95% BMI= obese ```
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# Define SCFE Define Blount's Dz
Most common hip d/o in obese PTs when rapid femur growth weakens plate and causes slipage backward off of epiphysis Growth issue causing tibia to angle inward
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# Define NASH What is the SMART acronym for obesity?
Non-Alcoholic Steatohepatitis Severe form of fatty liver ``` Specific Measurable Achievable Relevant Timely ```
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What are diet goals for Peds at 7y/o
<7- maintain weight, let linear growth catch up | >7= 1lb/mon until <85% BMI
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What appears first, anorexia or bulemia? What neonatal sign may be seen in anorexia?
Anorexia, bulemia presents w/ BPD/o Lanugo
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How is Anorexia treated? When do they need to be hospitalized?
Feeding program to restore weight ``` >25% loss of ideal weight Suicide risk Bradycardia/Hypothermia Dehydrate/hypo-K/dysarrhythmia Failed OutPT ```
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Dx criteria for bulemia How is it treated?
``` 2x/wk x 3mon Discrete eating Loss of control Compensatory over reactions Self eval of unwanted size ``` Anti-Depressants
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# Define Female Athelete Triad What happens to the brain during this d/o
Too much exercise dec estrogen Attempted weight loss to inc performance Low bone density, inc Fx risk BF% dec and stops hypothal/pit/gonad system
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What meds can be used for Female Athlete Triad What is the SIGECAPS acronym for Dep/Suicide
OCPs to restore menses, won't correct bone loss Ca, K Vit D supplements Mainstay= life modification Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Safety/Suicide
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What is a leading cause of death in teens that surpasses MVAs? What med is used for depressed/suicidal adolescents?
Suicide Fluoxetine or Escitalopram Risk- SSRIs, inc suicide risk
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# Define Anxiety What is the difference between Anxiety and anxiety d/o
Dread or Apprehension ``` Anxiety= not pathologic D/o= pathologic, most common psych d/o of childhood ```
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When does Separation Anxiety D/o develop
10-18mon | By age 3, can accept temporary absence
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When does Schizo frquency increase? What are the 4 Sx categories for Schizo?
13-18y/o Higher risk in monozygotic twins (identical) and 1* relatives Pos Sxs= hallucinations and delusions Neg Sxs= lack of motivation/social interaction Disorganization of thought/behavior Cognitive impairment- most common/disabling
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What are the 5 sub-types of Schizo
Paranoid- delusion persecutory Disorganized Catatonic- rare in kids/adolescents Undifferentiated- doesn't fit other types Residual- previous Dx, no current Pos Sxs
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What is the Substance Abuse Screening acronym
CRAFT | Car, Relax, Alone, Forgetting, Fam/Friends, Trouble