PNP-PC Part 2 Flashcards
If a child’s 0.9 g/dl, hematocrit is 32%, and serum ferritin is 25 mcg/L, what should her iron supplementation start at?
3 to 6 mg/kg/day of elemental iron until her hemoglobin (Hgb) reaches above 11 g/d
Once hemoglobin normalized, continue 2 to 3 mg/kg/day of elemental iron for 4 months
_________ ensures that NPs are qualified to provide safe health care, meet professional standards and minimal levels of acceptable performance, and comply with federal and state laws relating to NPs
privileging or credentialing
Credentialing
most definitive tools for confirming intussusception
Radiography and barium enema
which anemia is normocytic and normochromic
Anemia of chronic disease
microcytic and hypochromic anemias
iron-deficiency anemia
thalassemia
lead poisoning anemia
Which two vaccines should not be given to those allergic to streptomycin, neomycin, and polymyxin B?
IPV (polio)
Varicella
Which vaccines should not be given to immunocompromised patients as these are live vaccines that can cause them to become severely ill?
MMR
Varicella
Which vaccine should be not given to people who are allergic to eggs?
Influenza
A 12-month-old infant is brought to the nurse practitioner’s (NP) office because her left foot is turned inward. What is her probably condition?
Clubfoot
What are the necessary abilities to be able to give informed consent?
reason, differentiate, and communicate
Patchy infiltrates and pleural effusion on chest x-ray suggestive of pneumonia
Escherichia coli
lobar consolidation rather than patchy infiltrate on chest x-ray suggestive of pneumonia
Klebsiella and Streptococcus pneumoniae
diffuse interstitial, infiltrates that are apical or in the upper lobe on chest-ray suggestive of pneumonia
Pneumocystis pneumonia
You meet your new patient, Ali, in the exam room. You see that Ali has drawn a picture of her mother that includes a face, body, legs, arms, and hair. Based on this behavior, how old do you suppose Ali is?
4 years old
the leading cause of death among infant
Developmental and genetic disorders
Sudden head extension produced by light drop of head
Moro
Week of gestation that moro reflex appears
34-36 weeks
When does moro reflex resolve
5-6 months
Rotation of infant’s head to one side for 15 seconds
Asymmetric tonic neck reflex
When does asymmetric tonic neck reflex appear
38-40 weeks
When does asymmetric tonic neck reflex resolve
2-3 months
Scratching the skin of infant’s back from shoulder downwards, 2-3 cm lateral to spinous processes
Tunk incurvation/
Galant
Week gestation that trunk incurvation/Galant reflex appear
38-40 weeks
when does trunk incervation/galant resolve
1-2 months
placing index finger in palm of infant
palmar grasp
week gestation that palmar grasp appears
38-40 weeks
when does palmar grasp resolve
5-6 months
pressing tumb against sole just behind the toes in the foot
plantar grasp
week gestation that plantar grasp reflex appears
38-40 weeks
when does plantar grasp resolve
9-10 months
infant’s head turns toward cheek that is stroked to suck
rooting
week gestation that rooting reflex appears
38-40 weeks
when does the rooting reflex resolve
2-3 months
arms and legs extend in protective fashion when suspected in prone
parachute reflex
when does parachute reflex appear
8-9 months
when does parachute reflex resolve
it persists
In supine position with hip and knee flexed at 90 degrees, the patient has pain with extension at the knee
Kernig sign
While in supine position, patient flexes lower extremities during passive flexion of neck
Brudzinski sign
Headaches in occipital or consistently localized could mean what?
Underlying pathology
Worse in the morning upon awakening Nocturnal awakening Projective vomiting without nausea Seizures Fever VP shunt, hydrocephaly
Primary or Secondary Headache
Secondary headache
Commonly bilateral in young children, in adolescents, and young adults
Gradual in onset, crescendo pattern; pulsating; moderate to severe intensity; aggravated by routine physical activity
Patient prefers to rest in a dark, quiet room
2-72 hour duration
Nausea, vomiting, photophobia, phonophobia, aura (visual, but can involve other senses)
Migraine
Bilateral
Pressure/tightness that waxes and wanes
Patient may remain active or may need to rest
Variable duration
Tension-Type Headache
Always unilateral, usually begins around eye/temple
Pain begins quickly, reaches crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality
Patient remains pain
Duration: 30 minutes to 3 hours
Ipsilateral lacrimation and redness of eyes; stuffy nose; rhinorrhea; pallor; sweating; Horner syndrome; focal neurologic symptoms rare; sensitivity to alcohol
Trigeminal autonomic cephaloagia
Which is the most common migraine-type?
With or without aura
Without aura
What is the standard of care for migraine management?
Lifestyle modification and behavioral factors
- Adequate sleep
- Eating routine meals, not skipping
- Adequate exercise and physical activity
- Adequate hydration (at least 64 ounces of water/day)
- Limit screentime
- Avoid triggers or stressors
What is acute migraine medication management?
NSAIDs, acetaminophen, triptans, antiemetics
What are the approved migraine medications from the FDA?
Almotriptan, rizatriptan, sumatriptan/naproxen, zolmitriptan
TRIPTANS
What is the preventative medication for migraines?
Topiramate 25-100 mg/d for 12 years and up
Sudden and stereotyped alternation in motor activity, sensation, behavior, or consciousness due to abnormal electrical discharge of neurons
Seizure
Chronic neurological condition characterized by recurrent seizures (2 or more >24 hours apart) which are not provoked by systemic or acute neurologic insults
Epilepsy
Carbamazepine/Tegretol and valproic acid/Depakote can cause which side effects
Bone marrow suppression
Liver damage
Phenytoin/Dilantin can cause what side effects
Gingival hypertrophy
Oxcarbazepine/Trileptal can cause what side effects
Significant hyponatremia
Stevens-Johnson syndrome
What is the common age for febrile seizures?
6 months to 5 years
Bried, generalized seizures and associated with concurrent febrile illness
Simple febrile convulsion
Which antibiotics should you want to prescribe with caution with antiepileptics drugs?
Erythromycin, Azithromycin, Doxycycline
Prolonged (>15 minutes) seizure, focal, or repeated episodes within 24 hours that are associated with fever
Usually genetic predisposition
Complex febrile convulsion
Treatment for simple febrile seizure
Reduce fever with ibuprofen (>6 months) or acetaminophen
Manifested by both motor and phonic tics with onset during childhood
Tourette Syndrome
Coprolalia
Obscene words tic
Echolalia
Repetition of words tic
Palilalia
Repetition of phrase or word with increasing rapidity tic
Management for tics
Educating patient and family, teachers
Non-epileptic, paroxysmal event; occurs between ages 6 months and 4 years
Peak age 18 months
Start with provoking factors (frustration, anger, fright) and minor trauma (crying or emotionally upset) leading to a noiseless state of expiration (silent scream) with color change and eventually loss of consciousness and tone (briefly)
Breath-holding spells
What should be ruled out for breath-holding spells?
Iron-deficiency anemia (serum ferritin level)
Upper trunk nerve injury to C5 and C6 nerve roots from stretching of brachial plexus
Occurs usually unilaterally, weakness of deltoid and infraspinatus muscles and biceps
Neonatal brachial plexus palsy (Erb’s)
Upper arm adducted and internally rotated, forearm extended, hand/wrist movement preserved
Neonatal brachial plexus palsy (Erb’s)
Who would you refer a patient to for neonatal brachial plexus palsy (Erb’s)?
Physical Therapy for passive ROM
Heterogenous group of conditions involving permanent non-progressive central motor dysfunction that affect muscle tone, posture, and movements
Cerebral Palsy
Non-degenerative, non-progressive, chronic motor disorder
Cerebral Palsy
Muscle stiffening and tightness
Muscles cannot relax on their own
Can be hemiplegic or global
Spastic CP
Involuntary, purposeless movements
Athetoid CP
Affects balance and coordination
Ataxic CP
What is management referrals should be made for cerebral palsy patients?
Neurology
Nutrition
Auditory/Speech
Vision
Many anti-seizures medications are _________
Teratogenic
Genetic disorder of nervous system that primarily affects development and growth of nerve cell tissues; tumors grow on nerves and cause skin changes and bone deformities
Neurofibromatosis type-1
Multiple hyperpigmented skin macules (cafe au last spots), axillary or inguinal freckling, multiple skin neurofibromas, and iris hamartomas (Lisch nodules)
Neurofibromatosis type-1
Genetic disorder resulting in the development of bilateral acoustic neuromas; pressure on vestibulocochlear or facial nerve; typical first appearance in adolescent or early 20s
Neurofibromatosis type-2
Impaired/loss of hearing, tinnitus, unsteadiness, or facial weakness
Neurofibromatosis type-2
Raised, pigmented hamartomas of the iris
Lisch nodules
Lisch nodules are characteristic of Neurofibromatosis type 1 or Neurofibromatosis type 2?
Neurofibromatosis type 1
Cognitive impairment is associated with Neurofibromatosis type 1 or type 2?
Type 1
6 or more cafe au lait macules > 5 mm (0.5 cm) in greatest diameter in prepubertal children and >15 mm (1.5 cm) in postpubertal individuals
2 or more neurofibromas of any type or 1 plexiform neurofibroma
Axillary or inguinal freckling
Optic glioma
2 or more Lisch nodules
Distinctive bony lesions (sphenoid dysplasia or medullary narrowing and cortical thickening)
1st degree relative with disease
Neurofibromatosis type 1
Bilateral 8th nerve masses seen on neuroimaging
OR
1st-degree relative
Multiple spinal tumors (schwannomas, meningiomas)
Cutaneous schwannomas
Sporadic vestibular schwannoma in individuals younger than 30
Solitary meningioma or non-vestibular schwannoma in individual younger than 25
Neurofibromatosis type 2
Neurofibromatosis type 1 management
Monitor for hypertension (renal involvement)
Monitor for enlargement of plexiform
Examining skin routinely to see if there are new lesions
Yearly eye exam
Observing skeletal system for any changes
Ashleaf spots, adenoma sebaceum, shagreen patches, forehead fibrosis plague
Seizures, cognitive delay, learning disabilities
Tuberous Sclerosis Complex
Management for tuberous sclerosis complex
Monitor for seizures
Brain MRI every 1 to 3 years (up to 25 years old)
Neuropsychiatric assessment for aggressive behaviors
Annual skin examination
Periodic dental and oral inspections or examinations
Baseline echocardiography (repeat 1-3 years) and electrocardiography(every 3-5 years) for those <3 years
Diagnosis for tuberous sclerosis complex
2 major clinical features
or
1 major and 2 minor
Diagnosis for possible tuberous sclerosis complex
1 major or
2 or more clinical
Headache, nausea/vomiting, neck pain, light sensitivity, noise sensitivity
Vision problem, hearing problems/tinnitus, balance problems, dizziness
Confusion, difficulty concentrating, difficulty remembering, answers questions slowly, repeat questions
Irritable, more emotional than usual, sadness, nervous/anxious
Drowsiness/fatigue, trouble falling asleep, sleeping too much, sleeping too little
Concussion
Most common cause of head trauma in infants and toddlers
Fall and non-accidental trauma
Most common cause of head trauma in young children
Falls and bicycles
Most common cause of head trauma in adolescents
MVA, sport-related injuries, assaults
Treatment for minor head trauma
Observation in ED, clinic, or home
Physical rest for 24-48 hours followed by a gradual and progressive return to non-contact, supervised physical activity
Athletes should follow return to play protocol
Acetaminophen or Tylenol can be used briefly
Treatment for moderate head trauma
Admit for prolonged observation in ED
Indications for neuroimaging with head trauma/TBI
Age <2 Recurrent vomiting Loss of consciousness Severe mechanism of injury Worsening headache Amnesia Glasgow Coma Scale <15 Suspicion for skull fracture Non-frontal skull hematoma
Typical symptoms of migraine headache in 14 year old usually include recurrence and:
A. Unilateral forehead pain, nausea, photophobia
B. Bilateral temporal pain, cyclical vomiting, and vertigo
C. Unilateral forehead pain, ataxia, and photophobia
D. Bilateral forehead pain, nausea, and an aura
Unilateral forehead pain, nausea, and photophobia
How is bone age measured on a radiograph?
Left hand and wrist
Growth spurts start at which tanner stage in girls?
Tanner 2
Growth spurts start at which tanner stage in boys?
tanner 3
When does long bone growth stop?
~2 years after menarche or damage to the epiphysis
What are unique bone fractures in childhood?
Buckle fracture
Greenstick fracture
Growth plate injuries
Salter fractures
Salter fractures cause?
Growth arrest leading to shortening or angular deformity
Trendelenburg gait signals
weakness of hip abductors
Gower sign signals
weak hip extensors and abductors
Trendelenburg gait and Gower sign are common in which condition
Duchene Muscular Dystrophy
Equine gait
toe-walking or toe-to-heel
Equine gait is common with which conditions
Heel cord contracture
Limited dorsiflexion
Radial head subluxation/annular ligament displacement
Commonly occurs in age 1-4 years
Nursemaid’s Elbow
Nursemaid’s Elbow reduction maneuvers
Hyper-pronation
Supination/flexion
Support child’s arm at elbow, place moderate pressure with finger on radial head, examiner grips distal forearm with other hand and hyper-pronates forearm until click felt over radial head when reduced
Hyper-pronation
Supports child’s arm at the elbow, exerts moderate pressure on radial head, apply gentle traction, supinate forearm fully and flex elbow
Supination/flexion
Evaluations for scoloisis
Adams forward bend test
Scoliometer
Radiographs
Differences in shoulder/scapula height
Waist, truncal, or rib asymmetry
Asymmetry in distance that arms hands
S- or C- shape curve of the spine
Scoliosis
Red flags for scoliosis
Cutaneous lesion over spine
Weakness, atrophy, abnormal reflexes
Progressively worsening low back pain
When is observation ok for scoliosis
Cobb angle less than 20 degrees
When is bracing necessary for scoliosis
Cobb angle between 20-40 degrees
When is surgery necessary for scoliosis
Cobb angle greater than 50 degrees
Acute/gradual onset
Sharp, darting, dull pain
Point tenderness of costal cartilages along sternal border
coughing, sneezing, deep inspiration, movements can exacerbate pain
Costochondritis
Maneuvers to evaluate costochondritis
Horizontal arm traction/Crowing rooster
Management for costochondritis
NSAIDs
Idiopathic avascular necrosis of hip
Legg-Calve-Perthes Disease
Peak age incidence for Legg-Calve-Perthes Disease
5-7 years
Acute/chronic onset
Unilateral pain that is activity related
Insidious onset limp with groin, thigh, or knee pain
Pain with weight-bearing
Decreased abduction, internal rotation of hip
Legg-Calve-Perthes Disease
Which x-ray should you order for Legg-Calve-Perthes disease
AP and lateral pelvis
AP and lateral pelvis x-ray for Legg-Calve-Perthes disease
Cresent sign
Management for Legg-Calve-Perthes DIsease
Non-weight bearing
Referral to orthopedist
Femoral neck displaces at physis causing bone impingement
Slipped Capital Femoral Epiphysis (SCFE)
Peak age incidence for Slipped Capital Femoral Epiphysis (SCFE)
10-14 years
Knee, groin, and thigh pain Limping **Obesity (boys), delayed puberty External rotation fo thigh when hip is flexed Limited *abduction/extension
Slipped Capital Femoral Epiphysis (SCFE)
What type of Salter-Harris fracture is Slipped Capital Femoral Epiphysis (SCFE)?
Salter-Harris type I
risk factors for Slipped Capital Femoral Epiphysis (SCFE)
malnutrition
endocrine disorders
hx of displaced hip
chemotherapy/radiation exposure
What radiographs should you order for Slipped Capital Femoral Epiphysis (SCFE)?
AP pelvis, frog-leg lateral view
Management for Slipped Capital Femoral Epiphysis (SCFE)
Placement on crutches or wheelchair
Immediate referral to an orthopedist
How to decide if Slipped Capital Femoral Epiphysis (SCFE) is stable or unstable?
Ability to weight bear
Micro-trauma in deep fibers of patella tendon at its insertion on tibial tuberosity
Painful swelling caused by repetitive stresses (basketball, sports)
Seen after growth spurt
Boys > Girls
Osgood-Schlatter Disease
Increased pain with activity
Resolves with rest
** Pain can be reproduced with extension of the knee under pressure
Focal swelling and point of tenderness of tibial tuberosity
Osgood-Schlatter Disease
Classic prominent tibial tubercle above physis
Osgood-Schlatter Disease
Management for Osgood-Schlatter Disease
Avoid activities that cause pain Ice/cold therapy Stretching Knee immobilizers NSAIDs (with limited use due to prolonged nature of disease)
Inflammation of joint due to infection (staph and strep most common)
Septic Arthritis
Acute onset Hx of antecedent URI Knee/hip pain Redness, swollen, warm High fever, limp, refusal to bear weight, anorexia, **appears ill
Septic Arthritis
Confirmation of septic arthritis
CT or ultrasound-guided aspiration
Management of septic arthritis
referral for surgical draiange
IV antibiotic
Solid tumor of bone
Osteosarcoma
Common age for osteosarcoma
15-19 years
Local pain, local swelling, and/or tenderness at rumor site Decreased ROM Soft tissue mass at end of long bone Fever Increased pain with activity, limp
Osteosarcoma
Stretch or tear in ligaments or other connective tissue
Sprains
Stretch or tear in muscle or tendon
Strains
Pain/limp, tenderness to palpation, swelling, discoloration (ecchymosis or erythema)
Sprain
Minimal stretching of ligament with microscopic tears
Mild swelling and tenderness
No joint instability, patient is able to bear weight and ambulate with minimal pain
Grade I sprain
More severe injury involving an incomplete tear of ligament
Moderate pain, swelling, tenderness, ecchymosis
Mild to moderate joint instability with some ROM restriction and loss of function; weight-bearing and ambulation are painful
Grade II sprain
Complete tear of ligament
Severe pain, swelling, tenderness, ecchymosis
Significant mechanical instability, significant loss of function and motion; unable to bear weight/ambulate
Grade III sprain
PRICE for sprain management
Protect with splint/brace; limit weight bearing
Rest for 24-73 hours or until pain resolves
Ice
Compression with elastic bandage to decrease bleeding or swelling until edema is resolved
Elevation at or above heart level
When can you start passive ROM and stretching with sprains?
After 1-2 days of rest
Tennis, cheer
sports common with overuse syndrome
Fractures suggestive of abuse
Ribs, long bone, skull, fingers, clavicle/scapular, vertebral
Most common causes of fractures
Abuse, sports, falls, MVA, pedestrian/bicycle events
Pain, point tenderness, swelling, ecchymosis/erythema, loss of function, obvious deformity
Fracture
Management for fracture
Immobilization/splinting, compression, ice, elevation Pain medication (initially narcotic) Emergent referral to a pediatric orthopedist
