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31 Cards in this Set
- Front
- Back
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hypotension sx
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dizziness and visual disturbance
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hypoglycemia sx
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diaphoresis, anxiety, tremulousness, and a feeling of hunger
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syncope definition
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transient, usually brief, loss of consciousness and postural tone that results from inadequate cerebral perfusion. Syncope is typically self-limited with patients unconscious for less than 1 minute, followed by gradual return of cerebral perfusion and awakening
15% of children and adolescents will have a syncopal event between 8 and 18 years of age, and 15% to 50% of adolescents have at least one episode of syncope. Syncope accounts for 6% of hospital admissions with a peak incidence between 15 and 19 years of age. Most syncopal events in young patients are isolated and benign in nature. The history, physical examination and an electrocardiogram are sufficient to evaluate syncope in the great majority of cases. |
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syncope hx
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Loss of consciousness and its duration
time of the day, last meal, weight changes, activities leading up to the event, patient posture (sitting/standing/exercise) and associated symptoms (palpitations, chest pain, color change, headache, shortness of breath, nausea, diaphoresis, visual changes and hearing changes). Take a drug history family history of seizures, sudden death, myocardial infarction in family members < 30 years of age provides significant red flags. |
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seizure vs syncope
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1) All syncope associated with exercise or exertion must be considered dangerous and requires a thorough cardiac evaluation.
2) Prolonged LOC (> 5 min), association with chest pain or palpitations, an abnormal cardiac examination, or history of cardiac disease all favor the diagnosis of cardiac syncope. 3) Facial cyanosis, aura, frothing at the mouth, tongue biting, slow recovery or postictal drowsiness and prolonged mental status changes or confusion after the event suggest a seizure. 4) Syncope in the supine position; convulsion before LOC; warm, flushed or cyanotic skin color rather than pallor and diaphoresis - all suggest seizure rather than syncope. orthostatics, cardiac, and neuro exams not associated with exercise, chest pain or palpitations, so there is no reason to suspect an underlying cardiac disorder. |
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indicated in any patient with syncope
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electrocardiogram
impossible to rule out some of the important arrhythmic causes of syncope, such as Wolf-Parkinson-White syndrome and long QT syndrome, without the ECG. Hypertrophic cardiomyopathy is the most common cause of sudden death in young athletes and can first present with syncope. The ECG is abnormal in more that 90% no syncope= no tests |
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occurred while upright, thus making what likely
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neurocardiogenic (vasovagal) mechanism likely.
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Osgood-Schlatter
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Osgood-Schlatter is a common condition in young athletes that refers to irritation of a growth plate at the knee. It typically occurs in active teens during their growth spurt and resolves after the bone stops growing
hard, tender, bumps on the front of my legs right under the knees problem at the insertion of the patella tendon into the front of the tibia bone tibial tuberosity on the front of the tibia bone. Fortunately, this is usually a self-limited growing pain that resolves with rest and with finishing your growth spurt. Sometimes mild medications such as ibuprofen can help with the discomfort. As long as the pain goes away there is no chance of any complications The main symptom of Osgood-Schlatter is pain at the bump below the knee with activity or after a fall. There may also be swelling around or enlargement of the bump. This bump is usually very tender to the touch. Forceful contraction of the thigh muscles can also cause pain. common in athletes with repetitive stress on the growth plate below the knee. The condition usually resolves on its own as the athlete finishes growing. By treating symptoms and preventing further injury, most athletes can continue to play. In some cases calcification within the tendon can continue to cause symptoms even after growth has finished. |
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Osgood-Schlatter tx
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decrease stress at the tendon attachment site. In severe cases, athletes may need to stop or back off from their sport. Ice the injury for at least 20 minutes after activity with either an ice cup or an ice pack. Nonsteroidal anti-inflammatory drugs (NSAIDs) may also help with swelling and pain. A patellar tendon strap placed between the bump and the knee cap may help reduce pain. A knee pad
Stretching of the hamstring and quadriceps |
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Creatinine
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Nutritional supplements including creatine are not controlled or reviewed by the Food and Drug Administration for content, safety and labeling.
Creatine food sources include meat and fish. 95% of the body's creatine is present in skeletal muscles, and 5% is in heart muscles and all smooth muscles, sperm and neural tissue daily requirement of creatine is 2 grams- half from endogenous production and half from normal diet controlled laboratory studies, creatine supplementation seems to improve performance during brief(less than 30-seconds), high intensity exercise- not consistent in confirming improved sports performance when using creatine supplements and many studies have shown no performance improvements from creatine supplementation Even if the use of creatine supplements improves the quality of workouts that does not necessarily translate into improved athletic performance. side effects, including weight gain (due to water retention), cramps and heat intolerance in sprinters, muscle and tendon swelling (due to water retention) predisposing to sprains, and increased BUN, creatinine and CPK Anecdotal reports describe incidents of nausea, vomiting, fatigue and renal failure in a patient with nephrotic syndrome. Creatine is not recommended for patients with existing renal disease or those at high risk for renal failure. There is not enough evidence of the benefit and safety profile of creatine in the young and rapidly growing athlete. The American Academy of Pediatrics does not endorse its use for pediatric athletes |
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what is a contraindication to contact sports
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having one kidney
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most common cause of chest pain in an adolescent?
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Precordial catch syndrome
benign cause of chest wall pain by far the most common cause of chest pain in children unknown etiology most commonly in adolescents sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. brief, lasting seconds to a few minutes, and resolve spontaneously. The pain can often be "broken" with a forced deep inspiration. Onset: Precordial catch chest pain typically occurs sporadically, unassociated with exertion. Cardiac causes of chest pain are much more likely to be exertional. Quality: Precordial catch chest pain is typically described as sharp and is often well localized. Angina is described as a pressure or crushing sensation. Timing: Precordial catch chest pain is typically very brief, lasting only seconds to a few minutes. Ischemic chest pain typically lasts 10-15 minutes, rarely less than 1 minute. Precordial catch chest pain is unrelated to exertion. Pain may occur with exercise, but just as often occurs at rest. Angina occurs almost exclusively with some inciting event, usually exertion but also stress. Aggravating factor: Precordial catch chest pain is classically made worse by deep inspiration. This is one of the most useful ways to distinguish it from other causes of chest pain. As noted, the pain can often be "broken" with a forced deep inspiration. Associated symptoms: Syncope or palpitations associated with the chest pain raises the level of concern and should probably prompt referral to a cardiologist. |
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Costochondritis
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also a benign cause of chest pain but is much less common.
inflammation and typically will last for hours or days. |
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unlikely cause of chest pain in children
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Unlike adults, chest pain due to a cardiac cause is extremely uncommon in children. Asthma and GE reflux are potential causes of chest pain but are much less common than chest wall pain. Despite its benign nature in most patients, chest pain remains a source of anxiety for parents due to fear of serious causes.
Fever might suggest infectious etiology (pericarditis, pneumonia). Take a general look at the body habitus for any suggestion of genetic disorder that might be associated with cardiac disease (Marfan's) gastric or esophogeal irritation |
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meaning of 15q22.1
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15 indicates chromosome 15. The letter q means the longer arm of the chromosome. The shorter arm is designated by the letter p. The last number 22.1, simply refers to a segment of the chromosome in question. Each chromosome is divided into discrete regions in order to make it easier to know what region is being discussed.
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What is a linkage study?
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linkage is that the closer together two pieces of DNA are on a chromosome, the more likely they will be inherited together. In other words, let's say that a mutant gene causes hypertrophic cardiomyopathy. Let's also say that there's a bit of DNA right next to the mutant gene. If this bit of DNA shows up in almost all people with hypertrophic cardiomyopathy, it is evidence that the mutant gene is nearby. Scientists can look at the region near the bit to see if there is a gene that might cause hypertrophic cardiomyopathy. If they're lucky, they will find the bit of DNA right within the mutant gene.
Another way scientists can use linkage analysis is when they are trying to see if a gene is responsible for a condition. For example, Professor Mendel might think that gene GM causes hypertrophic cardiomyopathy. He can look at the area in or near gene GM and find a sequence of DNA. If this sequence of DNA is present only in people with hypertrophic cardiomyopathy, it is evidence that gene GM is involved. |
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Pain during exercise can point to
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exercise-induced bronchospasm or asthma. These may also present with coughing, respiratory distress and wheezing
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(GERD) may present as
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retrosternal, burning, non-radiating chest pain associated with meals
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S- Safety in heads can be used to screen for
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Violence is the major mortality in this age group, from accidents, homicide and suicide. This is independent of race, ethnicity and socio-economic status. It is important to assess the adolescent and his peer group for a history of violence. This includes participation in or witnessing violent acts, and the carrying of weapons by the individual or his peers. Some physicians also inquire about criminal charges and juvenile justice involvement.
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which of the following immunizations is first given at the pre-adolescence evaluation? (or during adolescence if missed at age 11)?
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Tdap and MCV4
Tdap vaccine is first recommended to be given at the pre-adolescent visit, at 11-12 years of age Pediatric DTaP ("big D") contains 3-5 times more diphtheria toxoid than the adult Tdap ("little d"). DT is used for children who cannot receive the pertussis component of the DTaP vaccine, and Tdap is used for adults and children 11 years of age and older who need booster doses of diphtheria, tetanus toxoid, and acellular pertussis. The meningococcal conjugate vaccine (MCV4) is recommended at age 11 or 12 years, with a booster dose at age 16 years. For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 thorough 18 years, before the peak in increased risk. Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose. Routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years. |
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HPV vaccine
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quadrivalent vaccine, HPV4). The human papillomavirus vaccine (HPV) is recommended for all males and females starting at age 11-12 years of age. A second dose is recommended two months after the first dose and the third dose six months after the first dose
quadrivalent HPV vaccine is approved for men between the ages of 9 and 26 years to reduce their likelihood of acquiring genital warts, anal cancer, and anal intraepithelial neoplasia (AIN). The bivalent HPV2 immunization is approved only for women and only for the prevention of cervical cancer, not genital warts or other neoplasms. |
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vaccines completed by adolescence
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Most adolescents have already completed the 3 dose series of Hepatitis B vaccine in early infancy
many will have completed the 2 dose series of Hepatitis A given at 12 and 18 months of age. Most also will have received the 4 required doses of polio (IPV) in early childhood. Like all immunizations required at younger ages, providers should verify dose and administer any routine vaccines that were not previously given. |
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overweight is defined as a
obesity is |
BMI in the 85th-95th percentile
BMI in the 85th-95th percentile, |
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determining or calculating total body fat:
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total body water
total body potassium bioelectrical impedance and dual-energy X-ray absorptiometry. Even though accurate methods to assess body fat exist, measuring body fat content by these techniques is often expensive and is not readily available clinically. Although bioelectrical-impedance devices are becoming more readily available, they lose accuracy in severely obese persons and are of limited usefulness for tracking changes in total body fat in persons losing weight. Thus, bioelectrical impedance offers no significant advantage over BMI in the clinical management of patients. No trial data exist to indicate that one measure of weight and body adiposity is better than any other for following overweight and obese patients during treatment. No studies have been published to compare the effectiveness of different measures for evaluating changes in body fat during weight reduction. BMI provides a more accurate measure of total body fat than relying on weight alone. It has an advantage over percent above ideal weight (e.g., based on the Metropolitan Life Insurance Tables). Ideal body-weight tables were developed primarily from white, higher socioeconomic status populations and have not been documented to accurately reflect body fat content in the public at large. In addition, separate tables are required for men and women. BMI is recommended as a practical approach for the clinical setting. BMI provides an acceptable approximation for assessment of total body fat for the majority of patients. |
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as the murmur of hypertrophic cardiomyopathy tends to be louder
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while standing
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Murmurs are common in healthy adolescents, but what deserves further evaluation?
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any murmur louder than grade III/VI, any diastolic murmur, or any murmur that increases with standing or Valsalva
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impt reasons for performing a GU exam:
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hernia
(Checking the male athlete for inguinal hernia is particularly important in sports that involve sprinting and weight lifting) undescended testes demonstrate self exam (Regular testicular self-exams have not been studied enough to show if they reduce the death rate from testicular cancer. That is why the American Cancer Society does not make recommendations about regular testicular self-exams for all men) "matching" athletes by Tanner staging for participating may potentially prevent injury better than matching the athletes by weight. While having only one kidney is a relative contraindication to contact sports, for other issues, athletes may simply need to use better safety equipment. ex having a single testicle is not a contraindication; however, a better protective cup to protect the single testicle is necessary and must be required. |
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GU exam
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genitourinary (GU) exam is not part of the female preparticipation evaluation, the GU exam is part of both the male and female adolescent annual health maintenance exam, including Tanner staging. Recently approved current guidelines from the American College of Obstetrics and Gynecology recommend a PAP smear starting at age 21. Sexually active adolescents should be screened for sexually transmitted infections on a regular basis
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Tanner Staging of sexual development in males, also known as Sexual Maturity Ratings (SMRs), are divided into five classes based on pubic hair and genitalia.
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Stage 2 marks the onset of puberty.
Stage 1 - Prepubertal: childlike phallus, testicular volume <1.5 ml; no pubic hair. Stage 2 - Childlike phallus, testicular volume 1.6-6 ml, reddened thinner and larger scrotum, small amount of fine hair along the base of scrotum and phallus. Stage 3 - Increased phallus length, testicular volume 6-12 ml, greater scrotal enlargement, moderate amount of more curly, pigmented, coarser hair extending laterally. Stage 4 - Increased phallus length and circumference, testicular volume 12-20 ml, further scrotal enlargement and darkening, and coarse curly adult like hair that doesn't yet extend to the medial surface of thighs. Stage 5 - Adult scrotum and phallus, testicular volume >20 ml, adult-type hair extending to medial surface of thighs. |
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does puberty arrive earlier
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NHANES III (National Health and Nutrition Examination Survey) demonstrated earlier attainment of early Tanner stages, including a median onset in boys of 9.9 years for stage 2 genital development and 11.9 years for pubic hair development. However, Tanner 4 (13.6, 13.6 for genital and hair, respectively) and Tanner 5 (15.8, 15.7) did not vary significantly from prior surveys, or the classic descriptions by Dr. Tanner in his original publications.
Another analysis of recent trends examined prior published literature reports. Among females in the US, 50% attain Tanner breast stage 2 at 9.5-9.7 years. However, there is no evidence that age of menarche or the attainment of Tanner 5 breast development has decreased over the past thirty years. Children who begin puberty earlier also complete puberty earlier and usually end up smaller than their peers because the growth spurt occurs at a younger age and smaller size. Once growth plates close, growth is complete. Bottom line? The true answer to the question "Is puberty moving earlier each generation?" has yet to be fully answered. |
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absolute early cut-off for precocious puberty
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(controversial, but some authors now recommend before age 6 in non-Caucasian girls / 7 in Caucasian girls and before age 9 in boys)
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