Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Quarter 2 > Peds Final > Flashcards

Peds Final Flashcards

1
Q

Still Murmur

innocent

A

Most common innocent murmur in YOUNG children (2-7 YO)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Still Murmur

innocent

A

Musical, short, high pitched, loudest LYING supine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pulmonary Flow Murmur

innoncent

A

Soft, loudest supine

3YO and older

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Venous Hum

innocent

A

Continuous musical hum, resolves when pt LYING supine

2YO and older

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Venous Hum

(innocent(

A

Louder in diastole and sitting position w head extended

Disappears w: turning head or lying supine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Venous Hum (innocent) best heard @

A

Right or Left Upper Sternal Border (R/LUSB)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Still Murmur (innocent) best heard @

A

Left LOWER Sternal Border (LLSB)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Umbilical vein

A

brings oxygenated blood from placenta to fetus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Ductus Venosus

A

short cut from umbilical vein to IVC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Foramen Ovale

A

R atrium –> L atrium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Ductus Arteriosus

A

blood from Pulmonary Artery –> Aorta (directs blood away from the lungs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

After birth, Ductus Arteriosus:

A

shunting not needed
Blood flow can continue: 1-5 days
Closure by: 7-14 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Most common congenital heart defect

A

VSD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

VSD is associated with

A

Tetralogy of Fallot

Trisomy 21

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Physical Exam of VSD

A

Harsh, holosystolic murmur at LLSB (Left LOWER sternal border)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

EKG of VSD will show

A

Left Ventricular Hypertrophy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

CXR of VSD will show

A

Cardiomegaly, increased Pulmonary vascular markings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Tx for VSD

A

May spont close
Treat CHF (diuretics)
Surgical: Septal occlusion via cardiac cath VS Surgical closure vie median sternotomy*** (preferred)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Preferred surgical tx for VSD

A

Surgical closure via median sternotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

ASD

A

Classified by anatomic location

Ostium Secundum: most common (usually isolated defect)

Ostium Primum (assoc w other stuff)

Sinus Venosus (more rare)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

ASD physical exam

A

Widely split S2

Rales, Respiratory retractions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Patent Ductus Arteriosus

A

More common in premature infants, F>M, and Maternal Rubella

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Patent Ductus Arteriosus

PDA

A

Sx depend on age, ductus size, other abn

infant: CHF, tachy, FTT, resp distress
child: SOB, easy fatigue
adult: Eisenmenger syndrome, clubbing, cyanosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Patent Ductus Arteriosus

PDA

A

Continuous MACHINERY like murmur
Wide pulse pressure
Bounding pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Tx for Patent Ductus Arteriosus

PDA

A

Keep open: Prostaglandins

Close: Endomethacin (Prostaglandin Inhibitor)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Coarctation of Aorta

A

Narrowing of aortic arch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Coarcation of Aorta

A

often seen w/ TURNER syndrome

Unexplained UE HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Physical Exam of Coarcation of Aorta

A

Absent/decreased Femoral pulse

Upper Extremity BP is 20 higher than Lower extremity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

CXR of Coarcation of Aorta

A

“Figure 3 sign”

“Inferior Rib Notching”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Tet of Fallot

A

VSD
Overriding aorta
RVH
RV outflow obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Most common cyanotic CHD

A

Tet of Fallot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Tet spells

A

sudden onset or worsening of cyanosis

irritable –> LOC

start 4-6 mo

toddlers may squat to increase SVR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Tet of Fallot exam

A

Harsh SYSTOLIC EJECTION

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

CXR of Tet of Fallot

A

Boot shaped heart

w/upturned apex

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Tx for Tet of Fallot

A

Tet spells: oxygen, knee-chest position increases SVR

surgical repair by age 1

can also do morphine, fluids, and BB or phenylephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Transposition of Great Arteries (TGA)

A

arteries completely switched, coming off the wrong ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

TGA

A

second most cyanotic CHD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

TGA presentation

A

VERY BLUE BABY but without respiratory distress or significant murmur

“Blue baby”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

CXR of Transp of Great Arteries (TGA)

A

Egg on a string

CXR is non diagnostic

ECHO is diagnostic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Tx of TGA

A

Cardiac cath
Prostaglandin EW - keep ductus arteriosus open
SURGERY (4-7 days)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Surgery for TGA

A

Done at 4-7 days
switch great arteries and re-implant Coronary arteries

> 95% operative survival

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Tricuspid Atresia (no tricuspid valve) BLOCKED

A

many other defects occur

if untreated, surv rate as low as 10% by age 1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Tricuspid atresia (blocked)

A

Central cyanosis @ birth

single heart sound S2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Tricuspid atresia tx

A

Initial: Prostaglandin E1 to keep ductus arteriosus OPEN and supportive care
THEN: surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Truncus Arteriosus

A

ONE BIG ARTERY coming from the heart

VSD always present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Truncus Arteriosus exam

A

Loud single S2
Narrow S2 Split

Prominent ejection click, systolic ejection murmur at LLSB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Treatment for Truncus Arteriosus

A

CHF tx, surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Total Anom Pulmonary Venous Return (TAPVR)

A

Pulm veins drain into venous system

oxygen rich and poor blood mix in R atrium

Presentation: severe cyanosis, resp distress, CHF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Tx for TAPVR

A

surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Hypoplastic Left Heart Syndrome

A

underdevelopment of L heart

Stenosis of Mitral and Aortic valves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Presentation of Hypoplastic L heart synd

A

mild cyanosis, but stable at birth while Ductus Arteriosus is still OPEN

rapid deterioration when it closes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Tx for Hypoplastic L heart synd

A

Prostaglandin E1 to keep Ductus Arteriosus OPEN ESSENTIAL

then, Staged surgeries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Conditions in which we give Prostaglandin E1 to keep Ductus Arteriosus OPEN

A

Hypoplastic L Heart Synd
Tricuspid Atresia
Transposition of Great Arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Fetal Alcohol Synd

A

VSD

ASD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Maternal Rubella

A

PDA

Pulm Stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Acute Rhemuatic Fever

A

2-4 wks after strep throat

Diagnosis by jones criteria: 2 major or 1 major and 2 minor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Major jones criteria

A

for Acute Rhemuatic Fever

Pancarditis (pericarditis, endocarditis, myocarditis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Acute Rheumatic Fever

A

Valvulitis (esp of Mitral 75% and Aortic valves- both on LEFT side of heart)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Tx for Acute Rheumatic Fever

A

ASA or corticosteriods- anti inflammatory
Abx
Heart failure management

no therapy to slow the progression of valvular damage

consider prophylactic abx if person has had this bc if they get it again, much higher risk to progress to Rhemuatic Heart Dz the next time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Kawasaki Dz

A

Vessel Vasculitis

Males > females

90% cases of children <5YO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Kawasaki Dz diagnosis

A

Fever >5 days AND
4 out of the 5 sx:
CREAM

62
Q

CREAM sx Kawasaki dz

A 
Conjunctivitis (bilateral non purulent)
Rash (maculopap)
Erythema palms and soles (w swelling)
Adenopathy, cervical (singular, unilateral node)
Mucous memb (strawberry tongue)
63
Q

Tx for Kawasaki dz

A

High dose ASA + IVIG

64
Q

Complications of Kawasaki Dz

A

Coronary artery aneurysm

can lead to MI and death

Obtain ECHO at dx, 2wks later, and 6 wks later

65
Q

Hypertrophic Cardiomyopathy

A

*leading cause of sudden cardiac death in young ppl

Most common: Familial Autosomal Dominant cause

66
Q

Hypertrophic cardiomyopathy

A

Exercise intolerance –> sudden cardiac death

67
Q

Physical exam Hypertrophic Cardiomyopathy

A

Presence of Audible S4 (this is always problematic)

68
Q

Tx of Hypertrophic cardiomyopathy

A

Exercise restriction, betablocker, calcium channel blocker, reduce septal size, defibrillator placement

69
Q

Tanner Stage 2 Breast

A

Elevated small mound

Areolar diameter increased

70
Q

Tanner Stage 3 Breast

A

Breast and areolar enlarged but no contour separation

71
Q

Tanner Stage 4 Breast

A

Areola and papilla form secondary mound

72
Q

Tanner stage 2 pubic hair

A

sparse, straight

73
Q

Tanner stage 3 pubic hair

A

Darker, beginning to curl

74
Q

Tanner stage 4 pubic hair

A

Course, Curly, Abundant

75
Q

Tanner stage 5 final pubic hair

A

Spread to medial thigh

76
Q

Tanner stage 2 Male genital

A

Enlarged scrotum, pink, altered texture

77
Q

Tanner stage 3 male genital

A

Penis lengthens, larger testicles

78
Q

Tanner stage 4 male genital

A

Larger penis- glans and breadth increases; larger, scrotum Dark

79
Q

Sequence of puberty in girls

A 
Thelarce/Breast develop
Pubic hair
Height peaks
Menses
Complete
80
Q

Sequence of puberty in boys

A 
Testicle size
Pubic hair and penile growth
Height peaks
Sperm
Complete
81
Q

Pre (early) puberty

A

2-3 Standard deviations

Breast before 8
Testicular enlargement before 9

82
Q

Delayed puberty

A

2-3 Standard deviations

Breast haven’t started by 12-13
Testicular enlargement hasn’t started by 13-14

83
Q

Mortality

A

Males 2-3x more likely to die

84
Q

Screen for only those at increased risk

A

Hyperlipidemia

Tuberculosis

85
Q

Immunizations by 11-12

A

Having A Buddy Makes Me Realize How Much Puberty Varies In Teens

86
Q

Immunizations

A 
Hep Aand B
MMR
HPV
Meningococcal
Pneumo
Varicella
Influenza
Tdap
87
Q

Questionarres

A

HEEADSSS- broad
CRAFFT- drugs and alcohol
PHQ-2- mental health

88
Q

Emancipated minor

A

provide own consent
status of legal adulthood
(marriage, military, living on own)

89
Q

Mature minor

A

recognized in some states (NOT AZ)
at least 14 YO
can consent on routine and low risk tx

90
Q

In AZ, minors can consent to

A

Sexual assault and Substance abuse if 12 YO or older

91
Q

In AZ, minor CANNOT consent to

A

Mental health screening

Abortion (w some exceptions)

92
Q

Main causes of bacterial cojunctivitis

A

Strep PNA
M Cat
H Flu

thick purulent discharge

93
Q

Tx for bacterial conjunctivitis

A

Erythromycin Ophtho ointment
and
Trimethoprim polymyxin B drops

94
Q

Neonatal conjunctivitis- Chlamydia

A

5-14 d after birth
watery to mucupurulent to bloody d/c
Chemosis, pseudomembrane

95
Q

Dx Neonatal conj (Chlamydia)

A

NAAT- Nucleic Acid Amplification Test (gold standard)

96
Q

Tx for Neonatal conj (chlamydia)

A

Oral erythromycin, must be oral! 50 mg

97
Q

Hyperacute bacterial conjunctivitis (Gonorrhea)

A

Severe and sight threatening
Develops 2-5d after birth (sooner than the Chlamydia)
Keratitis and perforation can occur

98
Q

Hyperacute bacterial conj (Gonorrhea)

A 
sooner than other one
Rapidly progressive, more d/c
PROFUSE, purulent d/c
Marked chemosis
Often accompanied by urethritis

Tx: IMMEDIATE Ophtho referral and hospitalization

99
Q

Keratitis

A

inflammation of cornea
Contact lens wearers
Risk of Pseudomonas Keratitis
Can happen w/in 24 hrs

100
Q

Keratitis sx

A

FB sensation, blepharospasm, visible corneal opacity with penlight

101
Q

Tx for Keratitis

A

Immediate ophtho referral if keratitis present

102
Q

In the absence of keratitis

A

stop contact use, appropriate Anti-pseudomonal abx, urgent Ophtho referral, see w/in 12-24 hrs

103
Q

Viral Conjunctivitis

A

Adenovirus
Burning, gritty sensation
Watery d/c
Rapid 10 min test for dx

104
Q

Tx of Viral Conjunctivitis

A 
Self limited, do sx relief
Warm/cool compress
Topical antihistamine/decongestant
OTC Naphcon-A >6YO
OTC Lubricant eye drop
105
Q

Most daycares require at least 24 hr of topical therapy before returning

A

if viral, depends on sport

non contact: when they can see clearly
contact: once daytime d/c has abated, usually 5 d later

106
Q

Allergic conjunctivitis

A

Stringy d/c
Pruritic
Bilateral

107
Q

Tx for Allergic conjunctivitis

A

Nonpharm/sx + Pharm: Antihistamine with mast cell stabilizing IF >3YO

108
Q

Other tx options for Allergic conj (not bolded)

A

Topical vasoconstrictor + antihistamine
Mast cell stabilizer >4YO
Topical NSAID
Topical glucocorticoid BY ORTHO ONLY - do not prescribe

109
Q

Tx for Kawasaki

A

High dose ASA and IVIG

110
Q

Strabismus

A

Potential cause of amblyopia “lazy eye”

Abnormal corneal light reflection- exo or esotropia

Refer to Ophtho

111
Q

Dacryostenosis

A

Nasolacrimal duct obstruction

Persistent tearing and ocular discharge

Etio: congenital

112
Q

Dacryostenosis sx

A

Mucoid discharge
Debris on lashes
Mild redness on lower eyelid from chronic rubbing

113
Q

Tx for Dacryostenosis

A

90% cases resolve on own by age 6
if longer than 7-6 mo, refer to Ophto
**FIRST LINE TX: Lacrimal sac massage
**DEFINITIVE TX: Surgical probe

114
Q

Dacryocystitis

A

a rare complication of Stenosis
Inflammation of lacrimal sac
ETIO: Staph Epidermidis and Staph Aureus

Tx: Treat promptly w Empiric Abx 7-10 d
Oral Clinda (mild)
Oral Vanco (severe) + 3rd gen Ceph
115
Q

Acute otitis media- bacterial

A

SMH pathogens
most common dx in sick kid/ most common abx

Otalgia, fever, bulging TM, erythematous

Complications: Cholesteatoma, facial N palsy, mastoiditis

116
Q

Tx for Acute otitis media

A

High dose Amoxicillin

Augmentin for recurrent

48-72 hour follow up

117
Q

When to use Prophylaxis for ear infection

A

more than 3 episodes in 6 mo
more than 4 episodes in 1 yr
daily use during winter months of Amoxicillin (40 mg) or Sulfisoxazole (50 mg)

118
Q

Swimmer’s ear

A

Pseudomonas Aurigonasa
Otalgia, tragus tenderness, erythema and edema of external canal

Dx: RAPID onset within 48 hrs, clinical dx, culture is reserved for severe

119
Q

Tx of swimmers ear

A 
Clean canal: Aural toilet
Floxin Otic solution (Ofloxacin)
Cortisporin Otic (avoid w perforation)
Ciprodex or CiproHC
Acidifying solution
Antiseptic
Ear wick PRN
120
Q

Allergic rhinitis

Seasonal vs Perennial

A

Family hx of Atopy is main cause

Intermittent: <4d/week for <4 wks total
Persistent: >4d/week for >4 wks total

121
Q

Sx of Allergic rhinitis

A 
Allergic shiners
Dennie Morgan lines
Allergic salute
Pale/bluish boggy nasal mucosa
Edematous turbinates
Cobblestoning posterior pharynx
122
Q

Tx for Allergic Rhinitis

A

Intranasal steroids- FIRST LINE

Immunotherapy as a last resort (very effective, injections, 3-5 yr total)

123
Q

Other tx options for Allergic rhinitis

A

Antihistamine, decongestant, mast cell stabilizer, LTR antagonist

124
Q

Nasal polyps

A

benign pedunculated, peeled grape appearance
rare under age 10
assoc w: Cystic Fibrosis, chronic sinusisis, complicated allergic rhinits

125
Q

Samter’s Triad

A

Nasal polyps, ASA sensitivity, Asthma

126
Q

Tx for Nasal polyps

A

Decongestant, intranasal steroid spray, systemic steroid, surgical removal for serious cases

127
Q

OTC Decongestant Caution

A

DO NOT USE in children <6YO

Avoid still in 6-12

128
Q

Acute sinusitis

A

6-8% cases develop into bacterial

Acute vs Chronic

129
Q

Sx and PE of Sinusitis

A

nasal sx, cough, fever, HA, sinus pain

erythema and edema of nasal turbinates, mucopurulent anterior nasal d/c, postnasal drainage

130
Q

Acute sinusitis

A

severe sx are >102.2 F, purulent d/c for 3 days or more, ill appearing

worsening: can have double sickening

131
Q

Chronic sinusitis

A

12 weeks of greater

2 or more of the following: mucopurulent drainage, nasal obstruction, facial pain/pressure, decreased sense of smell

132
Q

For acute sinusitis

A

X Ray, CT

culture is not routine

133
Q

For chronic sinusitis

A

X Ray, CT, MRI
Culture maybe
bloodwork and surgery maybe

134
Q

Bacterial Acute sinusitis

A

try symptomatic tx first

then, Augmentin 45 mg/kg/day

135
Q

Chronic sinusitis

A

Control allergies, nasal saline, steroids, maybe abx

ANTILEUKOTREINE agents
Refer out

136
Q

Viral URI

A 
common cold
last 14 d
RHINOVIRUS
non toxic
Infants: fever and nasal d/c
Children: nasal congestion, discharge, cough

NO abx, just supportive care

137
Q

Viral throat pharyngitis

A

Adenovirus and Coxsackie
sore throat and fever

Supportive care and sx relief- miracle mouthwash

138
Q

Mono

A

Epstein Barr virus
fatigue, sore throat, fever
Tender cervical lymph
Palpable splenomegaly

Heterophile antibody test- Monospot rapid serologic test

139
Q

Mono

A

may last 7-21 d
supportive care
Activity restriction for 4 WEEKS

140
Q

Group A strep

A

Strep pyogenes

Abrupt onset, sore throat, exudates, palatal petech, tender cervical lymph

141
Q

Central criteria for strep

4 choices

A

1 pt for each

  • tonsillar exudate
  • tender anterior cervical lymph
  • fever
  • no cough

<3 unlikely, no testing or abx
3 or greater: perform Rapid strep

142
Q

If rapid strep is negative but high clinical suspicion

A

order culture

143
Q

Strep throat tx

A

start within 48 hours to prevent complication and spread

Oral PENICILLIN, amoxicillin
1st gen Ceph
Azithro if PCN allergic

144
Q

Acute Rheumatic Fever

a complication of group A strep

A 
5 major manifestations:
Migratory Arthritis
Carditis
CNS involvement
SubQ nodules- firm, painless
Erythema marginatum- pink, faint, red non itchy rash on trunk and limbs
145
Q

Post strep glomeruloNephritis (PSGN) (a complication of strep)

A

Increased risk 5-12 YO
can be asympto
Sx: edema, gross hematuria, HTN

Can be FULL BLOWN Acute nephritic syndrome

Hematuria and proteinuria

146
Q

Tx for PSGN

A

supportive, treat volume overload with Diuretics and sodium/water restriction

Acute renal failure-dialysis

147
Q

When to get Tonsillectomy

A

7 episodes in past year
5 episodes in each past two years
3 episodes in each past three years

148
Q

Mumps

A

incubation 16-18 d
infectious 3 d befor esx and 9 days after sx

usually self limiting and resolves in few wks

HIGHLY contagious, preventable with MMR vaccine

149
Q

Parotitis develops within

A

48 hours of mumps sx onset

150
Q

Parotitis

A

most common 2-9 YO

if unilateral, often progresses to bilateral in 90% cases

151
Q

Bacterial parotitis

A

more common in adults, d/c from Stensen’s duct

152
Q

Tx for viral parotitis

A

none, supportive, acetiminophen, cold/warm pack

Quarter 2 (16 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions