Pnp 2010

Front 1

Freud

Back 1

Oral- birth to 1 yr
Anal- 1 1/2 to 3yr
Phalic or Oedipal 3 to 6 yr
Latency 6 to 11 yr
Puberty or Genital 11 to 14yr

Front 2

Erikson

Back 2

Trust vs Mistrust (oral)
Autonomy vs Shame and doubt (anal)
Initiative vs Guilt (phalic)
Industy vs Inferiority (latency )- master idenity
Idenity vs Role Confustion (puberty)

Front 3

Piaget

Back 3

Sensorimoter birth to 2yr
Preoperational 2-7 yrs
Concrete Operational 7-11yr
Formal Operational 12 and older

Front 4

Kohlberg

Back 4

Amoral birth to 18mths
Preconvetional Level I 18mth to 3yr - obedience and punishment
Conventional Level 2- 3 to 6yrs individualism and exchange
Postconventional Level 3- 6 to 11 yrs- interpersonal relationships and maintaining social order

Front 5

Mary Ainsworth

Back 5

Preattachment stage- birth to 6 wks- contact maintaining- keep mom in proximity
Attachment in the making - 6wks to 6/8 mths- infant plays a more active role, cry when leave but consoled
Clear cut attachment 6/8 mths to 18mths/2 yrs- infant becomes attached at 6 mths

Secure attachment- actively explore with mom present
Insecure/avoidant- avoids contact with mom
Insecure/resistant- distressed when mom leaves but comforted
Disorganized/disoriented- reflects greatest insecurity- looks at mom with flat affect

Front 6

Freud

Back 6

Oral- birth to 1 yr
Anal- 1 1/2 to 3yr
Phalic or Oedipal 3 to 6 yr
Latency 6 to 11 yr
Puberty or Genital 11 to 14yr

Front 7

Erikson

Back 7

Trust vs Mistrust (oral)
Autonomy vs Shame and doubt (anal)
Initiative vs Guilt (phalic)
Industy vs Inferiority (latency )- master idenity
Idenity vs Role Confustion (puberty)

Front 8

Piaget

Back 8

Sensorimoter birth to 2yr
Preoperational 2-7 yrs
Concrete Operational 7-11yr
Formal Operational 12 and older

Front 9

Kohlberg

Back 9

Amoral: birth to 18mths
Preconvetional Level I: 18mth to 3yr - obedience and punishment
Preconventional Level 1: 3 to 6yrs- individualism and exchange
Conventional Level 2: 6 to 11 yrs - interpersonal relationships and maintaining social order
Postconventional Level 3: 12 to 18yrs- social contract and individual rights and universal principle

Front 10

Mary Ainsworth

Back 10

Preattachment stage- birth to 6 wks- contact maintaining- keep mom in proximity
Attachment in the making - 6wks to 6/8 mths- infant plays a more active role, cry when leave but consoled
Clear cut attachment 6/8 mths to 18mths/2 yrs- infant becomes attached at 6 mths

Secure attachment- actively explore with mom present
Insecure/avoidant- avoids contact with mom
Insecure/resistant- distressed when mom leaves but comforted
Disorganized/disoriented- reflects greatest insecurity- looks at mom with flat affect

Front 11

Prenatal - medications

Back 11

Valproate- neural tube defects
dilantin- heart defects, dysmorphic features, learning problems
accutane- heart disease, dysmorphic features, learning problems
Radiology- dysmorphic features

Front 12

TORCH

Back 12

Toxoplasmosis- asymptomatic at birth or MR, learning disabilities, blindness
Other- catch-all
Rubella- deaf, blind, cardiac anomalies, limb deformaties
Herpes- CNS involvement, skin, eye & mouth involvement, liver damage

Front 13

Risk factors during perinatal period

Back 13

Are mother's other children living with her?
Mom not referring to child by name

Front 14

Neonates

Back 14

Most commonly react with cold stress, - increased oxygen consumption (hypoxia), hypoglycemia, metabolic acidosis. Hypothermia and hyperthermia both need to be investigated.

Front 15

Turners

Back 15

Wide spread nipples

Front 16

Hypoglycemia

Back 16

apnea, cyanosis, pallor
hypotonia, lethargy, inadequate suck
tremors, jitteriness
temperature instability, high-pitched cry, eye rolling, sz

Front 17

Jaundice

Back 17

If seen before 24 hours- think ABO/Rh incompatibiliity or sepsis.

Physiologic seen after 24 hours, peaks at about 48 hours, and gone by 5 days. breastfeed onset 2-4 days and rises by 2nd or 3rd week.

Front 18

The national goal for immunizations

Back 18

have 90% of children up-to-date on immunizations

Front 19

Cancer/immunizations

Back 19

can give if it is in remission and has not had chemo in 90 days or more.

Front 20

Trivalent influenza
and
Live attenuated

Back 20

TIV- recommended for 6mths to 5 years.
0.25 ml for age 6-35mths and 0.5ml for those at least 3yr

LIAV- for those 2yr and older. helathy 2-6 yrs can recieve either

for those 9 and younger first dose give 2 doses 4 wks apart

Front 21

Vaccines

Back 21

children not previously vaccinated with MCV4- give at 11 or 12 years or between 13 to 18 years and college freshman

final dose of inactivated poliovirus vaccine series- administer on or after 4th birthday and at least 6 mths following previous dose, if 4 doses administer before 4yrs, and additional (5th) dose should be given at age 4 - 6 yrs

Front 22

Diphtheria/Tetanus/Pertusis

Back 22

DTaP- 6wks to 7 years-

Tdap- adds Pertussis to Td, age 10-18 years, single dose. give every 10 years

DT- give to younger than 7 who have adverse rxn to Pertusis

Td- 7 yrs and older or adults who have had rxn to Pertusis

Schedule- 4 dose in infancy (2, 4, 6, & 12-18), booster at 4-6yrs, then Tdap at 10-18yrs and every 10 yrs.

If 4th dose given after 4years, omit 5th. Must be 6 mths between 3rd and 4th doses and between the 4th and 5th.

Front 23

IPV- subcut

Back 23

IPV- at 6 wks- 2mths, 4mths, and 6-18mtsh, and 4-6 years

4th dose is not necessary if the 3rd dose was administerd at 4 years old if recieved all IPV or all OPV

IF mixed series administer 4th dose

Front 24

HIB- IM

Back 24

Not given after 5 years of age

doses depends on age of first dose

first dose- 6 wks-6mos
series- 3 doses, 2mos apart
booster 12-18mos

first dose 7-11mos
sereies- 2 doses, 2mos apart
booster- 12 to 18mos

first dose 12-14mos
series- 1 dose
booster 2 most later

first dose 15-59 mos
series- 1 dose
booster- none

first dose > 60 mos
series- 0 unless chronic illness

Front 25

Hep B- IM (not in buttocks)

Back 25

Avoid if anaphylactic to bakers yeast

children 0-19 not vaccinated at birth
age 2, 4, 6-18mos or 0, 1, & 4-6mos

Front 26

Pneumococcal - IM

Back 26

for < 23mos, doses depends on age of first dose

first dose:
> 6 wks- 4 doses at 2, 4, 6, & 12-18mos

7-11 mos- 3 doses- 2 doses at least 4 wks apart, 3rd dose after 12 mos and at least 2mos after 2nd dose

12-23 mos- 2 doses- 2 doses at least 2mos apart

24mos - 9 years 1 dose and give Pneumovax- 23 valent (not for under 2years)

Front 27

MMR- subcut

Back 27

give at 2 times: 12-15mos and 4-6 years or 11-12 years

Skin tsting for TB can be done on the day of Measles vaccination or must be postponed for 4-6 wks because the vaccine can cause anergy to TB skin tests*

dont give to rxn to neomycin, gelatin ro eggs

Front 28

Varivax/chickenpox- subcut

Back 28

not given before 12 moths
booster at 4-6 years
If over 13yrs and no hx of chickenpox, they can receive 2 doses at 4 wks apart

can get MMR and varivax at same time, or if not must wait 4 wks between.

dont give to pregnant women

Front 29

Hep A- IM

Back 29

give to all infants 12-23 mos, with second dose 6 months later

Front 30

Rotavirus (Rotateq)- oral

Back 30

infants 2, 4, and 6 mths (RotaTec)
2 and 4 mths-Rotarix

dont initiate after 15 wks of age and all doses should be given by 32 wks age (8mos)

Front 31

HPV- IM

Menactra(Meningococcal) IM single dose

Back 31

11-27 yrs
dose 2 given 2 mos after dose 1 and dose 3 give 6mos after dose 1

11-12 yr old- adolescents at high school entry or 15 yrs, college freshman or military

Front 32

Physical

Back 32

Wt- regains birth wt by 2wks
0-6mos: 5-7 oz/wk, 2lbs/mo
6-12mos; 3-4oz/wk, 1lb/mo
5-6mos: doubles birth wt
1 year: triples birth wt
2 1/2 yrs: quadruples birth wt

Length:
0-6mos: 1in/mo
6-12mos: 1/2in/mo (add 6in)
1 year: 1 1/2 times birth length

Head circ:
0-6mos: 1/2 in/mo
6-12 mos: 1/4in/mo

Front 33

head:
fontanel

Back 33

Anterior- closes at 9-18 mos
Posterior- closes by 2mos

Cephalohematoma- does not cross suture line
Caput- overrides sutures

Cradle cap- greasy yellow scales on top of head or eyebrows

Front 34

Eye and Ear

Back 34

corneal light refles (Hirschberg)- assess at 4mos-

pseudostrabismus- false strabismus so look for light reflex

red reflex- absence or opacity- cataracts or white reflex- retinoblastoma

Lacrimal duct- tears by 2-3 mos- Dacrocstenosis- blocked tear duct

Front 35

Barlows and Ortolani

Back 35

Barlow- hip flexed, thigh ADDUCTED to check displacement (click)

Ortolani- hip flexed and ABDUCTED to check for relocation- clunck as it pops back

Allis sign- unequal leg length (measure ht of knees)

Front 36

Infant reflexes

Back 36

Rooting- present at birth, disappears by 3-4mths, except during sleep

Tonic neck - present at birth to 6wks, disappers by 4-6 mos

Palmar grasp: present at birth, disappears by 4-6mos

Stepping: present at birth, disappers by 3-4 mos

Moro- present at birth, disappers by 4-6 mos

Plantar grasp: present at birth, disappears by 10-12 mos

Babinski- normal up to 2years

Front 37

Infant skin:

Back 37

Atopic Derm: pruritis*** (itch-scratch cycle)- no scales

Psoriasis***- silvery scales***

contact derm: - vesicles, distinct pattern

Tinea Corporis or Capitis: raised well-circimscribed borders and central clearing

Front 38

child abuse and neglect:

Back 38

increased with males, excessively fussy infants, slow-to-develop, and handicapped children

Front 39

Vision

Back 39

Visual acuity testing using Snellen chart 20/20 in both eyes by 7 years

Front 40

Delayed Puberty

Back 40

dx: as no secondary sex changes (breast buddin; penis or testicle growth) at 13 for girls and 14 for boys

Front 41

Normal variations in stature

Back 41

***Short Stature is considered 2 SD below the mean: males below 5'4" and females below 4'11"

Familial Short Stature: do not reach adult height within the average range but no intervention is needed

Constitutional Short stature: average size at birth but growth slows during infancy and childhood, adolescent growth spurt and puberty are delayed but adolescent reached adult height within normal range. (late bloomer)

Accelerated growth is 2 SD above the mean but normal growth velocity

Front 42

Bacterial Vaginosis

Back 42

gray-white, thin, homogenous ***malodorous (fishy) discharge
Positive whiff test
Clue cells
pH > 4.5
not sexually transmitted disease by facilitated by sex- no need to treat partner

***Treat with Flagyl 500mg po BID x 7 days

Clindamycin should be used in second half of pregnancy

Front 43

Trichomonas

Back 43

***Yellow-green, green-gray, yellow or green odorous discharge
***Strawbeery cervix
flagellated protozoan
half of men and women asympotmatic

Treat with Flagly 2gm po x 1 or 500mg po BID for 7 days
**Treat all sex partners

Front 44

Gonorrhea

Back 44

Thick yellow and purulent or mucopurulent discharge

***Treat with Ceftriaxone 125mg IM single dose: Cefixime 400 mg PO single dose PLUS tx for chlamydia if not ruled out

Front 45

Chlamydia

Back 45

Sublte sxs: painful urination
can test with urine test

***Treat with Azithromycin or Doxycycline

f/u exam 4-6 wks
treat partner

Front 46

Herpes simplex virus

Back 46

***HSV 1- congenital and upper body infections
***HSV 2 - genital tract and transmitted by sexual contact.

Painful ulcer

Primary- infection to one who does not have antibodies to either 1 or 2- acutely ill with fever, lesions, and myalgia- viral shedding 1-2 wks
Nonprimary- 1st exposure to 1 or 2, but pt has antibodies
Recurrent- lesion at site previously affected, due to reactivation of latet virus

Treat with Acyclovir for 7 dyas

Front 47

HPV

Back 47

***Primary cause of cervical Cancer

Treat: Podofilox 0.5% solution or gel or Imiquimod 5% cream

Front 48

Syphilis

Back 48

***Primary: primary lesion or chancre appears within 4 wks of infection and ulcer is usually a single and painless***, with the ulcer resting upon a well-circumscribed base

Treat with Benzathine penicillin G 2.4 million units IM single dose (early latent)

7.2 million units as 3 doses of 2.4 million at 1 wk intervals forlate latent

Front 49

Risks for suicide/Depression

Back 49

***Degree of hopelessness is the #1 predictor: not future oriented
with depression get contract for safety

Treatment: ***Prozac (fluoxetine) FDA approved for children 8 and older

***trial of an SSRI should be at least 8-12 weeks; if no improvement, consider cross-tapering and substituting another SSRI

****Start low and go slow

Front 50

SSRI

Back 50

Always educate regarding risks of serotonin syndrome (agitation, insomnia, inc heart rate, sweating, dilated pupils, shivering, twitching)

use for at least 12mo after sxs resolve

Front 51

Hisotry of NP

Back 51

***role of NP developed in mid 1960's in Colorodo.
Aim was to develop clinical-based program to prepare nurses who would fill the role of bringing health to the people as public health nurses had historically done

*1996- masters program as entry level
Doctorate as entry level by 2015

Front 52

Helath People 2010

Back 52

established measurable goals to improve health and the quality of life for people in US

General goals:
increase the span of healthy lives
reduce health disparities
achieve access to preventive services

Front 53

Nurse Practice act

Back 53

statutory authority give state boards of nursing the power of licensure of RN's, establish scope of practice, and determine disciplinary actions.

Front 54

Definitions: NP

Back 54

Licensure: regulated by a governmental body (Board of nursing)

Certification: process by a non-governmental agency (PNCB or ANCC)

Credentialing: process of validation of required education, licensure, and certification

Privileging: process of granting a health care professional to perform specific clinical functions within a facility. JCAHCO

Scope of practice: varies widely form state to state

Front 55

Principles of ethics

Back 55

Autonomy: self-reliance; independence; protection of a person's right to self-determination

Beneficence: professional agreement or duty to help others

Nonmaleficence: professional agreement or duty to avoid inflicting harm or to do the least possible harm

Justice: impartiality and fairness, balance idividuals rights with whats best for community

Fidelity: faithfulness, commitment to keep promises

Utilitarianism: right act is the one that porduces the greatest good for teh greatest number

Veracity: duty to be truthful

Front 56

Iron-deficiency Anemia

Back 56

microcytic, hypochromic
doughy pale appearance
Inc RDW and dec ferritin

Treat: elemental iron 4-6 mg/kg/day- ferrous sulfate divided into 1-3 doses daily
recheck H&H monthly and cont supplementation for 2-4 mos after H&H returns

give with Vit C, no food, drink with straw

Front 57

Bleeding disorders- frequent nose bleeds, petechia

Back 57

hemophilia A- factor VIII def
hemophilia B (christmas disease)- factor IX def

***von willebrand: affects male and females- treat with DDAVP

ITP- recent viral illness, treat with IVIG

Henoch-Schonlein Purpura- abdominal pain, follows URI, involves crops of maculopapules that progress to purpuric rash on lower extremeties and buttocks; joint and bowel inflammation

Front 58

HIV

Back 58

HIV DNA PCR- done within first 48 hours and then at 2 wks, and also at 1-3 mths and 4 mos

HIV is dx'd by 2 positive PCR tests < 15mos old

over 15mos- antigen and antibody detection (ELISA)

Front 59

UTI

Back 59

presence of bacterial infection ***>1000,000 organisms/ml of the urinary tract

***Most common etiological agent is E. coli

Labs: UA,- ***inc WBC, RBC, & nitrite (breakdown of bacteria)

negative UA does not automaticall rule out a UTI

granular casts in urine are indicative of pyelonephritis

- blood cx should be done in infants <12mos with susptected sepsis and children with suspected pyelonephritis

*Treat: Bactrim 6 to 12 mg/kg/day of TMP and 30 to 60 mg/kg/day of SMX bid- for infancts older than 2mos of age

less than 8 wks and toxic need hospitalization with parental ABX therapy

***F/U UA and cx obtained 1-2 wks after completion of abx therapy. subsequent cxs done every 1-3 mos until free of infection for one year then cxs yearly.

Front 60

VU Reflux

Back 60

***AAP recommends children should be maintained on therapeutic dosages of ABX until imaging studies completed

VCUG: only means of identifing reflux (gold standard)

Front 61

Inguinal hernia

Back 61

9 times more common in males and increased incidence in premature infants***

Direct: greater than 3 years of age
Indirect: slip into scrotum and usually less than 3 years

***Silk glove sign: sensation of two surfaces rubbing together as inguinal canal is palpated

Front 62

Hydrocele

Back 62

Most common cause of PAINLESS*** scrotal swelling

translucent with transillumination
**Refer to surgeon if persists after one year of age***

Front 63

Cryotochidism (undescended testes)

Back 63

check at all well child exams

* if not descended by one year of age, refer to urologist

* surgical intervention (orchipexy)

*Testicular malignancy (appears after age 20 years) increased risk for gonads that are in the abdomen for 3 to 5 years

Front 64

Testicular Torsion

Back 64

Torsion of the spermatic cord which impedes blood flow, eventually resulting in gangrene of testicle if not corrected by emergency surgery. within 6 hours

* 10yo boy with ACUTE onset of testicular pain

* sudden, severe, unilateral pain of scroum, often awakening from sleep

***Prehns sign: lifting of testicle DOES NOT RELIEVE THE PAIN.

Front 65

Hematuria

Back 65

Cause: **Post streptoccal (Acute) glomerulonephrits (PSGN) (smoke or tea-colored urine, hypertenstion, and oliguria

h/o antecedent sore throat or skin infection (impetigo) **STREP

**macroscopic hematuria should be evaluated in collaberation with a physician

Front 66

PSGN
Post Streptococcal Glomerulonephritis

Back 66

**an immune response of the kidneys to group A beta-hemolytic streptococcus (GABHS)- strep pharyngitis, impetigo
also referred to as AGN- acute glomerulonephritis

**tea-colored urine
hospital admission
***ASO titer- to detect previous strep infection***

nephrosis***- tons of protein in urine and have generalized edema (to all body parts)

Front 67

Headaches

Back 67

* c/o HA with rage outbursts do EEG may indicate temporal lobe seizure
*
start with acetaminophen then ibuprofen

* Abortive meds: Imitrex contraindicated in cardiac disease, HTN and pregnancy

***Prophylactic meds: Propranolol (inderal): contraindicated in asthma, cardiac disease, depression, pregnancy, and diabetes due to beta blocker effects, but the best medication
Amitriptyline (tricyclic); useful for dpressed teens with migraine or tension HA, but not drug of choice since OVERDOSE rapidly leads to cardiac arrythmias and toxicity

Front 68

Pituitary Microadenoma

Back 68

***Female with c/o recurrent HA and skips menses.
-check serum prolactin: level > 80

Front 69

Learning disabilities

Back 69

**usually appear during school age years, esp. in the 3rd or 4th grade when children are: expected to perfom at higher standards; recall info rapidly; and demonstrate increased productivty and problem-solving skills

Neurological:* soft signs: clumsiness, fragmented movements, inability to perform rapid alternating movements, poor balance and coordintion which should normaly disapper by 8 years

Front 70

ADD/ADHD

Back 70

* more common in males 5:1

***sxs must persist for more than 6 months
***sxs must have been present before age 7

***At least 6 inattention sxs must be present
***at least 6 hyperactivity/impulsivity must be present

Treat: stimulant**(methylphenidate/ritalin-short acting)
*Stimulants work best when given regulary, including weekends and holidays; give in morning before breakfast

**SE: appetite suppression, stomachaches, wt loss, drowsiness, insomnia, HA

Front 71

Seizures:

Back 71

**Assess for signs of infection/systemic disease: ears, throat, nuchal rigidity***
early sign of meningitis in children more than 2 years old

***EEG- should be done when sleep deprived with hyperventilation and photostimulation to cause sz.

***Normal EEG when a child is not seizing does not rule out seizures
***An abnormal EEG without clinical conformation does not rule in seizures

Treat"** treat child not level Tegretol/Carbamazipine- may cause liver damage and bone marrow suppression

Dilantin/Phenytoin- cause gum hyperplasia

Depakene/Valproic Acid: cause liver damage and bone marrow suppression

Neurontin/Gabapentin: cause sedation, dizziness, ataxia and fatigue

Oxcarbazine/Trileptal: may cause hyponatremia which may be seen in first 3 mths

Education; ***never stop medications abruptly and comply with f/u evals

**cannot drive until seizure free

** use protection with sex bc meds decrease BC efficacy

Front 72

meningitis

Back 72

Nuchal rigidity is a late sign of meningitis in childrens less than 2 years of age

Infants and toddlers with meningitis typically have VOMITING, LETHARGY OR IRRITABILITY, BULGING FONTANELLE WHILE QUIET, AND HIGH PITCHED CRY.

children older than 2- nuchal rigidity, positiv brudzinski (flex foreward neck-pain) and positive kernigs (supine and lift leg)

Front 73

Developmental Dysplasia of the Hip (DDH)

Back 73

*primary sign of DDH in infants more than 3 mos- unequal leg lengths

In older children***
painless limp, short let with toe-walking on affected side and marked lordosis

U/S for less than 3 mos
X-ray for older than 3 mos

treat with pavlik harness- usually period of 3-6 mos

Front 74

Legg-Calve Perthes

Back 74

osteonecrosis of the hip
* painful limp, knee pain or hip pain, limited ROM
more common in boys and common age 5-9 years

Front 75

SCFE- slipped capital femoral epiphisis

Back 75

displacement of femoral epiphysis from metphysis

**commonly seen in overweight children, boys affected more, average age 8-14
c/o painful limp, limited internal rotation, abduction, and flexion- no pressure on leg

Front 76

.Sprain (ligament) or Strain (tendon) Grading

Back 76

Sprain
Grade 1 - stable joint, full ROM, positive wt bearing

Grade 2- refer- limited mobility and moderate joint instability

Grade 3- refer- complete tear, joint instability, and marked joint laxity

Strain:
Grade 1- local tenderness

Grade 2 - refer- palpable defect in muscle mass, moderate pain, edema, and discoloration

Grade 3 - severe pain, large palpable defect, severe edema and marked discoloration

Front 77

Concussion-

Back 77

alteration in cerebral function caused by trauma**
*transient LOC with amnesia

- assume that a head injured , unconscious athlete has sustained a severe neck injury until proven otherwise

* finger point tenderness- fracture
*generalized pain- soft tissue injury

Front 78

Common Overuse Syndromes- caused by repetitive movement injury

Back 78

always examine the corresponding joint or area in the other extremity

**Patellofemoral pain syndrome- chondromalacia- anterior knee pain; "knee gives out"

***Osgood-Schlatter disese- compression of the patellar femoral joint with medial pain tenderness confirms diagnosis

torn ACL- hear a POP- positive result with Lachman test and anteior drawer test

Front 79

Overuse and sprains and strains

Back 79

RICE- rest, ice, compression, elevate, nsaids, and strengthening excercies

Front 80

concussions:grades
immediate removal from game

Back 80

mild- grade 1- no HA, no LOC but showed signs of transient confusion, inattention that last up to 15 minutes- may return to play if asymptomatic, reexamine at 5-minute intervals both at rest and with exertion

Grade II- moderate- no LOC, but with confusion and difficulty recalling the event- can return to play after one week if asymptomatic during time period

Grade III- seveve- LOC and no memory of event- return to play after cleared by MD

Send to ER:
If LOC > 5 seconds
suspected fracture of skull or orbit
any evidence of focal neurologic deficit

Front 81

Sports Evaluation:

Back 81

***has child ever fainted or lost consciousness during exercise
ask about syncope, palpatations, and excessive dyspnea with exertion

***Family Hx: CV death or unexplained death before age of 50, prolonged QT, or marfans syndrome

Front 82

Excluding conditions from contact-collision sports

Back 82

Can't clear a single organ- refer
hepatosplenomegaly
poor controlled seizures
Carditis, CAD,
Long QT

Front 83

Can participate with control and f/u

Back 83

single ey or testicle can play
asthma
mild HTN
diabetes
controlled seizures
hernia

Front 84

most common place for fracture

Back 84

epiphyseal plate (growth plate)

Front 85

Diabetes mellitus

Back 85

Type 1 - destruction of beta cells- insulin dependent

Type 2 - non insulin dependent- insulin resistance due to obesity or insulin receptor abnormalities

***DX made with 1 of the 3 criteria must be met:
1. random plasma glucose > or equal to 200
2. fasting blood glucose of > or equal to 126 on 2 occassions- preferred method for children
3. A 2-hour after-meal plasma glucose > or equal to 200 during an oral glucose tolerance test

Front 86

Insulin

Back 86

Type 1 - placed on a fast acting (Novolog/humalong/apidra) with multiple daily injections to cover meals and snakcs (with an insulin to carb ratio) and a long acting insulin for basal coverage (lantus/levemir)

rapid- humalog/novolog
short- regular- humalin/novolin
intermediate- NPH
long- lantus

morning regular exets it effects from breakfast to lunch
morning NPH exerts it effects from lunch to dinner
afternoon regular exerts its effects from dinner to bedtime
afternoon NPH exerts effects from bedtime to the following morning

Front 87

Hypoglycemia

Back 87

mild: tremors, diaphoresis, hunger, palpatations- give carbs

modrate- pale, faint, weak, rapid pulse- give carbs

Severe: unresponsive, coma, convulsions, urine negative for glucose and ketones- administer 1mg max of glucagon

Front 88

Education of DM

Back 88

* first pathophysiology in type 1 is hyperglycemia which leads to polyuria, polydipsia, and polyphagia

exercise decreased blood sugar

illness increases blood glucose

stress increases blood glucose

alcohol usually lowers blood glucose

Hb A1C for children less than 6 years 7.5-8.5 and
ages 6 to 12- recommended less than 8
age 13 to 19 recommended to be less than 7.5

Front 89

Type 2 diabetes diagnosis

Back 89

one of the 3:
1. random glucose > or equal to 200
2. fasting glucose of > or equal to 126
3. oral glucose tolerance with 75mg and postprandial glucose > or equal to 200

* signs- acanthosis nigricans, insatiable hunger, rapid weight gain, sometimes c/o HA which may be due to unstable glucose

Front 90

Metabolic syndrome

Back 90

BMI >95th percentile and 2 of the following:
impaired glucose tolerance or DM
HTN
hypercholesterolemia/dyslipidemia
Ovarian dysfuntion- hirsutism, acne, menstrual problems
fatty liver
large waist circimference

Front 91

Causes of disproportional short stature

Back 91

Rickets- vitamin D deficiency or renal disease
characterized by frontal bossing, genu varum (bowlegs), craniotabes, and rosary enlargement of the wrists

Front 92

Growth hormone dificiency

Back 92

R/O with growth hormone/somatomedin C

Somatomedin C is the better test value as it does not fluctuate as much as growth hormone

Front 93

Thyroid Dysfunction: Congenital hypothyroidism

Back 93

**if untreated can lead to menal retardation.
PE of infant: dry, thick, scaly, coarse with jaundice, hypotonia, protrouding tongue (everything is slow)

* if thyroid screen is done prior to 24 hours of age, it must be repeated in 1 to 2 weeks

retest if clinically manifesting signs or sxs of disease.

Test results:
TSH: elevated (indicates primary hypothyroidism)
FT4: low (more sensitive)
T3: low

Front 94

Autoimmune Hyperthyroidism

Thryoid Storm: malignant hyperthyroidism which is rare in children

Back 94

Sudden onset:
hyperthermia
tachycardia
high cardiac output
heart failure
delirium or coma

hyper Labs: TSH: low
FT4 and T3 are high

Front 95

Amenorrhea

Back 95

Primary: ***failure to begin menstruation:-no menses by age 16 with normal sex characteristics
- without s&amp;amp;amp;s pubertal development and no menstration by 14 years
- or no menstration 4 years after pubertal development began

**Cervical mucus; positive ferning indicates circulating estrogen

*mangement is referral
- if no pubic hair by 14, absent breast development by 16, or failure to begin menses within 4 years after puberty onset refer to reproductive endocrinologist or adolescent medicine specialist

Secondary: cessation of menstruation for 6 months (3 cycles) after regualr menses has been established

Front 96

Chest pain

Back 96

not usually associated with heart disease

Front 97

PMI

Back 97

>8 years: 5th ICS slightly left of MCL

<8 years: 4th ICS at MCL

Front 98

ASD- Acycanotic with left to right shunt and incrased pulmonary blood flow

Back 98

incraesed blood flow through the pulmonary artery and a ***fixed S2 split (usually not heard until periphral vascular resistance drops at age 6 wks to 4 mos)

mild fatigue on excertion

Front 99

Murmur Grading

Back 99

Grade Volume /Thrill
1/6 very faint, only heard with optimal conditions/ no
2/6 loud enough to be obvious/ no
3/6 louder than grade 2 /no
4/6 louder than grade 3 /yes
5/6 heard with the stethoscope partially off the chest/ yes
6/6 heard with the stethoscope completely off the chest /yes

Refer grade 3 and greater

Front 100

Heart sounds

Back 100

Presence of an S3 is normal in almost all children. If S3 is loud, it typically indicates a high diastolic pressure in the ventricles as may be seen in CHF

Presence of a S4 is almost never normal and usually indicates high pressure in the right or left ventricle as seen in pulmonic or aortic stenosis

***Presence of a FIXED S2 split is suggestive of an atrial septal defect (ASD) or pulmonic stenosis- REFER

Innocent heart murmurs are heard loudest in the recumbent position and after exercise

Front 101

VSD- ventricle septal defect

Back 101

Most common- Acyanotic with left to right shunt and inceased pulmonary blood flow

H/O decreased growth, feeding difficulties, excercise intolerance (toddler)

***Loud, 3/6 holosystolic murmur heard beast at LLSB, usually with a palpable thrill
small- restrictive
large- non-restrictive

Front 102

PDA-

Back 102

acyanotic defect with left to right shunt and increased pulmonary blood flow

harsh, continuous "machinery" murmur

Front 103

Coarctation of the Aorta

Back 103

Acyanotic defect; obstructive lesion; normal pulmonary blood flow

***High BP in upper extremeties
***Low BP in the lower extremeties
- blood can't get to the lower extremeties as well
***weak or absent pulses in lower ext.
- bounding pulses in the upper extre.
Systolic ejection murmur in teh left infraclavicular region with transmission to the back and left axilla

Front 104

Tetralogy of Fallot

Back 104

Four defects: pulmonic stenosis, right ventricular hypertrophy, VSD, and overriding aorta

*Cyanotic defect with right to left shunt and too little pulmonary blood flow- Blueish

**Cyanosis at birth if severe otherwise usually by 4 mths

Tet spells- spells of hypoxia with cyanosis and tachypnea followed by weakness/limpness/syncope and will be hypercapnic

****Squatting is a compensatory mechanism which increases pulmonary blood flow

PE: cyanosis, clubbing, RTT, loud/harsch systolic ejection murmur with thrill and right ventricular heave**

Tests: will have polycythemia (increased hematocrit which is compensatory mech for hypoxia)

Front 105

Right sided heart failure
systemic congestion (back up of body)

Back 105

periorbital/facial edema
hepatomegaly
sudden wt gain
dependent edema and ascites
distended nec veins (rare in kids)

Front 106

Left sided heart failure
Pulmonary congestion (back up of lungs)

Back 106

tachypnea
increased respiratory effort
grunting and nasal flarring
retractions
crackles

Front 107

American Heart on prophylactic regimens for dental procedures

Back 107

Antibiotic prophylaxis with dental procedures is recommended only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including:

Prosthetic cardiac valve
Previous endocarditis
Congenital heart disease only in the following categories:
–Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits

–Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure*

–Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients with cardiac valvular disease
*Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.


Amoxicliin 50mg/kg (max 2gm)

SBE prophy is used for nonrepaired lesions or corrected lesions with residual shunts as well as lesions that are only pallliated. (per NAPNAP book)

Front 108

Acute Rheumatic Fever (ARF)

Back 108

inflammatory connective tissue disease that typically affects the heart, joints, CNS, and subcutaneous tissue

Usually result of infection with Group A Beta Hemolytic Streptococci infection

H/O: recent illness; pharyngitis or skin infection (impetigo), recent exposure to GABHS, wt loss, fever, change in activilty level, SOB, joint swelling, tenderness, limited ROM

Jones Criteria:
presence of 2 major or 1 major and 2 minor criteria stongly indicative or ARF:
Major: carditis, migratory polyarthritis, erythema marginatum, subcutaneous nodules, chorea
Minor: fever, arthralgia, elevated ASO titer

Tx: PVK x 10 days or
Pen GIM
ASA
Prednisone

Front 109

Hypertension

Back 109

*A minimum of three readings with an average systolic BP of 140 and diastolic of 90 establishes hypertension. 2 or more readings at seperate times should be taken after the initial screening

The younger the child and the higher the blood pressure, the greater the probability of secondary hypertension which usually results from renal path

Primary: no pathologic etiology: obesity, stress, and increased sodium intake may contribute

Secondary: renal disorders, vascular disorders, endocrine disorders, and other (oral contraceptives, corticosteroids)

***obtain 2 limb BPs (both arms and legs)
***obtain BP in the right arm lying, sitting, and standing
***All children age 3 and older should have BP done annually

Front 110

Prehypertension

Back 110

Any adolescent with BP of greater than or equal to 120/80 is considered prehypertensive

Repeat elevated BP twice and average them at one visit

Front 111

heart sounds

Back 111

S1 is created when the mitral and tricuspid valves (AV valve) close

S2 is produced when the aortic and pulmonary valves close, marks diastole

Front 112

Cataract

Back 112

***a loss of transparency (opacity) of the lens of the eye

***the most common cause of a white pupil reflex- immediate Referral

Front 113

Dacryostenosis

Back 113

blockage of the nasolacrimal duct

*continuous or intermittent tearing of the eye
*accumulation of mucus or crusts on teh lashes or lower lid margin, esp in the morning or after nap

Management: warm compresses followed by firm stroking of the nasolacrimal sac in the downward motion 10 times, four times daily

***refer if obstruction persists more than 8 to 12 months

Front 114

CBC shift to the left

Back 114

Increase in WBC
Increase in Neutrophils
Increase in bands

Bacterial infection usually

Front 115

organisms

Back 115

S. aureus- gram +
H. Influ- gram -
S. pneumonia- gram +

Front 116

Viral infection

Back 116

decreased WBC
increased lymphocytes

Front 117

Conjunctivitis- Viral

Back 117

***gonococcus: pus discharge presents 2 to 5 days of life- due to eye prophylaxis not getting in eye at birth
treat with hospitalization of 7 day course of ceftriaxone or cefotaximine

chlamydia- presents at 2 weeks
treat with erythromycin ethylsuccinate eye oint for 2 to 3 weeks

nongonococcal opthalmia neoatorum: treat with broad spectrum erythromycin .5% eye oint to each eye QID for 7 days

HSV: vesicles around the eye and can cause blindness- immediate referral

* high assoc with pharyngitis
H/O: watery discharge, beginning in one eye and then in approximately 10 days, then other eye*** (follicles when you pull bottom eyelid down)

refer child if vesicles are seen - HSV

Front 118

conjunctivitis- Bacterial

Back 118

most common in preschool children; frequent associated with OM

***Etiology: Pneumococcus and H. Influ, but can be streptococcus and staph aureus

PE: matting of eyelashes esp upon awakening, tearing, mucopurulent discharge, redness of conjunctiva, burning, and stinging.

Front 119

Eye

Back 119

**Always examine the ears when a child presents with conjuctivitis bc of the high association of OM

**periorbital cellulitis w/ associated findings of UNILATERAL eyelid edema, erythema, INDURATION, tenderness, fever, and an increased WBC (shift to left); requires hospitalization with IV abx

Front 120

Simple bacterial conjunctivits

Back 120

Tx: sodium salamyd ophthalmic solution 10% 2 gtts each eye every 3 hrs while awake (bacteriostatic)
or
Erythromycin .5% ophthalmic oint. to each eye qid (more aggrivated infections)
or
Fluoroquinolones:
Ofloxacin (Ocuflox) - for children over 1
ciprofloxacin
levofloxacin
vigamox- safe for less than 1 year old

inform child/parents that oint can cause temp blurry vision- warm compress

Front 121

Allergic conjunctivitis

Back 121

watery, ithcy eyes, exposure to irritant
- cobblestones

* smear of conjunctiva reveals eosinophils***

Tx: vasoco- do not use past 3 days to avoid rebound congestions
use oral antihistamines

Front 122

Strabismus

Back 122

esotropia- eye turns inward
exotropia- eye turns outward
hypertropia- eye turns upward
hypotropia- eye turns downward

PE:***Hischbery pupillary light refles: unequal
Cover/uncover test: movement of the eye outward or inward when covered; when uncovered the eye returns to midline

**REFER any child with diviation of the eye after 6 mths of age

Tx: patching the fixing eye, which forces the child to use the deviating eye, corrective lenses, then corrective surgery

Front 123

Hearing loss - conductive

Back 123

* may see kidney problems
***conductive hearing loss is the most common cause of hearing loss- result of blocked transmission of the sound waves from the external auditory canal to the inner ear.

**most common cause is OM or OME

* presents with language develoment delay

Front 124

Hearing loss- sensorineural

Back 124

damage to the coclear structure of the inner ear or auditory nerve

Front 125

refractory errors

Back 125

myopia (nearsightedness)- cant see far

hyperopia (farsightedness)- difficulty seeing close up

astigmatism- uneven curvature or cornea

anisometropia- diff error in each eye

amblyopia-decreased visual acuity caused by inadequate or unequal visual stimulation that is later not correctable with lenses- squinting, HA, nausea- REFER

age 7- vision 20/20

Front 126

AOM- Acute Otitis media

Back 126

***symptomatic infection the the middle ear

***1. h/o abrupt (acute) onset (fever, otorrhea, irritability, otalgia)
2. visual signs of middle ear effusion (MEE) (bulging TM, limited or no TM mobility, air-fluid level, otorrhea)
3. presence of signs and/or sxs of middle ear inflammation (distinct erythemia of TM, distince otalgia)

Risks: males, parents who smoke, bottle fed, day care, downs syndrome, native american or native alaskan, allergic rhinitis with eustachian tube dysfunction, pacifiers after 6mths of age, and craniofacial abnormalitites

Front 127

AOM- Etiology

Back 127

Streptococcus pneumonis (pneumococcus)- gram + declining due to PCV7 (treat with amoxicillin

Haemophilus influenzae - gram - (use augmentin)

Moraxella (Branhamella) catarrhalis- gram - (use augmentin)

Front 128

AOM- History

Back 128

older children: freq c/o of ear pain

younger children: show signs and sxs of pain through behaviors such as irritability, crying, sleeplessness, head rolling, or pulling at their ears, fever, hearing loss, ear fullness, diarrhea, vomiting, difficulty feeding, URI

Front 129

ABX treatment for AOM

Back 129

Amoxicillin remains first choice of uncomplicated AOM

***for child with low risk for colonization with penicillin-nonsusceptible Sreptococcus pneumoniae: 40 to 60 mg/kg/day BID 5 to 7 days

***for child with hight-risk for resistant pneumococcus, recent abx use, under 2 yrs, or in day care: use 80 to 100 mg/kg/day BID

- abx are indicated for tx of AOM, however, dx requires documented MEE and signs and sxs of acute or systmic illness

treat children under 2 with 10 day course and continue even if feels better

Front 130

ABX treatment for AOM

Back 130

If no response in 72 hours can be assumed that:
cause is bue to beta-lactamase producing organism, or a viral infection

* use augmentin: amoxicillin 80 to 100 mg/kg/day bid w/ clavulanic acid 10 mg/kg/day

Macrolide ABX: remember that pneumococcal and H. influe are resistanct to these
use for child who is allergic to penicillin and cephalosporins

Front 131

AOM-
Sulfa drugs

Back 131

TMP/SMX- bactrim is a good second-line choice bc of low-cose and tolerability, however, it is not very effective against resistant pneumococcus: 8 to 10 mg/kg/day BID

do not use in children with associated pharyngitis bc of inadequate coverage against group a strep

Front 132

Refer to otolaryngologist if:

Back 132

-AOM is not responsive to treatment
-chronic or persistant OM (>3mths)
-child has breakthrough infections while on abx prophylaxis
-child has hearing loss or delayed language development as a result of AOM

Front 133

OME- otitis media with effusion

Back 133

***fluid in middle ear and decreased mobility of TM as seen w/ pneumatic otoscopy w/o signs and sxs of acute infection. also referred to as serous or secretory OM and "glue ear"

Most common cause of hearing loss in children (conductive hearing loss)***

h/o hearing loss, feeling fullness in ear, inattentiveness to parents and teacher

Front 134

Mastoiditis

Back 134

fever, irritabilty, erythema, swelling, or redness of mastoid bone

Front 135

OME Treatment

Back 135

***initiate abx therapy if the effusion persists > or equal to 3 months- use one that is effective against beta-lactamase producing organisma (augmentin)

treat with antihistamines- allerigc rhinitis

if last longer than 4 to 6 mths and child 1 to 3 years recommend myringotomy/PE tubes

Front 136

Otitis Externa OE

Back 136

***Etiology: Pseudomonas aeruginosa- green/yellow/sweet smell fluid
enterobactor aerogenes
proteu mirabilis
**fungi, such as candida and aspergillus- think if failure to abx

Front 137

OE treatment

Back 137

Broadspectrum
Floxin gtts
ciprodex gtts
cortisporin gtts

*a cotton wick may be inserted into the canal to facilitate medication administration

antifungal- 1% clotrimazole

Front 138

Pharyngitis Etiology

Back 138

*Viruses: most common causes: adeno, entero, herpes, EBV which causes mononucleosis

*Group A Beta Hemolytic Streptococci (GABHS) rare under 3 years and in teens over 16

* mycoplasma pneumoniae (freq cause in older children greater that 8)

* Neisseria gonorrhea (std) recurrent sore throat

Front 139

Pharyngitis history

Back 139

* Viral: gradual onset, prominent nasal congestion and rhinorrhea

*Mononucleosis: exudates, posterior cervical lymph node enlargement, "Hot potato voice", fatigue*, sore throat, fever *(not higher than 103), may have petechiae
- do a monospot test
- CBC: elevated lymphocyte count

* GABHS: exudates, abrupt onset*, cervical lymph node enlargement, absence of nasal sxs, fever, rash(scarlet fever), may have petechiae
- present with fever, HA, vomiting w/o c/o sore throat

Front 140

GABHS

Back 140

* dx cannot be made solely on clinical findings.
* some children have a non-impressive throat and positive culture

*Throat culture
* CBC: elevated WBC with elevated polys

Front 141

Viral Pharyngitis

Back 141

* encourage fluids, acetaminophen, throat lozenges

GABHS: treat with PVK 25-50 mg/kg/day qid or tid x 10 days

- no bactrim if allergy: tx w/ erythromycin

- in fails tx w/ cephalosporins: cephalexin; omnicef

Front 142

Mononucleosis

Back 142

supportive tx

***no contact sports or strenuous physical activity until spleen is no longer palpable

Front 143

Peritonsilar abscess

Back 143

* can't open jaw

* one tonsil is larger than the other

* tonsils removed recently and cant open jaw

Front 144

Epiglottitis- Bacterial Process

Back 144

Etiology: H. Influenzae
Streptococcus pneumoniae
Staphylococcus aureus
GAGHS

* History:
Abrupt onset of high fever
dysphasia (bad sore throat)
drooling
dyspnea
"dog position"- sitting up, leaning forward with jaw thrust
quiet inspiratory stridor

***Never examine the pharynx: leave the child in a sitting position; do not cause further distress

***early signs of respiratory distress: restlessness/anxiety, tachycardia, tachypnea

**Cyanosis is a late sign of hypoxia (PO2 is <50)

***immediate referral and transoport to hospital

CBC will show shift to left

Front 145

Croup

Back 145

Etiology: Mostly virus (influenza A, adeno, RSV)
rarely bacteria

* h/o URI sxs for 1-7 days
**Bark-like seal metallic cough

- lateral neck x-ray shows normal epiglottis and an area of density below the larynx caused by swelling of treacheal soft tissues

* Tx: humidification
Racemic epi and dexamethasone once
Augmentin if suspicious of bacterial etiology

Front 146

Asthma (Reactive airways disease)

Back 146

*Reversible obstructive airways disease characterized by smooth muscle hyperreactivity and airway inflammation

**a normal PCO2 indicates worsening status in a child with asthma since in the early stage of an atack, PCO2 is usually low

DDX:
-foreign body: wheeze is on side of FB
-cystic fibrosis: no sxs free periods

Front 147

lower respiratory tract obstruction

Back 147

expiratory wheeze
rhonchi
crackles
substernal retractions

Front 148

Types of Asthma

Back 148

1.Brochospastic- wheezing is a predominant sign

2. cough variant- cough is predominant sign

3. inflammatory- chronic bronchitis and cough are the predominant sign

Front 149

Asthma
Patient history

Back 149

cough (chronic)
SOB with exercise
chest tightness
wheezing
"colds go right ot the chest"

Front 150

Asthma classifications

Back 150

1. Mild: prolonged expiration, expiratory wheezing, tachypnea and tachycardia

2. Moderate: mild findings plus: use of accessory muscles, inspiratory and expiratory wheezing

3. severe: mild and moderate findings plus:
cyanosis
decreased aeration, anxiety, diaphoresis, lethary

Front 151

Asthma
Medications: Bronchodilators

Back 151

Beta adrenergics: relax smooth muscle

*Short acting- Albuterol or levalbuterol (xopenex)
*medium acting- bitolterol
*long acting- Salmeterol (serevent)

**should not be used for rescue to relieve acute symptoms

* Theophylline****in addition to bronchodilator effect, may also have anit-inflammatory action. Indicated for adjunctive rather than primary treatment
*SE: abdominal pain, vomiting and diarrhea

Front 152

Asthma:
Medications: Anti-Inflammatory

Back 152

1. Cromolyn Sodium: not good for acute attacks- stablizes mast cells
- indicted for prophylaxis to decrease frequency of exacerbations- TID

2. Corticosteroids: powerful
- Prednisone burst: when maintenance drugs not conrolling sxs or w/ URI

- inhaled corticosteroids:**Rinse mouth after to prevent thrush
Beclomethasone, Fluticasone (Flovent), busesonide (pulmicort)

3. Lekotrient Receptor Antagonists: prophylaxis and chronic tx
- not for acute attacks
- Montelukast (singulair)

Front 153

Asthma

Back 153

* daily low-dose corticosteroids are preferred tx for mild persistant asthma

* goal of asthma tx is to control the sxs

* intial tx of an asthma exacerbation should begin witha short-acting beta agonist (albuterol inhaler). may be repeated every 20 mins for two more doses

Front 154

URI- upper respiratory tract infections

Back 154

- inspiratory stridor and suprasternal retractions

- encourage fluids
- cool mist humidifier
- saline nose drops for infants
- if topical decongestants are used only use for 3 days to avoid rebound congestion

Front 155

Pneumonia

Back 155

* treat presumptively for bacterial infection

* Etiology***
in children less than 5 treat with broadspectrum and avoid amoxicillin and start on Augmentin

**Streptococcus pneumoniae and H. Influenzae
Group b strept, Staph, E. Coli
Viruses (RSV)
chlamydia
CNV and pneumocystic carinii

**Etiology in older than 5 years:
Group A strept
Mycoplasma pneumonia
Staphylococcus

Front 156

Pneumonia

Back 156

PE: Crackles*** typically heard on inspiration; but ***decreased breath sounds may be the only finding; dullness to percussion; wheezing may be heard in RSV pneumonia

* shift to left in bacterial pneumonia
* increased lymphocytes and atypical lymphs in viral pneumonia
*moderate eosinophilia may be seen with C. trachomatis

-blood cx done if child looks toxic or has high fever

****F/U in 24-48 hours is critical

Front 157

Appendicits

Back 157

***Fever, crampy abdominal pain that begins as periumbilical and then localizes to the right lower quadrant (RLQ)
- pain usually starts first, then vomiting
-Mcburney point- abdominal pain w/ rebound tenderness
- Psoas sign- after perforation, abdomen will become tender and rigid absent bowel sounds

- CBC: WBC shift to left (increased bands or stabs and elevated neutrophil count)

***If abdomen in tense or there is involuntary guarding or distention w/ rebound or toxic appearance, admit to hospital immediately

Front 158

Malabsorption

Back 158

Swollen villi- congenital or acquired deficiency diseases that result in an inability of intestine to absorb or digest nutrients and electrolytes

1. lactose malabsorption: watery diarrhea, abdominal cramping, bloating, bloody stool

2. Celiac disease- congenital absoption- gluten sensitivity(wheat, oat, barley, or rye), irritability, pale, loose, bulky stools, muscle wasting. gluten-free diet should be followed

3. Cystic Fibrosis- intraluminal phase- recurrent pulmonary infections w/o symptom free periods, bulky stools, (steortorrhea), "salty" taste to skin. refer to pulmonologist for pancreatic enzyme replacement and fat-soluble vit supplementation as well as vigorous protein and caloric supplementation

Front 159

Encopresis

Back 159

rectal disimpaction- do no longer than three days

1. to prevent reaccumulation, laxatives are introduced to achieve spontaneous, multiple, soft BMs. Senna syrup or mineral oil (1 to 3 cc/kg/day) to a maximum of 10 ml bid

2. laxative therapy should be contd for several weeks or up to 3 months

3. a calender/reward systme should be implemented to reward child for BM in toilet

4. need bowel retraining, fluid and fiver intake should be increased esp when decreasing laxatives

Front 160

Gastroenteritis
viral causes

Back 160

1. Rotavirus: usually in winter, most common 6-24mths

Front 161

Gastroenteritis
bacterial causes

Back 161

usually in summer

1. Campylobacter: most common- person to person w/ contaminated food or water

2. Shigella: assoc. w/ poor hygeine environments

3. Salmonella- any age- assoc. w/ contaminated foods

4. E. coli- travelers' diarrhea- common in newborns

5. Yersinia enterocolitica- younger children. lasts 3days to 3 weeks

6. C. diff- antibiotic-assoc. diarrhea

Front 162

Gastroenteritis
Parasitic Causes

Back 162

** treat with Flagyl 15-30 mg/kg/day TID x 10 days

*Giardia lamblia is the most common cause of parasitic gastroenteritis in the us- predominates at day care centers

***Vomiting and/or diarrhea occur first in gastroenteritis then abdominal pain. increased bowel sounds

Front 163

Dehydration

Back 163

1. Mild: weight loss up to 5%, *slight thirst*, normal pulse and BP, moist mucus membranes

2. moderate: weight loss of 5-10%; *thirsty*, slight decrease in BP or orthostatic, delayed cap refil, mucus membranes dry, +/- tears (more than 8 hours in infants and more than 12 hours in children)

3. severe: weight loss 10-15%, drowsy, limp, tachycardic, decreased palpable pulses, hypotension, poor perfusion, eyes and fontanelles sunken, absent or scant urine

Front 164

Gastroenteritis

Back 164

CBC; an increase in WBC and bands is common in bacterial types, esp. shigella

Stool for C & S and O & P for any report of pus, blood, or mucus in stool

Front 165

Vomiting

Back 165

* Do not use plain water, apple juice, popsicles, or milk for rehydration

* rest stomach for 1-2 hours

* hydrate with WHO solutions, rehydrolyte, Rice lyte, pedialyte, infalyte. and cont breastfeeding

Front 166

Gastroenteritis Treatment

Back 166

1. Campylobacter- Erythromycin (40mg/kg/day) qid for 5-7 days or axithromycin

2. Shigella- bactrim (8 mg/kg/day) bid x 5 days

3. Salmonella- complicated cases only
Amoxicillin (40mg/kg/day 7-10 days) or bactrim8 mg/kg/day for 7-10 days.

4. Yersinia: bactrim (8mg/kg/day) bid x 5 days

5. C. diff. - Vancomycin (w/ pseudomembranous colitis)
- infants less than 13mths, immunocompromised and sepsis

Front 167

Viral Hepatitis:
A

Back 167

- infectious hepatitis, children 5 to 15 years

* spread by oral-fecal route, transmitted by contaminated water or food (shellfish)- highly contagious

Front 168

Viral Hepatitis:
B

Back 168

- Serum hepatitis

* spread by sexual contact w/ infected partner or transmitted to newborn during delivery.

Front 169

Viral Hepatitis;
C

Back 169

* most common cause of chronic liver disease in adults

Front 170

Viral Hepatitis:
D

Back 170

* Caused by a defective RNA virus; occurs only with HBV (hep B virus) infection (co-infection or super-infections with HBV and is spread in same manner

Front 171

Atopic Dermatitis (eczema)

Back 171

***must itch
- an intensely pruritic chronic cutaneous inflammaory condition

* highly correlated with allergic disorders
* strong family h/o allergies

***pruritic rash with crust (may weep)

Treatment:
1. apply topical steroids to reduce inflammation Lidex- do not use on face

2. wet compress: Burow's solution: domeboro
3. Oatmeal baths
4. Antipruritics

Secondary infections:
- topical abx: mupirocin
- acyclovir for HSV

* maintian hydration to skin: use moisturizing PH balanced soaps and cream emollients

Front 172

Diaper (irritant) dermatitis

Back 172

most common form of diaper rash

1. Pustules w/ secondary bacterial infection

2. ***Bright "fire engine" red w/ satellite lesions which crosses inguinal folds is secondary to candida

**scalded skin and pustules- staph infection

Front 173

Impetigo

Back 173

* superficial bacterial infection of the skin predominant involvement of the face

**primary pathogens are staphylococcus aureus, group A beta-hemolytic streptococci, and streptococcus pyogens

* management with burows solution

Front 174

Scabies

Back 174

- parasitic infection and highly contagious


***linear papulovesicular lesions w/ fine gray to skin-colored superficial 2 to 8 mm linear curved burrows, primarily concentrated in webs of the finges, axillae, flexures of the arms and wrists, belt line, and buttocks

***apply permenthrin 5% (Elimite)- to all skin surfaces after bathing and drying skin (infants head to feet; children from neck down); rinse after 8 to 14 hours; can be used for infants 2 months and older/
Repeat tx in 1 week.
*rash and pruritus may persist for up to 3 weeks following treatment

*Lindane (Kwell) should not be used in pregnancy and in infants under 6 mths of age due to neurotoxicity

Front 175

Pediculosis Capitis

Back 175

Head lice
- examine family members and close contacts. treatment is often advised even if they are nit free

* Treat w/
1. Nix (permethrin 1%)- first line treatment

Advise parents:
-wash all linen, clothing and head gear in hot water
-vacuum all funiture & carpets
- store all items that cannot be washed in sealed plastic bag for min of 4 weeks
- soak all brushes, combs, and hair accessories in pediculicide or alcohol for an hour, followed by hot-water rinse

Front 176

Tinea Capitis

Back 176

- scalp fungal infection
* most commonly caused by Trighophyton tonsurans, but also microsporum canis

**spread by direct and indirect contact w/ infected individuals, animals, caps, hair accessories, and other personal items

**scaly plaques of various sizes w/ broken hair, w/ or w/o areas of alopecia
* papules and pustules w/ honey color crusts
*erythematous areas w/ broken hairs leaving a "black dot" appearance (T. tonsurans)

***Wood's lamp will only fluoresece Microsporum canis (green)

***KOH scraping from affected areas of scalp or broken hairs will confirm hypae and spores of dermatophytes

Treat w/ Griseofulvin and ***administer with fatty foods such as ice cream
- monitor CBC and LFT's if on longer than 3 months

- may use lamisil

Front 177

Tinea Corporis

Back 177

-superficial fungal skin infection on face or body
"ring worm"

Treat with antifungal

Front 178

Tinea Cruris

Back 178

- superficial fungal skin infection of the groin, thighs, and intertriginous folds
"jock itch"

***itch rash in the inguinal, groin, and thigh area

- treat w/ lotrimin

Front 179

Tinea Pedis

Back 179

"athletes foot"

** itchy, stinging rash on feet w/ or w/o odor

-treat with lotrimin

Front 180

Tinea Versicolor

Back 180

* rash on trunk w/ intermittent mild itching

***apply selenium sulfide 2.5% shampoo to affected areas QOD for 10 to 15 minutes and repeat once a month

Front 181

Herpes Zoster1

Back 181

* communicable for 5 to 7 days after appearance of vesicles (contact and droplet)

**The child is contagious for varicella

**new vesicles can continue to appear for up to 1 week and take 2 to 3 weeks to completely resolve

Front 182

Psoriasis

Back 182

**acquired chronic skin condition w/ spontaneous exacerbations and remissions manifested by well demarcated thick **silver-gray white scales

- keep skin hydrated
-keratolytic shampoos for scalp (3% sulfur or 6% salicylic acid)

Front 183

Acne Vulgaris

Back 183

1. Comedomal acne:
open (blackheads)
closed (whiteheads)
2. Papulopustular acne:
inflammatory papules- bacteria under skin
pustules - bacteria under skin

3. cystic Acne
- nodules and cysts
scars

Front 184

Comedomal acne

Back 184

**Retinoic acid .01% to .25% in gel form

Front 185

Papulopustular acne

Back 185

1. Mild: topical keratolytic agent (benzoyl peroxide gel, ranging from 2.5% to 10%) once or twice a day

2. Moderate to Severe:
Topical Abx
- erythromycin 2% solution or clindamycin 1% solution or
- benzamycin topical gel w/ erythromycin and benzoyl peroxide or
- benzaclin topical gel w/ clindamycin and benzoyl peroxide or
- duac topical gel w/ clinda and benzoyl

Tetracycline- avoid sun exposure and stains teeth

Front 186

Cystic Acne

Back 186

**for severe cases, refer to dermatologist for possible accutane isotretinoin treatmnt

Front 187

Varicella (chicken pox)

Back 187

- peak incidence 5-10 years old
- spread by direct contact, droplet or airborne

* communicable 1-2 days before rash appears until all lesions are crusted.

*prodome: fever, malaise, anorexia 24 hours before onset of rash, rash begins on trunk, and then spreads to face and head, pruritis, and recent exposure

* fluid-filled (tear drop) vesicles on a erythematous base
- treatment is supportive but w/ immunocompromised pts can use acycloivir

Front 188

Varicella complications

Back 188

1. Secondary bacterial infections: impetigo, cellulitis, conjunctivitis

2. Pneumonia- adults

3. Reyes syndrome: persistent vomiting, behavioral changes (lethargy, agitation, disorientation, combativeness), coma

4. Encephalitis - most common CNS complication

*VZIG is not effective once the disease is established

Front 189

Rubella (German measles)

Back 189

* communicable from 7 days before to 4 days after onset of rash w/ incubation periods of 14-21 days

**mild prodrome:
malaise, slight fever, tender postauricular and occipital lymph nodes

****rash of faint, fine, discrete, erythematous MACULOPAPULES appearing on the face and spreading rapidly over trunk and extremeties- disappears by 3rd day

***RED palatal lesions (Forchheimer spots) on day 1 of rash

- supportive treatment

Front 190

Mumps (epidemic parotitis)

Back 190

***Etiological agent is parmyxovirus

- spread person-to-person w/ incubation period that averages 16-18 days but can be 12-25 days
- communicable from 2-7 days before the appearance of sxs to the disapperance of salivary gland swelling.
-locial pain around ear and jaw followed by swelling of the parotid gland, which reaches max size in 1-3 days, lasting 3-7 days
-pain is aggrevated by chewing, swallowing, opening mouth, and ingestion of sour substances

***Stensen's duct (opposite the upper second molor) may be puffy and red***
-swelling of one or both parotid glands

Front 191

Roseola (exanthema subitum)

Back 191

-contagious disease which manifests itself by a high fever, children 6-24 mths

***caused by human herpesvirus 6 (HHV-6)

h/o suddent onset of hight fever (>103) for 3-7 days
rash that appears once fever is gone
irritability and anorexia

**Child frequently looks alert and non-toxic despite the high fever and rash

* erythematous, maculopapular rash usually starts and is concentrated on the trunk and then spreads to arms, w/ less involvement of face and legs

Front 192

Rubeola (measles)

Back 192

* high in unimmunized persons

**contagioius form 3 to 5 days before the onset of rash (1-2 days before sxs appear)

-Prodome: fever, coryza, cough (dry "barking"), conjunctivitis, (the 3 Cs of measles)

**Kopliks's spots: fine white spots on a faint erythematous base that appear on the buccal mucosa, first oppostie the molar teeth, prior to appearance of rash

***Rash is pink, blotch, irregular, Macular erythema, which rapidly darkens and coalesces into larger red patches of varying size and shape; ***fade on pressure*** and can be on palmar surfaces

Front 193

Erythema Infectiosum (5th disease)

Back 193

***Cause is Human Parvovirus B19

-sudden appearance of rash that appears ***first on the cheeks and ears as a very red coalescent macules that are warm and slightly raised. **"slapped cheek" appearance

***Facial rash disappears w/in 4 days and is followed 1 day later by a lacy, reticulated Maculopapular erythematous rash that appears on the extensor surfaces of the extrementies and spreads over the next 2-3 days to the flexor surfaces and trunk.

* intrauterine infection (in first half of pregnancy) has resulted in fatal anemia w/ hydrops fetalis and fetal death in <10% of cases

* exposed pregnant women should be offered B19 IgG and IgM antibody testing to determine susceptibility

Front 194

Coxasackie virus (herpangina and Hand-Foot-and-Mouth disease)

Back 194

***Small vesicles or ulcerations, esp on the soft palate and tonsillar pillars w/ herpangian (posterior oropharynx)

Front 195

Kawasaki Syndrome (Mucocutaneous lymph node syndrome)

Back 195

* an acute febrile condition assoc w/ generalized/multi-system vasculitis

***Leading cause of acquired coronary artery disease in children

History:
- early:
persistant fever (> 5days), preceding or concurrent respiratory sxs, irritability, red tongue, lips and throat (strawberry tongue), red eyes (no exudate), rash, swollen lymph nodes (usually unilateral)

-mid-course (sub-acute)
-***dry, peeling skin on lips, fingers and toes (desquamation of fingers, toes, groin)

- Late:
-resolution of sxs

Front 196

Kawasaki DX criteria

Back 196

Persistent fever of a least 5 days + 4 of 5 sxs below:
1. ***bulbar bilateral conjunctivitis w/o exudate
2. erythematous mouth and pharynx, strawberry tongue
3. generalized erythematous rash can be morbilliform, maculopapula, urticarial, orscarlatinform w/in 4 days of fever onset
4. intense erythema of the palms and soles assoc w/ a variable degree of swelling w/ a firm indurated quality
5. cervical adenopathy consisting of a unilateral firm nodal enlargement

Front 197

Kawasaki treatment

Back 197

Immediate referral

***admission to hospital with high-dose IVIG (must be initiated w/in 10 days of onset of fever to prevent cardiac sequelae) and aspirin (anti clotting/anti-inflammatory at 80-100 mg/kg/day QID until fever controlled then low dose (3-5 mg/kg/day) for 6-8 wks or until sed rate and plt count decrease

Front 198

Lyme disease

Back 198

*** Cause is a spirochete, Borrelia burgdorferi, which is most often transmitted by a deer tick but also carried on wild rodents

- h/o camping- tick-rash

Front 199

Lyme disease PE

Back 199

1. Early Localized:***
erythema migrans is the distinctive skin lesion which is well-circimscribed, erythematous, annular rash w/ central clearing; may spread to 5 cm- occurrs at the site of bite

2. Early disseminated:
multiple EM rashes

3. Late disease:
weeks to years later: intermittent episodes of swelling and pain in large joints- recurrent arthritis

Front 200

Lyme disease

Back 200

* treat early to prevent complications:

- early stages:
- 8 years and under : Amoxilcillin
-over 9 years: Doxycycline
- For children allergic to PCN, give erytheromycin or cefuroxime (treat 14-21 days)

- late stage:when persistent arthritis, severe carditis, or neurologic involvement: parental ceftriaxone or pcn G.

Front 201

Effective antidepressant for adolescent

Back 201

Paroxetine- SSRI

Front 202

diaper rash consisting of pinpoint, erythematous rash w/ a scalloped border and satellite lesions or pustules

Back 202

Candidal diaper rash
TX with nystatin ointment

tx mom with nystatin powder to breast

Front 203

3-4 week h/o knee pain, which increases with activity. notable pain and tenderness over tibial tuberosity

Back 203

Osgood Schlatter disease-
- modify activities that casue pain until the inflammation subsides (RICE)

Front 204

Most usesful intervention in the tx of childhood obesity is

Back 204

behavior modification

Front 205

effects of CMV infection on hearing

Back 205

Hearing loss may be progressive after the newborn period

-leading cause of sensorineural hearing loss

Front 206

instructions for Epipen

Back 206

regular review of usage and experatin date.

- give IM

Front 207

institution that leagally defines scope of practice for PNP

Back 207

state legislation
-vary from state to state

Front 208

Persistent exercised induced asthma (EIA)- most effective inital treatment

Back 208

Inhaled corticosteroid

- Salmeterol is a controller therapy for EIA in these patients who are taking concurrent inhaled corticosteroids
-Leukotriene antagonists have a protective and additive w/ inhaled corticosteroids and may loser dose of steoids needed

Front 209

Prophylaxis for 2ndary prevention following a definitive dx of rheumatic fever

Back 209

PCN G IM every 28 days up until eary 20's or five years after initial dx.

Front 210

initial mgmt of puncture wound in the sole of a foot (stepping on a protruding nail)

Back 210

superficial irrigation of the wound w/ sterile saline and cleansing area of foreign matter

-prophylactic abx are not indicated unless risk is esp high such as cat bites, face wounds, and human bites.

Front 211

after one month tx of ferrous sulfate?

Back 211

cont medication for another 2 months

-check hct at least 1 month after completion of therapy

Front 212

most important mgmt of infant with clubfoot/talipes equinorvarus

Back 212

refer immediately to orthopedics for institution of serial manipulation (stretch) and splinting.

Front 213

15mo w/ tubes has had small amt of ear drainage and on exam reveals a white area behind an intact typanic membrane. Management?

Back 213

refer to otolaryngologist

-cholesteatoma (white area)

Front 214

current mgmt of croup w/ increased WOB

Back 214

oral corticosteroids.

-albuterol may worsen sxs

Front 215

if parent refuses immunizations

Back 215

validate parental concerns regarding individual immunizations

Front 216

For severe and extensive eczema on 18mo old: pt education on topical fluticasone

Back 216

avoid application to face

-topical steroid should no be applied to open skin, face, underarm, or groin. do not occlude and rub in until disappears

Front 217

Immunization w/ PCV-7 and 23PS for stated age and risk status

Back 217

20 mo old w/ high risk give 2 doses of PCV7 6-8 wks apart and 23PS at 24mo of age.

-At risk children should recieve both PCV7 and 23PS
-PCV7 for less than 24 mo of age

Front 218

highest cost:benefit ratio for sensorineural hearing loss

Back 218

genetic evaluation

-search for underlying cause

Front 219

intial step in tx of purulent OE

Back 219

cleaning external canal

-use ear drops only after clear of debris

Front 220

9yo treated w/ lyme disease 2 yrs ago and now has rash consitent w/ erythema migrans. Best action?

Back 220

treat w/ antibiotics

-w/ lyme disease treat on basis of clinical manifestations.
- may be positive for antibodies for years

Front 221

most appropriate analgesia for 4yo w/ post op tonsillectomy pain

Back 221

acetaminophen and oxycodone (Roxicet)

-bc of risk of hemorrhage use of NSAIDS, including ibuprofen, ketorolac and ASA are not recommended.

Front 222

15 yo previously healthy having school problems, feeling sad, insomnia, and disinterest in previously enjoyed activites. teen denies desire or plan to hurt himself or others. Initial management?

Back 222

refer to outpatient psychotherapy

-

Front 223

most appropriate mgmt of 14 yo sexually active pt who is positive for gonorrhea dn chlamydia

Back 223

Ceftriaxone 125 mg IM + azithromycin 1 g orally, single dose

single dose of cef or gonorrhea and single azith for chlamydia

-flagyl for trich to both partners and flagyl for 7 days for BV

Front 224

tx of primary nocturnal enuresis w/ highest relapse rate

Back 224

pharmacotherapy (80-89% relaspe rate

-motivational has succes rate of 25% but low relapse rate
- alarm has 70% succes rate but 1-15% relapse

Front 225

Best rationale for f/u echo in child w/ Kawasaki disease

Back 225

coronary artery pathology can change w/ the progression of the disease

Front 226

Best choice of antibiotic therapy for uncomplicated acute sinusitis in a 3 yo w/ asthma

Back 226

Amoxicillin

-bacterial organisms: streptococcus pneumonia, H. influ, Moraxessal cat, and GABHS

-allergy to pcn: give cefdinir, cefuroxime, or cefpodoxime for type 1 hypersensitivity and azithromycin or clarithromycin for severe rxn

Front 227

hypospadius and circumcision

Back 227

cicumcision is contraindicated and urologist will be consulted.

-repair done between 6-12 months of age
- check for undescended testes as well.

Front 228

23 mo w/ vaccine h/o
9 mo- DTaP, IPV, Comvx, PCV7
13mo- DTaP, IPV, Comvax, PCV7, MMR, Var

now give

Back 228

DTaP, Comvax, IPV, PCV7

Comvax= Hib/HepB

-needs 3rd IPV and 3rd dose of PCV7 since only 2 previously and 1 prior to 1st birthday

Front 229

phototherapy would cause most rapid decline in total serum bili when TSB is

Back 229

greater than 20mg/dl

Front 230

Inital mgmt of infant born at 32 wks and was in NICU and now at first visit has leukocoria

Back 230

review d/c summary to determine a previous dx of ROP (retinopathy of prematurity)

-if not ROP refer to ophthalmologist

Front 231

legistlation that provides wheelchair ramp for 14yo w/ juvenile rhematoid arthritis

Back 231

Rehabilitaiton Act- provides accomodations for teens w/ disabilites, not covered w/in the concept of the individual education plan.

-Americans w/ disabilites Act and supplemental security income (SSI) provide service after age 22

Front 232

generalized anxiety disorder

Back 232

cognitive behavior therapy leads to higher response rates than medication alone

Front 233

most common comorbidities w/ ADHD

Back 233

oppositional defiant disorder (coexists in 35% of child w/ ADHD

Front 234

4mo w/ congenital nasolacrimal duct obstruction w/ h/o several dacrocystitis episodes currently in hospital w/ cellulitis. approriate f/u?

Back 234

surgical referral for potential tear duct probing.

-most CNLDO resolve spontaneously by 12 mo of age but if havent or multiple episodes of dacryocystitis refer

-frequent massage and cleansing and application of aphthalmic abx or drops is useful

Front 235

guidlines for calculating oral replacement6 for child w/ moderate dehydration from gastroenteritis

Back 235

stool losses should be replaced in addition to maintenance requirements

Front 236

most important mgmt for 3yo w/ fever, pharyngitis, pre-auricular adenopathy and conjuctivitis:

Back 236

staying out of daycare as long as the eyes are red and tearing.

-symptoms are from adenovirus which is extremely contagious and can be life threatening for infants and children who are immunocomprimised.

-control w/ good hand washing

Front 237

Most successful therapy resulting in full response for the tx of functional nocturnal enuresis:

Back 237

combination of behavior modification, bladder control training and motivational therapy

-bladder trainin, waking child up for voids w/ or w/o alarmand motivational strategies which include rewarding child for dry nights is most successful

Front 238

according to NAEPP (national asthma educational and prevention program) expert panel 3 update, potential long-term adverse effect of chronic inhaled corticosteroids use in children include:

Back 238

vertical growth delay in the first year of treatment

-not sustained in subsequent years of treatment and is not progressive and may be reversible.

Front 239

2 week old w/ umbilical cord not fallen off now moist, erythematous, and malodorous w/ visible purulent drainage. Best mgmt:

Back 239

refer infant for sepsis work up

-infant w/ potentially infected umbilicus requires a work up for bacteremia or general sepsis. local infection can easily become systemic in a very young baby

Front 240

administration of HepB vaccine to premature and low birth weight infant appropriate when:

Back 240

mother's hepatitis B status is unknown and infant is w/in 12 hours of birth

-All infants born to hep B AG positive and hep B status unknown mothers should recieve hep B vaccine and HBIG by 12 hours of life.

Front 241

19mo w/ 5 minute episode of generalized shaking followed by brief unresponisveness. PE is unremarkable except for fever and bilateral OM. Initial appropriate mgmt:

Back 241

treat bilateral OM

-febrile sz (underlying cause is OM so tx first)

Front 242

beneficial tx option in the resolution of a cutaneous fluctuant abscess in a healthy child

Back 242

incision and drainage

I&D w/ culture first

Front 243

when should an asymptomatic carrier of giardia lamblia be considered for tx?

Back 243

a child whose mother is pregnant

- treat if parent or sibling is immunosupressed or mom is pregnant

Front 244

Most beneficial Initial treatment for an adolescent w/ a migrain HA?

Back 244

good sleep hygeine

-long term goal of migrain mgmt are reduce HA freq, severity, duration and diability and to reduce use of medications while improving quality of life.

Front 245

AAP recommends child ASSENT to participation in clincal research requires evidence of:

Back 245

being developmentally appropriate understanding of the nature of his condition.

- tell them what to expect w/ tests and treatments, make a clinical assessment of the patients situation and factors that influence how they response

Front 246

5yo w/ daily sxs of wheezing and coughing 2-3 nights per week. According to NAEPP which drug combination would be most appropriate?

Back 246

Fluticasone (corticosteroid) and Salmeterol (long-acting beta-2)

-combination of long-acting inhaled beta-agonist and lw-dose corticosteroid is best

Front 247

11 yo present w/ 3 day h/o cough at night, tachypnea, and URI sxs. exam reveals loud inspiratory and expiratory wheeze. What is first course of action?

Back 247

Administer inhaled albuterol.

-coughing, wheezing, SOB, and tachypnea, along w/ URI sxs indicate dx of asthma. first course of action is administer albuterol tx, consider steroid if wheezing persists after albuterol tx.

Front 248

3yo w/ h/o severe asthma w/ 6 hospitalizations over past 2 years one parent smokes around pt and one parents wants other reported. first?

Back 248

make sure parent has been adequately educated as to the danger of second hand smoke.

exposure of a child w/ asthma to smoke, a well-known environmental hazard and trigger of asthma, can be a manifestation of possible child neglect.

Front 249

infant born at 30 wks gestation, w/ BPD and an oxygen requirement for one month following hospitalization, presents for well care mid-winter season. PE is normal w/ no oxygen needed. Plan should be?

Back 249

arrange for RSV prphylaxis

-AAP recomments Synagis for preterm infants who required vent support of chronic oxygen therapy.
-dosed monthly for 6 months through out season

Front 250

Credentialing of PNP requires :

Back 250

verification of license

Front 251

Most accuate method of confirming a suspected food allergy?

Back 251

double-blind placebo controlled food challenge

Front 252

developmental milestones for a 5 mo old:

Back 252

rolling from back to front, reaching for an object and smiling spontaneously at familiar faces.

-can roll both ways, sit w/ support, but can not transfer object hand to hand

Front 253

4yo treated w/ amoxicillin for clinical signs of a right lower lobe pneumonia and 5 days after start of tx child has persistent fever to 102, cough, and severve lethargy. PE reveals decreased breath sounds in right middle and lower lobes. next step in mgmt?

Back 253

refer for lateral decubitus chest radiograph

- lateral decub will differentiate the presence of fluid in the pleural space, as a pleural effusion secondary to bacterial or viral pneumonitis.

Front 254

Effect that most correlates w/ sub-clinical lead exposure?

Back 254

decreased cognitive function

Front 255

in addition to hypoglycemia, the MOST common complications found in infants born to mothers w/ diabetes or gestational diabetes include?

Back 255

LGA, cardiomegaly, renal vein thrombosis and polycythemia

Front 256

which diagnositic criteria is Most consistent w/ finding of acute OM

Back 256

decreased mobility

Front 257

compared to onset of Type 1 DM, girls w/ Type 2 diabetes are LEAST likely to have:

Back 257

polyuria

-hypertension is rare w/ type 1 but may be seen w/ type 2, vaginal infections are rare w/ type 1 but occur in type 2, it is common in type 2 to be asymptomatic

Front 258

Guidelines for the mgmt of childhood obesity include:

Back 258

encourage families to modify their diets along w/ child, do not force child to clean plate, and promote daily physical activity

Front 259

10 yo w/ 0.2-0.3 inch swollen mass centrally located on his lefter upper eyelid. no pain and only mild erythema? most likely dx:

Back 259

Chalazion

-chalazion is granulomatous inflammation around the meibomian gland and usually centrally located and lacks an inflammatory changes

Coloboma- cleft like deformity of the eyelid, not a mass
Blepharitis- inflammation of the eyelid margins, and does not present w/ mass

Front 260

AAP recommendations for autiometric screening:

Back 260

screen all newborns

Front 261

Education regarding the newly FDA approved vaccine for HPV:

Back 261

the vaccine does not treat HPV, genital warts, or precancerous lesions.

-for girls age 9 to 26 and covers 4 HPV types

Front 262

anticipatory guidance for sleep pattern of a 1 year old?

Back 262

have a bedtime routine.

Front 263

diagnosis of long QT syndrome is best established by:

Back 263

ECG (electrocardiogram)

Front 264

4yo w/ close contact 10 days to a school classmate, now hospitalized w/ meningococcemia, currently has no sxs and a normal PE. no other cases have been reported in community. Approp. mgmt?

Back 264

reassurance.

- children in day care or nursery school who have been exposed to meningococcemia w/in 7 days are conisdered high risk and should receive the appropriate chemo-prophylaxis meds. Rifampin and ceftriaxone are good. not used after 7 days of exposure.

Front 265

15 yo girl w/ 3-wk h/o of dull lower abdominal pain, found to have negative urine HCG. in absence of cervical motion tenderness on PE, which, additional finding would meet the Minimum diagnostic criteria for PID?

Back 265

adnexal tenderness.

criteria:cervial motion tenderness or tenderness of teh uterus or adnexa. fever, WBC on microscopy of vaginal secretions, gram-negative intracellular diplococci on gram stain of endocervix, or positive gonorrhea or chlamydial cervical cultures.

Front 266

According to 2000 AAP guidelines, which child whould requie an ultrasound to rule out developmental dysplasia of the hip (DDH)?

Back 266

female infant age 3 wks w/ family h/o of DDH and soft tissue hip click

- U/S has been established as an accurate method of hip imaging during the first few months of life (less than 5 months of age).
After 5 months of age x-rays are indicated for babies w/ suspicious findings

Front 267

2 wk old fed Enfamil Lipil w/ iron in hospital now on ProSobee Lipil due to concern about allergies in older child. best response?

Back 267

Both formulas contain equal amounts of nutrients including iron.

Front 268

11 yo w/ c/o recurring headaches, which usually last several hours associated w/ nausea and sometimes blurred vision only relieved w/ sleep. Most likely dx?

Back 268

Migraine

Front 269

Most important safety question to ask 17 yo?

Back 269

Do you always wear a seat belt when driving or riding in a car?

-MVC is leading cause of death among children in US

Front 270

Exercise Induced bronchospasm characteristics

Back 270

sxs resolve typically 30-60 minutes after the activity ends.

- there is an initial 5-10 minute period of bronchodilation at the start of exercise w/o sxs, then bronchoconstriction peaks 5-10 minutes after exercise.
-SXS can often be controlled by breathing through the nose and using masks and scarves to prevent extremes in airway temps.

Front 271

Duchenne muscular dystrophy

Back 271

4 yo w/ waddling gait, thick calves and difficullty standing from a sitting position on the floor

-progressive degeneration of skeletal muscle. early sxs: clumsiness, easy fatguability, walking on toes, waddling gait and the "Gower" maneuver.

Front 272

most accurate test to dx infant w/ suspected HIV

Back 272

PCR (less than 15 months)

After 15 mo then ELISA and western blot

Front 273

Most accurate statement regarding the AAP current recommendtaiton for Vit D supplementation in breast-fed infants:

Back 273

All infants who do not take formula should receive supplementation

-supplement w/ 200 IU of Vit D per day

Front 274

Best screening indicator for iron def. in toddlers

Back 274

diet history

Front 275

All internationally adopted children should have what routine screening on arrival?

Back 275

intestinal parasites

-stool O&P is recommended

Front 276

14 yo suffers head blow whild playing football. He gets up immediately, but seems momentarily confused. w/in 2 minutes he is oriented and able to correctly recall preceding events. The immediate sideline eval for this injury is?

Back 276

digit recall, provacative testing and a brief neurologic exam.

-immediate removal after any concussion.

Front 277

14 yo female who has not began her menses. Pubic hair development started about 2 years ago, and breast development began about 18 months ago. She has grown 2 inches in height in past 6 monts. Most accurate response

Back 277

As menes will probably begin in next 6-12 months, a wait and see approach is best.

Breast development signals the beginning of puberty (thelarche).
Menarche typically occurs 2-2.5 years after breast development begins

Front 278

counseling for parents of 2 yo w/ lead poisoning:

Back 278

use high efficiency particulate air (HEPA) filters for vacuuming.

-wet dusting regularly
-repainting w/ no-lead-based paint.

Front 279

Advice regarding athletic pre-season strength training in preadolescents should include:

Back 279

benefit of increased resistance to injury.

Front 280

30 month (2 1/2) development

Back 280

walks backward, copies a crude circle w/ crayon, refers to self as "I"

-alteranate feet on walking stairs at 3-4 yrs

Front 281

What test has been added to majority of state core newborn screening panels

Back 281

Cystic Fibrosis

Front 282

Appropriate patient position for detecting a varicocele in an adolescent male

Back 282

Standing - fills the varicocele w/ blood and makes it palpable on exam

Front 283

12 month old with leukocoria

Back 283

Refer to ophthalmology

Front 284

ROS = review of systems

Back 284

history of birthmarks or skin lesions

-health hx with specific subjective history of body systems asked by the provider.

Front 285

Common characteristic of Prader-Willi syndrome

Back 285

lifetime obesity

-known as a genetic form of obesity

Front 286

language milestone for a 24 month old

Back 286

has a 30-50 word vocabulary

-put words together in short, 2-3 word sentences and name at least one object in a picture

Front 287

NP's can best assist teens in reducing behaviors that present health risks while socializing w/ peers by

Back 287

incorporating conversations w/ teens regarding safe sex, substance use and body art w/ regular health visits.

Front 288

Formula choice for an infant who presents at one week of life w/ constant diarrhea w/ blood and mucous is

Back 288

Nutramigen (casein hydrolysate).

-Isomil and ProSobee are soy protein based

Front 289

Most appropriate anticipatory guidance of adolecents should include suggestions to:

Back 289

establish realistic expectations for rules, enhance the child's self esteem by praise, recognition of positive efforts and emphasize the importance of school

Front 290

Afebrile 3yo w/ no h/o trauma presents w/ a one day h/o a limp. PE negative except for pain w/ weight bearing. H/O a viral illness one week ago. Most likely dx?

Back 290

Transieent synovitis- sudden onset consisting of refusal to walk, and is more common in boys.

Septic arthritis- fever, along w/ hip pain and limited ROM
osteomyelitis- trauma usually precedes it
Fracture- inflammation along w/ pain

Front 291

OTC medication w/ high abuse potential and is popular among adolescents bc of it euphoric effects.

Back 291

Dextromethorphan- antitussive causes mental status changes, euphoria, hallucinations, visual disturbances, tachycardia, hypertension, slurred speech, and ataxia

Front 292

Measurement that is most important indicator of overall glycemic control in an adolescent w/ Type 1 DM?

Back 292

serum HgA1c

Front 293

Most likely pathogen causing OM that requires abx

Back 293

Streptococcus pneumoniae

Front 294

First step in establishing a plan for weight management for a 5 yo w/ greater than 95th% for weight to height ratio?

Back 294

evaluating physical activity level

-primary goal is to normalize wieight not weight loss
-not recommended to restrict calories in a young child

Front 295

Most effective method of encouraging long term bicycle helmet use is?

Back 295

Parental use of bicycle helmets

Front 296

Only consequence of loss of primary incisors to trauma is?

Back 296

altered physical appearance of child

-early loss of primary anterior teeth has no irreversible effect on speech or spacing of permanent teeth.

Front 297

Counseling regarding meningococcal disease for prospecive college freshman who plans to live in a dormitory includes?

Back 297

the risk for meningococcal disease is increased for freshman college dormitory residents

Front 298

10 yo afebrile male presents w/ mild, scrotal pain, swelling and erythma. No inguinal mass is noted. Cremasteric reflex is present and a small tender indurated mass is palpated at the upper pole of the left testicle. UA is unremarkable. Most likely dx is?

Back 298

Torsion of testicular appendix

Testicular torsion- acute severe pain, absent cremasteric reflex
Incarcerated hernia- sxs of intestinal bstruction may occur

Front 299

Cow's Milk

Back 299

do not start until one year bc of the higher risk for allergy and is does not contain adequate nutrition for an infant

Front 300

Most common cause of pneumonia in children between age of 5 and 12, who present w/ a low grade fever is?

Back 300

Mycoplasma pneumoniae