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281 Cards in this Set
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Developmental Milestone-15mo
Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
15 mo
Gross Motor? stoop and recover Walk well Fine Motor? Put block in cup Scribble Cognitive/Linguistic/Comm? 1 word* Social-Emotional? wave bye bye drink from cup |
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Developmental Milestone-
18 mo Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
18 mo
Gross Motor? walk backwards run Fine Motor? scribble dump raisin, demonstrated tower of 2 cubes Cognitive/Linguistic/Comm? 3 words point to at least 1 body part Social-Emotional? help in house |
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Developmental Milestone-
2 years Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
2 years
Gross Motor? kick ball forward walk up steps Fine Motor? tower of 4 cubes Cognitive/Linguistic/Comm? point to 2 pictures Combine words Social-Emotional? remove garment |
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Developmental Milestone-
2.5 years Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
2.5 years
Gross Motor? jump up Fine Motor? tower of 6 cubes imitate vertical line Cognitive/Linguistic/Comm? name 1 picture point to 6 body parts speech half understandable know 2 actions Social-Emotional? put on clothing wash and dry hands |
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Developmental Milestone-
3 years Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
3 years
Gross Motor? throw ball overhand broad jump balance on each foot 1 sec Fine Motor? tower of 6 cubes imitate vertical line thumb wiggle Cognitive/Linguistic/Comm? name 4 pictures name 1 color know 2 adjectives Social-Emotional? brush teeth with help name friend |
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Developmental Milestone-
4 years Gross Motor? Fine Motor? Cognitive/Linguistic/Comm? Social-Emotional? |
4 years
Gross Motor? balance on each foot 2 seconds hop Fine Motor? tower of 8 cubes draw a person w/ 3 parts Cognitive/Linguistic/Comm? speech all understandable name 4 colors define 5 words Social-Emotional? copy a circle copy a cross (+) |
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Older children and adults may retain primitive reflexes, or the reflexes may reappear, when there is neurological pathology. what are some examples of neurological pathologies?
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cerebral palsy
dementia traumatic lesions CVA |
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when does the moro reflex occur? when does it disappear?
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Moro Reflex AKA Startle Reflex
Present at birth Disappears by 4-6 months |
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The moro reflex likely occurs if:_____
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1) infant's head suddenly shifts position
2) Temperature changes abruptly 3) started by a sudden noise |
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Describe the Moro Reflex
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-Legs and head extend
-Arms jerk up and out with palms up and thumbs flexed -Then, arms are brought together and the hands clench into fists, and infant cries loudly |
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What was the adaptive value of the moro reflex in evolution?
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May have helped infant cling to their mother when being carried around all day
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A bilateral absence of the moro reflex is significant because it indicates a ____.
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-CNS injury
-Unilateral absence could mean an injury during birth such as a fractured clavicle or an injury to the brachial plexus -Erb's palsy or some form of paralysis |
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How do you elicit the moro reflex?
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-hold the infant horizontally on their back and let their head drop slightly
-or produce a sudden loud sound against the surface |
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When is the walking or stepping reflex present? when does it disappear? and when does it reappear?
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walking or stepping reflex AKA placing reflex
Present at birth Disappears by 6 weeks Reappears voluntarily at 8-12 mo |
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how do you elicit the walking or stepping reflex?
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-when the soles of the feet touch a flat surface they will attempt to "walk" by placing one foot in front of the other
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When is the rooting reflex present? when does it disappear?
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Rooting Reflex
Present at birth Disappears at 4-6 mo |
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when does the rooting reflex occur?
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-it comes under voluntary control
-assists in breast-feeding -when hungry, newborn infant will turn his head toward anything that strokes his cheek or mouth -infant searches for the object my moving his head in steadily decreasing arcs until the object is found -after becoming used to responding in this way (if breastfed, approx 3 wks after birth), the infant will move directly to the object without searching |
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When does the sucking reflex occur? when does it disappear?
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Sucking reflex
It is present at birth Disappears at 6-8 mo |
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What is the sucking reflex?
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the child instinctively suck at anything that touches the roof of their mouth and suddenly starts to suck simulating the way they naturally eat
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There are 2 stages of the sucking reflex. What are the 2 stages?
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1) Expression--- activated when the nipple is placed b/w a child's lips and touches their palate. They will instinctively press between their tongue and palate to draw out the milk
2) Milking--- the tongue moves from areola to nipple, coaxing milk from the mother to be swallowed by the child |
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When does the assymetrical tonic neck reflex (ATNR) or fencing posture occur? when does it disappear?
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Tonic Neck reflex
Present at birth-1 mo Disappears 4-6 mo |
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how do you elicit the tonic neck reflex?
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Turn the child's head to the side, and the arm on that side will straighten and the opposite arm will bend
(motion can be subtle or slight) |
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what are you concerned about if an infant continues to have the tonic neck reflex past 6 months?
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The child may have a disorder of the upper motor neurons
-tonic neck reflex is a precursor to hand/eye coordination -it prepares the infant for voluntary reaching -this reflex must disappear for developmental progression- child will be unable to roll over if reflex is still present |
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when does the palmar grasp reflex occur? when does it disappear?
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Palmar Grasp Reflex
Present at birth Disappears 4-6 mo |
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How do you elicit the palmar grasp reflex?
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-when an object is placed in the infant's hand and strokes their palm, the fingers will close and they will grasp it
-grip is strong but unpredictable -may be able to the support the child's weight -may also release their grip suddenly w/o warning |
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what is the plantar or babinski reflex?
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NORMAL
-involves the plantar flexion of the foot -toes move away from the shin, and curl down ABNORMAL -dorsiflexion of the foot, foot angles towards the shin, big toe curls up -occurs when upper motor neuron control over the flexion reflex circuit is interrupted |
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why does the plantar reflex occur?
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the plantar (babinksi) reflex occurs in babies under 1 year, because of low myelination of the corticospinal tracts
-myelination is why infants need higher fat diet until age 2 |
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when does the galant reflex or trunk incurvation occur? when does it disappear
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Galant's infantile reflex or truck incurvation
Present at birth Disappears 4-6 mo **if the reflex persists past 6 mo, it is a sign of pathology |
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How do you elicit the galant reflex?
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-it is elicited by holding the newborn in ventral suspension (face down) and stroking along the one side of the spine. The normal reaction is for the newborn to laterally flex toward the stimulated side.
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when does the parachute relfex appear? when does it disappear?
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Appears at 8-10 mo
*appears before onset of walking Never disappears |
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how do you elicit the parachute reflex?
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-suspend the child by the trunk and suddenly lower as if the child were falling for an instant.
-the child spontaneously throws out the arms as a protective mechanism |
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A newborn's hand is held in a fisted position with the fingers flexed over the thumb. The hand should open intermittently and should not always be held in a tight fisted position.
What will cause the infant to open hands? When does an infant's hand become more open? |
-Rubbing the ulnar aspect of the hand or touching the dorsum of the hand will often cause extension of the fingers.
-Over the 1st 1-2 mo of life, babies hands become more open -persistence of a fisted hand is a sign of an upper motor neuron lesion in an infant |
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When should a normal head lag in a newborn disappear?
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by 6 months
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Describe the progression of newborn tone? 2 weeks? 2 months? 4 months
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Newborn-- when inverted and supported by the abdomen in a prone position, head and legs will droop downward
2 weeks- can move head side to side 2 months-can lift shoulders while prone 4 months-can lift up on hands/wrists, no head lag; when supported on tummy, should be able to bring head up and legs to plane of back |
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what is the landau reflex? when does it appear? when does it disappear?
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-When infant is supported on the abdomen, head will extend above the plane of the trunk with legs extended
-when examiner pushes the head into flexion, the legs drops into flexion appears 4-5 mo disappears 15 mo to 2 yrs |
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No OTC cough/cold medications for children under the age of ___
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6
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what is the earliest sign of hypoxia in children?
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increased respiratory rate
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Periodic breathing is common in infants less than ___ of age.
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3 months
*important to count all 60 seconds when obtaining RR |
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what is the normal RR range and what is considered tachypnea in:
2-12 mo? 1-5 yrs? 5+ yrs? |
1-12 months
Normal 25-40 tachypnea >50 1-5 yrs Normal 20-30 tachypnea >40 5+ yrs Normal 15-25 tachypnea >30 |
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What are always included in your differentials for respiratory illnesses?
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-foreign body
-allergic reaction -neoplasm/cancer -trauma |
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what age group is RTIs most common in?
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6 months to 5 years
*less than 6 mo-- maternal AB will fight infection *Over 5 yrs--stronger immunity |
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what is the average number of RTIs per yr in children?
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6-8 infections per year
*increased frequency in winter season |
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what are the most common causes of colds?
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Rhinoviruses
Parainfluenza Respiratory Syncytial virus (RSV) |
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what are congenital causes of cough?
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-vascular ring
-lobar emphysema -pulmonary cysts -chronic aspiration: tracheoesophageal fistula/GERD -foreign body aspiration |
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what are differentials for a recurrent cough?
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-allergies
-asthma/Reactive airway disease -drainage from upper airways (post nasal drip) -frequent upper resp infections |
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what are differentials for persistent cough?
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-hypersensitivity of cough receptors
-RAD/asthma -chronic sinusitis -tracheitis -cystic fibrosis/immunodeficiencies -foreign body aspiration -GERD -environmental irritants -laryngomalacia -pertussis -pneumonia |
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what are signs/symptoms of serious chronic lower respiratory tract disease?
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-persistent fever
-limitation of activity -failure to grow/gain weight -clubbing of digits (late sign) -chronic purulent sputum -persistent hyperinflation -refractory x-ray infiltrates -cyanosis and hypercarbia |
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what is epiglottitis?
what are common causes of epiglottitis? |
Epiglottitis
-bacterial infection and swelling of the supraglottic tissue (epiglottis) that can result in life-threatening airway obstruction -swelling an complete obstruction can occur within a few hours of onset -formerly caused by H.Flu type b or HiB -causes include Group A beta-hemolytic streptococcus, pneumococcus |
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what are clinical manifestations of eliglottitis?
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no cough....but,
-drooling -dyspnea -dysphonia -dsyphagia -tripod sitting position -high fever--- often 104 MEDICAL EMERGENCY |
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what is the 1st intervention in a patient with epiglottitis?
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Secure airway! (Call ENT/Anesth)
intubate with ETT 2 sizes smaller than normal size for child |
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Tests to order for epiglottitis
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Cultures, ABG, CBC
Xray-looking for thumb sign |
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Treatment of Epiglottitis
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-after securing airway, 100% o2
-IV fluids -IV abx x5 days (cefotaxime, ceftriaxone, cefuroxime) -if HiB is determined to be the cause, then treat whole family with prophylaxis Rifampin x4 days |
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what is croup?
what is the triad of symptoms? |
croup is an acute inflammatory/ obstructive disease of the larynx/subglottic tissues which narrows the airway.
Characterized by-- -varying degrees of stridor -barky cough -hoarseness |
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what is the peak months that croup occurs?
what is the age group of children that croup is most commonly found? |
peak between october to april
most common b/w 6 mo-3 yrs |
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what are the clinical manifestations of croup?
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-1 to 5 day hx of mild URI (rhinorrhea, cough, low grade fever, sore throat possible)
-around 1-2 days after onset of URI sx, stridor, barky cough, and hoarseness occur, possible lower airway wheezing -croup sx peak day3-4 -sx worse at night and with crying -may see retractions, hypoxemia |
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diagnosis of croup
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-diagnosis is usually clinical
-CXR (inspiratory & expiratory)-- not necessary -AP neck x-ray (may demonstrate subglottic narrowing) -CBC- wbc may demonstrate predominance of lymphocytes |
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what will you see in a AP neck x-ray if a patient has croup?
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-subglottic narrowing
-called steeple sign |
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what is treatment for mild croup?
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-humidification initial treatment
-corticosteroids (dexamethasone single dose 0.15 to 0.6mg/kg/dose to max of 10-12 mg) -budenoside inhalation -acetaminophen+ motrin -encourage fluids |
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what is treatment for moderate to severe croup?
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-racemic epinephrine--alpha and beta adrenergic effects (dose 0.05-0.1ml/kg/dose with normal saline)
-monitor for 2-3 hrs after administering hospitalize for severe symptoms -o2, iv fluids, intubation |
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Parental guidance for croup
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-cool mist humidity
-steamy bathroom -no cough or cold meds -antipyretics -fluids (but no red colored drinks) -lasts 3-4 days, worse at night -education on s/s of resp distress |
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what is bacterial tracheitis?
what is the most common causative organism? |
Bacterial tracheitis
-acute infectious disease of the airway -common features of epiglottitis -characterized by subglottic edema and copious muco-purulent material in the trachea -common causative organism is staph aureus or MRSA |
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what are s/s of bacterial tracheitis?
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-preceding mild URI suddenly gets worse over 8-10 hours
-hoarseness, brassy cough, stridor, and increasing airway obstruction -PE shows resp distress (cyanosis and retractions) -febrile, appearing toxic (103-106) -Blood cx positive/ can be neg -elevated WBC |
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Treatment of bacterial tracheitis?
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-antipyretics
-airway managment -oxygen -antibiotics |
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what is bronchiolitis?
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-acute infections, inflammation of the upper and lower respiratory tract to include the bronchioles
-inflammation, edema, and necrosis of epithelial cells with increased mucus production and bronchospasm -common, acute, contagious |
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what the are peak months that bronchiolitis occur?
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winter months
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what is the most common cause of bronchiolitis?
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80% of bronchiolitis is caused by RSV
other causes are parainfluenza, adenovirus, rhinovirus |
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what are the clinical manifestations of bronchiolitis?
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-clear, profuse rhinorrhea
-low grade fever; unless concurrent bacterial infection with a high grade fever -cough with use of accessory muscles -nasal flaring -intercostal retractions -dyspnea, tachypnea, wheee -apnea in preemies -happy wheezer vs. tired/fussy |
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what is the diagnostic evaluation of bronchiolititis?
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-pulse ox
-CBC + electrolytes not necessary -ABG -CXR may be considered if pt not improving -nasal wash for RSV and/or influenza |
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testing for RSV bronchiolitis
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nasopharyngeal wash-- RSV culture is the Gold standard
Rapid RSV tests, ElSA, and direct fluorescent antibody available in many offices |
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when do you consider consultation or admission for bronchiolitis?
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-infant younger than 3 mo or
-infants <6 mo and hx of prematurity -apneic episodes -resp rate >60 -child feeds poorly, not drinking -signs of dehydration -history of congenital heart disease or bronchopulmonary dysplasia -congenital or acquired immunodeficiency -recurring episodes of bronchiolitis |
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what is the treatment for bronchiolitis?
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-supplemental o2
-hydration, if not drinking then pt needs an IV -bronchodilators (controversial) -racemic epinephrine -glucocorticoids not recommended -antibiotices rarely indicated |
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what are some parental guidance for home management for bronchiolitis?
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-s/s of resp distress
- do not feed if RR>60 (risk for aspiration) -explanation on why meds are generally not effective (self-limiting illness, a virus) -clear secretions with bulb (mouth 1st then nose) -avoid environmental irritants -quiet activity, smaller feeds -no day care -increase environmental humidity *educate parent that 50% of infants will have another wheezing episode in the future |
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what is the follow-up plan for bronchiolitis?
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-f/u with family within 24 hrs
-scheduled visit in office within 48 hrs if child is still febrile or not responding to supportive treatment -ensure child is drinking/peeing |
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what is the criteria for referral to ER for bronchiolitis?
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-signs of hypoxia
-worsening resp symptoms -inability to tolerate oral fluids |
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what is an antiviral treatment for RSV?
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Ribavirin
-virostatic activity against many viruses -interferes with messenger RNA and prevents replication of the virus -rarely used, most often used with intubated pts |
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what is a drug used to prevent RSV?
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Palivizumab (Snyagis)
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what is the criteria for administering Palivizumab (Snyagis) in the prevention of RSV?
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Criteria
-infants with chronic lung disease -infants with hemodynamically significant CHD -considered for infants <1 yr who were born at <28 weeks gestation -considered for infants <6 mo who were born between 29-32 weeks gestation -infants <6 mo who were born between 32-35 weeks gestation if risk factors are present: -RF: childcare/day care, school aged siblings, exposure to air pollutants, congenital abnormalities of airway or severe neuromuscular disease |
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what is pneumonia?
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an acute respiratory infection of the lung parenchyma characterized by inflammation, obstruction, and consolidation.
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what are the clinical manifestations of pneumonia?
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-fever/chills
-tachypnea -cough -symptoms often preceded by URI -apneic spell under 3 mo -wheezing with viral and mycoplasma organisms |
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what is the diagnostic criteria for pneumonia?
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-CBC increased neutrophils
-Chest Xray Pa and lat Bacterial: patchy, lobar infiltrates, pleural effusion, atelectasis Viral: Perihilar streaking, increased interstitial markings, bronchial cuffing or patches -Gram stain of sputum -culture of pleural fluid |
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what would make you consider admission for children with pneumonia?
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-significant increase in work of breathing
-RR >25% of normal -02 requirement (O2 sat <94% room air) -toxic appearance -poor feeding/dehydration -inability to tolerate antibiotic therapy (constant emesis) -underlying disease state -recurrent penumonia-- immunocompromised? |
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what is the outpatient management of pneumonia?
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-symptomatic care (humidity, fluids, antipyretics)
-bronchodilators -incentive spirometer -f/u phone or return to clinic within 24-72 hours -if still symptomatic, change antibiotic -consider effusions or possible empyema if acute pneumonia fails to respond to therapy |
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what is pertussis?
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-known as whooping cough
-50% high pitched inspiratory whoop -caused by bordetella pertussis -transmitted by aerosol droplets from close contact |
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what are 4 factors that account for the persistence of pertussis?
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-infants initially unprotected for first 2 months
-vaccine does not always provide immunity until 3rd or 4th dose -increased refusal of child immunizations -immunity wanes after 10 yrs |
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what are the clinical manifestations of pertussis?
Catarrhal stage? Paroxysmal stage? Convalescent stage? |
Catarrhal stage (1-3 wks)
-mild cough, coryza, sneezing, fever 101 -typical URI sx Paroxysmal stage (2-4 wks) -persistent staccato, paroxysmal cough -ends with inspiratory whoop -vomiting at end of whoop -cyanosis, sweating, prostration, and exhaustion whoops Convalescent stage (2-3 wks) -waning of paroxysmal coughing episodes |
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what are specific findings in infants <6 months of age with pertussis?
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-apnea
-no inspiratory whoop |
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How do you diagnose Pertussis?
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-witnessed paroxysm
-identify from nasopharyngeal swab or nasal wash: PCR or culture on special media -CBC: Leukocytosis (20-30,000) with 70 to 80% lymphs |
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How do you treat pertussis?
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erythromycin 40-50mg/kg/day for 14 days
Azithromycin x5 days is approved for infants <2mo old *TX eliminates disease in catarrhal stage, does not affect paroxysmal stage |
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Who needs prophylaxis tx of pertussis?
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Close contacts <7 yrs
-DTaP boooster -Erythromycin Close contacts >7 yrs -Erythromycin |
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Who needs admission for pertussis?
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infants <6 mo
decrease intake oxygen requirement |
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what is tuberculosis?
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-airborne infectious disease, spread by droplet expelled by someone with disease, caused by mycobacterium tuberculosis
-most children asymptomatic when 1st noted to have + Mantoux skin test -80% do not progress to disease |
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What is a positive Mantoux skin test?
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induration >5mm
-children with close contact of known TB -children with suspected TB (findings on chest xray) or clinical evidence -children receiving immunosuppressive therapy Induration >10mm -children <4 yrs old -children exposed to high-prevalent TB areas -children with med conditions Induration >15mm -children >4 yrs old without R.F. (see pg. 160 in Peds text) |
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what is the treatment of TB?
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isoniazid
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what are risk factors for TB?
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-close contact with ppl with TB
-Born in TB prevalent part of world -HIV positive or immunocompromised -chronic diseases -incarcerated adolescent (group home) -resident of homeless shelter |
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what is cystic fibrosis?
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-autosomal recessive inherited disorder which mutations in gene results in exocrine glands failing to function normal particularly in resp, GI, and reporductive systems
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what are presenting symptoms of cystic fibrosis?
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newborn- meconium ileus, failure to thrive
older child-diarrhea, difficulty gaining weight, recurrent respiratory infection |
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what clinical manifestations would make you suspect cystic fibrosis?
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-recurrent pneumonia, bronchitis, or resp infections
-failure to thrive with steatorrhea -biliary cirrhosis -nasal polyps -meconium ileus -rectal prolapse -family hx of CF -clubbing (late sign) |
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how do you diagnose cystic fibrosis?
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sweat chloride test
>60 mEq sweat chloride concentration genetic analysis *treat pt with concern for pseudomonas when pt presents with infection |
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what is choanal stenosis or atresia?
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a congenital nasal airway obstruction
-associated with CHARGE 1:5000:8000 girls>boys |
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how do you assess for choanal stenosis or atresia?
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-no passage of air through nose (listen with stethoscope
-pass 5 or 6 Fr cath into nose- -CT *Urgent referral to ENT, bilat atresia is an emergency! |
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what is CHARGE?
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Coloboma
Heart disease atreasia choanae retarded neuro development genital hypoplasia ear anomalies |
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Clinical Findings of the Common Cold
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-sudden onset of clear or mucoid rhinorrhea, nasal congestion, fever
-sometimes mild sore throat or cough -fever low grade in older children -can be as high as 105deg in children <6 yo -fever resolves in 3-5 days -Sore throat resolves in 9 days -cough and nasal congestion can last 2 weeks+ |
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what is the treatment of acute nasal congestion and sinusitis in pt with sx <10 days?
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URI tract, viral sinusitis
pain managment humidified air saline nose drops cough suppressants (not <6 yo) |
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what is the treatment of acute nasal congestion and sinusitis in pt with sx >10-14 days or pts with periorbital edema sinus tenderness or severe headache?
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Most likely bacterial
Mild sx--> abx 10 days, if poor response after 3 days, then use 2nd line abx Severe sx or immunocompromised--> B lactamase stable antibiotic, imaging, eval for complications |
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what is the treatment of the common cold?
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-oxymetolazine nasal 12 hr 1-2 puffs BID x3 days
-bulb suction -cool mist vaporizer (clean q24h) -vaporub -antihistamines not effective -discourage codeine -no cough medicines, decongestants or cold meds <6yo |
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what are signs of complications of the common cold?
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-fast or difficult breathing--sign of bronchiolitis or penumonia
-prolonged fever or fever that begins or worsens in the middle of the illness--could mean OM or sinusitis. most likely bacterial |
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what is acute bacterial rhinosinusitis?
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caused by a bacterial infection of the paranasal sinuses. Symptoms include facial pain and pressure, purulent drainage, congestion and fever.
-usually occurs 2nd to a viral infection -a viral URI that does not improve after 10d or worsens after 5-7d -7% of URIs complicated by ABRS -maxillary and ethmoid most common sinusitis -frontal sinusitis unusual before 10yo |
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what are the most common pathogens of ABRS?
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-strep pneumoniae
-Haemophilus influenzae -Moraxella catarrhalis -Chronic- staph, pseudomonas -rare-TB, diptheria, syphilis |
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treatment of ABRS
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narrow spectrum abx
-consider decongestants, nasal steroids, antihistamines -consider a CT if suspect orbital or cranial complications, or not improving -if recurrent or chronic sinusitis, consider immunodeficiency? |
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s/s of allergic rhinitis
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frequent sneezing, rubbing nose, clear drainage, nasal congestion interferes with sleep, daytime somnolence, and hyperactivity
nasal crease, allergic shiners, swollen red, pink, or pale turbinates |
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Treatment of allergic rhinitis
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-nasal steroids
-nonsedating antihistamines -montelukast as additive therapy -ipratropium as adjunct (anticholinergic) -avoid triggers |
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what is vasomotor rhinitis?
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rhinitis not caused by an infection or allergy. cause is UNKNWN.
-triggered by something that interferes the nose, such as a dry atmosphere, air pollution, etc. |
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treatment of allergic rhinitis?
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-oral decongestants
-nasal steroids |
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what is epistaxis?
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nose bleeds
-episodes are common in children -commonly in the anterior nasal septum (kisselbach's area) -posterior epitaxis (rupture of sphenopalantine artery) is more severe and less common in children--- REFER TO ENT! |
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when is epitstaxis frequently seen?
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during winter months, in homes that have dry heat
-very rare during infancy and after puberty -more common in boys |
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Common causes of Epistaxis
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-digital trauma
-mucosal drying and local irritation -foreign bodies -other nasal trauma -allergic rhinitis -frequent URIs -chronic topical nasal steroids |
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management of epistaxis
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-have child sit up and lean forward to avoid swallowing blood-- can irritate GI tract
-pinch nose over bleeding site for 10 min -cold compresses -if continues, change position of compression -Afrin (oxymetazoline) or neosynephrine topically -packing if bleed is posterior-- call ENT |
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management of CHRONIC epistaxis
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-apply petrolatum, water based ointment or abx ointment to nasal membranes
-nasal saline irrigation or drops-- keep nose moist -humidifier -avoid aspirin and ibuprophen -cautery may be needed |
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when do you consult or refer to ENT for epistaxis?
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-bleeding more than 30 minutes and not controlled by compression
-recurrent bleeding from same nostril -persistent bleeding after trauma -bilateral bleeding -bleeding not from kisselbach's plexus (anterior) -Hematologic eval for FM of bleeding d/o, PH of easy bleeding (dental work, circumcision), spont bleeding, bleeding >30 min, onset before age 2 or any drop in HCT -high BP (rare) -for adolescents with recurrent epistaxis, consider angiofibroma, CT of nasal cavity and nasopharynx is diagnostic |
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what is a nasal furuncle?
|
-a boil-- infection of a hair follicle in the anterior nares; tender, firm, red lump
-caused by bacteria staph aureus |
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how do you treat a nasal furuncle?
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-diclox or keflex x5 days to prevent spread
-I&D as soon as it comes to head -topical bacitracin -education: do not pick or squeeze |
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complications of a nasal furuncle
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-cellulits or spread or infection requires hospitalization
-nasal septal abscess--> immediate hospitalization and I&D by ENT |
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signs of nasal fracture or cartilage dislocations
|
-persistent nose bleed after trauma
-crepitus or instability of the bones of the nasal bridge -marked deviation of the nose to one side -can only r/o by careful intranasal exam, xray not necessary *If you suspect- refer to ENT in within 48-72 hours of injury |
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what are s/s of nasal foreign body?
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unilateral rhinorrhea, foul smell, halitosis, bleeding, or nasal obstruction
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what is the treatment of nasal foreign body?
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Initial TX: aggressive nose blowing if old enough
Next option: topical anesth, nasal decongestion, good light, instrumentation, and physcal restraint -consider ENT if cannot be removed |
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what are aphthous stomatitis?
|
-canker sores
-3-10mm ulcers on inner aspect of lips/tongue rarely on tonsils or palate -painful, lasting 1-2 wks -can be recurrent |
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treatment of aphthous stomatitis
|
betamethasone valerate ointment BID (stomatitis solution, lidocaine swish and spit)
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associated symptoms of herpes simplex gingivostomatitis
|
fever, tender cervical nodes, generalized inflammation of mouth
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treatment of Herpes simplex gingivostomatitis
|
if early, acyclovir suspension 20mg/kg/dose qid for 5 days
*watch closely d/t poor feeding and drinking *may occasionally need hospitalization |
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what is a rare complication of herpes simplex gingivostomatitis?
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herpetic laryngotracheitis
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what is thrush?
|
-oral candidiasis
-whitish, velvety lesions in the mouth and on the tongue. -Caused by candida albicans, a fungus |
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risk factors of thrush
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-oral abrasions, immunocompromised
-antibiotics, systemic or inhaled corticosteroids |
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s/s of thrush
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refusal or feeding, white, curd like substance which cannot be washed away
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treatment of thrush
|
nystatin oral suspension 2ml qid x7days
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what are causes of traumatic oral ulcers?
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-biting
-hot foods -aspirin-->cause mucosal necrosis if held in mouth -caustics *oral ulcers can also occur w/leukemia and cyclic neutropenia |
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most common cause of pharyngitis and tonsilitis
|
90% caused by viruses (most commonly adenovirus; also enteroviruses)
Bacterial causes are Group A beta-hemolytic streptococcus and N Gonorrhea Corynebacterium diphtheriae |
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associated symptoms of viral pharyngitis
|
gradual onset
-rhinorrhea most common -sore throat -mild cough -low grade fever -exudate not uncommon |
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associated symptoms of Group A Beta hemolytic Strep
|
-usually sudden onset of sore throat, pain on swallowing, fever
-may also have h/a, n/v, abd pain |
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Group A Beta hemolytic Strep is primarily seen in what age group?
|
children 5-15 yo
usually in winter and spring |
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Clinical Manifestations of Group A strep
|
-tonsillo-pharyngeal erythema with or without exudate
-red swollen uvula, petechiae on palate -tender, enlarged cervical lymph nodes -tonsillar enlargement -strawberry tongue |
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how do you diagnose Group A strep?
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Throat culture, unless scarlet rash
10% of throat culture are false-neg -rapid strep >95% specificity -sensitivity 60-94% all negative rapid strep tests should be confirmed by throat culture (controversial) |
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treatment of Group A strep will help prevent_____
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-rheumatic fever
-suppurative sequelae of peri-tonsillar abscess -retropharyngeal abscess -cervical lymphadenitis -will not prevent acute post-streptococcal glomerulonephritis |
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treatment of group A strep
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oral penicillin x10 days or
benzathine penicillin IM If allergic to PCN, macrolides indicated -antipyretics -increase fluids, rest -may return to school/work after 24 hr of abx and when afebrile for 24 hrs |
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signs of scarlet fever
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-white furred tongue with red ages
-beefy red pharynx w/ exudate on tonsils -strawberry tongue -sudden high fever, malaise, vomiting, abd pain, ocassionally splenomegaly -rash "sand paper" texture; blanches with pressure -rash appears on chest about 24 h after onset of symptoms -pastia's lines -face flushed -circumoral pallor -exanthem last 4-5 days -begins to desquamate 1st on face, last on palms and soles |
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what is mononucleosis?
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a viral infections most commonly EBV
characterized by exudative tonsillitis, cervical adenitis, fever, usually older than 5, palapable spleen or axillary adenopathy increases suspicion, >10% atypical lymphs on CBC or + monospot supports dx EBV IgM capsid antibody is definitive |
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Treatment of mononucelosis?
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supportive care- antipyretics, rest, avoid contact activities
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what is herpangina?
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-3mm ulcers surrounded by a halo
-anterior pillars of the soft palate and uvula, but not in anterior mouth or on tonsils -Coxsackie A virus family TX: supportive |
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what is hand-foot-mouth disease?
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-enteroviruses (coxsackie viruses)
-ulcers occur anywhere in mouth -vesicles, pustules, papules on the palms, soles, interdigital area, and buttocks (young kids can have lesions on distal extremities and face) -fever, ST, and malaise TX: supportive (tylenol, adequate hydration) |
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what is pharyngoconjunctival fever?
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caused by an adenovirus and often is epidemic
exduative tonsillits, conjunctivitis, lymphadenopathy, fever TX: symptomatic |
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what is a peritonsillar abscess?
|
-tonsillar infection penetrates the tonsillar capsule
-spreads to surrounding tissues, causes cellulitis, necrosis and tonsillar abscess -Beta hemolytic strep, also group D strep, strep penumoniae, and aneorobes |
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signs of peritonsillar abscess
|
fever, unilateral, hot potato voice
soft palate and uvula deviate to uninvolved side late-- trismus, ear pain, dysphagia, drooling *URGENT to ER!, ENT must I&D |
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what is retropharyngeal abscess
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an abscess located in the tissues in the back of the throat behind the posterior pharyngeal wall (the retropharyngeal space).
-beta hemolytic strep, strep aureua -mostly kids <2 yo |
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signs of retropharyngeal abscess
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fever, respiratory symptoms and neck hyperextension
*Surgical Emergency |
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what is Ludwig angina?
|
cellulitis of the submandibular space
-causes airway obstruction and death -fever and tender swelling of the floor of the mouth |
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what is acute cervical adenitis?
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-local infections of ear, nose, and throat infect a regional node and form an abscess
-unilateral, solitary, anterior cervical node |
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when would you suspect a malignant tumor?
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-suspect if adenopathy persists after abx treatment
-nodes painless, nontender, firm to hard -fixed to underlying tissues -single node, unilateral in a chain, bilateral cervical or generalized |
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common malignancies present in the neck
|
Hodgkins, non-Hodgkins, rhabdomyosarcoma, thyroid carcinoma
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what are differential diagnoses of adenitis
|
-thyroglossal duct cyst
-branchial cleft cyst -lymphatic hygroma -parotits -ranula -sternocleidomastoid hematoma |
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true contraindications of breastfeeding
|
INFANT
-galactosemia -inborn errors of metabolism like PKU MATERNAL -HIV -radioactive substances -antimetabolites (antifolates, purines) or chemo -illegal drug use -herpetic lesions (shingles)-may nurse on unffected breat -active untreated TB |
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severe consequences of volume depletion
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-ischemic end-organ damange
-serious morbidity (renal failure, brain damage, etc) -shock, death |
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describe mild dehydration
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-3 to 5% volume loss
-hx of fluid losses may be the sole finding -clinical signs may be absent or minimal -may have a reduction in urine output |
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describe moderate dehydration
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-6 to 9% volume loss
-s/s: tachycardia, orthostasis, orthostatic hypotension, decreased skin turgor, dry mucous membranes, irritability, decreases peripheral perfusion, cap refill 2-3 sec, deep respiration without an increased RR, reduced urine output, decreased tearing, infants with open fontanelles will be sunken |
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describe severe dehydration
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>10% volume loss
-near shock presentation: hypotension, decreased peripheral perfusion with a cap refill >3 sec, cool and mottled extremities, lethargy, deep respirations with increased RR *severe hypovolemia requires immediate aggressive isotonic fluid resuscitation |
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what is the most useful laboratory test to assess degree of dehydration in children
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serum bicarbonate
*a value of <17mEq/L differentiates children with moderate and severe hypovolemia from those with mild hypovolemia |
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BUN and dehydration
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BUN rises with increasing severity of hypovolemia
reflects the decline in glomerular filtration rate and increase in sodium and water reabsorption and urea recycling *BUN can be increased by bleeding or catabolic tissue breakdown |
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labs used for assessing dehydration
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-serum bicarb
-BUN -chemistry -CBC -urine |
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Urine osmolality and Specific gravity
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high osmolality = hypovolemia
but, isosmotic value does not exclude hypovolemia Specific gravity is less accurate than osmolality. A value of >1.015 is suggestive of a conc. urine, as in hypovolemia |
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what is the IV management of severe dehydration
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isotonic crystalloids
0.9% saline solution 10-20ml/kg over 5-15 min -consult if pt needs more than 40ml/kg |
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what are indications for continued intravenous therapy for dehydration?
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-inability of the child to take oral rehydration therapy
-inability of the care taker to provide ORT -failure of ORT to provide adequate rehydration (vomiting) -severe electrolyte problems where ORT cannot be closely monitored or electrolytes frequently assessed |
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Describe ORT administration
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-administration of frequent small amounts of fluid by spoon or syringe
-no more than 5 ml administered every 1-2min by spoon or syringe -total of 50ml/kg in mild dehydration -100ml/kg in moderate dehydration -if pt is breastfed, breastfeeding is maintained during the rehydration phase and is continued into the maintenance phase. |
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what are types of fluids to avoid when a child is dehydrated
|
--Gelatin, tea, fruit juice, sports drinks, and soft drinks--> too much carbs, too little sodium, can increase diarrhea and increase risk of hyponatremia
--Chicken soup--> too much sodium and too liitle glucose |
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what is considered fever?
rectal? oral? axillary? |
Rectal temp >38 C (100.4F)
Oral temp >37.8 C (100 F) Axillary >37.2 C (99.0 F) |
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a typical fever can increase HR by ____ beats per 1C
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HR 10-15 increase per 1C
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what are some general rules about fevers in children?
admission criteria? children with complicating risk factors? |
-admit all toxic-appearing infants and children,
-admit febrile children younger than 28 days regardless whether or not they meet low risk criteria -the general fever "criteria" does not apply to children with complicating risk factors-- ie immunocompromised, indwelling devices, currently taking abx, or fever >5 days |
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what is a "toxic appearing" infant or child?
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cyanosis, decreased activity, hyper and hypo ventilation, inability to interact with parents or surroundings, irritability, lethargy, poor tone, signs of poor perfusion, tachycardia, or weak eye contact
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most common serious bacterial infection seen in febrile infants?
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urinary tract infection
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what is the workup for infants 0-90 days?
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-CBC and blood culture
-urine and urine culture -lumbar puncture and cultures -if resp s/s, do a chest xray |
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management of infants less than 28 days?
|
- assess temp taken
-if >38C or 100.4F, admit -if baby 28 days (4 weeks) to 8 weeks old, possible admission -Refer to peds or ED -will need a full septic workup -antibiotic therapy |
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what is the workup for infants 1-3 months old with >100.4F fever?
|
-WBC 5-15,000
-UA <5 WBC/hpf and nitrite/LE negative (cath UA) -CXR if resp symptoms -seasonal RSV or influenza swabs |
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what is the workup for infants 3-36 months?
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-no lab test or abx if fever without source is <39C or 102.2 F
-prescribe antipyretics -return to clinic if fever persists longer than 48 hrs or child is worse if temp is >39 C or 102.2F, then evaluate for bacteremia, UTI, & pneumonia |
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for children 3-36 months with fever of 102.2 F or more, you will evaluate for occult bacteremia..
what children is considered high risk? and what children is considered low risk? |
high risk
-less than 2 PCV vaccines -temp >40C or 104F -contacts with meningococcal disease -petchiae -prolonged gastroenteritis -abnormal urine test <18mo Low risk -more than 2 PCV and no high risk criteria - no blood testing |
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for children 3 to 36 months old, when evaluating and treating for occult bacteremia, there are 2 options
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Option #1
Blood culture +/- Ceftriaxone Option #2 Blood culture CBC with differential if WBC >15K, treat with ceftriaxone |
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who should be evaluated for occult UTI?
|
-all children <6 months
-girls <24 months if 1 or more risk factor is present: *fever *age <12 months *white rate *no alternative source for fever -uncircumcised boys <12 months -patients w/ fever 38.3-38.9C if they have 2+ risk factors |
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who should be evaluated for occult pneumonia?
|
obtain CXR if:
hypoxic tachypneic resp distress abnormal breath sounds regardless of fever consider if: -no other source identified -temp >39 and WBC >20K -prolonged cough or fever |
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which patients would you have to see immediately with fever?
|
-children <3 mo old
-fever over 40C/104F -child is crying inconsolably or whimpering -child cries when moved or otherwise touched -child is difficult to awaken -neck is stiff -any petechiae present on skin -child drooling saliva and is unable to swallow -convulsion/seizure -child acts or looks sick |
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what is the treatment of fevers? dosages?
|
Acetaminophen 10-15mg/kg/dose q 4-6 hours
*treat if fever >39C/102F and/or child is uncomforable Ibuprofen 5-10mg/kg/dose q 6-8 hours sponging lukewarm increase fluid intake |
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conduction
|
the loss of body heat to cooler substances in direct contact with the neonate
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convection
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the flow of heat from the body to cooler air
example-- infant inside an air conditioned room |
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evaporation
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heat loss when liquid is converted to a vapor
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radiation
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loss of body heat to cooler, solid surfaces near (but not in direct contact) to the neonate
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what are the stage of fever?
|
1) prodromal
2) phase of increase 3) climax 4) descent |
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what are some bacterial infections seen in febrile infants?
which is the most common? |
most common-UTI
meningitis bacteremia penumonia osteomyelitis |
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Describe Autosomal Recessive inhertiance
|
Both parents carry a normal gene (N), and a faulty, recessive, gene (n). The parents, although carriers, are unaffected by the faulty gene. Their offspring are affected, not affected, or carriers.
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Decribe Autosomal Dominant inheritance
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One parent has a single, faulty dominant gene (D), which overpowers its normal counterpart (d), affecting that parent. When the affected parent mates with an unaffected and non-carrier mate (dd), the offspring are either affected or not affected, but they are not carriers.
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Define penetrance in autosomal dominant disorders
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Penetrance is the ability to recognize the presence of the abnormal gene by the phenotypic appearance. Expressed as a percentage
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Define variability in autosomal dominant disorders
|
Variability is the differences in expression of a condition among those with the condition
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Name common AD conditions
|
Apert syndrome
Marfan syndrome Neurofibromatosis Waardenburg syndrome (Look at pictures) |
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autosomal recessive or autosmal dominant?
-involves enzymatic disorders -males and females equally affected -increased chance of parental consanguinity, particularly with very rare disorders |
autosomal recessive disorders
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name common AR conditions
|
cystic fibrosis
sickle cell anemia tay-sachs disease phenylketonuria PKU congenital adrenal hyperplasia mucopolysaccharidoses urea cycle abnormalities |
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describe X linked disorders
|
-mutations on the X chromosome
-disorder is expressed in males -absence of a normal X chromosome -no male to male transmission -daughters of affected males are carriers -1/3 are new mutations -2/3 passed from a carrier mother -females can express if: -affected father and carrier mother -they have only one X (Turner syndrome 45,X) -they have an X-autosomal translocation |
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Name common X linked conditions
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-hemophilia A and B
-duchenne and becker muscular dystrophy -deutan color blindness 1:10 males -glucose-6-PD |
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name conditions with extra chromosomes
|
Down Syndrome (trisomy 21)
-1:700 live births Trisomy 18 -1:3000 live births Trisomy 13 -1:5000 live births |
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name conditions with missing chromosomes
|
-Turner syndrome (45, X) 1:5000 live births
-Robertsonian translocation- chromosomes 13 and 14 occurs 1:1300 live births |
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name conditions with missing
-4p- -5pi- |
4p- Wolf-Hirshorn syndrome
5p- Cri du chat |
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what is multifactorial anomalies?
|
-interaction of multiple genes and environment
-no predictable recurrence pattern -higher risk if >1 family member affected, affected person in less commonly affected sex (ie male with breast cancer), more severe intial condition -reduced risk if more distant relationship (negligible in 3rd degree relative) |
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Name multifactorial disorders
|
-neural tube defects
-congenital heart disease -isolated cleft lip/palate -club foot -congenital hip dislocation -pyloric stenosis 5% in male/20% in females -endometriosis -anecephaly -encephalocele -spina bifida -sirenomelia (mermaid) |
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what is mitochrondrial inheritance?
|
-different mitochondria may or may not have the mutation
-severity of disease proportional to proportions of normal and abnormal mitochrondrial DNA -affected females transmit to all their children; affected males cannot transmit the disease |
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define the terms: syndrome, association, sequence
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syndrome: specific pattern of abnormalities with a presumed genetic cause
association: collection of abnormalities occurring together without a genetic cause sequence: collection of abnormalities occurring as the result of an abnormal function of a preceding structure |
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define the terms: malformation, deformation, disruption, dysplasia
|
malformation: structural defect with very early onset (ie neural tube defect, cleft lip/palate)
Deformation: mechanical force causing abnormal form, shape or position (ie oligohydramnios, clubfoot) Disruption: structural defect d/t interference with originally normal development (ie teratogens, amniotic bands) Dysplasia: abnormal organization of cells into tissue (ie connective tissue and bone dysplasia) |
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syndrome with poor muscle tone
|
prader-willi syndrome-- inherited by mother, deletion 15q
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Assessment of cry
high pitch? low pitch "growly"? kitten-like? |
-high pitch- brain damage
-low pitch "growly"- hurler's syndrome or hypothyroidism -kitten like cri du chat deletion 5p |
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syndrome associated with a flattened face
|
zellweger syndrome
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syndrome associated with synophrys (unibrow)
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de Lange syndrome
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disorder associated with ear lobe creases
|
beckwith-wiedemann
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syndrome associated with a beaked nose
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rubinstein-taybi
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syndrome associated with a saddle nose
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wegener's granulomatosis
down syndrome |
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syndrome associated with a receding chin
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nijmegan breakage syndrome
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syndromes associated with neck webbing
|
turner syndrome
down syndrome |
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common tests in Newborn screen
|
congenital adrenal hyperplasia
congenital hypothyroid sickle cell galactosemia Phenylketonuria, Maple syrup urine disease homocystinuria biotinidase deficiency |
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Red flags of musculoskeletal pain
|
-fever, acute joint pain, and swelling (infection)
-pseudoparalysis in a single limb (infection) -bone pain, esp at night (malignancy) -stiffness after immobility (inflammatory arthropathy) |
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"rheumatism"
|
non-specific term describing any painful disorder affecting the loco-motor system including joints, muscles, connective tissue, soft tissue around the joints and bones
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|
assessment of the musculoskeletal system, what does STeP-e-WaR stand for?
|
-swelling- effusion, synovial/capsular thickening, soft tissue induration
-tenderness- focal bony, tendon, ligament, synovium, alllodynia (diffuse hyperesthesia) -pain in motion -erythema -warmth -range of motion- passive vs active |
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|
what are the 3 types of JRA?
|
acute febrile form
polyarticular pattern pauciarticular disease |
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describe the acute febrile form of JRA
|
-fever, evanescent salmon-pink macular rash, arthritis, hepatosplenomegaly, leukocytosis, polyserositis
-episodic illness, remission of systemic symptoms in 1 year -no iritis |
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describe polyarticular pattern in JRA
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-resembles adult disease, chronic pain and swelling of many small or large joints symmetrically
-fewer systemic features, but low fever, fatigue, rheumatoid nodules, anemia, and iritis possible -long-standing arthritis with some waxing and waning -may have + RF in older children |
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describe pauciarticular disease in JRA
|
-chronic arthritis of a few joints, often weight bearing joints, asymmetric
-systemic features uncommon -severe extra-articular involvement with inflammation of eye -30% have insidious, asymptomatic iritis *opthalmologic exams Q3m if ANA + and Q6m if ANA - |
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what are treatment options for JRA?
|
primary- nsaids, aspirin
secondary- methotraxate tertiary- lefulnomide, etanercept, infliximab opthalmology to treat iritis |
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|
spondyloarthropathy
|
- lower extremity arthritis esp boys >10
- associated with tendonitis of tibial tubercle and heels -low back pain and sacroilitis -80% positive for HLA-B27 -no autoantibodies but ESR and CRP are high -symptoms intermittent *treat with Indocin NSAIDS |
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enteropathic arthritis
|
-includes reiter syndrome, reactive arthritis, arthritis of inflammatory bowel disease and celiac disease
-lower extremity arthritis with preceding or concurrent GI sx -reactive arthritis can follow diarrhea from salmonella, shigella, yersinia, and chlamydia in those who are HLA-B27 positive (genetic predisposition) -IBD associated manifestations include irits, stomatitis, hepatitis, and erythema nodosum *treat similarly to RA |
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|
what are possible lab findings in SLE?
|
leukopenia, anemia, thrombocytopenia, high ESR, hypergammaglobulinemia, urine red cells, white cells, red cell casts, and proteinuria
-ANA r/o SLE, +ANA is not specific to SLE, so consider anticardiolipin ab, lupus anticouagulant |
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treatment of SLE
|
tailor to individual organs involved
-prednisone, plaquenil (antimalarial), NSAIDS, cyclophosphamide, tacrolimus, cyclosporine, mycophenalate |
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|
what is dermatomyositis (polymyositis)?
|
-inflammatory disease of muscle and skin, uniquely responsive to corticosteroids, last 1-3 years
-in children, vascular changes found in skin, muscle, kidney, retina and GI tract -can have thrombus formation -muscle weakness in pelvis and shoulder, may have tenderness, stiffness and swelling -late onset neuro involvment |
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|
diagnosis of dermatomyositis?
|
muscle enzymes including aldolase
ANA + electromyography (EMG) |
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Treatment of dermatomyositis
|
prednisone
methotrexate immunoglobulin cyclosporine |
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|
what is polyarteritis nodosa?
|
-inflammation and vasculitis of medium sized arteries
-thrombosis and diseased arteries may cause organ infarction -large array of symptoms, difficult to diagnose, unexplained fever, conjunctivitis, CNS, cardiac sx more prominent in kids -may appear as acute myocarditis rare but significant numbers in childhood and infancy - |
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diagnosis of polyarteritis nodosa
|
biopsy
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treatment of polyarteritis nodosa
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prednisone
other immunosuppressants IV immune globulin |
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what is scleroderma?
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-skin disease starts as indurated and depigmented patches (morphea) or streaks of skin on an extremity (linear scleroderma)
-over time SQ tissues becomes atrophied and contractures develop in affected joints |
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diagnosis of scleroderma
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biopsy
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treatment of scleroderma
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-physical therapy
-methotrexate -vit d analogues (ergocalciferol) |
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what is raynaud phenomenon?
clinical presentation? diagnosis? treatment? |
-intermittent vasospasm of fingers and toes
-10% adults, common in children -triphasic presentation- cold induced pallor then cyanosis, followed by hyerpemia -DX: thorough ROS and exam including evaluation for nail fold capillary abnormalities -TX: hand warming (mittens, not gloves), stress management, calcium channel blockers in the winter |
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what are nonrheumatic pain syndromes?
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-Reflex sympathetic dystrophy
-Fibromyalgia -Chronic Fatigue syndrome |
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Reflex sympathetic dystrophy
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severe extremity pain leading to loss of function, color changes temperature differences, dyshidrosis of affected extremity, feet most common
*TX: rehab and densnsitization |
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Fibromyalgia
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diffuse pain syndrome without associated swelling, exacerbated by weather and fatigue, appear normal except classic trigger points
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chronic fatigue syndrome
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difficult to diagnose, severe fatigue with a definable date of onset, low grade fever, lymphadenopathy, neuropsyc problems, not fully explained
DX of exclusion |
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what is hypermobility syndrome
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-ligamentous laxity
-common cause of joint pain, improper joint alignment -episodic joint pain, and ocassionallly swelling that lasts a few days after increased physical activity |
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diagnosis of hypermobility syndrome
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DX: thumb to forearm, hyperextension of the fingers so they are parallel to forearm, hyperextension of the elbow genu recurvatum, able to put palms on the floor with knees extended
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treatment of hypermobility syndrome
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graded conditioning program
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what is jaundice?
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yellowish discoloration of the skin caused by deposition of the pigment bilirubin
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what is icterus?
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jaundice
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what is kernicterus?
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type of brain damage chacterized by athetoid cerebral palsy (uncontrollable movement of the face, body, arms, and legs) and deafness.
-due to marked jaundice in the newborn period -the high blood level of the pigment bilirubin results in its deposition in the brain, which damages the brain |
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indirect (unconjugated) bilirubin
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-insoluble in water
-travels through the bloodstream to the liver, where it is changed into a soluble form (aka direct or conjugated bili) |
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Direct (conjugated) bilirubin
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-direct bilirubin soluble in water
-made by the liver from indirect bilirubin |
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jaundice with breastfeeding
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-breastfeeding jaundice is most common in preterm and term infants who nurse <8 times in 24 h and have difficulty establishing an effective feeding pattern
-poor feeding results in a catabolic state and increased serum total bilirubin (TSB) -increasing frequency and amount of breastfeeding will help relieve this state, as well as stimulating the excretion through urine and feces |
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what is "breast milk jaundice"?
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-an elevation in unconjugated bilirubin
-breast milk has beta-glucoronidase which coverts conjugated bili to unconjugated bili -usually presents after 5 days of age and can persist for several months -STB decrease with cessation of nursing for 24 h (only done if necessary) |
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What is "breastfeeding failure" jaundice?
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-occurs within the 1st week of life as lactation failure leads to inadequate intake
-with significant weight and fluid loss resulting in hypovolemia -causes hyperbilirubinemia (jaundice) -hypernatremia > 150meq/l -decreased intake also causes slower bilirubin elimination and increased enterohepatic circulation that contributes to elevated STB |
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causes of Increased bilirubin production leading to hyperbilirubinemia
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-increased bilirubin production from breakdown of RBCs secondary to ABO, RH or minor blood group incompatibilities, polycythemia, extravasated blood
-hemolysis from ABO incompatibility is seen in 10% of A or B pos infants born to O pos moms -Rh sensitization is more severe but less common -caused by G6PD deficiency or pyruvate kinase deficiency and hereditary spherocytosis -congenital infections from CMV, rubella, or taoxoplasmosis can increase hemolysis |
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what are some other causes of hyperbilirubinemia?
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-metabolic d.o.'s
-A-1 antitrypsin deficiency -Cystic fibrosis -fructosemia, galactosemia, glycogenesis -biliary atresia -gilbert disease -sulfisoxoazole, monolactam |
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risk factors of hyperbilirubinemia
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-asian, native american, mediterranean
-Diabetes mellitus, including GDM -RH or ABO incompatibility, other coombs positive hemolytic conditions -use of oxytocin in hypotonic solutions during labor -instrumentation during labor -breast-feeding -preemies and near term infants (35-37 weeks) -infants with sibling who had jaundice -polycythemia -cephalohematoma, hidden bleeding or bruising |
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clinical jaundice
estimation of bili levels if jaundice present in: -face? -body to naval? -lower body/limb? -hands and feet? |
Facial jaundice: 4-8
Body jaundice to naval: 5-8 Lower body/limb jaundice: 8-12 hands and feet jaundice: >15 *while these aren't exact, they give a rule of thumb * if jaundice below the level of the chest or worsening, measure! |
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Lab tests for evaluation of hyperbilirubinemia
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-serum direct and indirect bilirubin
-CBC with peripheral smear -retic count -blood type -direct coombs -end tidal Carbon monoxide -UA and blood cultures, if sepsis supected -If direct bili is elevated, initiate a work up for metabolic or genetic disease or cholestasis/biliary atresia |
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what is the criteria that supports pathologic jaundice?
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-clinical jaundice in 1st 24 hours of life
-STB >95% for age in hours -STB increasing by >0.05 mg/dl/hr -direct serum bilirubin exceeding 1.5 to 2 mg/dl -clinical jaundice persisting >2weeks in a full term infant |
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Hyperbilirubinemia:
who is low risk infants? medium risk infants? high risk infants? |
LOW risk
->38 wks gestation w/o risk factors MEDIUM risk ->38 wks gestation w/ risk factors, or -35 to 37 6/7 wks gestation w/o risk factors HIGH risk -35 to 37 6/7 wks gestation w/ risk factors |
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labs values that will indicate phototherapy for LOW RISK infants
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24h, 48h, 72h
>12, 15, 18 |
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labs values that will indicate phototherapy for MEDIUM RISK infants
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24h, 48h, 72h
>10, 13, 15 |
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labs values that will indicate phototherapy for HIGH RISK infants
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24h, 48h, 72h
>8, 11, 13.5 |
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what is exchange transfusion for treatment of hyperbilirubinemia?
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exchange transfusion is used to remove bilirubin from the circulation when intensive phototherapy fails or in infants with signs of bilirubin-induced neurologic dysfunction
*starts at STBs of 15-19 based on level of risk or symptoms |
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what was the ACE study?
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ACE= adverse childhood experiences
study was to see if there was a relationship between multiple categories of childhood trauma (ACE) and health/behavioral outcomes later in life |
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What are the 2 categories of ACE?
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ABUSE
-psychological -physical -sexual HOUSEHOLD DYSFUNCTION -substance abuse -mental illness -mother treated violently -criminal behavior in household |
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ACE determines the probability of risk for the 10 most common causes of death in the US. what are the 10 most common causes?
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smoking
physical inactivity suicide attempt illicit drug use 50+ sexual partner severe obesity alcoholism IV drug use h/o STD |
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at what age is bruises very uncommon or should not be present at all?
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under 6 months
there should be no: facial bruises very rare to have scalp bruises no extremity, hand, or foot bruises no truncal or buttock bruises |
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Tests that should be ordered if a child has bruises or injuries on body.
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-if less than 2 yo, must order skeletal survey
-head CT -eye exam (to eval for subconjunctival hemorrhage) -CBC/PT/PTT |
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what is phytophotodermatitis?
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-exposure to psoralens by plant juices followed by sunlight
-can look like purple-red pattern bruise, hives or blisters, or healing burns |
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what is henoch-schonlein purpura?
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systemic vasculitis that causes blood vessels in the skin to become inflamed, causing red spots. when the blood vessels in the skin get inflamed, they can bleed, causing purpura (rash)
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what is Ehlers-Danlos?
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-autosomal dominant defect, type V collagen
-hyper-elastic skin, joint hypermobility -poor wound healing -minor trauma leading to bruise |
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When does a D have the right to remove a case to federal court?
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D can remove if the case could have been filed by P in federal court, so must have FQ or diversity jurisdiction.
The rules? |
1) Only D can remove
2) One-way Street, parties can't request back to state court 3) Judge can remand if removal was improper |
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Celebrex
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Celecoxib
sell-ah-COX-ib |
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symptoms of MILD INTERMITTENT
asthma? treatment? |
daytime <2x/week
nighttime <2 nights/month >80% FEV1 SABA PRN |
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symptoms of MILD PERSISTENT asthma?
treatment? |
daytime >2x/week but <1x/day
night time >2 nights/month >80% FEV1 low dose ICS |
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symptoms of MODERATE PERSISTENT asthma?
treatment? |
daytime daily
daily use of SABA night time >1 night/wk 61-80% FEV1 low to med dose ICS & LABA |
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symptoms of SEVERE PERSISTENT asthma?
treatment? |
daytime- throughout the day
night time- every night <60% FEV1 high dose ICS & LABA |
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