Comprehensive AANP Review (LEIK/Barkley/Fitzgerald) pt. 4* (women,pregnancy,childbirth/peds)
The most likely causative pathogen in a 26-year-old women with PID is:
C trachomatis
You examine the 28-year-old woman who has immigrated from a country where tuberculosis is endemic. He has documentation of receiving BCG vaccine as a child. With this information you consider that; A. She will always have a positive tuberculin skin test results. B. Biannual chest radiographs are needed to assess her health status accurately C. A tuberculin skin test finding of 10 mm or more induration should be considered a positive result D. Isoniazid therapy should be given for six months or skin test is undertaken
C. A tuberculin skin test finding of 10 mm or more induration should be considered a positive result Positive skin test result usually noted 2-10 wks of acquiring organism
What are prevalent organisms for PID?
C. Trachomatis N. gonorrhaeae E. coli G. vaginalis H. Influenzae Strep agalactiae
You are caring for a 45-year-old woman from a developing country. She reports that she had "yellow jaundice" the young child. Her physical exam is unremarkable. Her lab studies are as follows: AST 22 (0-31) ALT 25 (0-40), HAV IgG positive. Test reveals: A. Chronic hep a B. no evidence of prior or current hepatitis A infection C. resolved hepatitis A infection D. prodromal hep A
C. resolved hepatitis A infection
Which lab test can you check if you are suspicious of ovarian cancer?
CA-125
Routine prenatal screenings
CBC Blood type with Rh antibodies UA and culture Pap STI screen RPR HBsAg Rubella titer Cystic fibrosis screening
MMR: r/t traveling
CDC recommends giving 1 dose to infants *6-11 mons* of age if traveling outside of the US, regardless of country.
What does Low-grade SIL indicate on pap?
CIN 1 (HPV or mild dysplasia)
What is CIN? Describe the various stages
CIN = cervical intraepithelial neoplasia. Dysplasia (precancerous changes) of the cervical epithelial cells 3 stages: CIN 1: mild dysplasia, usu corresponds to HPV infx (esp in adolescents/younger women) CIN 2: moderate dysplasia CIN 3: equivalent to carcinoma in situ, where the dysplastic lesion has invaded from two-thirds to the entire thickness of the tissue layer, but has not yet broken through to invade surrounding tissues
What does High grade SIL indicate on pap?
CIN2-moderate dysplasia CIN3-severe dypslasia CIS-carcinoma in situ
5 & 6 years
CM- good articulation, tells simple story using full sentences, appropriate tenses, counts to 10, names at least 4 colors CG- follows simple directs, dresses and undresses with minimal help P- able to tie knot, mature pencil grasp, draws person with 6 parts, print some letters and numbers, copies squares and triangles
Pharmacologic management of ADHD
CNS stimulants (increase availability of neurotransmitters to increase focus and attention) Start slow and low, titrate.
Emergency contraception options
COCs (Yuzpe Method) progestin only (Plan B, Next Choice) -not as effective if obese ulipristal acetate progesterone (Ella) Copper IUD (Paraguard)
Mindy, age 42, is pregnant for the first time she wants a CVS performed for genetic testing. Which statement is true regarding CVS
CVS detects only chromosomal anomalies and not anatomical aberrations such as an open neural tube defect
Dietary-lifestyle management of PMS?
Caffeine restriction, Vitamin E, Salt restriction, vitamin B6, exercise
Which supplement has the highest amount of elemental calcium?
Calcium carbonate
List methods of natural family planning
Calendar method (counting days) Basal body temperature (temp drops prior to ovulation and rises after, no sex until elevated x 4 days) Cervical mucus changes (aka "Billings" method) Symptothermal method (all types combined)
What do we do if a child has been exposed to measles or will be traveling to endemic areas?
Can give MMR as early as 6 months of age but pt still needs to continue primary series at the appropriate time
What is language development like for a 4 year old
Can understand phrases and simple analogies
What is PKU
Cannot break down phenylalanine, a common protein. If not identified, baby may develop severe retardation, seizures, etc.
An early indicator of hypoperfusion is
Capillary refill of greater than two seconds
Head Findings
Caput succedaneum is diffused edema of the scalp that crosses the midline. Caused by intrauterine and vaginal pressure from prolonged or difficult vaginal labor. The scalp becomes molded and "cone-shaped." Self-limited and resolves spontaneously.
What are the xray findings of CoA
Cardiomegaly, pulmonary venous congestion, rib notching due to collaterla circulation
Children with Williams syndrome typically have problems related to
Cardiovascular disease.
TSS
Cause by Staph aureaus RF: tampon use, skin/resp infections, post-surgery, postpartum Sx: 2-3 prodrome of malaise, myalgia, fever >102, sunburn-like rash on palms and soles, vomiting, watery diarrhea, abd pain followed by organ failure and shock Tx: hospitalize immediately!
What is vaginal atrophy? What causes it?
Caused by decreased estrogen levels. Vaginal atrophy is characterized by: Thinning of the epithelium loss of vaginal elasticity narrowing & shortening of the vagina Vaginal secretions decrease pH more alkaline (alters flora, increased infx risk)
What are the permanent teeth?
Central incisor lateral incisor cuspid first bicuspid second bicuspid first molar second molar
What are the primary teeth?
Central incisor lateral incisor cuspid aka canine first molar second molar
What is the order of tooth eruption for primary teeth?
Central incisor, lateral incisor, cuspid (canine), first molar, second molar (come little children, munch meat)
When do Primary teeth erupt?
Central incisor: 6-7.5 months Lateral Incisor: 7-9 months cuspid: 16-18 months first molar: 12-14 months second molar: 20-24 months
What direction does physical growth occur in?
Cephalo to caudal proximal to distal
What is predictable sequence of growth?
Cephalo---> Caudal Proximal--->Distal
Justin age 18 months crosses his legs when lifted from behind rather than pulling them up. HIs legs are also hard to separate, making diaper changing difficult. What condition do you suspect?
Cerebral palsy
Spontaneous abortions in the second trimester are most commonly a result of?
Cervical incompetence Infection Uterine abnormality
What is secondary amenorrhea?
Cessation of menstration after establishment of normal cycling
Cervical cyanosis
Chadwicks Sign - first trimester
What do we do when a mother's hep B status is unknown?
Check status immediately after birth, give Hep B vaccine within 12 hours of birth, and give hep B immune globulin within 1 week of age if mother tests positive
When can amniocentesis and chorionic villus sampling be done?
Checks fetal DNA Chorionic villus sampling 10-12 wks Amniocentesis 15-18 wks
Gina is a two year old and presents with a three day history of fever crankiness and congested cough. Respiratory rate is more than 50% of the upper limit Tubular breath sounds are noted at the right lung base. skin turgor is normal and she is wearing a wet diaper. She is alert resisting the exam as age appropriate and engages in eye contact temperature is 100°F Gina's diagnostic evaluation should include
Chest x-ray
Kawasaki disease most commonly occurs in what age group
Children aged 1 to 8 years.
When considering a person's risk for measles, mumps, and rubella, the NP considers the following
Children should have two doses of the MMR vaccine before their sixth birthday.
Most cases of roseola caused by human herpes virus 6 occur in
Children younger than 24 months old.
What test is the earliest genetic indicator for IUP?
Chorionic villus sampling
Spontaneous abortions in the first trimester are most commonly a result of?
Chromosomal abnormalities that occur randomly and do not repeat and subsequent pregnancies
Possible patho with primary amenorrhea?
Chromosomal defects, anatomic anomalies, hormonal imbalance, tumor, trauma
Which of the following best describes the pathophysiology and resulting clinical presentation of asthma
Chronic airway inflammation with superimposed bronchospasm
Which of the following antimicrobials provides an effective activity against atypical pathogens
Clarithromycin
PCOS
Classic signs: obesity, hirsutism, acne, menstrual irregularities, infertile, insulin resistance Polycystic ovaries are at the end point of the process RF: fam hx (autosomal dominant) Dx: hCG, TSH, prolactin, progesterone, testosterone, DHEA, lipids, dexamethosone, transvag US Tx: exercise, wt. loss, OCs, metformin
What should you remind your patients that use spermacides?
Clean up well after sex. Will cause skin irritation if left on.
Sepsis is defined as the
Clinical manifestation of systemic infection
What other delays are common with PDD?
Cognitive and learning delays, emotional unresponsiveness.
Ethinyl estradiol + norgestimate (ortho cyclen..., Ethinyl estradiol or menstranol Norethindrone...
Combined Oral contraceptive
Stages of tooth eruption?
Come little children munch meat: Central incisor lateral incisor cuspid 1st molar 2nd molar
Why might Marfan child not be cleared for sports?
Common cardiac complications (aortic regurg, and mitral valve prolapse)
What is the common bacterial infections in the first month? Second Month?
Common organisms noted in the first month are: Group B Streptococcus (GBS) and gram-negative enteric organisms Second month: S. Pneumoniae and H. Influenzae
What is Z-Score in Dexa Scan?
Compares the patient with the population adjusted for gender, age, race
What is the Cognitive phase in school age children? (Piaget)
Concrete operational (acquiring new knowledge)
Miranda is playing with clay and realizes that she can roll alum of clay into a long snakelike sharp and then return that snakelike shape to a lump. What stage of Piaget?
Concrete operations
A 2 year old is brought to the clinic for his annual exam. His mother tells you that he can speak approx 5-10 single words but that she can udnestandn what he is saying only 25% of the time. To make his needs known, he typically resorts to gesturing rather than trying to use words/ He appears to understand half of her commands. The child does not live in a bilingual household. What steps are indicated?
Conduct an ear examination with pneumatic otoscope and refer to audiology/speech clinic for evaluation.
Confidentiality
Confidentiality can be broken in the following situations: ■ Gunshot wounds, stab wounds must be reported to the police (regardless of age). ■ Child abuse (actual or suspected abuse) must be reported to the authorities. ■ Suicidal ideation and/or attempt (discharge to parents/guardians or hospital). ■ Homicidal ideation or intent (especially mental health providers).
What babies are eat risk for visual problems?
Congenital cyanotic heart diseases where the baby receives oxygen (hyperoxygenation)
Four year old Jamie believes that there is more juice in a tall, thin glass than in a shoer wider one. Jamie has not yet achieved which of the principles of Piaget?
Conservation
When providing care for a febrile patient the NP bears in mind that all the following are true EXCEPT that
Consistent use of an antipyretic provides a helpful way to shorten the course of infectious illnesses
What is the venous hum
Continuous humming murmur, heard best at RUSB, heard best in the sitting position and disappears in the supine position, also obliterated by turning the head or compressing the neck ipsilaterally
age >35, smoking, uncontrolled bp, hx of blood clots
Contraindication to Nuva Ring
hx of thromboembolic disorders CVA, CAD, pregnancy, cancer, benign tumors, cholethiasis during pregnancy undiagnosed uterine bleeding
Contraindications for oral contraceptives
What type of play do preschoolers exhibit
Cooperative, physical, dramatic
What are the fine motor skills of a 3 year old
Copies a circle, builds a tower
What are the fine motor skills of a 5 year old
Copies a square, copies multiple shapes, prints letters, ties shoes
Paraguard
Copper IUD May be left in place for *10 years* Effective immediately, may be used as emergency contraception. Increases inflammatory response of uterus, impedes sperm and ova transport, fertilization, and implantation, causes lysis of blastocyst
insert within 5-6 days of intercourse . 99%effective
Copper Releasing IUD
Long-term consequences of Kawasaki disease include
Coronary artery obstruction
Clinical presentation of progressive primary TB most commonly includes all of the following except: A. Malaise B. Fever C. Dry cough D. Frank Hemoptysis
D. Frank Hemoptysis Clinical presentation for active disease: malaise, weight loos, fever, night sweats, and chronic [dry] cough with blood tinged sputum; evolve over 4-6 weeks; atypical presentation common in immunocompromised individuals.
Risk factors for development of infection reactivation in patients with latent TB infection include all of the following except: A. Diabetes mellitus B. Immunocompromise C. long-term oral corticosteroid therapy D. Male gender
D. Male gender
S/S of primary dysmenorrhea?
Cramping that radiates to the back and thighs, ha, diarrhea, fatigue, n/v. self-limiting to 72 hours
WHO Precautions for Use of copper containing IUD: Category 4, refrain from use
Current PID (within 3 months) Current purulent cervicitis or chlamydial infection or gonorrhea Unexplained vaginal bleeding Cervical cancer, awaiting treatment Uterine fibroids with distortion of uterine cavity
Davy age 4 is here for a well child visit. To assess for age appropriate fine motor skills, what activity would you ask him to perform?
Cut on a line with scissors
12. The results of a prenatal exam for a patient who is 16 weeks pregnant show normal findings. The nurse practitioner should schedule the patient's next prenatal visit ________ form today. A. one week B. two weeks C. three weeks D. four weeks
D
19. A patient in the early second trimester of pregnancy is experiencing seizures. She says that she experiences a severe, unrelenting headache and blurred vision prior to each episode. The blood pressure readings indicate that her BP is consistently elevated above 160/100 mm Hg. Based on these findings, for what condition should be treated? A. Pregnancy -induced hypertension B. Preeclampsia C. Hemolysis, elevated liver enzymes, and low platelets syndrom D. Eclampsia
D
20. Both cocaine use and poor nutrition are known risk factors for which pregnancy-related complication A. Placentia previa B. Preeclampsia C. Hemolysis, elevated liver enzymes and low platelets syndrome D. Premature labor
D
24. All of the following factors are known to contribute to pregnancy-induced hypertension except: A. Diabetes B. Multiparity C. Maternal age D. Uterine tumor
D
28. Fetal monitoring commonly involves the conjunction of a non-stress test, biophysical profile and which other diagnostic procedure? A. Blood pressure surveillance B. Complete blood count C. Liver function test D. Kick count
D
36. All of the following situations constitute a high risk situation in pregnancy except: A. Multiple gestations B. Thrombocytopenia C. Premature rupture of membranes D. Rh desensitization
D
38. Which of the following methods would be most approprate to use for an induced or elective abortion on a patient who is 22 weeks pregnant? A. Vacuum dilation and curettage B. Administration of mifepristone and prostaglandin C. Tocolytic therapy and steroid injections D. Dilation and evacuation procedure
D
Approximately 95% of extopic pregnancies occur in which location? A. Cervix B. The cornua of the uterus C. Ovaries D. Fallopian tubes
D
During a prenatal exam, your patient says: "I've been getting some really bad headaches lately. They start at the base of my skull, and then spread through my head." She is 36 weeks pregnant, and her history shows that she has been seen for high blood pressure on previous visits. You note that she's gained 5 pounds since her last visit the week prior, and that she has edema of the hands and feet. These findings are most likely indicate what condition? A. Hemolysis, elevated liver enzymes and low platelets syndrome B. Eclampsia C. Pregnancy-induced hypertension D. Preeclampsia
D
Elective abortion management
D&C to 12wks medical abortion up to 49 days pregnant 1st trimester: mifepristone 2nd trimester: prostaglandin (misoprostol)
Compared with TST potential advantages of the QuantiFERON-TB Gold (QTF-G) include all of the following except: A. Ability to have entire testing process complete with one clinical visit B. Results are available within 24 hours C. Interpretation of test is not subject to reader bias D. Provides a prediction as to who is at greatest risk for them to disease development
D. Provides a prediction as to who is at greatest risk for them to disease development Tests results from a PPD can be compromised by poor injection or use of inferior PPD; PPD has low sensitivity in people with immunosuppression. QTF-G is a blood test to detect interferon-y, that is released by T lymphocytes in response to M. TB- specific antigens. Can be obtained from a blood sample in a single visit, results are available within 24 hrs. Greater sensitivity in pts with immunocompromise or hx of BCG vaccine. CXR to exclude dx of active pulmonary TB
Examples of neural tube defects include all of the following except: A. anencephaly B. spina bifida C. encephalocele D. omphalocele
D. omphalocele
Dietary sources of calcium?
Dairy, sardines, salmone, green leafy, tofu
What is pubic hair tanner stage III
Darker, increased amount, curlier
Meaning of decreased and increased alpha-fetoprotein
Decr = Down's Incr = pregnancy dating error, multiple gestation, or neural tube defects
What does breakthrough bleeding on day 10-21 or delayed menses indicate?
Deficiency in progesterone
Menopause
Defined as 1 year without menses resulting in absence of fertility. Sx: hot flashes, sweats, sleep disturbance, fatigue, irritability, PMS, mood changes, vaginal dryness, urinary complaints Average age 51.4. Average onset of perimenopause=47.5, lasting 4 years Changes: decreased bone density, incr. total cholesterol & LDL, decr. HDL, decr. bladder control
Disadvantage with Depo?
Delayed fertility (12-18 mo) Injection Reduction in bone density (since estrogen=bone density)
What is the tool for developmental screening for children 6 years old or younger?
Denver Developmental Screening Test, 2nd edition (Denver II)
What are standardized tests used for developmental monitoring?
Denver II Bayley Scales of Infant Development (BSID-II) Newborn Behavioral Assessment Scale (NBAS) Bayley Infant Neurodevelopmental Screener (BINS)- accurate up to 42 months Ages and Stages Questionnaire
Emergency contraception mechanism of action
Depending on time taken during menstrual cycle, most likely effect is inhibit or delay ovulation. Can also inhibit tubal transport of egg or sperm or interfere with fertilization. Unlikely to inhibit implantation of fertilized eggs, results in little to no alteration to endometrium.
long acting progestin IM. inhibits ovation. inject q 3 mo. do not massage injection site use backup for 1st 2 weeks
Depo Provera
27-year-old woman taking Phenytoin (Dilantin) for seizure disorder treatment requests hormonal contraception. Which is most appropriate choice?
Depo-Provera use will most likely not interfere with seizure medication.
Pharmacological intervention for patients with urge incontinence includes:
Detrol (tolterodine)
What is Cause of urge incontinence?
Detrusor overactivity CNS abnormalities (stroke) Infections of the GU tract Urinary stones Neoplasm
How is PCOS diagnosed?
Diagnosed with ROTTERDAM CRITERIA - pt must have 2 of the 3: 1. oligo/anovulation 2. hyperandrogenism - clinical (hirsutism or male pattern alopecia) or - biochemical (raised FAI or free testosterone) 3. polycystic ovaries on ultrasound ('pearl necklace' - follicles that are lined up on the ovaries)
check for holes Have it refitted if wt gain exceeds 20b avoid oil based lubricants must leave in for 6hr after sex
Diaphragm guidelines
flexible, dome shaped cup used to prevent pregnancy by blocking transport of sperm
Diaphragm/Cervical Cap
are infants abdominal or diaphragmatic breathers?
Diaphragmatic breathers
Secondary syphilis
Diffuse maculopapular rash involving palms and soles, generalized lymphadenopathy, low grade fever, malaise, artralgias and myalgia, headache
Common signs and symptoms of pertussis in a 3-year-old child include all the following EXCEPT
Diffuse rash. (They will have a uncontrollable cough vomiting and fatigue.)
During nursery rounds you examine a 12 hour old newborn. The infant has a yellow tint to the skin and sclera. what Lab tests will you order to further evaluate this infant?
Direct coombs test
spermicides the sponge: insert up to 6 hr before sex, leave in for 6hr following Condoms: no oil based lubricant, leave 1/2 in of empty space at end
Disposable barriers
Influenza Vaccine
Do not give before age of 6 months because it is not effective (immature immune system). It takes 2 weeks to produce antibodies after vaccination. Two types of flu vaccines: ■ Inactivated vaccine (trivalent inactivated fl u vaccine). — Minimum age is 6 months. Administer starting in November. Recommended for everyone, but especially for children with congenital heart disease, asthma, cystic fibrosis, or sickle cell anemia. ■ Live attenuated influenza vaccine (FluMist). — Indicated only for healthy persons ages 2 to 49 years (except pregnant women). — Administered as a nasal spray. Contraindications Flu Injection (Trivalent Inactivated Vaccine) ■ Age younger than 6 months. ■ Severe egg allergy. ■ Moderate to severe illness with fever (wait until patient is better). ■ History of Guillain-Barré syndrome. Live Flu Nasal Spray (FluMist) Avoid giving the FluMist vaccine to these groups of children. Use the inactivated injection form of the flu vaccine. ■ Children younger than age 2 years. ■ Children aged 2 to 4 years who had wheezing the past 12 months. ■ Children who have any other underlying condition that predispose them to infl uenza complications. For these children, use inactivated form of the flu vaccine (injection form).
What is a cephalohematoma?
Does not cross the midline - blood under periosteum, requires coloser examination
Sally Ann is concerned that she cannot afford special walking shoes for her baby, who is beginning t o pull himself up to his feet. What do you tell her?
Don't worry; special shoes are not necessary. The more flexible the shoe, the better.
When is it possible to give oral polio vaccine?
Doses 3 and 4 only (live virus)
Elevated inhibin-A is noted when a pregnant woman is at increased risk of having an infant with:
Down syndrome
What are brushfield spots of the iris associated with
Down syndrome
While assessing the eyes of baby Thomas, you observe inner cantonal folds and Brushfield spots. What do you suspect?
Down syndrome
Up to 17% of Down's syndrome patients have atlantoaxial instability (increased distance between the C1 and C2 joints). Medical clearance is necessary for sports participation. All children/adolescents (or older) with Down's syndrome who want to participate in sports need cervical spine x-rays (including lateral view). Patients with atlantoaxial instability are restricted from playing contact sports (i.e., basketball, tackle football, soccer, etc.) and other high-risk activities (i.e., trampoline jumping). Persons with Down's syndrome without evidence of atlantoaxial instability may participate in low-impact sports and sports not requiring extreme balance.
Down's Syndrome Atlantoaxial Instability
What are the fine motor skills of a 4 year old
Draws a person with 4-6 parts, builds a tower of 10 blocks
How is the varicella virus most commonly transmitted?
Droplet transmission
What preventive health topics should be discussed with adolescents?
Drugs, STIs, Sex, Mental health and suicide, dental health,
S/S of menopause?
Dry skin, loss of elasticity, atherosclerosis, CAD, decrease in breast size and tone, vasomotor instability, mood changes, depression, sleep disturbance, osteoporosis, cystitis, stress incontinence, atrophic vaginitis, dyspareunia, uterine prolapse,
What is used for testing for osteoporosis?
Dual energy Xray absorptionmetry (DEXA) scan
HEALTH PROMOTION
During a physical examination or wellness visit, assess teenager for high-risk behaviors. Intensive behavior counseling is recommended. The following are high-risk behaviors to screen for: ■ Sexually active: Use of condoms, birth control, intimate partner violence (i.e., rape), signs/symptoms of STDs. ■ Safety: Driver safety, seatbelt/helmet use, smoking, alcohol, and drug use. ■ Social history: Family, peers, school performance, work. ■ Signs/symptoms of depression and antisocial behaviors (i.e., gangs).
When can the IUD be inserted?
During cycle (increase in expulsion during menses) 4-8 weeks postpartum
What a pregnant woman at risk for developing a congenital rubella syndrome
During the first 16 weeks of pregnancy
S/S of excess estrogen?
Dysmenorrhea N/V Chloasma CVA-DVT-Thromboembolic events Telangiectasias Hepatic carcinoma Breast tenderness
What is dyspareunia? Treatment of dyspareunia?
Dyspareunia = difficult or painful intercourse. Caused by vaginal atrophy Treatment= 1. HRT: effective b/c atrophy is directly related to a hypoestrogenic state 2. LUBRICANTS: preferably water-based rather than alcohol-based or mineral / vegetable oils
What labs should u order in a workup of PCOS? What other disorders do u need to rule out / assess for?
LABS: TSH prolactin testosterone (total, free) SHBG estradiol progestin (17-hydroxyprogesterone ) Must rule out 1. congenital adrenal hyperplasia 2. androgen secreting tumours 3. Cushing syndrome 4. thyroid dysfunction 5. hyperprolactinaemia
What type of hypertrophy is associated with aortic stenosis
LVH
What type of hypertrophy is present with a PDA?
LVH to biventricular hypertrophy
What is a common side effect with HPV vaccine?
Labile syncope, postural hypotension, vasovagal response - sit for 15 minutes after receiving the vaccine
Primary amennorhea (definition and DDx)
Lack of menarche by age 16, or age 14 with no secondary sex characteristics, or >5 yr after thelarche DDx: genetic/congenital abnormality (Turner syndrome, Rokitansky-Kuster-Hauser, testicular feminization, Mullerian fusion abnormalities), ovarian failure, pituitary/hypothalmic dsyfunction, gonadal dysgenesis, adrenal hyperplasia *30% of primary amenorrhea is caused by genetic abnormality
What 4 defects do you have with Tetralogy of Fallot?
Large VSD, pulmonary stenosis, overriding aorta, RVH
One physical sign of fragile x syndrome in males includes
Large forehead
Freud's School age stage?
Latency
What stage are school agers in, according to Freud?
Latency (sexual drive repressed, socialization occurs, super ego and morality development)
Environmental influences for ADHD
Lead, Dietary: dye, additives, sugar
Common co-morbidities with ADHD
Learning disability Anxiety/depression, oppositional defiant disorder
Acyanotic heart defects involve what type of shunting
Left to right
Where do you hear the pulmonic valve
Left upper sternal border
What type of hypertrophy is present with a ventricular septal defect?
Left ventricular hypertrophy progressing to biventricular hypertrophy if large VSD
At what age is a child at greatest risk of death from pertussis
Less than one year old
Complains of extreme fatigue and weakness. Pale skin and easy bruising. May have petechial bleeding (pinpoint to small red spots). May have bleeding gums and nosebleeds. Some have bone or joint pain, lymphadenopathy, or swelling in the abdomen.
Leukemia
A part of the evaluation and afebrile 3-year-old boy the following white blood cell count with differential is obtained wbc's 22,000; neutrophils 75%; bands 15% ;with a side 4% which of the following best describes the WBC with differential results
Leukocytosis with neutrophilia
otc for girls >17. take within 72hr of sex not the abortion pill n/v/headache and changes in next cycle
Levonorgestrel (plan b)
MMR Vaccine Facts
Live attenuated virus vaccine Not recommended before 12 months (not effective due to immature immune system). If dose is given before 12 months, must be repeated
What characterizes the formal operational thought stage?
Logcal conclusions - can conclude based on what is before them, complex problem solving
What characterizes the concrete thinking stage?
Logical operations - school agers are able to categorize, classify, etc
Acute Dacrocystitis
Look for redness, warmth, tenderness, and swelling on one of the lacrimal ducts. Culture discharge and treat with systemic antibiotics for 7 to 10 days. Usually caused by strep or staph organisms. Severe cases may spread and cause orbital cellulitis. Plan ■ Lacrimal sac massage: Place fi nger on lacrimal sac and massage downward toward mouth. Perform maneuver two to three times per day.
Describe the process of the menstrual cycle
Low estrogen promotes the hypothalamus to secretes gonadotropin releasing hormone (GnRH) which causes the pituitary gland to release leutinizing and follicle stimulating hormone (LH & FSH). FSH promotes development of follicles into a corpus luteum which secretes progesterone. Progesterone thickens and stabilizes the endometrial lining Estrogen is secreted by the ovaries proliferates the endometrial lining. A surge of LH causes ovulation (egg is released). (Starts leuteal phase) High estrogen and progesterone levels activate the negative feedback loop, and FSH and LH production is stopped. Estrogen and progesterone levels drop causing ischemia and vasoconstriction of endometrium. 4-24 hr later, the endometrium begins to slough away (menstruation) Bleeding starts day 1 of menses and follicular phase
Which pill should you start someone on?
Low-dose combo, 35 mcg or less
Which of the following is not seen during body temperature increase found in fever
Lower rate of viral replication
What negative behavior is an expectation in school age children?
Lying--confront in a positive way
The following symptom indicates possible acute human immunodeficiency virus infection
Maculopapular rash
What characterizes the preoperational/preconceptual stage?
Magical thinking, no cause and effect reasoning
Biologic influences of ADHD
Male, familial, prenatal smoking, prematurity, fetal distress, prolonged labor, perinatal asphyxia
Diagnostics with breast cancer?
Mammogram, FNA cytology, excisional biopsy allows staging
Diagnostics with fibrosystic breast disease?
Mammography, FNA cytology, Excisional biopsy is most reliable
Management of child abuse
Mandatory reporting
With tooth eruption, which occurs first, mandibular or maxillary?
Mandibular (lower jaw), then maxillary
Hattie age 6 appears to be masturbating when she runs herself back and forth agains the rug. Her mother ask for advice. What is your response?
Masturbation causes no physical, sexual, or mental problems.
Gardasil
May give to males or females age 9-26. Prevents HPV 6,11,16,18 which prevents 70% of cervical cancer Administer at 0, 2, and 6mo intervals
Koplik's spots are small white papules inside the cheeks (buccal mucosa) by the rear molars.
Measles
Why is alternating between acetaminophen and ibuprofen not recommended?
Medication errors are common due timing and dosage inaccuracies and no evidence that temp is better
What is congenital hypothyroidism associated with
Mental retardation, neurologic abnormalities, metabolic abnormalities
Treatment for Trichomonas?
Metronidazole 2 grams po once OR 500 mg po bid x 7 days
Treatment for BV?
Metronidazole: 2 grams po once OR 500 mg po bid x 7 days OR Metrogell 5 grams Intravaginally BID x 5 days OR Clinda cream 5 grams inravaginnally q hs x 7 days OR Clindamycin 300 mg po bid x 7
Treatment for Candidiasis?
Miconazole 5 grams qhs x 7 days OR Clotrimazole 5 grams q hs x 7 days OR Terconazole 80 mg suppository q hs x 3 days
Essure Permanent Birth Control
Micro-insert is placed in fallopian tube. Tissue grows over it over a 3-month period and causes scarring. Obstruction must be demonstrated on hysterosalpingogram. Good for women who are not candidates for hysterectomy (obese, abdominal mesh, colostomy, adhesions, on anticoagulants, contra. to general anesthesia)
Middle School (Age 11-12 years) ■ Tdap booster. ■ MCV4 (meninogococcal conjugate vaccine/Menactra). ■ HPV (human papilloma vaccine/Gardasil). ■ HPV vaccine is now indicated for both girls and boys. Need a total of three doses of vaccine. ■ Age 13 to 14 years (or older): Give Tdap if did not receive it at age 11 to 12 years. ■ If no history of varicella immunization (or the disease), then give the varicella vaccine. ■ If child did not complete hepatitis B series (less than three doses), administer hepatitis B booster. Do not restart Hepatitis B series.
Middle School (Age 11-12 years)
Esotropia
Misalignment of one or both eyes ("cross eyed"). Infants (younger than 20 weeks) may have intermittent esotropia, which usually resolves spontaneously. ■ Some infants with obvious epicanthal folds appear "cross eyed" (pseudostrabismus). Refer if in doubt.
What valve is most commonly affected by rheumatic fever
Mitral
What is S1
Mitral/tricupid (AV) valve closure - A is the first letter of the alphabet!
Smooth wax-like round (dome-shaped) papules 5 mm size. Central umbilication with white plug.
Molluscum contagiosum
A poorly defined flat blue black macule present at birth and usually on the trunk and buttocks is
Mongolian spot
Breast cancer screening
Monthly BSE starting age 20 20-39: clinical exams q1-3yr Start yearly mammograms and clinical exams age *40* Start mammograms 10 yr before diagnosis of first degree relative May stop at age *75*
Prenatal visit schedule
Monthly until 28 weeks Biweekly until 36 weeks Weekly until delivery
Disadvantages of OCP?
Mood changes No STI protection *Clotting *Rare liver tumors N/V/HA/breakthrough bleeding
Pseudogynecomastia
More common in obese boys. Bilateral enlarged breast is due to fatty tissue (adipose tissue). Both breasts feel soft to touch and are not tender. No breast bud or disc-like breast tissue is palpable. Labs None. Diagnosed by clinical presentation.
What is the minimum number of café au lait spots that should be of concern
More than 5
Which of the following is inconsistent with the diagnosis of asthma
Morning sputum production
Postpartum depression
Most common at 2-4 months postpartum but can occur at any time in first year after giving birth. Characterized by depressed mood for >= 2 weeks with change in appetite,sleep disturbance, guilt, and worthlessness. Greatest risk for death is suicide.
Gilbert's syndrome
Most common herditary hyperbilirubinemia. Autosomal dominant defect in glucuronyl transferase in males
What is still's murmur
Most common innocent murmur - heard best between LLSB and apex due to turbulence in the left ventricular outflow tract
Mastitis
Most commonly a Staph aureus infection from milk stasis More common in individuals with eczema due to colonization of Staph Tx: warm compress, massage, continue to breastfeed Dicloxacillin or clindamycin x 10-14 days Nonpeurperal: Augmentin x 10-14 days I/D if abscessed
Most concerning menopausal symptom? Most common menopausal symptom? How do u treat it?
Most concerning: bone density loss Most common: HOT FLASHES (VASOMOTOR SYMPTM): - Short-lived sensation of intense heat w/sweating in the upper body. Associated with FLUSHING, ANXIETY, TACHYCARDIA. Treatment HOT FLASHES: 1. estrogen therapy (PO, transderm patch, skin creams) 2. SSRIs (venlaxafine, paroxetine, fluoxetine) 3. GABAPENTIN
Milia, Milaria, or "Prickly Heat"
Multiple white 1-2 mm papules located mainly on the forehead, cheeks, and nose. Common locations are the nose and the cheeks. Due to retention of sebaceous material and keratin. Most common in neonates. Spontaneous resolution.
What medications are used for urge incontinence?
Muscarinic receptor agonists: Immediate release 1. Oxybutynin 2. Tolterodine 3. Trospium
What do you need to tell patients before taking Flagyl?
NO ALCOHOL will vomit like antabuse
What are the cervical cancer screening recommendations for women aged 21 and YOUNGER?
NO SCREENING (even if they are sexually active) risks outweigh the benefits
What patients are safe to receive estrogen only HRT for menopause symptoms?
NO UTERUS (post hysterectomy) ** if u have a uterus, unopposed estrogen increases risk of endometrial cancer - use combined estrogen/progesterone therapy**
Risk factors for BREAST CANCER
NON-MODIFIABLE: fam hx BRCA & other genes MODIFIABLE: HRT therapy obesity alcohol use ionizing radiation to head & chest
Diagnostic tests for BV?
NS shows clue cells
Diagnostic tests for Trichomonas?
NS shows motile trichamonas
What is coarctation of the aorta
Narrowing of part of the aorta
The most helpful test to support the diagnosis of pertussis include which of the following
Naso pharyngeal culture and PCR testing
planned abstinence during fertile phase : calendar method: determine fertile phase by subtracting 18 days form shortest cycle and 11 days from longest cycle BBT: temp drops 12-24hr before ovulation. Cervical mucus: billings test spinnbarkeit. abstain for 4 days after mucus change
Natural Family Planning
How to estimate a due date
Negelli's Rule: LMP + 9 mo + 7 days
What Age? Strong reflexes. Minimum of: BMs x 6 to 8/day. Voids x 8/day Abnormal: Jaundice at birth (hemolysis). High-pitched cry. Irritable. "Floppy." Poor reflexes.
Neonate
VASCULAR LESIONS "Port Wine" Stain (Nevus Flammeus)
Neonates with pink to red fl at stain-like skin lesions located on the upper and lower eyelids or on the V1 and V2 branches of the trigeminal nerve should be referred to a pediatric ophthalmologist to rule out congenital glaucoma. Blanches to pressure. Irregular in size and shape. Large lesions located on half the facial area may be a sign of trigeminal nerve involvement and Sturge-Weber syndrome (rare neurological disorder). The lesions do not regress and grow with the child. These lesions can be treated with the pulse-dye laser (PDL) therapy.
Most common presentation is a painful abdominal (retroperitoneal or hepatic) mass that is fixed, firm, irregular, and frequently crosses the midline. The most common site is the adrenal medulla (sits on top of the kidneys). About half of patients present with metastatic disease. May be accompanied by weight loss, fever, Horner's syndrome (miosis, ptosis, anhidrosis), periorbital ecchymoses ("racoon eyes"), bone pain, hypertension, others. Most are diagnosed in children between the ages of 1 and 4 years. Elevated urinary catecholamines and anemia. Initial imaging test is the ultrasound. Refer to nephrologist.
Neuroblastoma
When assessing the skin of an infection, you note care au late spots. Which disease should be ruled out?
Neurofibromatosis
The parent of a newborn asks you about the relationship between the infant's development and early experiences. Which theory guides your response?
Neurons and the connections among them continue to develop throughout early childhood.
When is the newborn period and when is the infancy period?
Newborn is 1-2 months Infancy is 1-12 months
Is a booster of meningococcal needed if first dose was given at or after 16 years?
No
Is TB screening universally done?
No - done based on risk
Normal findings of pap test?
No atypia, no malignancy
What does red reflex replaced by a block spot mean?
No clear pathway from the lens to the retina
Benefits of nuva ring?
No meds passed through liver Fewer mood swings Shorter periods
Right to Consent and Confidentiality
No parental (or guardian) consent is necessary for the following: ■ Contraception ■ Treatment for sexually transmitted diseases (STDs) ■ Diagnosis and management of pregnancy
Do you ever give a rotavirus vaccine after 32 weeks?
No!
Is TB screening done routinely in toddlers?
No, based on risk
When to restart hormonal contraceptives
Non-breastfeeding: progestin at any time, estrogen at 3 wks Breastfeeding: estrogen or progestin only at 6 wks
Physical exam with breast cancer?
Non-tender with poorly defined borders, fixed, firm, dimpling, bloody discharge, lymphadenopathy
Miss Garcia calls regarding her 18 month old son's cough and cold. She asked the clinician's medication should I give him? What cough and cold products would you recommend
None. Cough and cold products are not recommended for children under 2.
Hemoglobin and Hematocrit
Normal newborns have hemoglobin F (fetal hemoglobin) and hemoglobin A. Healthy babies have enough iron stores to last up to 6 months. Screening for anemia is done in late infancy (9-12 months) for full-term, healthy infants. Not screened at birth because it is elevated from maternal red blood cells (RBCs) mixed in fetal RBCs.
Elevated Alkaline Phosphatase
Normally elevated from puberty to teenage years, secondary to rapid growth spurts. Enzyme is produced by growing bone or patients healing from major fractures.
Daisy age 2 has a blank that she carries with her at all times. Her mother is concert at if she does not get rid of ti Daisy will remain attached to this blanket forever. What do you tell her?
Not to worry. This normal attachment may last thought the preschool years.
When assessing a febrile child the NP considers that
Nuchal rigidity is usually not found in early childhood meningitis
What is T-Score in Dexa Scan?
Number of standard deviations around the mean bone density
flexible, prescriptive contraceptive ring releases hormones activated by vaginal contact. once per month insertion. left in for 21 days. Must be reinserted within 3 hrs if falls out . can't use diaphragms as back up.
Nuva Ring
Jack is 4 weeks old an has oral candidiasis because his mother had an intrauterine infection that was successful treated with antibiotics. What would you anticipate treating Jack with?
Nystatin
Who can get Emergency contraception pills?
OTC> 17 y.o Rx<17 y.o.
You are watching a baby play with a toy in the exam room. You move the toy and over it with a cloth. The baby removes the cloth and reclaims the toy. This is an indication that the baby has achieved which of the following ?
Object permanence
Johnny, age 3, is at the clinic for his well child visit. He has trouble removing his own shirt as requested. His mother yanks off hi shirt after smacking his wrist and saying You must do was your told--quickly" Which action is indicated?
Observe Johnny for signs of child abuse.
A 6 year old boy has a one year history of moderate persistent asthma that is normally well-controlled with budesonide via dry powder inhaler twice a day and the use of albuterol once or twice a week as needed for wheezing. Three days ago he developed a sore throat clear nasal discharge and a dry cough. In the past 24 hours he has had had wheezing requiring the use of albuterol two puffs with the spacer. Your next most appropriate action is to
Obtained a peak expiratory flow measurement.
Tay-Sachs Disease
Occurs 1:2,500 births *Ashkenazic Jewish Normal at birth deterioration begins at ages 3-6 months
What is primary dysmenorrhea?
Occurs in adolescent women due to ^ levels of prostaglandin, no pelvic pathology
Optimal time to receive flu vaccine
October to November - about 1 month prior to flu season
Postpartum blues
Often begins within days of giving birth, characterized by emotional lability, sleep disturbance, difficulty concentrating. 80% resolve by week 2, 20% evolve to postpartum depression.
What lubricants should be avoided with diaphragm?
Oil based--destroys latex
How is the Ortho Evra patch used?
Once per week x 3 weeks, off for one week Start on the first day of bleeding This day is now known at "Patch Change Day"
When is nighttime control in toilet training achieved on average?
One year after daytime control.
When should fluoride be supplemented?
Only when local water supply is deficient - less than 0.6 ppm (parts per million) Supplementation in not needed for 1st 6 months of life
What is precocious puberty? Boys/Girls?
Onset of menses before 8 in girls, 9 in boys
What is a patent ductus arteriosus (PDA)?
Opening between the aorta and pulmonary artery, acyanotic.
What is an atrial septal defect?
Opening between the two atria, acyanotic (left to right shunting)
What is a ventricular septal defect?
Opening between the two ventricles, acyanotic (left to right shunting)
Freud's Infancy stage?
Oral Oral passive: Birth -6mo Orally aggressive: 7 mo-18 mo.
Glenda gave birth to Jack four weeks ago. Her postpartum course was complicated by an intrauterine infection that was successfully treated with antibiotics today she called the office concerned because Jack has white patches on his tongue and gums. Based on this data what diagnosis do you suspect for Jack?
Oral candidiasis
daily tablets containing estrogen and/or progestin that interfere with fertilization or implantation
Oral contraceptives
What stage are infants in, according to Freud?
Oral stage
Young child complains of abrupt onset of deep eye pain that is aggravated by eye movements and is accompanied by a high fever and chills. Affected eye will appear to be bulging (proptosis or exophthalmos). Extraocular eye movements (EOMs) exam will be abnormal due to ophthalmoplegia (limited movement of eyeball) form infection of the ocular fat pads and muscles. More common in younger children. Ethmoid sinusitis is more likely to cause orbital cellulitis compared with frontal/maxillary sinusitis. Can be life-threatening. A serious complication of rhinosinusitis, acute otitis media, or dental infections. Refer to ED. CT scan or MRI is done in the ED.
Orbital Cellulitis
Women who have trouble remembering to take a daily pill are often good candidates for:
Ortho Evra (contraceptive patch) or NuvaRing (vaginal ring)
What should be ruled out if the sclera is a deep blue
Osteogenesis imperfecta
More common in infants and children. Infected bone or joint is red, swollen, warm, and tender to touch. Patient is febrile and irritable. If patient walks with a limp, may have infection on the hip, knee, or leg. If infection involves the upper extremities, will favor infected limb (avoids using the limb). Growth plate infection results in growth stunting of the affected limb. Refer for hospitalization and high-dosed antibiotics.
Osteomyelitis
Concerning selective estrogen receptor modulator therapy such as raloxifene (Evista):
Osteoporosis risk is reduced with use
Warning signs of perforation during IUD insertion
P - Pain, abdominal or with intercourse A - abnormal bleeding or period late I - infection exposure (STI), abnormal discharge, itching, pain N - not feeling well, fever, chills, fatigue S - string missing or change in length
Which of the following can be used to differentiate pertussis from acute bronchitis or asthma exacerbation
PCR assay
Undesirable effects with IUD:
PID, Lost string Spotting/bleeding/cramping,
Definition of preeclampsia?
PIH + proteinuria + generalized edema after 20 weeks gestation
Preeclampsia
PIH +proteinuria+generalized edema AFTER 20wks gestation
Which 4 diseases are all 50 states required to screen for?
PKU, galactosemia (liver dysfunction, coagulopathies), sickle cell disease, congenital hypothyroidism
PELVIC INFLAMMATORY DISEASE Presentation: Treatment:
PRESENTATION: *cervical motion tenderness* *fever* vag discharge irritative voiding symptoms TREATMENT: *ceftriaxone 250 mg IM x 1
AMENORRHEA Define Primary Amenorrhea? Most common cause? Define Secondary Amenorrhea Most common cause?
PRIMARY AMENORRHEA: absence of menarche by age 15 *50% of cases d/t CHROMOSOMAL DISORDERS* SECONDARY AMENORRHEA: absence of menses for 3 cycles OR for 6 months Most common cause = *pregnancy* - other causes: PCOS, stress, anorexia, ovarian disorders
What is Paget's disease of the breast? What are the symptoms?
Paget's Disease: rare breast cancer that starts at the nipple & extends to the areola **Nipple changes often assoc w/underlying carcinoma (usu of mammary ducts)** Symptoms: Flaky or scaly skin on nipple Crusty, oozing or hardened skin resembling eczema on the nipple, areola or both Itching Redness Tingling or burning Straw-colored or bloody nipple discharge A flattened or turned-in (inverted) nipple A lump in the breast Thickening skin on the breast
Major fears for school age children?
Pain Loss of control Death
S/S of secondary dysmenorrhea?
Pain in regard to etiology
What is the obturator sign
Pain with internal rotation of the right thigh. Indicative of appendicitis.
What is the psoas sign?
Pain with right thigh extension. Indicative of appendicitis.
S/S of breast cancer?
Painless mass, asymptomatic, Late signs: pain, erythema, dimpling, ulceration, nipple retraction
Are lymph nodes palpable in an infant?
Palpable lymph nodes are normal in anterior cervical, axillary and inguinal regions.
at 6 months no lag should be noted when pulled to a sitting position, if noted it could be first sign of?
Palsy
What kind of 'play' is characteristic of toddlerhood?
Parallel play
Who is the primary influence in adolescents
Parents
Ovoid white nits on hair hard to dislodge. Red papules that are very itchy and nits are initially located in the hairline area behind the neck and the ears.
Pediculosis capitis or head lice
Sam is a 4-year-old boy who presents with a one-week history of intermittent fever rash and watery red eyes. Clinical presentation is of an alert child he was cooperative with exam but irritable with a temperature of 100.4 pulse rate of 132 and respiratory rate of 38. Physical exam findings include nasal crusting dry erythematous cracked lips red and enlarged tonsils without exudate and elevated tongue papillae. The diagnosis of Kawasaki disease is being considered for additional findings are likely to include
Peeling hands
What is tanner stage III in boys
Penis elongates
What is tanner stage IV in boys
Penis enlarges in breadth and evelopment of glans, rugae appear
What is systole
Period between S1 and S2
What is diastole
Period between S2 and S1
Freud's Preschool stage?
Phallic (recognizing differences)
What stage are preschoolers in, according to Freud?
Phallic stage (love of opposite sex, oedipal complex)
What are the three primary domains of growth and development
Physical, Cognitive, psychosocial
What is focus for physical, cognitive, and psychosocial?
Physical: Gross Motor (cephalocaudal) Fine Motor (Proximal >distal) development Cognitive: Sensorimotor Psychosocial: Developing trust
What kind of nipple discharge would you expect to see in physiologic drainage vs ductal ectasia vs malignancy?
Physiologic (normal if ever breastfed): white to brown Ductal ectasia: thick, cheesy, green Malignant: clear, serous, serosanguinous, or sanguineous
Physiologic Jaundice
Physiologic Jaundice Also known as neonatal unconjugated hyperbilirubinemia and neonatal icterus. Jaundice first appears on the head/face (sclera is yellow) and progresses downward to the chest, abdomen, legs, and soles of the feet. Jaundice appears when bilirubin level is 5 mg/dL or higher. Physiologic jaundice starts after 24 hours and will usually clear up within 2 to 3 weeks. The total bilirubin levels in Caucasians and African American infants can peak at 7 to 9 mg/dL, but Asian infants have higher peak values (range of 10 to 14 mg/dL). Breast Milk Jaundice Onset is later than physiologic jaundice. Breast jaundice usually starts to show after seven days of life. It peaks in 2 to 3 weeks and can take more than 1 month to clear. It is thought to be caused by insuffi cient breast milk intake and/or breast milk from some mothers who have a substance that slows down hepatic conjugation of bilirubin. Bilirubin Bilirubin (breakdown product from old RBCs) binds to the brain and the nerves (neurotoxic). Elevation is due to increased breakdown of fetal RBCs combined with exceeding the infant liver's capacity to conjugate bilirubin.
What is pectus carinatum?
Pigeon chest
Grasp Reflex (Palmar Reflex)
Place a finger on the infant's open palm. The infant close his hand around the finger. Pulling away the examiner's fi nger causes the infant's grip to tighten.
Barlow Maneuver/Test
Place your index and middle fi nger over the greater trochanter. Gently push both knees together at midline downwards. ■ Positive: "Clunk" sound or palpating trochanter being displaced by the index/middle finger. If either exam is positive, refer to a pediatric orthopedist. Order an ultrasound of the hips. Older Infants ■ Look for adbduction or lateral rotation of affected leg (turns outward). ■ One femur appears shorter. ■ Limited hip range of motion. ■ Abnormal: If above is present, order a hip ultrasound and refer to orthopedic specialist. *Avoid performing both tests too many times because the ligaments on the hips can become damaged.
Patient presents at 27 weeks with painless bleeding that began immediately after vaginal intercourse. Suspect what?
Placentia previa Mgmt: NOTHING IN THE VAGINA - no bimanual exam
What is rheumatic fever/heard disease?
Post-infectious inflammatory disease that can affect the heart, joints, and CNS
WHO Precautions for Use of Combined Oral Contraceptive pills - Category 3, exercise caution:
Postpartum <21 days Lactation 6 wks - 5 months Undiagnosed vaginal bleeding Age >=35 and smoking <20 cigarettes/day History breast cancer but no recurrence in past 5 yrs Interacting drugs (select antiepileptics such as phenytoin, carbamazepine, valproate) Gallbladder disease DM type 1 or type 2 >20 years duration or with vascular disease Hypertension adequately controlled without vascular disease
What is tanner stage I in boys
Preadolescent testes, scrotum, penis
You examine a 15-year-old boy who has infectious mononucleosis with marked tonsillar hypertrophy exudative pharyngitis significantly difficulty swallowing and a patent airway. You consider prescribing a course of oral
Prednisone
When evaluating a child who has aseptic or viral meningitis the NP expect the find CSF results
Predominance of lymphocytes
Eclampsia
Preeclampsia + seizure activity
Definition of eclampsia?
Preeclampsia plus seizure activity
Most common cause of secondary amenorrhea?
Pregnancy
Diagnostics with primary amenorrhea?
Pregnancy test, Refer to endocrinology
Diagnostics with secondary amenorrhea?
Pregnancy test, Referral
In whom is serological document of immunity to rubella advised?
Pregnant women and women of childbearing age who could become pregnant
Who is at high-risk for complicated Pyelonephritis?
Pregnant, high fever, renal dysfunction
When is varicella contraindicated
Pregnant, immunocompromised, streptomycin allergy
When is MMR contraindicated
Pregnant, immunosuppressed
Occurrence of frequent and regular contractions after 20 weeks but prior to 37 weeks?
Premature labor
What are common causes of wide fontanels?
Prematurity, IUGR, hydrocephalus, down synddrome, and hypothyroidism
Counseling a woman about COC use, you often advise:
Premenstrual syndrome symptoms are often improved with use of COC
Cyndy is 5 years old and cannot understand how the half cup of veggies on her plate is the same amt as half cup in the pan. According to Piaget, she is at which stage of cognitive development?
Preoperational
When does Intuitive thinking occur (Piaget)?
Preschool 4-7 y.o.
What age is Erikson's theory of Initiative vs. guilt?
Preschool age kids
Mongolian Spots
Present in almost all Asians (85% to 100%) and in more than half of Native American, Hispanic, and Black neonates. Blue- to black-colored patches or stains. A common location is the lumbosacral area (but can be located anywhere on the body). May be mistaken for bruising or child abuse. Usually fades by age 2 to 3 years. Mongolian spots are the most common type of pigmented skin lesions in newborns.
More common than orbital cellulitis. An infection of the anterior portion of the eyelid that does not involve the orbit/globe or the eyes. Rarely causes serious complications (compared with orbital cellulitis). Younger children are most likely to be affected. Young child complains of the new onset of red swollen eyelids and eye pain (sometimes none). Eye movements do not cause pain and EOM exam is normal (both are abnormal with orbital cellulitis). No visual impairment. May be hard to distinguish from orbital cellulitis. Refer to ED.
Preseptal Cellulitis (Periorbital Cellulitis)
After Seventh Birthday (Never Been Vaccinated) ■ Td (three doses primary, then every 10 years). ■ IPV (three doses). ■ Hepatitis B (three doses). ■ MMR (two doses). ■ Varicella (two doses) if no history of chickenpox. ■ HPV (three doses; give if younger than age 26 years).
Primary Series of Vaccination: Missing or Not Done
When are DTaP vaccines given?
Primary at 2-4-6 months and two boosters at 15 months and 6 years
Weight gain, increased appetite, fatigue, depression, acne, hirsutism caused by too much of which hormone?
Progestin
What hormone causes amenorrhea or hypermenorrhea?
Progestin
What is the main hormone in implanon?
Progestin (etonogestrel)
Mirena
Progestin IUD May be left in place for *years* Very effective in treating dysmennorhea Use alternative birth control for first 7 days
mini pill; not as effective , affects the cervical mucus and endometrium and transport of sperm Used in bf moms, hx of migraines
Progestin only pill
What is the main symptom of pyloric stenosis
Projectile non-bilious vomiting after eating, hungry after eating
What EKG change is common with rheumatic fever?
Prolonged PR interval with evidence of group A strep infection
What is Menometorrhagia?
Prolonged, frequent, excessive, irregular bleeding.
TESTICULAR TORSION (ACUTE SCROTUM)
Pubertal male awakens with abrupt onset of unilateral testicular pain that increases in severity. Pain may radiate to the lower abdomen and/or groin. Almost all patients (90%) also have nausea and vomiting. Ischemic changes result in severe scrotal edema, redness, induration, and testicular pain. Ipsilateral (same-side) cremasteric reflex is absent. Highest incidence is during puberty. Urinalysis: Negative for WBCs. Doppler ultrasound is the initial diagnostic test. Testicle not functional after 24 hours if not repaired. Refer to ED. A surgical emergency.
NSAID use during pregnancy have been linked to which condition in newborns?
Pulmonary hypertension
What to do if the nuva ring comes out?
Put it back in within three hours
What happens at 20 weeks gestation?
Quickening, fundus at umbilicus, sex determination, able to do Leopold maneuvers
The most common causative organism of bronchiolitis is
RSV Respiratory Syncytial Virus
# of vaccines at 2, 4, and 6 months - which ones?
RV (rota virus) DTaP (diptheria, tetanus, pertussis) Hib (Haemophilus influenza type B) PCV (pneumococcal) IPV (Inactivated poliovirus)- maybe not at 6 months
What type of hypertrophy is associated with pulmonary stenosis
RVH
Hemangioma (Strawberry Hemangioma)
Raised vascular lesions ranging in size from 0.5 to 4.0 cm that are bright red in color and feel soft to palpation. Usually located on the head or the neck. The lesions grow during the first 12 months of life, but the majority will involute spontaneously over time. Watchful waiting is the usual strategy. Can be treated with PDL therapy.
Caution with bisphosphonates?
Rare osteonecrosis of the jaw in women with an underlying diagnosis of cancer
Which of the following statement is correct about the varicella vaccine?
Rarely, mild cases of chickenpox have been reported in immunized patients
Infants and toddlers
Rear-facing car seat until age of2 years. Convertible car seats can be used as rear-facing and front-facing car seats.
What is basal body temperature method of family planning?
Record BBT daily over 3-4 mo., same time every morning. Note temperature *drops* 12-24 hours before ovulation, *avoid intercourse 2-3 days before expected drop*. Temp rises after ovulation
What is cervical mucus/billings test?
Record changes in cervical mucus over 3-4 months, increase in spinnbarkeit (egg white like) during ovulation, Abstain from sex at mucus change til 4 days after until is resumes thickness again.
What is the calendar method of family planning?
Record serial cycles, determine fertile phase by subtracting 18 days from shortest cycle, 11 days from longest cycle
What is febrile in the very young infant?
Rectal Temperature greater than or equal to 100.4 F or 38 C. In the very young infant, temperatures can be subnormal with infection as they are unable to thermoregulate
What is osteoporosis?
Reduction in bone mass/density leading to fractures
With the use of levonorgestrel intrauterine system (Mirena), what is normally noted?
Reduction in menstrual flow
Management of AUB?
Refer
Which abnormal pap results should be referred?
Refer CIN 2, CIN3, or CIS
Management for eating disorders:
Referral!
What is Childhood Disintegrative Disorder (CDD)
Regression in multiple areas of functioning following a period of 2 years of normal development
What is Menorrhagia?
Regular frequency, excessive or prolonged bleeding
A middle school student presents asking for a letter stating that he should not participate in gym class because he has asthma the most appropriate response is to
Remind him that with the appropriate asthma care he should be capable of participating in gym class
Management for ASCUS?
Repeat pap, HPV testing, colposcopy
What characterizes the sensorimotor stage?
Responding to the environment - hurt, cold, wet. Simple problem solving.
How to assess the degree of illness in an infant?
Responses are behavioral
What happens if ortho evra is left off for >24 hours?
Restart whole pack and use back up
What does red reflex replaced by a whitish color mean
Retinoblastoma or congenital cataracts
What is expansion of thought process in school age?
Reversibility Cause and effect Deductive reasoning Time/money concepts Classify
History of febrile viral illness (chickenpox, influenza) and aspirin or salicylate intake (Pepto-Bismol, etc.) in a child. Abrupt onset with quick progression. Death can occur within a few hours to a few days. Mortality rate of up to 52%. Although most cases are in children, disease has been seen in teenagers and adults. This disease is now rare. Five Stages of Progression ■ Stage 1: Severe vomiting, diarrhea, lethargy, stupor, elevated alanine transaminase, and aspartate aminotransferase. ■ Stage 2: Personality changes, irritability, aggressive behavior, hyperactive reflexes. ■ Stages 3 to 5: Confusion, delirium, cerebral edema, coma, liver damage, seizures, death. Theoretical risk of Reye's syndrome after varicella immunization; avoid using aspirin before, during, and after immunization.
Reye's Syndrome
What type of hypertrophy is common with ToF
Right
What type of hypertrophy is common with transposition of the great arteries
Right
What type of hypertrophy is common with CoA?
Right progressing to left
Cyanotic heart defects involve what type of shunting
Right to left
Where do you hear the aortic valve
Right upper sternal border
What type of hypertrophy is present with an atrial septal defect?
Right ventricular hypertrophy
Name three bisphosphonates?
Risedronate Alendronate Ibandronate
Strong contraindications of IUD?
Risk for PID Irregular bleeding
Which of the following viruses i s potent teratogen?
Rubella
You examined a 15-year-old presenting with a one-day history of sore throat low-grade fever maculopapular rash and posterior cervical and occipital lymphadenopathy. The most likely diagnosis is
Rubella
Which of the following is not a risk factor for asthma death
Rural residents
4 years
S- describes features of self, acts appropriately according to family values, can describe play CM- gives first and last name, sings song from memory, knows what to do when cold, tired, or hungry, clearly understandable CG- names 4 colors, plays board/card games, draws person w/ 3 parts, predicts stories P- hops on one foot, balances on 1 ft for 2 sec. copies a cross, tower of 8 blocks, pours and cuts food, brushes own teeth, dresses self including buttons
3 years
S- self-care, elaborate imaginitive play CM- conversations with 2-3 sentences, understandable 75% of time, names a friend CG- knows names of objects, identifies gender P- builds tower of 6-8 cubes, rides a tricycle, walks up stairs with alternating feet, balances on 1 ft for 1 sec, copies a circle, draws person w/ 2 body parts, daytime toilet trained
2 months
S-attempts to look at parents, smiles, consoles and comforts self (bring hands to mouth) CM-starts differentiated crying, coos CG-indicates boredom P-begins to push up when prone, consistent head control when sitting, symmetrical movements, diminished newborn reflexes
2 years
S-imitates adults, incr. pretend play, interactive play, refers to self as "I" and "me" CM-vocab of 50 words, uses 2-word phrases, asks to read book CG-follows 2 step commands, names pictures, completes sentences in familiar books P-stacks 5-6 blocks, horizontal and circular crayon strokes, turns book pages one at a time, imitates food preparation, throws ball overhead, kicks a ball, jumps up
2.5 years
S-incr. imaginative and interactive play, fearful of unexpected changes CM- short phrases of 3-4 words, understandable 50% of time CG- knows animal noises, has friends, points to 6 body parts P- washes and dries hands, brushes teeth with help, dresses self with help, copies vertical line
12 months
S-interactive games, imitates activities, waves bye-bye, hands books when wants to play, strong attachment to caregivers, separation distress CM- protoimperative pointing, speaks 1-2 words, imitates vocalizations, jabbers with inflections CG-follows simple instructions, identifies people on request P-bangs 2 cubes held in hands, stands alone
18 months
S-laughs in response to others, explores alone but in close proximity to parents, spontaneous with affection CM- vocalizes and gestures, speaks 6 words CG- points to 1 body part, follows simple instructions without gestures, knows name of favorite books, shows interest in doll or stuffed animal P-walks up steps, runs, stacks 2-3 blocks, uses a spoon and cup w/o spilling
15 months
S-listens to a story, imitates activities, may help in house CM- protodecrative pointing, says 2-3 words with meaning CG- understands simple commands, scribbles P-walks well, stoops and recovers, takes steps backwards, puts blocks in cup, drinks from a cup
1 week
S-periods of wakefulness for feedings CM-turns and calms to parents' voice, undifferentiated cry CG-fixes briefly on faces or objects, follows face to midline P-strong primitive reflexes, able to suck, swallow, and breathe, able to lift head briefly when prone
Newborn
S-periods of wakefulness, responsive to parental voice and touch CM-calmed when picked up CG-looks at parents when awake P-moves in response to auditory stimuli
6 months
S-recognizes familiar faces, starts to recognize strangers CM-strings of vowels, turn-taking vocalizations, recognizes name, starts to use consonant sounds CG-begins oral exploration P-rolls over and sits, bounces, starts to crawl
1 month
S-responsive to calming actions when upset CM-able to follow parents' eyes, recognizes parents' voice CG-starts to smile P-able to lift head when prone
4 months
S-smiles spontaneously, elicits social interactions, solid self-comforting skills CM-differentiated crying, expressive babbling CG-responsive to affection and changes in enviro., indicates pleasure and displeasure P- pushes chest up to elbows, begins to roll and reach
9 months
S-stranger danger, seeks parent for play, comfort, and resource CM-wide variety of repetitive consonants and vowels, points out objects CG-object permanence, peek-a-boo, looks at books P-crawls to sitting, pulls to stand
The most common causative bacterial pathogen in ABRS Acute bacterial rhino sinusitis
S. Pneumoniae
What are the common bacterial organisms in the second month of age
S. pneumoniae and H. influenzae
What does breakthrough bleeding in first days 1-9 indicate?
S/S of deficiency in estrogen
GAP Pneumonic
SAFETEENS: Shots, Accident, Firearms, Emotions, Toxins, Environment, Exercise, Nutrition, Sexuality
What type of murmmur is heard with transposition of the great arteries?
Same as VSD - holosytolic thrill at LLSB
Located in interdigital webs of hands, waist, axillae, penis, etc. Very pruritic, especially at night.
Scabies
"Sandpaper" rash with sore throat. Strawberry tongue not specific (but also seen in Kawasaki disease).
Scarlet fever
A four-year-old child presents with fever exudative pharyngitis anterior cervical lymphadenopathy and a fine raised pink rash. The most likely diagnosis is
Scarlet fever
What is Russels sign?
Scarring on knuckles-bulimia
What age are kids in Erikson's theory of Industry vs. inferiority?
School age kids
What are the cervical cancer screening recommendations for women aged 21 - 65 yrs?
Screen every 3 years if using PAP only Screen every 5 years if co-testing w/PAP and HPV
Delayed Puberty
■ Absence of secondary sexual characteristics by the age of 13 years for girls (such as a breast bud) or at the age of 14 years for boys. The child remains in Tanner Stage I (prepubertal). ■ Primary amenorrhea: Absence of menarche by age of 15 years. Labs Serum Pregnancy Test ■ Check prolactin level. If prolactin level is elevated, next step is to order a computed tomography (CT) scan of the sella turcica (location of pituitary gland inside the skull). ■ For primary amenorrhea (no menses by age 15 years), rule out hypogonadism by checking hormone levels (i.e., estrogen, progesterone, DHEA, FSH, TSH). Rule out chromosomal disorders, absence of uterus/vagina, imperforate hymen. X-ray of the hand is used for estimating "bone age": - When the long-bone epiphyses (growth plates) are fused, skeletal growth is finished. - Refer to pediatric endocrinologist if no growth spurt, delayed puberty, others.
Most Common Cause of Death
■ Accidents (i.e., motor vehicle crashes)
Safety Education
■ Advise parent to learn infant CPR (Basic Life Support/BLS course). ■ Avoid heating formula in the microwave. ■ Do not leave a baby on the changing table (i.e., to answer phone). ■ Do not position cribs next to strings. When the child is crawling, hide electrical Car Safety (Table 20.2)cords. ■ Close toilet seats (safety lock). Lock bathroom doors. Lock all cleaning products. ■ Turn pot handles away from the edge. Use rear burners on the stove. ■ Use safety locks for stove handles, low cabinets, and doors.
Exam Tips
■ All college freshmen living in dormitories: High risk of meningococcal infection. Meningococcal conjugate vaccine (MCV4) is recommended by the CDC. ■ Live attenuated infl uenza virus (LAIV) nasal only: If indicated, use only on healthy persons from ages 2 to 49 years. ■ High risk for fl u with vaccination recommended: HIV, asthma, heart disease, sickle cell, cystic fibrosis, diabetes, others. Household members/health workers caring for or living with any person with the above conditions and infants also need to be vaccinated. ■ Vaccine Adverse Event Reporting System (VAERS): Governmental program to report clinically adverse events.
Solid Foods
■ Can start at 4 to 6 months. Start with rice cereal (fortifi ed with iron) before other type cereals or food groups. ■ Introduce one food at a time for 4 to 5 days (if allergic, easier to identify offending food).
Cryptoorchidism
■ Cryptoorchidism: Retention of one or both testicles in the abdominal cavity or the inguinal canal. Markedly increases risk of testicular cancer. Order inguinal and abdominal ultrasound.
Scoliosis Treatment Parameters: >40 Degrees
■ Curves greater than 40 degrees: - Surgical correction with Harrington rod used on spine and other options.
Scoliosis Treatment Parameters: <20 Degrees
■ Curves less than 20 degrees: - Observe and monitor for changes in spinal curvature.
Scoliosis Treatment Parameters: 20-40 Degrees
■ Curves of 20 to 40 degrees: - Bracing (i.e., Milwaukee brace).
Exam Tips
■ Do not give varicella and MMR vaccine before age of 12 months. ■ Youngest age for fl u vaccine is 6 months. ■ Only vaccine at birth is hepatitis B. ■ If HBsAg positive mother, give the neonate HBIG (hepatitis B immunoglobulin) and the hepatitis B. ■ Do not use DTaP if age 7 years or older. Use Td or Tdap form of vaccine. ■ Give Tdap vaccine at age of 11 to 12 years as a booster. If older, then replace one dose of Td with a Tdap (once in a lifetime). ■ Any vaccine that has a time range (i.e., 3rd dose polio can be given from 6 to 18 months) is not on the exam.
Epispadias
■ Epispadias: Urethral meatus is located on the dorsal aspect (upper side) of the penis.
2 Months Old
■ Follows objects past midline. ■ Coos vowels (i.e., aa) and makes gurgling sounds. ■ Lifts head up 45 degrees when prone. ■ Smiles in response to others.
Hydrocele
■ Hydrocele: Presence of fl uid inside the scrotum (tunica vaginalis/processus vaginalis) that results in swelling of the affected scrotum. Skin is normal color and temperature. Fairly common in newborn males. Incidence rate is 10 to 20 cases out of every 1,000 live births.
Exam Tips
■ Hypospadias occurs when urethral opening is located on ventral aspect of the glans (or on the shaft) of the penis. Refer to pediatric urologist. ■ Hydrocele is fl uid collection inside the scrotum (tunica vaginalis/processus vaginalis). ■ Cryptoorchidism increases risk of testicular cancer. Refer. ■ Transillumination used to assess for hydrocele and scrotal masses. ■ Do not confuse questions asking for the "first tooth" with the "first permanent tooth." ■ Birth weight doubles at 6 months/triples at 12 months. ■ Head circumference: grows by up to 12 cm (fi rst 12 months). ■ Caput succedaneum crosses midline and cephalohematoma does not (blood blocked by scalp sutures). ■ Colostrum secreted first few days of breastfeeding before milk release. ■ Avoid cow's milk fi rst 12 months of life. ■ Breastfeeding: supplement with vitamin D the fi rst few days of life.
Hypospadias
■ Hypospadias: Urethral meatus located on the ventral aspect of the penis. Location may be at the glans or on the shaft. Some have two urethral openings; one opening is normal and the other opening is lower on the glans or shaft. Refer to pediatric urologist.
Amblyopia ("Lazy Eye")
■ If corrected early, affected eye can have normal vision.
Exam Tips
■ If strong Moro reflex in an older infant (age 6 months or older), abnormal, indicative of brain damage. ■ Epsteins's pearls: white papules found on gum line resembles erupting tooth. ■ Hypospadias: urethral opening under glans/shaft (refer). ■ Epispadias: urethral opening on top of glans/shaft (refer). ■ Asymmetry of thigh/gluteal folds: rule out congenital hip dysplasia or hip fracture.
Car Safety
■ Infants and toddlers up to the age of 2 years should be in a rear-facing car seat. ■ Safest place in the car for infant/child less than 13 years of age is in the back seat. ■ Avoid used infant safety seats if its parts are missing or if it is damaged. ■ Air bags in cars can cause serious brain injury if it hits the child's head/neck area. ■ Turn off the air bag on the front seat if the person who is using the seat is under the weight limit. The weight limit is usually set at 100 lbs (check car manual).
Newborn female vagina with small amount of blood
■ Newborn female vagina with small amount of blood: Caused by maternal hormones and will disappear within a few days.
Newborn Vision
■ Newborns are nearsighted (myopia) and have a vision of 30/400. ■ They can focus best at a distance of 8 to 10 inches. ■ During the first 2 months, the infant's eyes may appear crossed (or wander) at times (normal fi nding). If one eye is consistently turned in or turned out, refer. ■ Human face is preferred by newborns. ■ Newborns do not shed tears because the lacrimal ducts are not fully mature at birth. ■ Caucasian neonates are born with blue-gray eyes. It is normal for their eye color to change as they mature.
stage is when the child (age 3-6 years) expresses the desire to marry the parent of the opposite sex.
■ Oedipal stage
Anorexia Nervosa
■ Onset usually during adolescence. Irrational preoccupation with and intense fear of gaining weight. ■ Two types: Restriction (dieting, excessive exercise) or binge eating and purging. Some examples of purging are excessive use of laxatives, enemas, diuretics, vomiting. Clinical Findings ■ Marked weight loss (>15% of body weight, BMI <18.5 or less). ■ Lanugo (increased lanugo especially in the face, back, and shoulders). ■ Stress fractures (osteopenia or osteoporosis from estrogen depletion and low calcium intake). ■ Swollen feet (low albumin), dizziness, abdominal bloating. ■ ED: Weight <70% of ideal body weight, low pulse (40 or less), vital signs unstable, hypotension.
Adolescent Idiopathic Scoliosis
Screening Test: Adams Forward Bend Test Lateral curvature of the spine that may be accompanied by spinal rotation. More common in girls (80% of patients). Painless and asymptomatic. Scoliosis will most likely worsen (66% of cases) if it starts in the beginning of the growth spurt. Rapid worsening of curvature is indicative of secondary cause (Marfan or Ehlers-Danlos syndrome, cerebral palsy, myelomeningocele, etc.) Classic Case Pubertal to young teen complains that one hip, shoulder, breast, or scapula is higher than the other. No complaints of pain. Adams Forward Bend Test (or Forward Bend Test) Bend forward with both arms hanging free. Look for asymmetry of spine, scapula, thoracic, and lumbar curvature. Check height. Measure the Cobb angle (degree of spinal curvature). Full-spine x-rays are used to measure degree of curvature. Management ■ Check Tanner stage (Tanner Stage II up to Tanner Stage V). ■ Order spinal x-ray (PA view) to measure Cobb angle. *Refer all patients with scoliosis to a pediatric orthopedic specialist.
Light Reflex Test or Corneal Light Reflex (Hirschberg Test)
Screening test for strabismus. Abnormal if corneal light reflex is not clear or if it is "offcenter." ■ Procedure: Shine light directly on eyes (24 inches away) using a fi xation target. Infant/child must look directly forward with both eyes aligned. Observe for the symmetry and brightness of light reflecting from both eyes.
Older child to teenager
Seat belt with lap belt.
Use with caution, consider if benefits outweigh risk of using postmenopausal estrogen therapy:
Seizure disorder (owing to potential drug-drug interaction) Dyslipidemia, particularly hypertriglyceridemia (transdermal, intravaginal hormone therapy has limited lipid impact)
What do temperatures greater than 101.8 (38.9) in infants?
Serious bacterial infection
Exam Tips
■ Ortolani and Barlow are screening tests for DDH. Positive sign is if "click" or "clunk" sound is heard and/or if examiner palpates the trochanter becoming displaced (temporarily) from the hip socket. ■ Learn how to screen infants for coarctation of the aorta. ■ Poor latch-on if infant makes clicking noises while breastfeeding. Remedy is to push more of the areola inside the infant's mouth. Most of the areola should be inside infant's mouth. ■ The vaccine table in this chapter only contains the childhood vaccines that must be given by a definite age (no "wiggle room"). For example, the fi rst dose of the hepatitis B vaccine must be given at birth. ■ If a vaccine has an age range, there will be no questions about that time period. For example, the third dose of hepatitis B can be given between 6 and 18 months. Another example is the polio vaccine (IPV), which can be given between the age of 6 and 18 months. For a complete list of all the vaccine schedules, visit the CDC website at www.cdc.gov/vaccines/.
Primary amenorrhea
■ Primary amenorrhea: Absence of menarche by the age of 15 years (with or without development of secondary sexual characteristics). Half are caused by chromosomal disorders (50%).
Exam Tips
■ Puberty starts at Tanner Stage II in girls (breast bud) or boys (testicular enlargement and scrotal rugation/color starting to become darker). Puberty ends at Tanner Stage V (adult stage). ■ Tanner Stage III in boys is elongation of the penis (testes continues to grow). Only Tanner Stages II to IV need to be memorized for the exam. ■ There is no need to memorize pubic hair changes for either gender. Memorize only the breast changes (girls) and the genital changes (boys). ■ Adolescent health history is obtained from both parent and child initially, then the adolescent is interviewed alone without the parent. ■ Memorize the criteria for an emancipated minor. Do not confuse the right to confi dentiality with emancipated minor status.
Exam Tips
■ Recognize how anorexic patients present (i.e., lanugo, peripheral edema, amenorrhea, weight loss >10% of body weight). ■ Increased risk of osteoporosis or osteopenia. For birth control, avoid Depo Provera and other progesterone-only contraceptives since they can cause bone loss. ■ Low albumin level.
Choking
■ Remove objects smaller than 2 inches. ■ Cut up food into small pieces (i.e., hot dogs, carrots, grapes). ■ Choking sources: grapes, raw carrots, hot dogs, latex balloons, coins, buttons. ■ Avoid giving hard candy to children less than 6 years of age. ■ Encourage at least one parent to attend Infant Basic Life Support (BLS) course.
Exam Tips
■ Scoliosis treatment for a 10-degree curve (observe for worsening). ■ Screening test for scoliosis is the "Forward Bend Test." ■ Osgood-Schlatter presentation. ■ Primary and secondary amenorrhea defi nitions. ■ Gynecomastia vs. pseudogynecomastia (know the difference). ■ No parental consent is needed for health services related to sexual activity (STD testing, pregnancy tests, birth control prescriptions). ■ If not related to sexual activity, then need parental consent (dysmenorrhea, headache, URI). ■ Emancipated minor defi nition. ■ Anorexia nervosa presentation (lanugo, etc.), low albumin (pedal edema).
Secondary amenorrhea
■ Secondary amenorrhea: Absence of menses for three cycles or 6 months if previously had menses. Most common cause is pregnancy. Others are ovarian disorders, stress, anorexia, polycystic ovary syndrome (PCOS). Secondary Amenorrhea Associated With Exercise and Underweight ■ Excessive exercise and/or sports participation have a higher incidence of amenorrhea (and infertility) due to relative caloric deficiency. ■ "Female athlete triad": Anorexia nervosa/restrictive eating, amenorrhea, and osteoporosis. Labs ■ Pregnancy test (Serum hCG) ■ Serum prolactin level (rule out prolactinoma-induced amenorrhea). ■ Serum thyroid-stimulating hormone (TSH). Also follicle-stimulating hormone (FSH) and luteinizing hormone (LH) (rule out premature ovarian failure). ■ If amenorrhea for more than 6 months, measure bone density. ■ Educate about increasing caloric intake and decreasing exercise. ■ Calcium with vitamin D 1,200-1,500 mg daily. Vitamin D 400 IU daily. Complications ■ Osteopenia/osteoporosis (stress fractures). Infertility. ■ BMI less than 18.5 associated with excess mortality for smokers and nonsmokers (mechanism unknown).
Girl's Tanner Stages
■ Stage I: Prepuberty. ■ Stage II: Breast bud (onset of thelarche or breast development). ■ Stage III: Breast tissue and areola are in one mound. ■ Stage IV: Areola/nipples separate and form a secondary mound. ■ Stage V: Adult pattern.
Pubic Hair (Both Genders)
■ Stage I: Prepuberty. ■ Stage II: Sparse growth of straight hair that is easily counted. Few straight, Fine. ■ Stage III: Hair darker and starts to curl. ■ Stage IV: Hair curly but not on medial thigh yet as in adult. Hair is coarser. ■ Stage V: Adult pattern, hair spreads to medial thigh and lower abdomen.
Boy's Tanner Stages
■ Stage I: Prepuberty. ■ Stage II: Testes begin to enlarge/increased rugation of scrotum. ■ Stage III: Penis elongates. Testicular/scrotal growth continues. Scrotal color starts to darken. ■ Stage IV: Penis thickens and increases in size. Larger testes and scrotal skin darker. ■ Stage V: Adult pattern.
Newborns
■ Strong primitive refl exes (e.g., Moro, rooting, fencing, rooting, etc.). ■ Head lag. ■ Grasp fi nger tightly if placed on the hand (grasp refl ex). ■ Pasty yellow stool after each feeding (especially if breastfed). ■ Eats every 2 to 3 hours or nurses from 8 to 10 times a day. ■ Newborns do not have tears when crying. Tear ducts are not yet mature at birth. ■ Sleeps 16 hours per day. ■ Report: High-pitched cry, "cat-like" cry, fl oppy, hypotonic microcephaly.
Transillumination
■ Transillumination: Affected testicle(s) will show increase in the "glow" of light. Darken the room and place the light source on the scrotal skin. Compare each scrotum.
Strabismus
■ Uncorrected strabismus can result in permanent visual loss and abnormal vision such as: Diplopia (double vision)
Josephine age 6 is just learning to hop on one foot. You know that
She should have been able to do that at age 4.
Signs / symptoms of a hip fracture (d/t osteoporosis): Intervention:
Signs/symptoms = Woman older than 50 yrs New groin pain after a fall One leg shorter or rotated after a fall Inability to bear weight after a fall What to do = Order X-rays (A-P view w/maximum internal rotation, lateral view, & A-P pelvic view)
What body systems does Marfan's affect
Skeletal, cardiac, ophthalmic
Disadvantages of diaphragm use?
Skin/vaginal irritation and infections
What are the gross motor skills of a 5 year old
Skips, jumps rope, plays ball
Incidence of PMS?
Slow increase after adolescence Peaks during 30's Decline after 40
Erythema Toxicum Neonatorum
Small pustules (whitish yellow color) that are 1 to 3 mm in size and surrounded by a red base. Erupts during the second to the third day of life. Located on the face, chest, back, and extremities. Lasts from 1 to 2 weeks and resolves spontaneously.
What may put a woman at increased risk for abnormal pap?
Smoking HPV Multiple partner or male with multiple partners
What is PMS?
Somatic and affective symptoms which arise 7-10 days prior to menstruation and ends with the onset of menstruation
What medications must be monitored while taking with OCPs
St. Johns Wort, antibiotics, anticonvulsants, warfarin, insulin, hypoglycemics
What do you do if three pills is missed?
Start over Use back up Buy a crib!
What are the fluoride supplementation guidelines if the water supply is less than 0.6 ppm?
Start supplementation 6 months-3 years: 0.25 mg/day 3-6 years: 0.5 mg/day 6-16 years: 1 mg/day
surgical procedure that interrupts fallopian tube to prevent passage of sperm Female : tubal Male: vasectomy
Sterilization
Which following following is not consistently performed as part of the workup for sepsis
Store culture
Rooting Reflex
Stroking the corner of the mouth causes baby to turn toward stimulus and suck. Disappears by 3 to 4 months.
When do you refer for stuttering?
Stuttering lasts > 6 months, child >6 years, child avoids speaking
Subjective and objective signs of vaginal atrophy:
Subjective: ITCHY DRY PAINFUL SEX DISCOMFORT WITH SPECULUM EXAM Objective: DRY, PALE OR PINK IN COLOR DECREASED RUGAE (VAGINA IS SMOOTH) ABNORMAL PAP (d/t atrophic changes)
Moro Reflex (Startle Reflex)
Sudden loud noise will cause symmetric abduction and extension of the arms followed by adduction and fl exion of the arms over the body. Disappears by 3 to 4 months. ■ Absence on one side: Rule out brachial plexus injury, fracture, shoulder dystocia. ■ Absence on both sides: Rule out spinal cord or brain lesion. ■ Older infant: Persistence of Moro refl ex abnormal. Rule out brain pathology.
What is pectus excavatum?
Sunken chest, most common congenital deformity of anterior wall of the chest
What is the path of blood flow through the heart
Superior vena cava, right atrium, tricuspid valve, right ventricle, pulmonic valve, pulmonary artery, lungs, pulmonary veins, left atrium, mitral valve, left ventricle, aortic valve, aorta, body
What is Estrogen's mechanism of action in oral contraceptives?
Suppress LH/FSH=Inhibits ovulation Alters endometrium=inhibits implantation Ovum transport is accelerated Luteolysis may occur as estrogen causes progesterone levels to fall
How does Depo-Provera prevent pregnancy?
Suppresses FSH/LH=inhibits ovulation Thickens mucus Alters endometrium
Where is ABNORMAL lymph enlargement in toddler/preschooler?
Supraclavicular
Susie is 18 months old and does not seem the least bit interest in being toilet trained. What do you tell her mother?
Susie behavior is typical because most children are not ready for toilet training until age 2.
Younger adults seem to have a greater disease burden in what two influenza strains?
Swine flu (H1N1) and Avian flu (H5N1)
Gonococcal Ophthalmia Neonatorum
Symptoms usually show within 2 to 4 days after birth. Infection can rapidly spread causing blindness. Do not delay treatment by waiting for culture results. Symptoms includes injected (red) conjunctiva with profuse purulent discharge and swollen eyelids. Majority of cases of congenital gonorrhea infection acquired during delivery (intrapartum). Any neonates with acute conjunctivitis presenting within 30 days or less from birth should be tested for chlamydia, gonorrhea, herpes simplex, and bacterial infection. Order GC culture (Thayer-Martin), herpes simplex culture, and chlamydial PCR with Gram stain of eye exudate. Hospitalize and treat with high-dose intravascular (IV) or intramuscular (IM) ceftriaxone. Preferred prophylaxis is with topical 0.5% erythromycin ointment (1 cm ribbon per eye). Test (and treat) mother and sexual partner for sexually transmitted diseases (STDs).
Chlamydial Ophthalmia Neonatorum (Trachoma)
Symptoms will show within 4 to 10 days after birth. Eyelids become edematous and red with profuse watery discharge initially that later becomes purulent. When obtaining a sample, collect not only the exudate, but also conjunctival cells as well. Rule out concomitant chlamydial pneumonia. Treated with systemic antibiotics such as azithromycin IM or oral erythromycin base or erythromycin ethylsuccinate syrup QID × 14 days. Treatment only 80% effective. May need second course. Use only systemic antibiotics. Prophylaxis is with topical 0.5% erythromycin or tetracycline ointment (1 cm ribbon per eye). Reportable disease. Test (and treat) mother and sexual partner for STDs.
Common symptom of intrauterine pregnancy in the second trimester?
Syncopal episodes
What murmur is heard with ToF?
Systolic ejection click at the middle and upper left sternal border, may have thrill
What type of murmur is heard with CoA?
Systolic murmur with radiation to the left interscapular area, may have ejection click at the apex and RUSB if bicuspid valve is involved
What type of murmur is present with an atrial septal defect?
Systolic murmur, heard best at the left upper sternal border
What type of murmur is associated with aortic stenosis?
Systolic thrill at right upper sternal border, systolic ejection click, does not vary with respirations
What type of murmur is associated with pulmonary stenosis
Systsolic, loudest at LUSB, intensity decreases with inspiration and increases with expiration
T/F: HT is effective in preventing osteoporosis and osteoporotic fractures
T
T/F: Women > 9 years post menopause should NOT be started on hormone therapy or estrogen therapy for CAD prevention.
T
T/F: estrogen therapy (ET) most effective tx for dryness and dyspareunia caused by genital atrophy
T
T/F A HIV+ mother can deliver vaginally if her viral load is <400
T.
Management for lower UTI:
TMZ-SMZ, Ciprofloxacin, Augmentin x 3 days
Management for uncomplicated pyelonephritis?
TMZ/SMZ, Ciprofloxacin
What's following is most likely to be noted in a three-year-old with community acquired pneumonia
Tachypnea
A 22-year-old woman taking 35-mcg ethinyl estradiol COC calls after forgetting to take her pills for 2 consecutive days, she is 2 weeks into the pack. What do you advise her to do?
Take 2 pills today and 2 pills tomorrow
At birth Jake had an open neural tube defect and now has spina bifida with a loss of function of his lower extremities Jack and Jill want another child and ask if there's anything they can do to prevent a recurrence of neural tube defects in the future was your best response?
Take 4 mg a day of folic acid beginning before conception
What do you do if two pills is missed?
Take two today, take two tomorrow Use back up
What do you do if one pill is missed?
Take two tomorrow Use back up
An 18-year-old woman requests emergency contraception after having unprotected vaginal intercourse approximately 18 hours ago. Today is day 12 of her normal 27 to 29 day menstrual cycle. You advise her that:
Taking emergency hormonal contraceptive offers an effective emergency contraceptive option
Klinefelter's syndrome physical features
Tall statue transverse crease abnormal body proportions underdeveloped sexual characteristics *Gynecomastia** learning disability personality impairment
At what Tanner stage does the female breast and nipple project as a secondary mound?
Tanner 4
After 7th birthday, patients with missing or not done vaccines only need what?
Td - 3 doses primary, then every 10 years IPV - 3 doses Hepatitis B - 3 doses MMR - 2 doses
IMMUNIZATION SCHEDULE FOR ADOLESCENTS
Tdap (Boostrix, Adacel) All 11 or 12 year olds: give Tdap as booster, then Td every 10 years for lifetime. HPV (Gardasil) All 11 or 12 year olds: give to girls and boys. OR HPV (Cervarix) Girls/females only (do not give to males). Minimum age (HPV vaccines): 9 years old. All 11 or 12 year olds: give 1st shot. Booster: 16 years old, give 2nd shot. Meningococcal/MCV4 (Menactra, Menveo) College freshmen living in dormitories. Influenza inactivated Vaccinate everyone from age 6 months and older. Influenza live virus (FluMist) Healthy people 2 to 49 years of age. Hepatitis B (Recombivax HB) Catch-up: give the third dose if not completed. MMR Catch-up: give the second dose if not completed. Varicella If no reliable history of chickenpox (verbal okay). Live virus contraindications.
TESTICULAR CANCER
Teenage to adult male complaints of a testicular or scrotal mass that may be tender to touch or asymptomatic. Some patients may have testicular discomfort, but not pain. The patient reports a sensation of heaviness in the affected testicle. The affected testicle has a firm texture. More common in males from the age of 15 to 35 years. Cryptoorchidism is a strong risk factor.
What temperatures suggest a serious bacterial infection in early infancy?
Temperatures higher than 101.8 F (38.9 C) Conversion to C is subtract fahrenheit by 32 and then divide by 1.8
What is S4
Ten-ne-ssee = stiff ventricular wall
Physical exam with fibrosystic breast disease?
Tenderness, cystic, mobile, variable, occasionally clear nipple discharge
What are the basic guidelines in pediatrics
The American Academy of Pediatrics (AAP) Bright Futures: Guidelines of Health Supervision of infants, children, and adolescents
What serves as a primary guide for child health supervision?
The American Academy of Pediatrics' (AAP) Bright Futures: Guidelines of Health Supervision of Infants, children, and adolescents.
What is the Barlow Maneuver and when is it used?
The Barlow Maneuver a test for hip dysplasia is done by guiding the hips into mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, again producing a palpable sensation of subluxation or dislocation. sensitive test up until 3 months
Which younger women should be screened for osteoporosis?
The Female Athlete Triad: 1. Eating disorder/excessive exercise 2. Amenorrhea 3. Deacreased estrogen
What are Ortlani's signs?
The Ortolani Test is a hip dysplasia test. The examiner's hands are placed over the child's knees with his/her thumbs on the medial thigh and the fingers placing a gentle upward stress on the lateral thigh and greater trochanter area. With slow abduction, a dislocated and reducible hip will reduce with a described palpable "clunk." sensitive test up until 3 months
ortho evra. once /wk administration. not for women >90kg increased risk of cardioembelic events IF PATCH stays off for >24hrs, restart a new 4 wk cycle and use backup
The Patch
Mrs. Peterson found pinworms on an 8-year-old Randy. The clinician knows that treatment for pinworms with pyrantel pamoate includes treating
The entire household.
Infant Colic (Rule of 3s)
The goal when evaluating an infant with colic is to rule out conditions causing pain and/or discomfort, infections, environment, and formula "allergy." ■ Crying and irritability lasting a total of 3 hours a day in an infant younger than 3 months. ■ Occurs more than 3 days in a week and crying lasts more than 3 hours a day. ■ Crying usually occurs at the same time each day. Usually resolves by 3 to 4 months.
What is LAM method?
The idea that breastfeeding may delay ovulation/menstruation for six months.
Fruit juice intake is acceptable in children 6 months and older per the following recommendations?
The juice is mixed in small amounts to flavor water Only 100% juice is used No more than 6 oz (177mL) per day is recommended for children 6 months to 5 years
Mrs. Froome calls the clinic to say she is distressed that her 3 month old baby is still not sleeping through the night. Your best response to her would be
The length of sleep for young babies is variable but most sleep through the night bt the end of the first year.
When counseling a family of an otherwise healthy two year old child who just had a febrile seizure you consider the following regarding whether the child is at risk for future febrile seizures
The occurrence of one febrile seizure is predictive of having another and intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence
Sickle Cell Disease
The required test can detect four types of hemoglobin (hemoglobin F, S, A, and C).
How to suppress lactation?
The safest way is to wean the baby off of the breast in a 3 week period. If abrupt stopping is desired, avoid nipple stimulation, wear a supportive bra, and apply ice packs
Cross cultural studies of Piaget theory of cognitive development provide which of the fowling conclusions?
The stages and sequence of cognitive development are universal.
Why are younger children more predisposed to acute otitis media that older children?
Their eustachian tubes are more flaccid and more horizontal than those of older children.
Sally who is 18 weeks pregnant had a MSAFP (alpha fetal protein level) done the results are elevated what does this mean?
There is an increased risk that the fetus has an open neural tube defect
A 24-year-old woman who requests emergency contraception pills wants to know the effects if pregnancy does occur.
There is no increased rate of spontaneous abortion, birth defects, or placental abruption.
The parent of Jorge a 27 moth is concerned because Jorge insist on going through the same sequence of washing his hands and face sitting at the table, and using the same cup at every meal and ankle, He cries of has a tantrum when it's not possible. Your response to his parent should be based on which rationale?
These are normal and expected behaviors for the age
Emancipated Minor Criteria
These minors may give full consent as an adult without parental involvement: ■ Legally married ■ Active duty in the armed forces
Difference between nightmares/night terrors
They wake up in nightmares.
Meconium
Thick dark green to black color that is odorless. Most full-term neonates pass meconium stool within a few hours of birth. Failure to pass meconium within 24 hours of birth is worrisome and may be a sign of intestinal obstruction.
S/S of candiditis?
Thick, white, curd-like discharge, vulvovaginal erythema with pruritis
What is Progesterone's mechanism of action in oral contraceptives?
Thickened cervical mucus=decrease sperm transport Suppression of endometrium=inhibits implantation Slowed ovum transport HPO axis alteration=inhibits ovulation
Mechanism of action w/ OCPs with progesterone?
Thickens mucus=decrease sperm transport Slows ovum transport Suppression of endometrium=hinders implantation Inhibits ovulation by interfering with HPO axis
Which cardiac finding can be normal in children and young adults?
Third heart sound (S3)
Jason is in first grade. His mother expresses concern because he pronounces the th sound as f. For instance he says "Free" for "three". You respond to his mother,
This is normal at his age.
What type of defect are tet spells associated with
ToF
What age is Erikson's theory of Autonomy vs. shame and doubt referring to?
Toddler
When does preconceptual thinking occur (Piaget)?
Toddler 2-4 y.o.
Clues that a child is ready: child is walking, indicates when diaper is dirty, child can pull down his own pants, can stay dry for up to 2 hours at a time, interested about the toilet or potty seat. Most children are ready for potty training from 18 to 24 months. Some children may not be ready until 3 years of age. By age of 5 years, most achieve both daytime and nighttime control. Daytime control is achieved first (before nighttime control). Some infants are "trained" in as early as 3 to 6 months; each child is different.
Toilet Training
What may asymmetircal enlarged tonsils indicate
Tonsillar lymphoma
Recommendations for pap screening in women with a hysterectomy?
Total hysterectomy (no cervix)= no screening, unless it was done for treatment of cervical cancer
What is management of 'infection' result on pap?
Treat infection, repeat pap in 3-4 months
Osgood-Schlatter Disease: Treatment Plan
Treatment Plan Follow RICE: Rest affected knee. Use ice pack 3×/day for 10 to 15 minutes. Avoiding aggravating activities or sport will typically reduce/resolve pain. Adolescent may continue to play based on degree of pain after sports participation. Play does not necessarily worsen the condition. Tylenol or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain as needed.
Common causes of vulvovaginitis? (3)
Trich, BV, candida
What is down syndrome
Trisomy 21
Blood volume increases by 40-50% during normal pregnancy peaking at week 32
True
Decrease in diastolic blood pressure is most notable during second trimester.
True
Many over-the-counter progesterone creams contain sterols that the human body is unable to use, true or false?
True
Physiologic systolic ejection murmur usually evident during pregnancy.
True
S1 heart sound becomes louder during normal pregnancy.
True
Sources of lead that can contribute to plumbism include select traditional remedies such as azarcon and greta
True
T/F - hospital rates for influenza-related illness among children younger than 24 months are comparable to rates among adults over 65
True
The presumptive diagnosis of fragile X syndrome can be confirmed by a blood test
True
True or false: After vaginal diaphragm insertion, the cervix should be smoothly covered.
True
David a new father expresses his concern that his newborn son does not smile as him when he talks to him. What do you tell him?
True social smiles usually don't emerge until 4-9 weeks of age.
What stage are infants (birth to 1 year) in, according to Erik Erikson?
Trust vs mistrust
Faun Tail Nevus
Tufts of hair overlying spinal column usually at lumbosacral area. May be a sign of spina bifida occulta. Order an ultrasound of the lesion to rule out occult spina bifi da.
Tonic Neck Reflex (Fencing Reflex)
Turning head to one side with jaw over shoulder causes the arm and leg on the same side to extend. The arm and leg on the opposite side will flex.
How many vessels are in the umbilical cord
Two arteries and one vein
What are the diagnostic criteria of Rheumatic fever?
Two major or one major and two minor Jones criteria Major - carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules Minor - arthralgia without inflammation, fever > 102.2, elevated ESR or CRP, prolonged PR on ECG
COCs decrease the effectiveness of which medications?
Tylenol, anticoagulants, benzos, oral hypoglycemics, methlydopa
Diagnostics with pyelonephritis?
UA, Urine culture, CBC, BMP
Where is the fundus palpable at 20 weeks gestation?
Umbilicus - grows approximately 1 cm per week thereafter
What is Galeazzi sign
Unequal knee height
Sudden Infant Death Syndrome (SIDS)
Unexplained and sudden death in apparently healthy infants younger than 12 months. Higher risk with prematurity, low birthweight, maternal smoking and/or drug use, and poverty. Cause unknown; theories range from CNS abnormalities, cardiac arrhythmias, suffocation from soft, thick bedding, and so on. To decrease risk, position infants on their back (supine) only. Avoid side-lying and prone positions. Avoid "overheating" infant and use of thick quilts, soft beds, pillows, and so on.
Contraindications to postmenopausal estrogen therapy:
Unexplained vaginal bleeding Acute liver disease Chronic impaired liver function Thrombotic disease Neuro-opthalmologic vascular disease Endometrial cancer (controversial- short term use for management of severe menopausal symptoms is occasionally acceptable) Breast cancer (controversial- short term use for management of severe menopausal symptoms is occasionally acceptable)
Top Causes of Death Age 1 to 24 Years (Toddlers to Young Adults) ■ Accidents or unintentional injuries. Age 5 to 14 Years ■ Accidents. ■ Cancers. ■ Developmental and genetic conditions.
United States Statistics
Top Three Causes of Death Age 1 to 4 Years ■ Accidents or unintentional injuries ■ Congenital and genetic conditions ■ Cancer Cancer in Children Top Three Cancers in Children ■ Leukemia (34%) ■ Brain and nervous system tumors (27%) ■ Neuroblastoma (7%) The most common cancer in children is leukemia. The most common type of leukemia in children are acute lymphocytic leukemia (ALL) and acute myelogenous leukemia (AML). The most common renal malignancy in children is Wilm's tumor.
United States Statistics
The cause of Kawasaki disease is
Unknown
What are the gross motor skills of a 4 year old
Up and down steps with alternating feet, rides a bicycle with training wheels
What are the gross motor skills of a 2 year old
Up and down steps, kicks ball without falling, runs with wide gait
How long should children be given whole milk?
Up to 2 years old.
Language development (How many words by 2 y.o.)?
Up to 30-50 words
How many words does a 3 year old know?
Up to 900 words
Plantar Reflex
Upward extension of the big toe with fanning of the other toes. Starting on the heel, stroke firmly the outer side of the sole towards the front of the foot. Also called the "Babinski reflex."
Diagnostics with UTI?
Urinalysis: Pyuria >10 WBC Nitrate specific but not sensitive for bacteriuria
What to do if a pill is missed
Use back up BC x 7 days If 1 pill is missed: Take the missed pill as soon as you forget or 2 the next day and continue as normal If 2 pills are missed: Take 2 the next day and 2 the day after. Continue as normal. If 3 pills are missed: Throw away pack and start a new one (3 strikes, you're out!)
How is genital atrophy treated when no other indication for HT (hormone therapy) is indicated?
Vaginal ET (creams, rings, slow release vaginal tablets)
A 38-year-old nulliparous woman who smokes 2.5 ppd is in an "on-and-off" relationship and presents seeking contraception, what is the most appropriate method?
Vaginal diaphragm
What is intermenstrual cycles?
Variabile quantity between cycles
8-year-old Scott presented the clinic with a rash. It is centripetal and began on his trunk. It has very itchy lesions progressing from spots to teardrop vesicles according to his mother. Clinician considers which of the following infectious diseases
Varicella
Generalized rash in different stages; new lesions crop daily. Papules vesicles pustules crusts. Pruritic. Very contagious.
Varicella
WHO Precautions for Use of Combined Oral Contraceptive pills - Category 4, refrain from use:
Venous thromboembolism CHD, CVA Structural heart disease Breast cancer Pregnancy Lactation (<6 wk postpartum) Acute hepatitis Hepatic adenoma Headache with focal neurological symptoms Major surgery with prolonged mobilization Age >35, smoking >=20 cigarettes/day Hypertension (>160/>100 or with vascular disease) Known thrombotic mutations (factor V Leiden, prothombin mutations, protein S, C or antithrombin deficiency)
What supplement should accompany calcium?
Vitamin D 800-1000 IU/day
What supplements should be started at 2 mo of age in breastfed babies?
Vitamin D: 400 International Units per day
Fissures at lip corners could be indicative of
Vitamin deficiency or cheilosis
What is language development like for a 5 year old
Vocabulary > 2000 words, uses sentences regularly, knows at least 4 colors
What is language development like in a 2 year old
Vocabulary of 50 words, can follow 2-step commands, talks constantly
What Does DEXA scan measure?
WASH-- Wrist Ankle, Spine Hip
Normal Lab Changes in Pregnancy
WBC elevates up to 16,000 with neutrophilia Hgb and Hct decrease Alk phos incr. due to fetal bone growth ESR incr Total T3 and T4 incr. due to incr. binding globulin (TSH and free levels unchanged) Incr. lipids Incr. GFR
Management of fibrosystic breast disease?
Warm soaks, Low sodium diet, vitamin E, Hormones, surgical intervention
S/S of BV?
Watery, gray fishy smelling discharge Pruritus Vaginal spotting
Indicated for preeclamptic patients with IUP <34 weeks?
Weekly betamethasone injections for fetal lung maturity
How is adequate nutrition confirmed in infants?
Weight gain
What is most commonly found after 1 year of Depo-Provera use?
Weight gain
Weight Loss (More Than 7%)
Weight loss (up to 7%) of birth weight should be regained within 10 to 14 days. Weight loss beyond 7% in neonates is considered abnormal. Assess the infant for dehydration and the mother and infant for lactation diffi culties.
Signs/Symptoms of Eating disorder:
Weight loss, Anemia, Constipation, Dry skin, Amenorrhea, Lanugo,
Which shall be moved from a car seat to a regular seat with the seat belt?
When a child weighs 40 pounds.
When is fluoride supplementation needed?
When local water supply is deficient (less than 0.6 parts per million), start at 6 months
When do children need further evaluation re: growth?
When they cross over multiple sequential percentile lines
Risk factors for osteoporosis:
White race Age Smoking (current) Etoh (2+ daily) Low body weight Tall height Family hx
Risk factors for Osteoporosis?
White, think elderly, smoker, caffeine, sedentary lifestyle, alcoholism, menopausal,
Asymptomatic abdominal mass that extends from the fl ank toward the midline. The nontender and smooth mass rarely crosses the midline (of the abdomen). Some patients have abdominal pain and hematuria. One fourth of patients have hypertension. Higher incidence in Black, female children. Peak age is 2 to 3 years. The most common renal malignancy in children. While performing the abdominal exam, palpate gently to avoid rupturing the renal capsule (causes bleeding and seeding of abdomen with cancer cells). Initial imaging test is an abdominal ultrasound.
Wilms's Tumor (Nephroblastoma)
When should back up method be used in terms of missed pills?
With even ONE missed pill
And caring child with an acute asthma flare the NP considers that antibiotic use is recommended
With evidence of bacterial infection
When does urine leak with stress incontinence?
With increased pressure on bladder: Laugh Cough Exercise Sneezing
How do you do Ortolani/Barlow's meaneuvers
With the hips flexed at 90 degrees and knees togethehr, begin by abducting, then adduct while the examiner's fingers are over the greater trochanters.
When should diaphragm be refitted?
With weight change of 20 lbs or more
When should period be expected after using emergency contraception?
Within three weeks,
What is secondary dysmenorrhea?
Women >20 y.o. more likely associated with pathology
Alport's syndrome
X- linked recessive IV collagen bm, kidney, ear and eye--nephritis and defness ocular disturbances
What is Turner's syndrome?
XO karyotype
Medical management of PMS?
Xanax, Buspar, Tricyclics, SSRI, OCP, progesterone
Sidney who is 30 weeks pregnant is planning to travel outside of United States she ask you which immunization she should or shouldn't have which immunization do you recommend she NOT receive?
Yellow fever.
Can women with elevated FSH levels still get pregnant?
Yes, women with elevated but not post menopausal FSH levels are still at risk of pregnancy and must continue to use contraceptive measures
What should be avoided with calcium carbonate supplement?
^Fiber foods Aluminum containing antacids (Calcium+aluminum=bind)
As the uterus enlarges it tends to lean to the a. right b. left
a
Can HSV pt have vaginal delivery? a. yes b. no
a
Despite douching, semen can remain in vaginal canal for over a. 90 sec b. 4 hours c. 1 hour d. douching eliminates the semen
a
Does the diaphragm have to be inserted by a professional? a. yes b. no
a
Does the vaginal diaphragm need to be left in after intercourse a. yes b. no
a
If a child has involuntary movement, then deceases, after cord was cut is it considered a live birth a. yes b. no
a
In the temp method, what happens to temp 24-36 hours after ovulation a. drop b. increase
a
Most common lab to determine pregnancy a. urine b. blood c. US
a
Normal weight gain acoording to ACOG a. 25-35 b. 20-30 c.<45 d. 35-45
a
Parity is a. total births b. total pregnancies
a
Presumptive sign of preganacy is a blue cerivx known as a. chadwicks b. spider telangiectasia c. linea nigra d. chlosama
a
What birth control method is associated with ectopic pregnancy a. copper iud b. coc c. nuvaring
a
What has to be taken everyday at the same time? a. POP b. COC
a
What is a side effect of EC a. nausea b. fatigue c. migraine
a
What is recommended for women who have hx. breast ca, sickle cell, migraines, HTN, breastfeeding a. POP b. COC
a
What must be used with the cervical diaphragm in order for it to be effective a. contraceptive jelly b. condom c. lotion
a
When does rise in temp occur a. luteal phase b. ovulation c. end of menses
a
When is there a greater effect of tetragenic drugs a. organogensis b. 3rd trimester c. 1st trimester
a
Which of the following should not receive vaccination against influenza?
a 4 month old infant who was born at 32 weeks gestation.
What is hypospadias?
a congenital condition and a genitourinary abnormality in males in which the opening of the urethra is on the underside of the penis.
What is Phimosis?
a congenital narrowing of the opening of the foreskin so that it cannot be retracted.
What loss of decibels indicate hearing loss?
a loss of 20-30 decibels
Which tooth is the first to erupt in an infant?
a lower central incisor
Findings in estrogen deficiency (atrophic) vaginitis include:
a pH greater than 5.0
What is cheilosis?
a painful inflammation and cracking of the corners of the mouth. It also is called cheilitis. It sometimes occurs on only one side of the mouth, but usually involves both sides. Cheilosis is caused by a yeast (Candida) infection.
Which wound presents the greatest risk for tetanus infection?
a puncture wound obtained while playing in a garden
Postmenopausal HT use can result in:
a reduction in the frequency and severity of vasomotor symptoms
Diastasis recti is?
a separation between the left and right side of the rectus abdomens muscle, common in newborns
Which of the following children is most likely to have lead poisoning?
a toddler who lives in an 85 year old home.
Vaccine "superfund"
a vaccine "superfund" exists to care for children with serious sequelae from vaccinations. A portion of the price of each bottle of vaccine sold in this country goes toward this fund. If it is proven that a child has been permanently damaged from a vaccine (brain damage), the child's healthcare for a lifetime is paid for by the fund.
Which of the following do you expect to find in an examination of a 2 week old infant
a visual preference for the human face
Pregnancy is diagnosed by SATA a. amenorrhea b.positive test c. elevated temp d. morning sickness
a,b
What tests are done at the first prenatal visit a. cbc b. ABO c. VDRL/RPR d. HIV e. antibodies rubella f. syphillis g. hep B h UA
a,b,c,d,e,f,g,h
nursing infants generally maximally receive about which percentage of the maternal dose of a drug? a. 1% b. 3% c. 5% d. 10%
a. 1%
at 3 wks of age, the average-weight, formula-fed infant should be expected to take: mL a. 2 to 3 oz, or 60 to 90 mL, every 2 to 3 hrs b. 2 to 3 oz, or 60 to 90 mL, every 3 to 4 hrs c. 3 to 4 oz, or 90 to 118 mL, every 2 to 3 hrs d. 3 to 4 oz, or 90 to 118 mL, every 3 to 4 hrs
a. 2 to 3 oz, or 60 to 90 mL, every 2 to 3 hrs
Three month old Rachel cannot remain seated upright without support. At what age will she acquire the seated position with support? a. 7 months b. 9 months c. 12 months d. 14 months
a. 7 months
Which of the following is most likely to be reported in a patient taking a statin? a. AST 41, ALT 28 b. AST 320, ALT 190 c. AST 32, ALT 120 d. AST 440, ALT 670
a. AST 41, ALT 28
Which of the following conditions is associated with 3 stages of rashes? a. Fifth disease b. Erythema infectiosum c. Varicella d. Rocky Mountain spotted fever
a. Fifth disease Fifth disease has 3 stages: Prodromal stage: begins with symptoms of a URI such as low-grade fever, HA, chills, and malaise 2nd stage: red rash appears on the cheeks, known as "slapped cheek" rash, resolves in 2-3 days. 3rd stage: rash moves to arms and legs, becomes a "lacy" appearing rash that is flat/purple in appearance; may last for a few weeks
What are the important distinguishing characteristics of a cancerous breast mass? How does this differ from a fibroadenoma? In what age group are fibroadenomas most common?
a. Firm, fixed and painless mass b. No change with menstrual cycle c. Most common is the upper outer quadrant and breast tail (Tail of Spence) ** May need diagnostic mammography or sonography Fibroadenoma: painless. well defined & MOBILE, may increase or decrease in size. 50% resolve spontaneously w/in 5 years. Most common in females 20-30 yrs old. Benign tumors. Contain both fibrous & glandular tissue. Must be monitored closely to ensure they are not growing. Presence increases the risk of breast CA
A 40-yr-old female is positive for anti-hepatitis C virus. Which test is appropriate for follow up? a. HCV RNA b. HCV antibodies c. HCV core antigen d. Hep C surface antigen
a. HCV RNA
When discussing the use of immunoglobulin (Ig) with a 60yr old woman who was recently exposed to the hep A virus, you consider that: a. Ig is derived from pooled donated blood b. the product must be used within 1 wk of exposure to provide protection c. its use in this situation constitutes an example of active immunization d. a short, intense flu-like illness often occurs after its use
a. Ig is derived from pooled donated blood
Stella works in the housekeeping dept of a hospital. She present to the employee health clinic with a complaint of a needle stick to her left thumb. The needle was from one of the garbage bags left from the ER. The patient had little bleeding that stopped spontaneously. Which of the following is the next step? a. Order ELISA test as soon as possible b. Recommend tetanus booster in 1 week c. Offer the pt hep B immunoglobulin d. Order CXR
a. Order ELISA Employee health clinic protocols for needlesticks recommend ordering ELISA test ASAP to establish baseline blood work for the employee.
A 14-yr-old female who is sexually active is brought in by her mother for an immunization update. According to the mother, her daughter had 1 dose of the hep B vaccine. Which of the following would you administer at this visit? a. Td and hep B b. DTap (diptheria, tetanus, acellular pertussis) and Hep B c. Hep B only d. MMR and Td
a. Td and hep B CDC recommends Td and hep B for 14-yr-old females. It is recommended for her to continue the hep B series (rather than restart), which includes a total of 3 injections.
Clinical findings in patients with acute hep B likely include all of the following except: a. abdominal rebound tenderness b. scleral icterus c. a smooth, tender, palpable hepatic border d. report of myalgia
a. abdominal rebound tenderness
A positive obturator sign might signify which of the following conditions? a. acute appendicitis b. acute pancreatitis c. acute cholecystitis d. acute hepatitis
a. acute appendicitis
A 28-yr-old male nurse of Hispanic descent reports a hx of a cold that resolved 2 wks ago except for a dry cough and pain over his right cheek that worsens when he bends down. The patient denies fever. He tells the employee health NP that he is very allergic to both cephalexin (Keflex) and erythromycin. The VS show temp 99.2, HR 72, RR 12. Which of the following is most likely? a. acute sinusitis b. acute bronchitis c. fever secondary to the previous URI d. Munchausen's syndrome
a. acute sinusitis Symptoms include cough, facial pain, and low grade fever
What is the correct sequence of motor development in average infants? a. Reach and miss, sit alone, creep, climb stairs, stand alone b. Creep, sit alone, climb stairs, stand alone, reach and miss c. Creep, sit alone, climb stairs, reach and miss, stand alone d. Sit alone, creep, climb stairs, reach and miss, stand alone
a. reach and miss, sit alone, creep, climb stairs, stand alone
A 22 year old woman taking a 35 mcg ethinyl estradiol COC calls after forgetting to take her pills for 2 consecutive days. She is 2 weeks into the pack. You advise her to: a. take the last pill missed immediately, even if this means taking 2 pills today. b. discard two pills and take two pills today. c. discard the rest of the pack and start a new pack with the first day of her next menses. d. continue taking one pill daily for the rest of the cycle.
a. take the last pill missed immediately, even if this means taking 2 pills today.
Which of the following is commonly found after 1 year of using (DMPA) Depo-Provera? a. weight gain b. hypermenorrhea c. acne d. rapid return of fertility when discontinued
a. weight gain
The classic clinical triad of ectopic pregnancy includes:
abdominal pain, vaginal bleeding, and adnexal mass
When does the anterior fontanel close
about 18 months
Does bone loss accelerate or decelerate during the menopausal transition?
accelerates and continues for the first few yrs after menopause....Tx early and long term unless contraindicated
What are the most commonly used drugs in infancy?
acetaminophen and ibuprofen. Acetaminophen is first line of therapy; 10-15 mg/kg every 4-6 hours Ibuprofen (approved after 6 months of age) is 10mg/kg every 6 hours.
The reductions in free androgens noted in a woman using COC can yield an improvement in:
acne vulgaris
Children with the flu often present with these additional symptoms
acute otitis media, nausea and vomiting
Double sickening is defined as
acute worsening of respiratory symptoms new fever occurring 6 to 7 days after signs of upper respiratory infection
What is corrected gestational age?
adjustment of developmental expectations for premature infants up to 2 years old. *Actual age in weeks minus Weeks premature = Corrected age
Which group is shown to have the highest rate of varicella mortality?
adults aged 30-49
TDaP - SE
advise parent to give acetaminphen or ibuprophen every 4-6 hours x 1-2 days after fever (100.4F) in up to 50% of patients swelling and redness at inj. site in up to 50% of pts irritability in up to 50% of pts acute encephalopathy 1 in 110,000
Tx for PMS and PMDD
aerobic exercise stress reduction balanced diet reduction in alcohol, caffeine, sugar, sodium adequate sleep stop smoking SSRIs (for PMDD) May also use continous BCPs x 3 mo, NSAIDs, and vitamin supplements (B6, E, Mg, Ca) R/O thyroid, depression, anxiety, PCOS, sleep disorders, endometriosis, substance abuse
What is attachment in an infant?
affective bond that develops over the first year and will differentiate into other emotions later. Secure attachment. Insecure attachment is detachment issues such as avoidance, anxiety, disorganization.
Which of the following statements is true about oral poliovirus vaccine (OPV)
after administration of OP, attenuated live poliovirus can be shed from the stool
What is a key differentiation between autism and asperger's
age of onset of symptoms with language development. Autism is typically diagnosed between 18 and 30 months, aspergers after 3 years
A mildly ill infant will appear
alert, active, smile, and feed well
safety
all visits
A healthy 3 year old child is in your office for well child care. You expect this child to be able to
alternate feet when climbing stairs
Klinefelter syndrome and risk for having a child with the condition can be accurately identified by
amniocentesis and blood testing for carrier state
Which of the following is a first line therapy option for the treatment of ABRS in an otherwise well child
amoxicillin-clavulanate
Acondroplasia
an autosomal dominant disorder that is only one type of dwarfism; short arms and legs
Alternatives to HRT for tx of hot flashes
antidepressants gabapentin clonidine CAM: black cohosh, soy, red clover, vitamin E, flaxseed (no better than placebo in studies)
Ectopic pregnancy
any conceptus that implants outside the uterine cavity Women with HX of PID 95% in fallopian fubes dark tarry spotting , unilateral lower quadrant pain tender adnexa, cervical motion tenderness,
The most important aspect of skin care for children with eczema
application of lubricants
LAIV is approved for who? Not for who?
approved for healthy people 2-49 y/o not for - children under 2 y/o, pt's with high risk for complications such as chronic heart disease, asthma, COPD, kidney failure, people with a history of Guillain-Barre syndrome, pregnant women, people with a history of allergy to eggs
Where can the patch be applied? Where should it NOT be placed?
arm, buttocks, torso, abdomen *Not breast!
Patients with urethral stricture often report urine loss:
as dribbling after voiding
Testing for sexually transmitted infection should be initially obtained:
as early as possible in pregnancy
Patients with urge incontinence often report urine loss:
associated with a strong sensation of needing to void
At what age can the health care provider stop measuring head circumference in normal, full term children whose gosht has been normal to this point?
at 3 years of age.
When does fear of separation develop?
at 8 months
When does stranger danger develop?
at six months fear of strangers
What is active against C trachomatis?
azitrhomycin
Back up method of BC should be used how long when starting OCP a. month b. week c. 14 days
b
Calculate the EDD by adding ___days to the first day of LMP, and subtracting ___ months plus __ year a. 5,2,1 b. 7,3,1 c.4,3,2 d. 6.2.1
b
Fundal height begins at a. 30 wk b. 20 weeks c, 14 weeks d. conception
b
Gestation is usually ___ weeks before ovulation a. 1 b. 2 c. 3 d. 6
b
Gravida is a. total births b. total pregnancies c. total stillbirths
b
How long should FA be taken prior to conception a. 3 weeks b. 3 mos c. 1 month d. 2 weeks
b
How many additional cal are needed during pregnancy a.500 b. 300 c.200
b
How much FA should pt with IDDM or seizure take a. 4 b. 1 c. 0.4
b
If fitting of nuvaring required by a professional a. yes b. no
b
Urinary ketones indicates the mother needs to increase a. sugar b. carbs c. insulin d. water
b
Vegetarians should have what supplemetation a. a b. b12 c. d d. k
b
What OC is NOT recommended to smoker over 35 a. POP b. COC
b
What antibiotic is DOC in pregnancy with syphillis a. fluoroquinolone b. penicillin c. bactrim
b
What is used to treat chlaymdia a. penicillin b. azithromycin c. fluoroquinilone
b
What may be the first sign of preeclamsia a. edema in LE b. upper ext. edema c. headache d. protein in urine
b
What trimester can flu shot be given a. only 3rd b. any c. none
b
When is 1 hour OGTT given a. prenatal b. 24-28 weeks c. 39 weeks d. 12-24 weeks
b
In an immunocompetent adult, the length of incubation for the influenza virus is on average: a. Less than 24hrs b. 1-4 days c. 4-7 days d. More than 1 wk
b. 1-4 days
Due to an increased risk of blood clots, an alternative to the contraceptive ring (NuvaRing) or patch (OrthoEvra) is preferred in all of the following women except: a. a 42 year old nulliparous woman b. 31 year old woman with history of naturally occurring multiple gestation pregnancy c. 28 year old who smokes one pack per day d. 33 year old woman with a family history of venous thrombosis
b. 31 year old woman with history of naturally occurring multiple gestation pregnancy
A child just starting to reach for objects placed in front of him is probably around: a. 1 month b. 4 months c. 7 months d. 9 months
b. 4 months old
A nursing home resident reports to his physician that his previous roommate was recently started on TB treatment. A Mantoux test and chest x-ray are ordered. What is the minimum size of induration considered positive for this patient? a. 3mm b. 5mm c. 10mm d. 15mm
b. 5mm The Mantoux test requires a dose of 5 tuberculin units in 0.1mL solution injected intradermally into the forearm and read 48-72 hours later. Results measured by size of induration, not erythema. Standard results of 10mm or less are considered negative for a low risk population. For a high-risk population, such as recent exposure, 5mm induration or more is positive.
All of the following patients received a dose of antipneumococcal vaccine 5yrs ago. Who is not a candidate for receiving a second dose of the immunization? a. A 45 yr old man with chronic bronchitis b. A 72 yr old woman with HTN c. A 35 yr old man with a hx of asthma d. A 58 yr old woman with immunosuppression
b. A 72 yr old woman with HTN Pts with HIV should receive antipneumococcal vaccine as soon as dx made. One-time dose of revaccination after 5 yrs recommended for chronic renal failure or nephrotic syndrome, asplenia, and immunocompromised. One-time revaccination for 65+ vaccinated 5+ yrs previously and was younger than 65 at time of primary vaccination.
According to the U.S. Medical Eligibility Criteria for Contraception Use, which of the following is a clinical condition in which use of a copper containing IUD should be approached with caution? a. uncomplicated valvular heart disease b. AIDS defining illness c. hypertension d. dysmenorrhea
b. AIDS defining illness
Which of the following dx is most likely in this pt? (Extreme fatigue, dark-colored urine, denies generalized muscle soreness) a. Rhabdomyolysis b. Acute drug-induced hepatitis c. Acute mononucleosis d. A major depressive episode
b. Acute drug-induced hepatitis Liver enzymes, ALT and AST, can be elevated with the use of medications, such as statins. High liver enzymes can cause acute drug-induced hepatitis.
Hep B vaccine should not be given to a person with a hx of anaphylactic rxn to: a. Eggs b. Baker's yeast c. Neomycin d. Streptomycin
b. Baker's yeast Recombinant hep B vaccine does not contain a live virus. The flu shot is contraindicated in people with egg anaphylaxis. IPV, MMR, varicella contraindicated in neomycin anaphylaxis. IPV, smallpox contraindicated in streptomycin, polymyxin B, neomycin anaphylaxis.
When examining 10 year old Bob's teeth, you note that the upper incisors slightly overlap the lower incisors. The second and lower first molars are absent. Your assessment is: a. Malocclusion b. Delayed mandibular dentition c. Normal dentition d. Hyperdontia
b. Delayed mandibular dentition
A 22-yr-old man is starting a job in a college health ctr and needs proof of MMR immunity. He received childhood immunizations and supplies documentation of MMR vaccination at age 1.5yrs. Your best response is to: a. Obtain rubella rubeola and mumps titers b. Give MMR immunization now c. Advise him to obtain IG if he has been exposed to measles or rubella d. Advise him to avoid individuals with skin rashes
b. Give MMR immunization now
A newborn's mother is discovered o be HBsAg positive. Which of the following would you recommend for this infant? a. Give the baby hep B immunoglobulin b. Give the baby both hep B vaccine and hep B immunoglobulin c. Give the baby hep B vaccine only d. Send the baby home b/c he is not infected
b. Give the baby both hep B vaccine and hep B immunoglobulin For a mother who tests positive for HBsAg, the new born should be given both vaccine and immunoglobulin for protection.
A pt is positive for anti-HCV (hep C virus antibody). What is the next step to further evaluate this pt? a. Refer the pt to gastroenterologist b. Order hep C polymerase chain reaction test c. Order hep B comprehensive panel d. The pt is immune to hep C and no further testing is indicated
b. Order hep C polymerase chain reaction test When a pt tests positive for anti-HCV, labs ordered should include hep C PCR to further evaluate
You are following up a 65-yr-old male who has been on a new prescription of fluvastatin (Lescol) for 6 wks. During a follow up visit, he reports feeling extremely fatigued and having dark-colored urine. He denies any generalized muscle soreness. Which of the following is the most appropriate treatment plan? a. Order CBC with diff b. Order liver function profile c. Recommend an increase in fluid intake and rest d. Order a urine C&S test
b. Order liver function profile Statin meds, such as Lescol, can affect liver fxn and increase liver enzymes, as well as cause the pt to feel weak, fatigued, and have muscle aches.
The most common mode of flu virus transmission is via: a. Contact with a contaminated surface b. Respiratory droplet c. Saliva contact d. Skin-to-skin contact
b. Respiratory droplet
The bacille Calmette-Guerin (BCG) vaccine is used to immunize a person against which of the following? a. Enterobiasis b. Tuberculosis c. Anthrax d. Smallpox
b. TB the BCG vaccine is given routinely in some countries where TB is endemic or epidemic. One of the few exceptions for the BCG vaccine in the US is for health care workers who see a high percentage of pts infected with M. tuberculosis strains resistant to isoniazid and rifampin. BCG is considered a biohazardous material and proper handling and disposal must be followed.
The mother of a 4-month-old calls your office and reports that the infant has a fever of 101.4. The infant received her immunizations yesterday. Which of the following is correct? a. The fever is most likely due to the combination of the MMR and Polio vaccines b. The fever is most likely due to the pertussis component of the DTP vaccine. c. The infant is probably starting a viral URI d. The infant had an allergic reaction to one of the vaccines given and should be brought to the emergency room.
b. The fever is most likely due to the pertussis component of the DTP vaccine.
Concerning the MMR vaccine, which of the following is true? a. The link between use of MMR vaccine and childhood autism has been firmly established b. There is no credible scientific evidence that MMR use increases the risk of autism c. The use of the combined vaccine is associated with increased autism risk, but giving the vaccine's three components as separate vaccines minimizes this risk d. The vaccine contain thimerosal, a mercury derivative
b. There is no credible scientific evidence that MMR use increases the risk of autism MMR vaccine contains live attenuated virus. 2 shots 1mo aprt recommended for those born after 1957. Additional doses given to patients with unclear immunization hx is safe.
Which of the following characteristics is predictive of severity of chronic liver disease in a pt with chronic hep C? a. female, younger than 30 b. co-infection with hep B, daily ETOH use c. acquisition of virus through IV drug use, hx hep A infection d. frequent use of ASA, nutritional status
b. co-infection with hep B, daily ETOH use
a mother of a 10 month old, ask about progression of solid foods into her baby's diet. Which item would be best to introduce last? a. egg yolk b. egg white c. fruits d. vegetables
b. egg white.
compared with the use of infant formula, advantages for the baby of breastfeeding include all of the following except: a. lower incidence of diarrheal illness b. greater weight gain in the first few weeks of life c. educed risk of allergic disorders d. lower occurrence of constipation
b. greater weight gain in the first few weeks of life
Which of the following hepatitis forms is most effectively transmitted from the man to the woman via heterosexual vaginal intercourse? a. hep A b. hep B c. hep C d. hep D
b. hep B
To prevent an outbreak of hep D infection, an NP plans to: a. promote a campaign for clean food supplies b. immunize the population against hep B c. offer antiviral prophylaxis against the agent d. encourage frequent hand washing
b. immunize the population against hep B
The most common reasons for discontinuing oral contraception use is breakthrough bleeding and: a. nausea/vomiting b. inconvenience of use c. cost d. high failure rate
b. inconvenience of use
1 23 y-o woman is breastfeeding her healthy newborn. she wishes to start using hormonal contraction. which of the following represents the best regiment? a. combined oral contraception initiated at 2 wks b. progesterone-only oral contraception initiated at 3 wks c. medroxyprogesterone acetate (depo-provera) given day 1 postpartum d. use of all forms of hormonal contraception is discouraged during lactation
b. progesterone-only oral contraception initiated at 3 wks
Which of the following is true concerning hep B vaccine? a. the vaccine contains live hep B virus b. the NP should consider checking postvaccination HBsAb titers only for individuals at highest risk for infection c. the vaccine is contraindicated in the presence of HIV infection d. Postvaccination arthralgias are often reported
b. the NP should consider checking postvaccination HBsAb titers only for individuals at highest risk for infection
which of the following is appropriate advice to give to a mother who is breastfeeding her 12 hr old infant? a. you will likely have enough milk to feed the baby within a few hrs of birth b. the baby might need to be awakened to be fed c. supplemental feeding is needed unless the baby has at least four wet diapers in the first day of life d. the baby will likely have a seedy yellow bowel movement today
b. the baby might need to be awakened to be fed
Which of the following is NOT a relative contraindication for OCPs? a. active hep A infection b. thrombosis related to an IV needle c. undiagnosed vaginal bleeding d. migraine headache without focal aura
b. thrombosis r/t an IV needle
This result increase the likelihood that the cause of the above-mentioned child infection is
bacterial
Hepatitis B vaccine should not be given to a child with a history of anaphylactic reaction to
baker's yeast
Which of the following is the most appropriate response in a developmental exam of a health 5 year old?
being able to name a best friend
The feature of fragile X syndrome that should be evaluated during well child exams include
being easily overwhelmed by stimuli and language delays
COCs enhance the effect of which medications?
beta blockers, steroids, alcohol, theophylline, diazepam;
Risk factors for ABRS include all of the following EXCEPT
beta-thalassemia minor
Varicella series is given when
between 12 months and 12 years, minimum of 3 months apart
At which of the following ages in a young child's life is parental anticipatory guidance about infant sleep position most helpful
birth
At which of the following ages in along child life is parental anticipatory guidance about protection from falls most helpful?
birth
Hep B immunizations
birth, 2 months, 6 months
what are the caloric requirements according to age?
birth-6 months: 120 kcal/kg/day 7 months to 1 year: 100 kcal/kg/day Two-Ten years: 100-70 kcal/kg/day adolescents: 45 kcal/kg/day
Examples of phytoestrogens include:
black cohosh, ginseng, soy products (does not include Vitamin E)
Common clinical findings in a young child with bronchiolitis include all of the following EXCEPT
bradycardia (WILL HAVE: pharyngitis, tachypnea, and conjunctivitis)
Signs of deficient progestin in BCP
breakthrough bleeding (not enough endometrium stabilization) androgenic effects (hirsutism, acne, oily skin, edema, incr. libido)
A healthy full term infant at age 3 to 5 moths should deb able to
bring hands together
When does an infant triple their weight?
by 1 year of age
When does the infant double their weight?
by 5 mo.
When should a newborn return to birth weight?
by 7-14 days
Cervix that has widen and is soften is known as what a. chadwick b. kernig c. hegar
c
How long can lactation amnenorrhea be used? a. 3 mos b. as long as breastfeeding c. 6 mos
c
How much FA is recommned in pregnancy a. 4 b. 1 c.0.4
c
Protein >2 may indicate a. twins b. dm c. preeclampsia
c
Uterus palpated at the pubic symphisis indicated a. 12 weeks b. 30 weeks c. 8 weeks d. 20 weeks
c
What birth control method is recommended for reduction of sickle cell a. COC b. Nuvaring c. Depo
c
What exacerbated chloasma a. drugs b. weight gain c. sunlight d. quickening
c
What is a late sign of fetal demise a. spotting b. morning sickness c. lack of movement d. increase in BP
c
What is preferred med in pregancy for candida What is used to treat chlaymdia a. penicillin b. clotimazole c. fluconazole
c
What is the lifespan for copper IUD? a. 3 years b. 5 years c. 10 years
c
What is used to treat chlaymdia a. penicillin b. azithromycin c. ceftriaxone
c
What med treats t. vaginalis What is used to treat chlaymdia a. penicillin b. azithromycin c. mertonidazole
c
What must be maintained if breastfeeding is the method of birth control a. withdrawal b. another form of BC c. amenorrhea
c
What should be increased if taking Depo shot? a. folic acid b. vit D c. calcium
c
When is GBS done a. 12 weeks b. 12-24 weeks c. 35-37 weeks
c
When is considered the fertile period of temp method a. first spike of temp b. day after the temp spike c. third day after temp spike
c
When is repeat CBC done a. never b. each trimester c. thrid trimester
c
Which of the following is the most appropriate response to a 27 year old woman who is taking phenytoin (Dilantin) for the treatment of a seizure disorder and is requesting hormonal contraception? a. "A barrier method would be the preferable choice." b. "COC is the best option." c. "Depo-Provera (medroxyprogesterone acetate in a depot injection (DMPA) use will likely not interact with your seizure medication." d. "Copper containing IUD use is contraindicated."
c. "Depo-Provera (medroxyprogesterone acetate in a depot injection (DMPA) use will likely not interact with your seizure medication."
at what point after childbirth can a combined oral contraceptive be started without other risk factors for venous thrombosis in a woman who is not breastfeeding? a. 1 day b. 1 wk c. 3 wks d. 6 wks
c. 3 wks
What is considered minimal weight gain in a normal newborn after discharge from the hospital? a. 10 gms/day b. 20 gms/day c. 30 gms/day d. 40 gms/day
c. 30 gms/day
in infants, solid foods are best introduced no earlier than: a. 1 to 3 months b. 3 to 5 months c. 4 to 6 months d. 6 to 8 months
c. 4 to 6 months
Children do not generally exhibit a fear of strangers until after about: a. 2 months b. 4 months c. 6 months d. 2 years
c. 6 months
During a well child visit you teach parents that an infant may first transfer an object from hand to hand at: a. 2 months b. 4 months c. 7 months d. 9 months
c. 7 months
the average required caloric intake in an infant from age 0-3 months is usually: a. 40 to 60 kcal/kg/d b. 60 to 80 kcal/kg/d c. 80 to 100 kcal/kg/d d. 100 to 12- kcal/kg/d
c. 80 to 100 kcal/kg/d
The following children are considered higher risk for TB except: a. A child who has recently been diagnosed with leukemia b. An infant whose family is homeless c. A child who was born in Japan d. A Hispanic child with asthma who is using a steroid inhaler
c. A child who was born in Japan Risk factors for TB include: compromised immune system (ex. leukemia), high risk populations (minorities, foreign born people, prisoners, nursing home residents, indigents, migrant workers, and healthcare providers). Steroid therapy and blood disorders also increase risk of TB.
Which of the following statements is true concerning vaginal diaphragm use? a. When in place, the woman is aware that the diaphragm sits snugly against the vaginal walls b. This is a suitable form of contraception for women with recurrent urinary tract infection c. After insertion, the cervix should be smoothly covered d. The device should be removed within 2 hours of coitus to minimize the risk of infection
c. After insertion, the cervix should be smoothly covered
A new mother reports that her 6-mo-old infant has a cold and has a fever of 99.8. The infant is not irritable and is feeding well without problems. The mother wants to know whether it is okay for him to be immunized at this time. Which of the following statements is true? a. The infant should not be immunized until he is afebrile b. An infant with a cold can be immunized at any time. c. An infant with a cold can be immunized as long as the infant's temp is no higher than 100.4 d. Because immunization is so important, it should be given to the infant as scheduled
c. An infant with a cold can be immunized as long as the infant's temp is no higher than 100.4 Immunization acceptable as long as the temp is not over 100.4
A 44-yr-old woman with asthma presents asking for a flu shot. She is current taking Cipro for treatment of a UTI, does not have a fever, and is feeling better. You inform her that she: a. Should return for the immunization after completing her abx tx b. Would likely develop a significant rxn if immunized today c. Can receive the immunization today d. Is not a candidate for influenza vaccine
c. Can receive the immunization today
You see a 48yr old woman with nonalcoholic fatty liver disease. Eval of infectious hepatitis includes anti-HAV IgG: neg; anti-HBs: neg; anti-HCV: neg. When considering her overall health status, you advise receiving which of the following vaccine? a. Hep A and B as based on her lifestyle risks b. Hep B and C c. Hep A and B d. Hep A, B, and C
c. Hep A and B
A 19-yr-old female has recently been diagnosed with acute hepatitis B. She is sexually active and monogamous. What would you recommend for her male sexual partner who was tested for hepatitis with the following results: HBsAg (-) anti-HBs (-), anti-HCV (-), anti-HAV (+)? a. A hep B vaccination b. Hep B immunoglobulin c. Hep B vaccination and hep B immunoglobulin d. No vaccination needed at this time
c. Hep B vaccination and hep B immunoglobulin Hep B vaccination is given for long-term prophylaxis treatment to prevent hep B infection. Hep B immunoglobuin is given for prevention of hep B infection when the person has been directly exposed to the hep B infection. The immunoglobulin is not a vaccine and does not protect against long-term prophylaxis
When advising a pt about immunization with the influenza vaccine nasal spray, the NP considers the following: a. Its use is acceptable during pregnancy b. Its use is limited to children younger than 6 years c. It contains live, attenuated virus d. This is the preferred method of flu protection for individuals with severe allergic rxn to egg and egg products
c. It contains live, attenuated virus Flu symptoms in uncomplicated cases resolve in about 1 week; cough and malaise often persist for 2+ weeks. Individuals with ongoing health problems (pulmonary/cardiac disease, young children, pregnant women) have increased risk of flu-related complications including pneumonia. Flu viruses spread through respiratory droplet. Incubation period in immunocompromised is 1-4d (avg 2d) and can remain infectious for 3wks. Illness passes 1 day before onset of sxs. Injectable vaccine does not contain live virus, can be used during pregnancy and is recommended for all pregnant women, can be given to infants 6mos+. The nasal flu vaccine is live virus, used for healthy people 2-49, not for chronically ill, high dose ASA, Guillain-Barre, pregnant women, ppl allergic to eggs.
A middle-aged man with COPD who is about to receive injectable influenza vaccine should be advised that: a. It is more than 90% effective in preventing influenza b. Its use is contraindicated in the presence of eczema c. Localized reactions such as soreness and redness at the site of the immunization are fairly common d. A short, intense flu-like syndrome typically occurs after immunization
c. Localized reactions such as soreness and redness at the site of the immunization are fairly common
Which of the following is true concerning hep C infection? a. It usually manifests with jaundice, fever, and significant hepatomegaly b. Among health care workers, it is most commonly found in nurses c. More than 50% of persons with acute hep C go on to develop chronic infection d. Interferon therapy is consistently curative
c. More than 50% of persons with acute hep C go on to develop chronic infection
In which of the following groups is routine HBsAg screening recommended? a. Hospital lab workers b. Recipients of hep B vaccine series c. Pregnant women d. College students
c. Pregnant women
A sexually active 22-yr-old man is asking to be screened for hep B b/c his new girlfriend has been recently diagnosed with a hep B infection. His lab results are: anti-HBV (-), HBsAg (+), HBeAg (-). Which is indicated? a. Pt is immune to Hep B virus b. Pt not infected with hep B virus c. Pt needs hep B vaccine and hep B immunoglobulin d. Pt only needs hep B immunoglobulin
c. Pt needs hep B vaccine and hep B immunoglobulin Because HbsAg is + and anti-HBV - and HBeAg -, he needs hep B immunoglobulin and hep B vaccine
Concerning HBV vaccine, which of the following is true? a. The vaccine contains live, whole HBV b. Adults should routinely have anti-hepatitis B surface antibody titers measured after 3 doses of vaccine. c. The vaccine should be offered during treatment for STDs in unimmunized adults. d. Serologic testing for hep B surface antigen (HBsAg) should be done before hep B vaccination in adults
c. The vaccine should be offered during treatment for STDs in unimmunized adults.
In small children with AIDS, which of the following vaccines is contraindicated? a. Diptheria and tetanus (Td) b. Hepatitis B and mumps c. Varicella d. Td and oral polio
c. Varicella The data regarding efficacy of varicella is insufficient; therefore varicella vaccine is contraindicated in HIV-infected individuals
Which of the following women is the best candidate for progestin only pill (POP) use? a. an 18 year old woman who frequently forgets to take prescribed medications b. a 28 year old woman with multiple sexual partners c. a 32 year old woman with adequately controlled hypertension d. a 26 year old woman who wants to use the pill to help "regulate" her menstrual cycle
c. a 32 year old woman with adequately controlled hypertension
All of the following are implicated in causing chronic cough except: a. chronic bronchitis b. allergic rhinitis c. acute viral URI d. GERD
c. acute viral URI Chronic cough can be caused by chronic bronchitis, allergic rhinitis, and GERD.
Monitoring for hepatoma in a pt with chronic hep B or C often include periodic eval of: a. ESR b. HBsAb c. alpha-fetoprotein d. urobilinogen
c. alpha-fetoprotein
Noncontraceptive benefits of COC use include a decrease in all of the following except: a. iron deficiency anemia b. pelvic inflammatory disease (PID) c. cervicitis d. ovarian cancer
c. cervicitis
In addition to lab work described, results reveal the following for above mentioned patient: HBsAg positive. These finding are most consistent with: a. no evidence of hep B infection b. resolved hep B infection c. chronic hep B d. evidence of effective hep B immunization
c. chronic hep B
The most common source of hep A infection is: a. sharing IV drug equipment b. cooked seafood c. contaminated water supplies d. sexual contact
c. contaminated water supplies
when counseling a breastfeeding woman abut alcohol use during lactation, you relate that: a. drinking a glass of wine or beer will enhance the let-down reflex b. because of its high molecular wt, relatively little alcohol is passed into breast milk c. maternal alcohol use causes a reduction in the amt of milk ingested by the infant d. infant intoxication can be seen with mother's having as few as one to two alcoholic drinks
c. maternal alcohol use causes a reduction in the amt of milk ingested by the infant
guidelines recommend that a breastfeeding mother waits until breastfeeding is well established for approximately 6 months before using combined oral contraceptives (COC) because: a. in early breastfeeding, the amt of hormone in COC could cause significant harm to the nursing infant b. efficacy of COC could be compromised by breastfeeding c. milk flow could be compromised by COC d. COC oral contraceptive use could affect mother's sleep patterns
c. milk flow could be compromised by COC
A 35-yr-old male has a hx of a viral URI 4 weeks ago. He reports that he started feeling short of breath and now complains of sharp pain in the middle of his chest that seems to worsen when he lies down. The patient's physical is WNL with exception of a precordial rub on auscultation. The most likely dx would be: a. pulmonary embolism b. dissecting aneurysm c. pericarditis d. esophageal reflux
c. pericarditis Pericarditis is inflammation of the sac around the heart. Common signs/symptoms include chest pain over the center/left side of the chest; shortness of breath, esp with lying down, low-grade fever; weakness; fatigue; dry cough; and abdominal or leg swelling. Pericardial rub may be auscultated.
Which of the following is a contraindication to estrogen/progestin containing methods (combined oral contraception COC, patch OrthoEvra, or ring NuvaRing? a. mother with a history of breast cancer b. personal history of hepatitis A age 10 years c. presence of factor V Leiden mutation d. cigarette smoking one pack per day in 22 year old
c. presence of factor V Leiden mutation
most drugs pass into breast milk through: a. active transport b. facilitated transfer c. simple diffusion d. creation of a pH gradient
c. simple diffusion
to remove a drug from breast milk through "pump and dump", the nursing mother should refrain from taking the offending med and the process must be continued for: a. two infant feeding cycles b. approximately 8 hrs c. three to five half-lives of the drug d. a period of time that is highly unpredictable
c. three to five half-lives of the drug
regarding physiologic jaundice in the newborn, select all that are correct: a. it occurs between the first 12 and 24 hrs of life b. it progresses from the abdomen toward the head of the infant c. unconjugated bilirubin is elevated d. risk of development of hyperbilirubinemia can be reduced in a breastfed infant with frequent breastfeeding every 2 to 3 hrs per 24 hrs e. it can be avoided by supplemental water and dextrose feedings between breastfeeding int he first 3 to 4 days of life to increase infant hydration while awaiting mother's milk to come in
c. unconjugated bilirubin is elevated d. risk of development of hyperbilirubinemia can be reduced in a breastfed infant with frequent breastfeeding every 2 to 3 hrs per 24 hrs
Which medications reduce efficacy of oral contraceptives?
carbamazepine/Tegretol phenytoin/Dilantin rifampin warfarin insulin oral hypoglycemics
Marfans syndrome key point
cardio problems eye problems (ectopia lentis, iridodensis)
Rubella
causes a mild, 3-5 day illness with little risk of complication to the person infected. When rubella is contracted during pregnancy, however, the effect on the fetus can be devastating. Immunizing the entire population against rubella protects unborn children from the risk of contracting congenital rubella syndrome.
A 5 year old girl presents with ABRS. She has a PCN allergy but is otherwise well is going to be treated with an antimicrobial. You prescribe
cefdinir
What is active against N gonorrhoeae?
cefixime
Post coital bleeding is a classic sign of:
cervical cancer
Which pelvic diseases can Pap smears find
cervical cancer and HPV Trich Candida BV Herpes
A concomitant health problem occasionally seen with genital condyloma acuminatum is
cervical carcinoma
Chadwick's sign
cervical cyanosis
Definition of menopause: Definition of primary ovarian insufficiency:
cessation of menses for 12 months (in the absence of other causes) primary ovarian insufficiency (premature ovarian failure): menopause prior to age 40 = ABNORMAL
Intervention for a child with a lead leave of 5 to 44 mcg/dL usually includes all of the following except:
chelation therapy
Intervention for a child with a lead level of 40 to 50 mcg/dL usually includes:
chelation therapy
Jonathan, 2 and 1/2 year old has come to see you because his mother say he has been fussy and irritable. When you examine his ears, the TM is bulging and red. Fever 102.2. You look at his record and he has had 3 episodes in 6 months. You are concerned about this because
children younger than 3 years of age with recurrent otitis media are at increased risk for impaired speech and language development.
For a woman with bothersome hot flashes who cannot take HT, alternative options with demonstrated efficacy include the use of all of the following except:
clonidine (helpful- gabapentin, sertraline, venlafaxine)
Treatment of vulvovaginitis caused by Candida albicans includes:
clotrimazole cream
With regard to seasonal influenza prevention in well children the NP considers that
compared with school aged children, younger children (<24 months) have an increase risk of seal influenza related hospitalization.
You are examining an 18 month old boy who is not speaking any discernible words. Mom tells you he has not said mama or dada yet or babbled or smiled responsively. You
conduct further evaluation of milestone attainment
DiGeorge (Velocardiofacial) syndrome
congenital defect of the parathyroid, thymus and conotruncal region of the heart
Premature Labor
contractions after 20 wks but before 37 wks that result in dilitation and effacement of os RF: drug use (smoking, cocaine), young or old mother, poor nutrition and wt. gain, multiple gestation, hx of preterm Sx: cramping, low back pain, spotting, frequent contractions Tx: hospitalization, tocalytic meds to stop labor (Terbutaline), betamethasone if <34 wks for lung development
Premature Labor
contractions after 20wks but before 37wks young and old mom at risk give B methadone if under 34 weeks
Flu virus is mainly spread via?
cough or sneeze - respiratory droplet
When is penicillin given with a GBS+ woman a. at delivery b. entire pregnancy c. to fetus d. during labor
d
When the uterus is palpable at the umbillicus how far along a. 12 weeks b. 30 weeks c. 8 weeks d. 20 weeks
d
the anticipated average daily weight gain during the first 3 months of life is approximately: a. 15 g or 0.53 oz b. 20 g or 0.7 oz c. 25 g or 0.88 oz d. 30 g or 1 oz
d. 30 g or 1 oz
Which of the following is an expected lab result in a pt with acute hep A infection? (normal values: AST 0-31, ALT 0-40) a. AST 55, ALT 50 b. AST 320, ALT 190 c. AST 320, ALT 300 d. AST 640, ALT 870
d. AST 640, ALT 870 Hepatic enzyme elevation is universal. Liver enzymes evaluate degree of hepatic inflammation. AST increases in response to heapatocyte injury (from ETOH abuse, acetaminophen misuse or overdose, and, rarely, statins). If AST elvated with normal ALT and mild macrocytosis (MCV >100), long-standing ETOH abuse likely cause. ALT is more specific to liver; elevation persists after damage has ceased. Greatest elevation of ALT likely seen in hepatitis caused by infection or inflammation. Increase in bilirubin found in viral hepatitis.
Which type of hepatitis virus infection is more likely to result in chronic hepatitis and increased risk of developing hepatocellular carcinoma? a. Hep A virus b. Hep B virus c. Hep C virus d. Both hep B and hep C
d. Both hep B and hep C Both are associated with hepatocellular cancer
A 4-yr-old boy is brought in by his mother for a wellness visit. His mother tells the FNP that he had a bad case of chickenpox 1 yr ago. Which of the following immunizations are indicated? a. IPV, Hib, hep B b. IPV, Hib, MMR c. DTap, IPV, MMR, hep B d. DTap, IPV
d. DTap, IPV
A 15-mo-old infant is in your office for a well baby check. The mother denies history of chickenpox infection. Which immunizations is indicated this visit? a. Dtap, Hib, IPV, hep B b. DTap, Hib, PCV, IPV, MMR c. MMR, hep B, varicella d. DTap, IPV, MMR, varicella
d. DTap, IPV, MMR, Varicella
When advising a pt about injectable influenza immunization, the NP considers the following about the vaccine: a. Its use is contraindicated in pregnancy b. Its use is limited to children older than 6 years c. It contains live virus d. Its use is recommended for virtually all children age 6mos to 18yrs
d. Its use is recommended for virtually all children age 6mos to 18yrs
When advising patient about antipneumococcal immunization, the NP considers the following about the vaccine: a. It contains inactivated bacteria. b. Its use is contraindicated in individuals with asthma c. It protects against CAP caused by atypical pathogens d. Its use is seldom associated with significant adverse rxns
d. Its use is seldom associated with significant adverse rxns
An adult pt is being evaluated for TB infection with a Mantoux test. The PPD result is 10.5mm. The pt denies wt loss, cough, and night sweats and has a negative chest x-ray. The pt reports that he is in the US illegally and is fearful about discovery. What is the most appropriate action? a. The pt is an illegal alien/migrant and the NP has a legal duty to report the pt to the local State Dept responsible for illegal migrants. b. Health care workers are legally mandated to report illegal migrants to state authorities. c. The NP should call the state health dept and report that the pt has a TB infection. d. NPs have the ethical duty to provide quality health care to pts.
d. NPs have the ethical duty to provide quality health care to pts. Health caregivers are not required to report illegal aliens to the state or local authorities. The pt does not have signs or symptoms of active TB disease (cough, wt loss, night sweats) and has a negative CXR, therefore he has a latent TB infection and is not contagious. Only pts with active TB disease must be reported to public health department.
A college student is seen as a walk-in appt in a college health clinic. She complains of the abrupt onset of sore throat, nasal congestion, runny nose, and malaise. VS are T 99.8, HR 84, RR 14. The physical reveals erythematous throat, swollen nasal turbinates, and rhinitis. The NP suspects viral URI. All of the following treatments are appropriate except: a. Saline nasal spray (Ocean nasal spray) b. Psudoephedrine (Sudafed) c. Ibuprofen (Advil) d. Oral prednisone (Medrol Dose Pack)
d. Oral prednisone (Medrol Dose Pack)
You see a woman who has been sexually involved with a man newly diagnosed with acute hep B. She has not received hep B vaccine in the past. You advise her that she should a. Start a hep B immunization series b. Limit the number of sexual partners c. Be tested for HBsAb d. Receive hep B immunoglobulin and hep B immunization series
d. Receive hep B immune globulin and hep B immunization series
Which of the following is true about the MMR vaccine? a. It contains inactivated virus b. Its use is contraindicated in pts with a hx of egg allergy c. Revaccination of an immune person is associated with risk of allergic rxn d. Two doses at least 1mo apart are recommended for young adults who have not been previously immunized
d. Two doses at least 1mo apart are recommended for young adults who have not been previously immunized
According to Erikson, the "cornerstone of vital personality" is the development of: a. Symbiosis b. Autonomy c. independence d. basic trust
d. basic trust
When answering questions about hep A vaccine, you consider that all of the following are true except: a. it does not contain live virus b. it should be offered to individuals who frequently travel to developing countries c. it is a recommended immunization for health care workers d. it is given as a single dose
d. it is given as a single dose
When counseling a women about COC use, you advise that: a. long term use of COC is discouraged because the body needs a rest from birth control pills from time to time. b. fertility is often delayed for many months after discontinuation of COC. c. there is an increase in the rate of breast cancer after protracted use of COC. d. premenstrual syndrome symptoms are often improved with use of COC.
d. premenstrual syndrome symptoms are often improved with use of COC.
A 38yr old man with recent hx of injection drug use presents with malaise, nausea, fatigue, and "yellow eyes" for the past week. After ordering dx tests, you confirm dx of acute hep B. Emancipatory lab results include: a. HBsAg b. neutrophilia c. thrombocytosis d. presence of HBsAg
d. presence of HBsAg
You see a woman who has been involved with a man newly diagnosed with acute hep B. She has not received hep B immunization. You advise her to: a. start hep B immunization series b. limit the number of sexual partners c. be tested for HBsAb d. receive hep b immune globulin and start hep B immunization series
d. receive hep b immune globulin and start hep B immunization series
Hyperbilirubinemia can cause all of the following except: a. potential displacement of highly protein-bound drugs b. scleral icterus c. cola-colored urine d. reduction in urobiolinogen
d. reduction in urobiolinogen Bilirubin in urine found in the absence of icterus.
A 70-yr-old male patient complains of a bright red spot in his left eye for 2 days. He denies eye pain, visual changes, or headaches. He has a new onset of cough from a recent viral upper respiratory infection. The only medicine he is on is Bayer ASA 1 tablet/day. Which of the following is most likely? a. corneal abrasion b. acute bacterial conjunctivitis c. acute uveitis d. subconjunctival hemorrhage
d. subconjunctival hemorrhage A subconjunctival hemorrhage is a benign disorder that occurs from an increase in intraocular pressure that may be caused by coughing, vomiting, forceful exertion in labor during childbirth, straining while having a BM, weight lifting, or lifting a heavy object.
which of the following is appropriate advice to give to a mother who is breastfeeding her 10-day-old infant? a. your milk will come in today b. to minimize breast tenderness, the baby should not be kept on either breast for more than 5 to 10 min c. a clicking sound made by the baby during feedings signifies a good latch and suck d. the baby's urine should be light or colorless
d. the baby's urine should be light or colorless
A 38 year old nulliparous woman who smokes two and a half packs a day is in an "on and off" relationship. The woman presents seeking contraception. Which of the following represents the most appropriate method? a. contraceptive ring (NuvaRing) b. COC c. contraceptive patch (OrthoEvra) d. vaginal diaphragm
d. vaginal diaphragm
Adjust BCP dose based on complaint: nausea, edema, breast tenderness
decrease estrogen
Adjust BCP dose based on complaint: pre-hypertension
decrease progestin
Adjust BCP dose based on complaint: weight gain
decrease progestin
Benefits of birth control pills (besides contraception)
decreased menstrual cramping and bleeding some improve acne DO NOT HELP with mood, likely to cause mood swings
urogenital effects of diminished hormone levels
decreased urine pH (may lead to pruritis/malodorous discharge), insertional dyspareunia, atrophic cystitis (if present) can mimic UTI,
Signs of excessive progestin in BCP
depression fatigue transient HTN breast tenderness decr. menstrual bleeding duration increased appetite
Factors that contribute to urge incontinence include:
detrusor overactivity
Without intervention, approximately 40% of infants both to mothers with HBV infection will go on to
develop chronic Hepatitis B
Eczema is thought to be caused by
digression of mast cells
DDx of nipple discharge
duct ectasia endocrine alterations inhibition of dopamine prolactinoma malignancy Meds: methyldopa, illicit drugs, neuroleptics, phenothiazines, oral contraceptives, tricyclics, opiates)
Average duration of menses and interval between menses
duration 2-7 days interval 28 days +/- 7 days
Women with PID typically present with what?
dysuria, cervical motion tenderness, abdominal pain
S/S of Lower UTI?
dysuria, frequency, nocturia, urgency, suprapubic pain, gential infections, hematuria
S/S of preeclamsia a. headache b. blurrry vision c. edema of face d. epigastric pain e. all
e
What are the temperaments of an infant?
easy slow to warm difficult/cyclic
In a game of hide and seek, 3 year old Michael hides his face and believe that no one else can see him. This behavior is an example of
egocentric thought.
Milia is typical caused by
enlarge sebaceous glands
You are devising a program to screen preschoolers for lead poisoning. The most sensitive component of this campaign is
environmental history
A six year old boy presents with a one-day history of a fiery red maculopapular facial rash concentrated on the cheeks. He has had mild headache and myalgia for the past week. The most likely diagnosis is
erythema infectiosum
A 10 day old child presents with multiple raised lesions resembling flea bits over the trunk and nape of the neck. The infant is nursing well and has no fear or exposure to animals. The lesions likely represent
erythema toxicum neonatorum
OrthoEvra
estrogen + progestin patch Change patch Q3wks, leave off during week 4 May place patch mostly anywhere *except breast* Reduced efficacy in those *>198lb/90kg* May not be left off for >24 hr
NuvaRing
estrogen + progestin vaginal ring Leave ring in vagina (place as far in as possible) for 3 weeks. Remove for 1 week. Cannot be out for >3hr.
How often should 20-60 y.o. get a complete PE?
every 5 years
Which of the following in one of the more common sources of Hep A in the US?
exposure to fecally contaminated food
A common site for eczema in infants is the
face
Treatment option for HHV-2 genital infection includes
famciclovir
Which of the following is the route of transmission of poliovirus
fecal-oral
Breast cancer risk factors
female North America or northern Europe older age early (<11) or late menarche (>14) late menopause (>55) nulliparity first pregnancy >35yo never breastfed use of oral contraceptives >4yr obesity excessive alcohol tobacco use hx of breast cancer BRCA gene + family hx
Symptoms of the flu
fever, myalgia, headache, malaise, nonproductive cough, sore throat, rhinitis
When reviewing the use of nutritional supplements for the management of menopausal symptoms, the NP considers that:
few high-quality studies support the use of these products
When do ectopic pregnancies most commonly rupture?
first 8-12 wks
The following chromosomal synod is a common etiology of social and verbal developmental delay sin boys
fragile X
A moderately ill infant may be
fussy or irritable, but continue to feed, are consolable and may smile; these infants may have otitis media
HPV Vaccine - recommended ages
girls recommended at ate 11 or 12 with catch-up vaccination at ages 13 through 26 boys - 9-26
You are making round in the nursery and examine the neonate of a mother who is HBsAG positive Your most appropriate action is to
give hepatitis B immunization and HBIG
A healthy 3 year old child is expected to
give his or her first and last name
You examine a 2 month old infant with a port wine lesion over her right cheek. You advise the parents that this lesion:
grows proportionally with the child
Diagnostic tests with abnormal uterine bleeding?
hCG (quantitative), prolactive, TSH, CBC, Pap, STD, urinalysis
When is hCG produced and how soon will pregnancy tests be positive?
hCG produced by chorion by day 8 High quality pregnancy tests can be positive by the first missed period (2 weeks from conception)
You examine a healthy 9 moth old infant from a full term pregnant and expect to find that the infant
has the ability to recognize his or her own name
Signs of too much estrogen and not enough progestin combo
heavy bleeding dysmennorhea headaches irritability bloating syncope
In advising a perimenopausal woman about HT, you consider that it may:
help preserve bone density
An example of an X linked recessive condition or trait is
hemophilia
Which LH and FSH level may indicate PCOS?
high LH or LH/FSH ratio >3
transformation zone
highest risk area of cervix where stratified squamous epithelial tissue intersects with columnar epithelial Is well-outside external os in young women and migrates in with cervical disruption (pregnancy)
HEADSSSW
home, edu, activities, drugs, safety, suicide, sex, weight teen visits
In advising a woman about menopause, the NP considers that
hot flashes and night sweats occur in about 80% of women
Risk Factors for ectopic pregnancy
hx of STIs or PID, adhesions, IUDs, pelvic/abd surgery, infertility therapy, inconsistent or nonuse of birth control, hx of ectopic
Physical examination of a 19-year-old woman with a 3-day history of vaginal itch reveals moderate perineal excoriation, vaginal erythema, and a white clumping discharge. Expected microscopic examination findings include:
hyphae
How are uterine polyps diagnosed?
hysterectomy
A healthy child with no evidence of immunity is exposed to chickenpox at school. How soon after exposure will a dose of the varicella vaccine prevent or modify the disease in the child
if given within 3 to 5 days
What are the cervical cancer screening recommendations for women 65 yrs + ?
if not high risk & has had adequate prior screening: NO SCREENING ** a woman of any age with prior hysterectomy & cervix removal w/no hx of precancerous lesions needs NO SCREENING **
Pathophysiology of osteoporosis:
imbalance between osteoclast (destroys/resorbs bone) and osteoblast (builds bone) activity. Osteoclast / osteoblast activity is influenced by cytokines & hormones including parathyroid hormones, calcitonin, calcitriol, thyroid hormone, sex hormones & also glucocorticoids.
When can a woman safely conceive after discontinuing COC?
immediately
Which of the following terms describes the mechanism of action of imiquimod (Aldara)
immune modulator
What is malocclusion?
imperfect positioning of the teeth when the jaws are closed
Adjust BCP dose based on complaint: spotting (after 3 mo)
increase dose
Adjust BCP dose based on complaint: amennorhea or hypermennorhea
increase progestin
What are the major endocrine changes during the menopause transition?
increased FSH; decreased estradiol & inhibin
Which groups with no history of varicella infection or previous immunization should be targeted for vaccination?
individuals >8 years old with HIV infection with CD4+ T lymphocyte counts >200 cells/uL and daycare workers
Galactasemia
infant doesn't make galactase, can't convert to glucose and it builds up in blood and does brain damage
The rate of bronchiolitis is the highest in which age group
infants younger than 2 years
Most common type, location, and age at diagnosis for breast cancer
invasive ductal carcinoma age 45-65 (70% dx >50) most commonly in upper outer quadrant
The most common form of acquired anemia during pregnancy is:
iron deficiency anemia
Noncontraceptive benefits of COC use include a decrease in all of the following:
iron-deficiency anemia; pelvic inflammatory disease (PID); ovarian cancer. But NOT: cervicitis
Menometorrhagia
irregular intervals WITH excessive duration or flow
Metorrhagia
irregular intervals of bleeding, includes bleeding between periods ("t" for time)
Sturge-Weber syndrome (SWS)
is a rare disorder characterized by the association of a facial birthmark called a port-wine birthmark, neurological abnormalities, and eye abnormalities such as glaucoma.
You examine a newborn with a capillary hemangioma on her thigh. You advise her parents that this lesion:
is likely to increase in size over the first year of life
Fragile X syndrom is usually diagnosed when a child
is past the toddler stage
When advising a patient about immunization with the nasal spray flu vaccine, the NP considers the following
it contains live virus
When advising a patient about immunization with the influenza vaccine nasal spray, the NP considers:
it contains live, attenuated virus
HELLP management
jaundice, ruq pain, thrombocytopenia below 50000 Refer, hospital, deliver
Which of the following would NOT be found in newborns?
lack of defensive blink
Klinefelter syndrome is most commonly marked by
language impairment in males
Oligomennorhea
large intervals between menses (>40 days, <6mo)
Placental Abruption
late 2nd-early 3rd trimester Severe abdominal PAIN, may or may not have dark red bleeding, uterus feels hard RF: trauma, smoking, alcohol, cocaine, previous abortion, pregnancy complications Often bleed out, go into DIC, and both mom and baby die
Mrs. Marcello called you in a panic because her a euro daughter has head lice. Which of the following medications is not recommended as a first-line therapy?
lindane shampoo
A severely ill infant - temperatures of 104 F (40 C) will appear
listless, cannot be consoled, feed poorly or not at all; hospital admission is recommended
Name of the nasal spray flu vaccine
live attenuated influenza vaccine (LAIV) (FluMist)
Treatment of vaginal atrophy:
local ESTROGEN therapy is best choice (vaginal ring, creams). PO estrogen therapy ok as well *use of topical therapy helps decrease risk of recurrent UTI*
A 7 year old child with Type 1 diabetes is bout to receive injectable influenza vaccine. His parents should be advised that
localized immunization reaction are common
Problems after tetanus immunization typically include
localized reaction at site of inspection
When should you order an endometrial biopsy?
long duration of unopposed estrogen (erratic bleeding with PMS) amennorhea >1 yr undiagnosed abnormal vaginal bleeding >3mo
Risk factors for preeclampsia include:
low maternal weight, age younger than 16 years or greater than 40 years, or collagen vascular disease.
What's the following is most likely to be found in the laboratory data of a child who has infectious mononucleosis
lymphocytosis
Placenta previa
mal-implantation of placenta in the lower uterine segment. bleeding late 2nd early 3rd. PAINLESS. Nothing in vagina
Kleinfelter's
male with more than one X chromosome (XXY) enlarged breasts (gynecomastia) sparse facial hair and body hair small testes inability to produce sperm, very tall
Women with bacterial vaginosis typically present with
malodorous discharge
Delayed development can be the resettle of malnutrition from a deficiency of protein, calories, or both. This is referred to as protein energy malnutrition, kwashiorkor, or
marasmus
At birth, a baby's head circumference should
measure about 2 cm great hate the chest circumference
Prolonged uterine bleeding occurring at irregular intervals:
menometrorrhagia (think anovulation)
Primary reason for prescribing HT
menopausal symptoms
Common cause of anemia in females of reproductive age
menorrhagia
Most common gyn disorder of reproductive age women:
menorrhagia
A preferred treatment for trichomaniasis is
metronidazole
Uterine bleeding occurring at irregular but frequent intervals:
metrorrhagia (think anovulation)
Trisomy 21 physical features
microcephaly flattened nose protruding tongue inner epicanthal fold upward slanting eyes short broad hands/fingers; single palmar crease delayed growth hypotonia
Patients with plumbism present with which kind of anemia
microcytic, hypochromic
The progestin component of HT is given to:
minimize endometrial hyperplasia
What is likely to be noted with short term (less than 1 to 2 years) HT use in a post-menopausal woman?
minimized menopausal symptoms
An Asian couple comes in with their 4 week old infant who has a blue black macule scattered over the buttocks. The most likely represent
mongolian spots
How often should the patient check the IUD string?
monthly
Fibrocystic disease
most common benign breast changes, affecting 50% of women Bilateral breast tenderness with multiple mobile tender lumps, usually fluctuate with cycle Ages: 30-50 Dx: US or mammo, FNA Tx: reduce caffeine and chocolate, wear supportive bra, COC, Vit. B6, E, Mg, NSAIDs
Fibroadenoma
most common benign palpable breast lesion in adolescents and young adults (up to 25) Usually in upper quadrants Caused by inflammatory reaction to ductal irritation Sx: achy tender breasts, pain and size of mass incr. with menses, may have nipple discharge Mass is unilateral, well-defined, round, rubbery, and mobile Dx: US, biopsy, excision or monitor
Bacterial Vaginosis
most common cause of vaginitis Caused by replacement of Lactobacillus flora with overgrowth of anaerobic flora RF: sexual activity w/ multiple partners or a new partner, STI, douching, Black, IUD Sx: fishy-smelling vaginal discharge, discharge is white-gray, normal cervix Vag pH >4.5 (normal is 4), + whiff, clue cells Tx: metronidazole 500mg BID x 7 or intravaginally x 5 or clindamycin PO or intravag x7 No partner tx is needed
Post polio syndrome is commonly marked by
muscle atrophy
Which of the following laboratory tests can identify the causative organism of bronchiolitis
nasal washing antigen test
Is Tuberculosis screening universally done for infants?
no it is based on risk
Secondary amennorhea (definition and DDx)
no menses for 90 days (3 missed cycles) after having established menses DDx: pregnancy, PCOS, thyroid, hypothalmic dysfunction, hyperprolactemia, ovarian failure, endocrine (DM, thyroid), meds like antidepressants, anti-HTN, steroids
The recommended length of use of Depo-Provera is:
no more than 2 years
Cautions with progestin-only pills
no placebos, take everyday use back-up method if pill is even 2-3 hr late failure rate is 5x that of COCs
Milia are treated by the following
no special skin care
Acne neonatorum treatment options include which of the following:
no special skin care is needed because these lesions are self resolving low dose benzoyl peroxide
Progression of exam with a toddler/preschooler
non-invasive to invasive (HEENT last)
Sx of cervical cancer
none. It is asymptomatic until well-advanced
What is Galeazzi sign test for?
observes for Unequal knee height as an indication for congenital hip dislocation or femoral shortening
Which type of lube breaks down latex?
oil-based (including vasaline, lotions, canola oil, etc) Must use water-based!
Reduction in frequency of menses, between 35 days and 6 months:
oligomenorrhea (often inappropriately called ammenorrhea, think anovulation)
Typical distribution of acne neonatrum consists of open and closed comedian and pustules
on the forehead and cheeks
Milia is usually marked by white pinpoint papular lesions found
on the nose and cheeks
What type of play do toddlers exhibit
on-looker and parallel play
How often should PPD be done in adolescents?
once
How many doses of the MMR vaccine should a child 6 to 11 months of age receive before traveling outside the US
one dose
An 11 year old well child presents with no document primary tetanus immunization series. Which of the following represents the immunization needed?
one dose of Tdap followed by two doses of Td in 1 and 6 months
The typical HT regimen contains how much of the estrogen dose of COC?
one-fourth
Which of the following represents a therapeutic option for ABRS in an otherwise well 7 year old child who has not had significant clinical improvement but is not worse after 72 hours of observation
oral clindamycin and cefixime
Treatment options for bacterial vaginosis include
oral metronidazole, clindamycin cream, oral clindamycin
You see four-year-old girl who has a two day history of signs and symptoms of acute asthma resulting from a viral upper respiratory infection. She is using in inhaled budesonide and albuterol as directed. she continues to have difficulty with increased occurrence of coughing and wheezing. Respiratory rate is within 50% of upper limits of normal for her age. Her medication regimen should be adjusted to include
oral prednisolone
Sequalae of mumps
orchitis
COCs may provide protection against which cancers?
ovarian and endometrial
Vaginal candidiasis
overgrowth of Candida normal flora Common if taking abx, steroids, or anti-estrogen meds Screen for diabetes Sx: thick white nonodorous vaginal discharge, pruritis, dyspareunia pseudohypea and buds on wet mount Tx: fluconazole/Diflucan 150mg PO x 1 (or other azole intravaginally) You may treat presumptively. Wet mount has poor sensitivity.
Dysmennorhea
painful menstruation (low midline cramps, may radiate to back or thighs, may occur with HA, N/V, diarrhea) RF: young age (but not in first 2-3 yr after menarche due to anovulation), nulliparity, smoking, low fish intake, Paraguard use, endometriosis, uterine fibroids R/o pregnancy, PID, STIs Tx: NSIADS (bc its a prostaglandin-mediated problem) COCs, Mirena, or Depo can be tried Vitamin B1 and magnesium *Note: advise against aspirin bc it is a weak prostaglandin inhibitor and will increase menstrual flow
Signs of endometrial cancer
painless abnormal bleeding Pap shows "atypical glandular cells of undetermined significance" (AGCUS) Transvag US shows endometrial stripe >/= 10mm in postmenopausal women Any bleeding in postmenopausal women
Primary syphilis
painless genital ulcer with cleanbase and indurated margins, localized lymphadenopathy
Be suspicious of ovarian cancer if you find what on exam?
palpable ovary in females of NON-childbearing age OR females of childbearing age with a persistent ovarian cyst >/=5cm for >6wks
Factors that contribute to stress incontinence include:
pelvic floor weakness
First line treatment option for primary syphilis is
penicillin
FSH findings during peri and true menopause
peri-menopause: FSH > 20IU/mL menopause: FSH >30IU/mL
Interventions for patients with stress incontinence includes:
periurethral bulking agent injection
Amanda sates that he baby will not go to bed without her bottle. You tell her that if the baby must have bottle at night, tit should be a bottle containing
plain water.
A healthy infant at age 9 to 11 moths is expected to
play peek a boo
The following benchmarks indicate normal development by a health child born at term who is now 12 months of age
pointing to a desire object and reaching to a desired object
A parent asks about varicella zoster immune globulin and you reply that it is a
pooled blood product with an excellent safety profile.
What is pubic hair tanner stage I
preadolescent
What is tanner stage I in girls
preadolescent breasts
Abortion
pregnancy termination any time before 24 wks Sx: vag bleeding, cramping, low back pain, ROM
What is a contraindication to combined oral contraception (COC)?
presence of factor V Leiden mutation
Amenorrhea can be primary or secondary:
primary: never had menses, think structures secondary: no menses for 3-6 months after establishing a regular cycle (does not apply to 1st 2 years after menarche)
DepoProvera
progestin only IM injection Q3mo (2 week grace period) May help with anemia, cramps, and ovulatory pain SE: menstrual irregularities, weight gain, headaches, mood changes, hair loss, decr. HDL, decr. bone density (returns) Fertility return my take 1-2 years after d/c Get urine hCG before first 2 injections to r/o pregnancy. Use back-up BC for 2 wks after first injection May start 30 days postpartum
Nexplanon and Implanon
progestin only subdermal implant Effective for 3 years Nexplanon can be seen on x-ray, Implanon cannot May help with dysmennorhea SE: menstrual abnromalities
To best help parents foster social emotional development in their preschooler, age 4, you advise them to
provide frequent opportunities to interact with other children.
Infection with Corynebacterium diphtheria usually causes
pseudomembranous pharyngitis
Cervical Cancer Screening
q3yr age 21-65 (regardless of sexual history) q5yr + HPV testing age 30-65 Yearly for immunocompromised or hx of precancer or cancer
After conducting the Tumbling E Snellen eye test on a verbal 4 and half year old boy, you determine that his vision is 20/30 in both eyes. Your next step is to
recheck vision at the next well child exam
abortion management spontaneous
refer bedrest, abstinene
Menorrhagia
regular intervals excessive duration or flow (>7 days, >80cc) ("n" for never-ending)
Hypomenorrhea
regular intervals reduced duration or flow (<60cc)
Main reasons for treating sx of menopausal transition
relieve vasomotor sx; reduce risk unwanted preg; avoid irregular menses; preserve bone; decrease risk of dz; improve quality of life
A healthy 6 to 7 month old infant is able to
roll from back to stomach
Non dairy sources of calcium,
sardines almonds (and some other nuts) tofu spinach
Maternal iron requirements are greatest during what part of pregnancy?
second and third trimesters
Syphilis is most contagious during which stage?
secondary
Trisomy 21 physcial problems
seizures Cardiac problems (VSD) Endocrine (DM) Early dementia (30-40) Obesity Leukemia
What are common co-morbidities with down syndrome
seizures, congenital heart disease
Abruptio placenta
separation of placenta from uterine wall. bright red blood SEVERE PAIN
Adding an androgen to an HT may be well suited for a woman with:
severe hot flashes despite maximized estrogen therapy
Measles
severe illness with serious sequelae, including encephalitis and pneumonia.
Eclampsia
severe unrelenting headache, RUQ pain, visual changes bp consistently >160/100 tonic-clonic seizures REfer, MgSO4, delivery
During the MT (menopausal transition) is the cycle shorter or longer?
shorter at <25 days
When answering questions about Hep A vaccine you consider stating that it
should be given to all children unless contraindicated
Polymenorrhea
small intervals between periods (<21 days)
Hegar's sign
softening of cervicouterine junction
Goodell's sign
softening of cervix
While examining 12 month old boy whose family recently immigrated to US from Mexico. You notice weight is 95%tile and height is 50%tile. You discuss this and the mom is proud of the son's size. Your response to her is guided by your understanding that
some cultures believe that a fat baby is a healthy baby.
What is pubic hair tanner stage II
sparse, pale, fine
a healthy 2 year old child is able to
speak in phrase of two or more words
Most common type of cervical cancer
squamous cell carcinoma
baby proofing
start at 9 mo
Seborrhea dermatitis/ cradle cap: when prevalence decreases
steadily decrease in prevalence at 7% in 1-2 yrs old
What is the first line tx for polycystic ovary disease?
stress reduction, weight loss, diet modification
What can cause hypothalmic dysfunction?
stress, excessive exercise, severe drop in body fat (anorexia), malnutrition, severe systemic illness, stress
Preeclampsia
sudden wt gain , frontal headaches , visual disturbances htn>140/90, trace to 1+ PROTEINURIA, Edema facial, Wt gain >2lb per wk or 6 in a month.
Usual treatment option for a child with Hep A includes
supportive care
In most children with bronchiolitis, intervention includes
supportive care (NOT oral steroid therapy)
Action of estrogen
suppresses FSH secretion, decreases follicular maturation proliferation of endometrium
Action of progestin
suppresses LH secretion, preventing ovulation thickening of cervical mucus (impedes sperm and ova transport) decreased peristalsis in fallopian tube thickens and stabilizes endometrium
During perimenopause, what is likely to be noted?
symptoms are most likely in the week before the onset of the menses
describe temporal pattern of symptoms:
symptoms may begin up to 6 y prior to final menstrual period and as postmenopause yrs progress, loss of ovarian response to gonadotropins, assoc. symptoms also decline
Pregnant women should take iron supplement in 2nd/3rd trimester T/F
t
Marfan physical characteristics
tall *arm span exceeds height long narrow face Pectus carinatum or excavatum (tall with large armspan) kyphoscoliosis
sex, drugs, psych issues
teens
Diane is the mother of a child diagnosed with autism. After the clinician recommends the seasonal flu vaccine for the family. Diane asks "Does the flu vaccine contain thimerosal"? The clinician knows that
the nasal spray does not contain thimerosal
Because children are curios about sexual feelings and developmental changes in their bodies form the preschool years onward, education about these feelings and changes should begin during
the preschool years
What is hyperdontia?
the presence of extra (supernumerary) teeth. Hyperdontia can be associated with developmental abnormalities such as cleft lip and/or palate, Gardner syndrome, and cleidocranial dysplasia
When assessing growth and development from a cross cultural perspective health care providers need to be aware that
there may be differences in normal growth curves
Which hot the following is true about the MMR vaccine
this vaccine contains live virus
When should adolescents have a physical?
three visits 11-14 15-17 18-21
Nausea, edema, breast tenderness caused by?
too much estrogen
A 53-year-old woman who is taking hormone therapy (HT) with conjugated equine estrogen, 0.625 mg/d with MPA, 2.5 mg, has bothersome atrophic vaginitis symptoms. You advise that:
topical estrogen may be helpful
Victoria's mother bring her for her 1 year checkup. As you are weighing her, you remember that at 1 year, her weight should be
triple her birth weight
The quad screen is used to help detect increased risk for which of the following conditions in the fetus?
trisomy 21 and open neural tube defects
The mother of a 2 year old toddler is concerned about her child's frequent temper tantrums ash asks how to decrease their frequency. To address her cover, you advise her to
try to avoid situations that tend to provoke tantrum such as hunger fatigue and frustration
Shannon age 4 months is waiting in the exam room with her mother. When you walk into the room, you expect Shannon to
turn her head toward the sound of the door or your voice
A 9 year old child with no documentation of vaccination come in for an MMR update. Her parent states that the child received some vaccines, but no documentation is available. How many does of the the MMR should the child review and what what frequency?
two MMR doses 1 month apart.
When giving influenza vaccine to a 7 year old who has not revived in the past should consider that
two doses 4 weeks or more apart should be given
The Hep A vaccine should be administered in children per the following schedule
two doses 6 months apart
Family members and caregivers of an international adoptee should be given the Hep A vaccine per the following schedule
two doses 6 months apart, one dose before the child arrives
Children younger than nine who are receiving their initial flu vaccine need what?
two doses of the vaccine separated by 4+ weeks
Administration of MMR
two immunizations 1 month apart for all adults born after 1957
What is the grace period between Depo shots?
two week grace period--if > two weeks do a HcG before giving
How does meaningful word usage in sentence correlate to age?
two words together by 2 y.o. three words together by 3 y.o four words together by 4 y.o. five words together by 5 y.o.
HPV Vaccine - types it protects against
types 6, 11, 16, 18 - in HPV 4 type 16, 18 - in HPV 2
CI for estrogen therapy:
undiagnosed vaginal bleeding severe liver dz pregnancy venous thrombosis personal hx breast cancer
Absolute contraindication to postmenopausal HT includes:
unexplained vaginal bleeding
When are chest and head measurements equal?
up to age 1
Which of the following findings is most consistent with the diagnosis of acute bacterial rhino sinusitis in children
upper respiratory tract infection symptoms persisting beyond 10 days
Which form of urinary incontinence is most common in elderly persons?
urge
When does urine leak with urge incontinence?
urgency, involuntary urine loss, nocturia, frequency, "overactive bladder"
With genitourinary tract exposure to the spermicide nonoxynol-9, a woman is likely at increased risk for:
urinary tract infection
When a local site of infection cannot be found in an infant, consider the diagnosis of
urinary tract infection (UTI)--which can also be considered with behavior change.
What is not a normal finding in a woman during the reproductive years?
vaginal epithelial cells with adherent bacteria
Pelvic exam findings d/t diminished hormone levels (post menopause)
vaginal surface becomes pale, rugation diminishes (smooth vaginal walls), ovary diminishes (may not be palpable), loss of pelvic muscle tone in older women
What best describes lesions associated with condyloma acuminatum?
verruciform
Tx of ovarian cysts
very common in adolescents Usually resolve spontaneously May use COCs to help. If >10cm, or getting larger, or last >6 wks, refer for excision
When to send someone with PID to the hospital
very young unreliable pregnant fever >101 WBC >11,000 evidence of peritonitis suspect abscess decreased bowel sounds anorexia immunocompromised no response to tx in 72 hr
Which body area has the greatest concentration of estrogen receptors?
vulva
What to check at subsequent prenatal visits
weight BP urine for protein and glucose fundal height Leopold maneuvers fetal heart tones edema
Osteoporosis prevention strategies:
weight bearing exercise HRT calcium supplementation 1500 mg/day (1200 if on HRT) vit D supplementation (600 units/Day)
Common SE of progestin
weight gain depression hypertension
The most likely weight of a 1 year old child whose birth weight was 6 1/2 pounds would be what? a. 19-20 lbs. b. 13-14 lbs. c. 25-26 lbs d. impossible to estimate
weight triples by 1 year. or 6.5 x 3 = 19.5 lbs. or a. 19-20 lbs.
One of the most prominent clinical features of bronchiolitis is
wheezing
Patients with stress incontinence often report urine loss:
with lifting, coughing, sneezing
If an infant is discharged from hospital prior to 48 hours, the first visit should be
within 3-5 days
MMR Vaccine - is it live?
yes - contains live but attenuated (weakened) virus
Antiviral for the flu most common in US
zanamivir (Relenza) and oseltamivir (Tamiflu) - treat influenza type A and B treatment can shorten the time a person infected with the flu feels ill by approximately 1 day if treatment is started during the first two days of the illness zanamivir is inhaled
A diet low in the following nutrients encourages lead absorption
zinc and magnesium
Benefits of HRT:
• Prevents osteoporosis & bone fracture • Improved mood & sense of mental well-being in some women • Decreased tooth loss • Lowered risk of COLON CANCER • Lowered risk of DIABETES • Modest improvement in joint pains • Lower death rate for women who take hormone therapy in their 50s.
Weight Gain and Length
■ 0 to 6 months: 6 to 8 ounces per week and 1 inch per month. ■ 6 to 12 months: 3 to 4 ounces per week and 1/2 inch per month.
Vision Screening
■ 1 month: Infant can fi xate very briefl y on the mother's face. Prefers the human face. ■ 3 months: Infant will hold the hands close to the face to observe them. Hold a bright object or a toy in front of the infant. Watch behavior as the infant fi xates on the toy for a few seconds. Avoid using objects/toys that make noises when testing vision. ■ 6 months: Makes good eye contact. Scans surroundings at 180-degree visual fi eld. ■ 12 months: Makes prolonged eye contact when spoken to. Will actively turn head around 180 degrees to observe people and surroundings for long periods. Recognizes parents and favorite people from a longer distance. ■ Retina and optic disc: Set fundoscope lens at 0 to -2 diopters. Fundus appears pink to red.
First Permanent Teeth (Deciduous Teeth)
■ 6 years of age: Central incisors and the fi rst molars.
Indications for Referral
■ Abnormal red refl ex (rule out retinoblastoma, cataract, glaucoma). ■ Presence of white refl ex (rule out retinoblastoma). ■ Strabismus (rule out CN 3, 4, and 6 abnormalities, retinoblastoma). ■ Vision of 20/30 or worse in a child more than 6 years of age. ■ Greater than two-line difference between each eye. ■ Esodeviation present after 3 to 4 months of age ■ Abnormal result corneal light refl ex test. ■ Shape/appearance of pupils not equal. ■ New onset of strabismus (brain mass, abscess, bleeding, lead poisoning, etc.).
What is the most common cause of UTI in women?
E. coli
When a client complains of dyspareunia in the lower back during orgasm, what dx should come to mind?
ENDOMETRIOSIS (when formulating the diff dx for a pt w/dyspareunia, it's important to note the location of the pain)
Prevention for osteoporosis?
ERT--Estrogen replacement therapy Weight bearing exercise (30 min walking 3-5x/week), walking, jogging, dancing, climbing stairss, aerobics, strength training, Increase calcium intake
Which is preferrable - estrogen only or combined estrogen/progesterone HRT?
ESTROGEN ONLY - fewer side effects * unfortunately combined is needed d/t risk of endometrial CA w/estrogen only*
Postpartum psychosis
Early onset usually by day 3 postpartum. Characterized by delusions, hallucinations, agitation, insomnia, confusion. Risk of infanticide usually secondary to delusion about infant. maternal suicide risk also increased.
Patient presents with unilateral lower quadrant pain that radiates to lower back, +CMT and recent h/o dark brown or tarry abnormal uterine bleeding/spotting?
Ectopic pregnancy - she will also have positive peritoneal signs if rupture has occurred
When is influenza contraindicated
Egg allergy
What xray finding is common with transposition of the great arteries
Egg on a string with cardiomegaly
Significance of alpha-fetoprotein
Elevated in twins or a bad birth defect
used to prevent fertilization or the implantation of a fertilized egg
Emergency contraception
What is the most common cause of abnormal uterine bleeding?
Endocrine issues
What is tanner stage II in boys
Enlargement of scrotum and testes, scrotum roughens and reddens
What is Stage 2 Tanner boys?
Enlargement of scrotum/testes Scrotum roughens/reddens
Acute and rapid onset of high fever, chills, and toxicity. Child complains of severe sore throat and drooling saliva. Won't eat or drink, muffled (hot potato) voice, and anxious. Characteristic sitting posture with hyperextended neck with open-mouth breathing. Stridor, tachycardia, and tachypnea. Usually occurs between ages 2 and 6. Before the Hib vaccine was used, most cases were due to Haemophilus infl uenzae type b (75%). Other pathogens are Staphylococcus aureus, Streptococcus pyogenes, fungi, others. Now rare due to the Hib conjugate vaccine. Prophylaxis with rifampin (duration is 4 days) for close contacts. Reportable disease. A medical emergency. Call 911.
Epiglottitis
What hormone deficiency causes menopausal symptoms?
Estrogen
Cause of osteoporosis in women?
Estrogen deficient
What is unopposed estrogen?
Estrogen produced in the absence of the balancing effects of progesterone. Progesterone is produced by the corpus luteum and promotes thickening of the endometrium in preparation for a fertilized ovum. Progesterone also inhibits the actions of estrogen on certain tissues. In an anovulatory woman, no corpus luteum is formed = no progesterone. Estrogen is predominant prior to ovulation
Drug therapy for osteoporosis prevention? (2)
Estrogen, Bisphosphonates
What is Ortho-Evra? Contraindications?
Estrogen/progesterone patch patients >180 lbs
Management of menopause with hormonal therapy?
Estrogen: Conjugated estrogen, estradiol, estrone sulfate Progestin:Cyclic or continuous Exercise, calcium
■ Recognize hand-foot-mouth disease, scabies, impetigo, varicella. ■ Recognize how Fragile X syndrome looks. ■ Immunizations needed at age 11 to 12 years (Tdap, HPV, MCV4). ■ Child at age of 11 years is at "early abstract" thinking (Piaget). ■ Molluscum is caused by the poxvirus. ■ Human papillomavirus vaccine (Gardasil) youngest age group is 9 years.
Exam Tips
Celeste is a nine year old girl with moderate persistent asthma. She is not taking a prescribed and held corticosteroid but is using albuterol . to relieve her cough and wheeze. According to her mother she currently uses about six albuterol doses per day in particular for a cough and wheeze after active play. You consider that
Excessive albuterol use is a risk factor for asthma death
A newborn delivered by mother with no prenatal care exhibits the following dysmorphic facial features including short palpebral fissures a thin upper lip and enlongated and flattened philtrum and a flattened midface region. You suspect that the mother engaged in what behavior during pregnancy?
Excessive alcohol intake.
Gynecomastia
Excessive growth of breast tissue in males. Can involve one or both breasts. Physiologic gynecomastia is benign and is more common during infancy and adolescence. Normal in up to 40% of pubertal boys (peaks at age 14). Most cases resolve spontaneously within 6 months to 2 years. Classic Case Pubertal to adolescent male is brought in by a parent who is concerned about gradual onset of enlarged breasts or asymmetrical breast tissue (one may be larger). Child is embarrassed and scared about breast changes. Affected breast may be tender to palpation. Objective Round, rubbery, and mobile mound (disc-like) under the areola of both breasts. Skin has no dimpling, redness, or changes. If mass irregular, fixed, hard; rapid growth in breast size; or suspect secondary cause, refer to specialist. Treatment Plan ■ Evaluate for Tanner stage (check testicular size, pubic hair, axillary hair, body odor). ■ Check for drug use: both illicit and prescription (i.e., steroids, cimetidine, antipsychotics). ■ Rule out serious etiology (testicular or adrenal tumors, brain tumor, hypogonadism, etc.). ■ Recheck patient in 6 months to monitor for changes.
Seborrheic Dermatitis ("Cradle Cap")
Excessive thick scaling on the scalp of younger infants. Treated by softening and removal of the thick scales on the scalp after soaking scalp a few hours (to overnight) with vegetable oil or mineral oil. Shampoo scalp and gently scrub scales with soft comb. Prevention is by frequent shampooing with mild baby shampoo and removing scales with soft brush or comb. Self-limiting condition and resolves spontaneously within a few months.
Which of the flown is most consistent with a normal developmental exam for a thriving 5 month old infection born at 32 weeks gestation?
Experimenting with sound
Which of the following is most consistent with a normal developmental exam for a 3 month infant born at 40 weeks gestation?
Experimenting with sound
The mother of your 3 year old patient is concerned because the child stutters. What would your approach be?
Explain that that can be normal until 4 years old.
What is Klinefelter's syndrome
Extra X chromosome in males (a little more female-ness)
XXY syndrome (Klinefelter's syndrome)
Extra X chromosome; only in males 1:1,000 males *presents in puberty *may present initially a **infertility
Which of these infant characteristic is associated with readiness for the introduction of sold food into an infants diet?
Extrusion reflex has faded
Blink Reflex
Eyelids will close in response to bright light or touch.
An infant is born with port wine said and Sturge-Weber syndrome. The two conditions are unlikely to be related.
FALSE
The clinician anticipate that a child with mongolian spots will cry out easy of the discomfort when the area is gently pressed
FALSE
What diagnostics are used to detect endometrial cancer?
FIRST LINE: pelvic ultrasound - r/o other reasons for abnormal bleeding postmenopausal women: Transvaginal ultrasound to evaluate thickness of the endometrial lining
What hazard is incontinence associated with?
Falls/fractures
A child need to demonstrate more than one developmental red flag to warrant further evaluation
False
Bronchiolitis most commonly occurs in the US during the warm weather months
False
Evidence demosncate that the MMR virus acquired via vaccine can be shed into the body during lactation
False
It is considered a developmental red flag if a child does not respond to his or her name by nine months of age
False
Thyroid decreases in size in normal pregnancy.
False
Which are the following behavior ratings is not included on the Denver developmental screening test?
Fearlessness
Thyroid-Stimulating Hormone (TSH)
Federally mandated testing. Lack of thyroid hormone results in mental and somatic growth retardation. Treated by thyroid hormone supplementation.
Phenylketonuria (PKU)
Federally mandated testing. Severe mental retardation if not treated early. Disorder is an inability to metabolize phenylalanine to tyrosine because of a defect in the production of the enzyme phenylalanine hydroxylase. Perform test only after infant has protein feeding (milk or formula) for at least 48 hours. Higher risk of false negatives if done too early (under 48 hours). Treated by following special diet (phenylalanine free diet).
What is Barlow's maneuver
Feeling of a slip as the femoral head slips away from the acetabulum, causing the dislocation
Who gets Rett's disorder?
Females only.
Which screening test has the highest sensitivity and specificity for diagnosing our deficiency in anemic clients
Ferritin
What are the diagnostic criteria of Kawasaki disease?
Fever for >5 days, bilateral conjunctival injection without exudate, polymorphous rash, inflammatory changes of lips and oral cavity (strawberry tongue), changes in extremities (erythema, edema), and cervical lymphadenopathy
S/S of pyelonephritis?
Fever, N/V, chills, flank pain, abdominal pain, CVA tenderness, ill,
What is fibrosystic breast disease?
Fibrosis of breast tissue
Slapped Cheek Caused by *Parvovirus
Fifth's Disease
You are examining a previously healthy 6 month old who was derived by cesarean section at 32 weeks gestation. Exam reveals presence of Moro, Babinski, and Landau reflexes. Which interpretation of findings is accurate?
Findings are normal
12 Months Old
Fine Motor ■ Can use "sippy" cup. Gross Motor ■ Stands independently. ■ Walks independently. ■ Waves "bye bye." Language ■ Knows at least two to four words. ■ Specific "mama," "dada." ■ Knows first name. Other ■ Growth rate slows down. ■ Labs: Check for anemia, lead poisoning if high risk. ■ Report absence of weight bearing, inability to transfer objects hand to hand.
15 Months Old
Fine Motor ■ Feeds self with spoon. ■ Can drink from Gross Motor ■ Walks independently for longer distances. Language ■ Follows commands with gestures. ■ Knows four to six words.
6 Months Old
Fine Motor ■ Palmar grasp of objects. ■ Reaches for toys using palmar grasp. ■ Brings things to their mouths. ■ Starts to pass things from one hand to the other. Gross Motor ■ Begins to sit up independently without support. ■ Rolls over both directions (back/supine to stomach and stomach to the back/supine) Language ■ Starts to say consonants (i.e., da-da, ba-ba). ■ Very curious and will look around environment Other ■ Report failure to follow objects past midline (180 degrees), poor eye contact.
9 Months Old
Fine Motor ■ Pincer grasp starts and can pick up things (i.e., food) between thumb and forefinger. ■ Waves "bye bye." ■ Feeds self. Gross Motor ■ Pulls self up to stand. ■ Crawls and "cruises." ■ Bears weight well. Language ■ Plays peek-a-boo ■ "Stranger anxiety" very obvious. ■ Report absence of babble, inability to sit alone, strong primitive reflexes such as the Moro (startle reflex), fencing (tonic neck reflex).
When do permanent teeth erupt?
First Molar; 6-7 years Central incisor: 6-8 years Lateral incisor: 7-9 years Cuspid 9-12 years First bicuspid and second bicuspid; 10-12 years Second Molar; 11-13 years
Café au Lait Spots
Flat, light brown to dark brown spots greater than 5 mm (0.5 cm). If six or more spots larger than 5 mm (0.5 cm) in diameter are seen, rule out neurofi bromatosis or von Recklinghausen's disease (neurological disorder marked by seizures, learning disorders, etc.). Refer to pediatric neurologist if the spots meet the same criteria to rule out neurofi bromatosis.
S/S of PID?
Flu + Gyn 1. Fever, chills, N/V 2. Discharge, dysuria, dyspareunia, lower abdominal pain, infertility
What is caput succedaneum?
Fluid under the skin, simple swelling, crosses the midline. Resolves in 2-3 days.
Which SSRI has the longest half life (given for postpartum depression)
Fluoxetine
What supplement should all women of child-bearing age take?
Folate 400mcg daily to prevent neural tube defects
Influenza is an annual vaccine, except when?
For children younger than 9 years it is two doses, 1 month apart
Toddler to preschool
Forward-facing car seat with safety harness. Weight limit ranges from 80 to 100 lbs (depends on brand).
Classic Case Large head circumference. Mental retardation. Delayed physical developmental milestones, such as crawling and walking. Autism common. Hyperactive behavior. Tends to avoid eye contact. Patient has a long face with prominent forehead, jaw, and large ears. Large body with flat feet. Plan ■ Refer patient for genetic testing. ■ Refer patient to psychiatrist/psychologist for psychosocial, behavior, and mental evaluation.
Fragile X Syndrome
What is the most common inherited cause of mental retardation in children?
Fragile X syndrome
What is polymenorrhea?
Frequent irregular bleeding frequency is <18 days
Name 3 prodromal symptoms of eclampsia?
Frontal or occipital headache Visual disturbances with worsening condition Epigastric or RUQ px which progressively or suddenly worsen
When and it is around 6 months of age of solid foods are usually added to the diet generally in a recommended sequence the first solid food recommended is serial what the second type of solid food recommended?
Fruits.
Freud's adolescent stage?
Genital
What stage are adolescents in, according to Freud?
Genital
Anal Wink
Gently stroke the anal region. Look for contraction of the perianal muscle. Absence is abnormal and suggestive of a lesion on the spinal cord (i.e., spina bifida).
What do we do when an infant is born to a hep B positive mother?
Give hepatitis B vaccine, give hepatitis B immune globulin within 12 hours of birth, and test for hep b antigens and antibodies after finishing series of hep B vaccine
When evaluating a child who has bacterial meningitis the NP expect to find cerebrospinal fluid results
Glucose at about 30% of serum levels
Softening of cervix
Goodell's sign - first trimester
Goodell's, Hegar's, & Chadwick's signs
Goodell's: softening of cervix Hegar's: softeing of cervical-uterine junction Chadwick's: cervical cyanosis
The G Apgar stands for
Grimace
18 Months Old
Gross Motor ■ Can walk up steps. Fine Motor ■ Turns pages of book. Language ■ Can point to four body parts. ■ Knows 10 to 20 words. Other ■ Chronic exposure to second-hand smoke increases rates of: SIDS, otitis media, bronchitis, pneumonia, wheezing and coughing, affects lung development, and exacerbates asthma.
What are the common bacterial organisms in the first month of age
Group B strep, gram negative enteric organisms
What is GAPS?
Guidelines for Adolescent Preventive Services
Late or tertiary syphilis
Gumma (granulomatous lesions involving skin, mucous membranes, bone), aortic insufficiency, aortic aneurysm, Argll Robertson pupil, seizures
Mnemonic Device (HEARS) for High-Risk Factors for Hearing Loss
H (hyperbilirubinemia) E (ear infections that are frequent) A (Apgar scores low at birth) R (rubella, CMV, toxoplasmosis infections) S (seizures) Premature infants and infants admitted to NICU units have a higher incidence of hearing loss compared with full-term infants.
Swine flu
H1N1
Avian flu
H5N1
If a young woman (<20) has cervical cancer, what should you screen for?
HIV
Main immunizations to consider in adolescents
HPV, meningococcal, TDaP
What cardiac anomaly is associated with Turner syndrome
HTN - coarctation of aorta
A 2 year old presents with pustular ulcerating lesions on the hands and feet and oral ulcers. The child is cranky well hydrated and afebrile. The most likely diagnosis is
Hand foot and mouth disease
Hand-Foot-Mouth Disease A common acute viral illness that mainly affects children younger than 10 years of age. Most common cause is the coxsackievirus A16. Spread through direct contact with nasal discharge, saliva, blister fl uid, or stool. Patient is most contagious during the first week of the illness. Classic Case Acute onset of fever, severe sore throat, headache, and anorexia. Multiple small blisters appear on the hands, feet, and diaper area. Ulcers are present inside the mouth, throat, tonsils, and the tongue. Child will complain of sore throat and mouth pain with acidic foods. Treatment Plan ■ Treatment is symptomatic. Self-limited illness. Complete recovery usually occurs within 5 to 7 days. ■ Ibuprofen or acetaminophen for pain and fever every 4 to 6 hours. Do not use aspirin. ■ Salt water gargle (1/2 teaspoon salt in 1 glass of warm water). ■ Drink cold fl uids (avoid soda drinks, orange/lemon juice, tomato juice).
Hand-Foot-Mouth Disease
Multiple small blisters appear on the hands and the feet. Small ulcers are inside the mouth, throat, tonsils, and the tongue. *Coasackie Virus
Hand-foot-mouth disease (HFM)
You are performing a physical exam of a 3 year old who is new to your clinic. Which finding requires immediate further eval?
Has an equal A-P and transverse chest diameter
Compared with albuterol levalbuterol (Xopenex)
Has the ability to provide greater bronchodilation with a lower dose
Jason is a healthy 19 year old who presents for primary care. According to his immunization record he received two dose of HBV vaccine 1 month apart at age 14 years. Which of the following best describe his HBV vaccination needs?
He should receive a single dose of HBV vaccine now
What type of murmur is heard in a PDA?
Heard best LUSB, machinery sound, systolic
Softening of the cervicouterine junction
Hegar's sign - first trimester
HELLP syndrome
Hemolysis Elevated Liver enzymes and Low Platelet count
HELLP syndrome
Hemolysis, Elevated Liver enzymes, Low Platelet Aka DIC
What vaccine is given at birth?
Hep B
Which of the following statements is true about the hepatitis B virus (HBV) vaccine?
Hepatitis B immunization series should be offered to all children
Potential adverse events of acetaminophen in a child with fever and mild dehydration include
Hepatotoxicity
How is kawasaki disease treated?
High dose ASA therapy
WHO Precautions for Use of copper containing IUD: Category 2, advantages outweigh risk
High risk for HIV HIV infection Age <20 Immediately post first-trimester therapeutic abortion Nulliparous Complicated valvular heart disease Severe dysmenorrhea
Lead Screening
High-risk children should be screened at age 1 to 2 years.
Wait sepsis and children have lowered in recent years mainly because of
Higher rates of select immunization
Developmental Dysplasia of the Hip (DDH)
Higher risk with breech births, female gender, family history, oligohydramnios. Birth to 3 Months ■ Look for asymmetry in the creases of the legs. Examine infant front and back without diapers. Check the gluteal, thigh, and popliteal folds match.
S/S of excessive androgenic effects
Hirsutism Acne Oily skin Edema Increased libido
When is the polio vaccine (IPV) contraindicated?
History of anaphylaxis to streptomycin
Contraindications with OCPs:
History of thromboembolic events CAD Breast cancer Pregnancy Liver tumor Cholelithiasis during pregnancy *undiagnosed abnormal uterine bleeding
HODGKIN'S LYMPHOMA
Hodgkin's lymphoma presents with enlarged and painless cervical and supraclavicular lymphadenopathy associated with fever (Pel-Epstein sign) and night sweats. May report an episode(s) of severe pain that is located on or over malignant areas a few minutes after drinking alcohol. The most common cancers in teens aged 15 to 19 years are Hodgkin's lymphoma (16%) and germ cell tumors (16%) such as testicular and ovarian cancer.
Step Reflex
Hold baby upright and allow the dorsal surface of one foot to touch the edge of a table. Baby will flex the hip and knee and place the stimulated foot on the tabletop (stepping motion). Absent with paresis and breech births. Disappears by 6 weeks.
Ortolani Maneuver/Test
Hold each knee and place your middle fi nger over the greater trochanter (outer thigh over the hips). Rotate the hips in the frog leg position (abduction, then adduction). During abduction, resistance may be felt at 30 to 40 degrees. ■ Positive: "Click" or "clunk" sound and/or if examiner palpates the trochanter becoming displaced (temporarily) from the hip socket.
What type of murmur is present with a ventricular septal defect?
Holosystolic, commonly associated with thrill, felt at the left lower sternal border
What are the gross motor skills of a 3 year old
Hops, rides a tricycle
Management for complicated pyelonephritis?
Hospitalization for IV antibiotics
List some symptoms associated with the menopausal transition
Hot flashes (flushes); insomnia; weight gain/bloating; mood changes; irrregular menses; mastodynia; depression; headache
Contraindications to estrogen
Hx of CV events or vascular disease Hx of cancer (esp breast, liver, estrogen-dependent) Surgery, Immobilization Pregnancy and Lactation <6 wks Postpartum Uncontrolled HTN (Stage 2) Diabetes with macrovascular complications Smoking (>35yo) Migraines with focal neuro signs Undx vaginal bleeding Active gallbladder disease Family hx of HLD or MI <50yo Malabsorptive procedure or disorder
Emotional S/S of PMS?
Hypersensitivity, irritable, mood swings, depressive sx, anxiety, tension, fear of loss of control, confusion
According to WHO guidelines, which clinical condition would cause a provider to approach use of a copper-containing IUD with caution?
Hypertension
Reduction in number of days, amount of flow, can be side effect of some medications
Hypomenorrhea
Why do children with down syndrome have a protruding tongue?
Hypotonia - they can't keep it in their mouth
Clinical characteristics consistent with a diagnosis of trisomy 21
Hypotonia, simian creases epicanthal fold and brushfield spots
Preschool (Age 4-6 Years) ■ Administer: MMR, varicella, inactivated poliovirus vaccine (IPV) (polio), and DtaP.
IMMUNIZATIONS
Coper releasing (paraGard): can leave in for 10 yrs Progestin: mirena: remain in up to 5 yrs Can prevent Asherman's syndrome associated with PID Requires informed consent
IUD
Concerning the use of antipyretics in a febrile young child which of the following statement is false
Ibuprofen should not be used if the child is also taking a macrolide antimicrobial
Growth hormone treatment for short stature remains controversy oh. The clinician should be aware of the following regarding the assessment of growth problems in Idiopathic short stature
Identification of growth problems is usually made by an auxlogical evaluation which compares the child's growth to standardize norms
What is Erikson's cognitive development stage in adolescents?
Identity vs Role confusion stage
What stage are adolescents (12-18) in, according to Erik Erikson?
Identity vs role confusion
How long should back up method be used after getting a Depo shot?
If given on DOC 1-5= No back up needed If given after DOC 5=2 weeks
Varicella Vaccine Facts
If no reliable history of chickenpox, give anytime after first birthday. Age 12 years of less: needs only one dose Age 13 or older: two doses 1 month apart Avoid salicylates x 6 weeks (theoretical risk of Reye's syndrome)
Work-up of amennorhea
If primary: consider karyotype CBC, CMP, UA, hCG, TSH, ESR FSH, LH, prolactin, DHEA-S, estradiol, testosterone Progesterone challenge (checks for estrogen/progesterone deficiency) Consider ACTH and urine free cortisol (Cushings) and transvag US
When should children 2 years - 5 years receive another dose of the 23PS (pneumovax)?
If they are immunocompromised
WHO Precautions for Use of copper containing IUD: Category 1, no restriction
Immediately post first-trimester therapeutic abortion Parous Hypertension Vascular disease Uncomplicated valvular heart disease Cervical intraepithelial neoplasia Uterine fibroids without distortion of uterine cavity Postpartum >4 weeks
Mechanism of action with IUD?
Immobilizes sperm and interferes with migration of sperm from the vagina to the fallopian tubes Speeds ovum transport Inhibits fertilization
An important part of the treatment of Kawasaki disease includes the use of
Immune globulin
Immunization contraindications: IPV, MMR, Varicella IPV, vaccinia (smallpox) Hepatitis B Influenza vaccie (nasal spray and injected) Varicella zoster MMR
Immunization contraindications: Neomycin - IPV, MMR, Varicella Streptomycin, polymycin B, neomycin - IPV, vaccinia (smallpox) Baker's yeast - Hepatitis B Egg - Influenza vaccie (nasal spray and injected) Gelatin, neomycin - Varicella zoster Gelatin - MMR
Immunization contraindications: Neomycin Streptomycin, polymycin B, neomycin Baker's yeast Egg Gelatin, neomycin Gelatin
Immunization contraindications: Neomycin - IPV, MMR, Varicella Streptomycin, polymycin B, neomycin - IPV, vaccinia (smallpox) Baker's yeast - Hepatitis B Egg - Influenza vaccie (nasal spray and injected) Gelatin, neomycin - Varicella zoster Gelatin - MMR
Hepatitis B Total of three doses over 6 months. If missing a booster, give until total of three doses. Do not repeat series. MMR Give second dose (if needs to catch-up). Live virus precautions Varicella Give second dose (if needs to catch-up) if no proof of varicella. Live virus precautions Tetanus Give Tdap age 11 to 12 years (or older if missed this dose). If older, Tdap can replace one Td booster Hepatitis A High-risk groups (homosexuals), endemic areas (certain areas of Southwest United States) Influenza Annually after age of 6 months (trivalent vaccine). FluMist is for healthy nonpregnant patients aged 2 to 49 years. Human papillomavirus Indicated for boys and girls. Give first dose at age 11 to 12 years. Catch-up at age 13 years if missed. Gardasil: need three doses. Give second dose 1-2 months after first dose. Give third dose 6 months after the first dose. Meningococcal First does at age 11 to 12 years. Give booster at age 16 years. All college freshmen living in dormitories. Meningococcal conjugate vaccine (MCV4).
Immunizations: Age 10 and Older
What is cause of stress incontinence?
Impaired muscle support Sphincter deficiency
"Honey-colored" crusted lesions. Fragile bullae (bullous type). Pruritic.
Impetigo
flexible rod containing etonogestrel and a low diffusion of progestin from the rod continuos protection for 3 yrs
Implant Contraception
Placenta Previa
Implantation of placenta in lower uterine segment late 2nd - early 3rd trimester Often precipitated by something going in vagina (sex) NO pain, bright red bleeding, uterus is soft RF: previous C-section, multigravida, malpresentation, hx of previa Dx: US, CBC, fetal monitoring, nonstress test, Tx: bedrest, hospitalization, nothing in the vagina
After inhaled corticosteroids or leukotrine modifier therapy is initiated clinical effects ar seen
In about 1 to 2 weeks.
When is stuttering normal?
In children less than six years old for less than six months.
When is a abnormal or impaired development in social interaction usually noted with autism?
In first year-often associated with language delay
Chlamydial Pneumonia
In infants with ophthalmia neonatorum, also rule out concomitant chlamydial pneumonia. Obtain nasopharyngeal culture for chlamydia. Infant will have frequent cough with bibasilar rales, tachypnea, hyperinfl ation, and diffused infiltrates on chest x-ray. Treated with erythromycin QID × 2 weeks. Daily follow-up. Reportable disease.
What is a major risk factor for down syndrome
Increased maternal/paternal age
Risks, Benefits, and Contraindications of Hormone Replacement Therapy
Increased risk of breast cancer, CHD, stroke, and dementia Best treatment for hot flashes, may prevent osteoporosis If used, it should be initiated within 10 yr of menopause and d/c after 3-5 years of use Contraindicated in hx of thrombosis, breast mass, endometrial cancer, unexplained bleeding, liver dz, seizures, HTN, familial HLD, migraines, gall bladder disease
DiGeorge (Velocardiofacial) syndrome presentation
Increased risk of infection (due to thymus aplasia) *risk of mortality associated with cardiac abnormalities Micrognathia (receding chin)
What are the risk factors for endometrial cancer?
Increasing age Unopposed estrogen therapy Tamoxifen therapy Early menarche Late menopause (after age 55) Nulliparity PCOS (chronic anovulation) Obesity DM Estrogen-secreting tumor Lynch syndrome (hereditary non-polyp colorectal CA) Cowden syndrome Family hX of endometrial, ovarian, breast, or colon ca
The mechanism of action and fever include which of the following
Indigenous pyrogens increase prostaglandin synthesis
What factors influence physical development?
Individual variability, genetic characteristics, ethnicities, and cultural practices
What stage are school agers (6-12) in, according to Erik Erikson?
Industry vs inferiority
What is Psychosocial phase of school age children? (Erikson)
Industry vs. Inferiority (Child wants to be brave)
What age are kids in Erikson's theory of Trust vs. Mistrust?
Infancy (0-1)
What is pyelonephritis?
Infection of upper urinary tract
An 18 yard woman has a chief complaint of a sore throat and swollen glands for the past three days. Her physical exam reveals pharyngitis minimal tender anterior and posterior cervical lymphadenopathy and maculopapular rash. Abdominal exam reveals right and left upper quadrant abdominal tenderness. The most likely diagnosis is
Infectious mononucleosis
Women with a history of ___ are at higher risk than the general population for ectopic pregnancy?
Infertility
What is PID?
Inflammation of infection infection of the uterus, fallopian tubes, ovaries and surrounding tissue
PELVIC INFLAMMATORY DISEASE Causative organism(s): What abnormal lab findings do u look for with pelvic inflammatory disease?
Inflammatory, infectious disorder of the female reproductive tract - may affect the UTERUS, FALLOPIAN TUBES, CERVIX, ADJACENT STRUCTURES CAUSATIVE ORGANISM: Chlamydia Gonorrhea Enterobacter 1. Leukocytosis (50% of the cases) 2. ESR elevated 3. C-reactive protein elevated
Cost condiderations with IUD?
Informed consent=increased cost
What is oligomenorrhea?
Infrequent irregular bleeding frequency is >40 days
What is Marfan syndrome
Inherited connective tissue disorder
Marfan syndrome
Inherited connective tissue disorder affecting skeletal, cardiac and opthalmic body systems 1:20,000 births
Best prenatal predictor of down syndrome?
Inhibin-A
How does the Nuva Ring work?
Inhibits ovulation Alters endometrim Thickens mucus
What is the recommended duration of pharmacological tx for osteoporosis?
Initial tx phase of 5 YEARS, then reevaluate with history, phys exam, and bone mineral density (BMD) testing - After 5 yrs, efficacy DECREASES, side effects INCREASE - If needed, u can continue the current med or switch to another one - Consider stopping pharm tx if BMD stable or improved, no more fractures, no new high risk meds or diagnoses
Debbie is developing self assertion, spontaneity, self sufficient, direction and purses as her mother encourages, reassures, and cheers her on. Which of Erikson's stages of ego developmental best characterizes Debbie?
Initiative versus guilt
What stage are preschoolers (3-6 years) in, according to Erik Erikson?
Initiative vs guilt
You examine a 10-year-old boy with suspected streptococcal pharyngitis. His mother asked if he can get a shot of penicillin wish of the following statements is true regarding the use of intramuscular PCN
Injectable penicillin oral amoxicillin and cephalexin are each strongly recommended as treatment of streptococcus pharyngitis. Injectable penicillin would be indicated for treatment if poor inherence to recommended therapy or inability to take full course of oral antibiotics is anticipated.
Teaching for nuva ring:
Insert once monthly Leave in for 21 days Remove and bleed At day 28 replace
What needs to be done for repeated intercourse with the diaphragm?
Instill spermicide in the vagina-- *DO NOT take the diaphragm out to do it!
What does serosanginous breast discharge indicate?
Intraductal papilloma-benign
What supplement should be started at 6 mo. in breastfed babies? How much? What should be given to babies of vegan/vegetarian moms?
Iron 1 mg/kg/day B12
Which of the following statements is true about inactivated poliovirus vaccine (IPV)
It is the preferred method of immunization in North America.
Melissa was born with a red to blue purple nodule on her thigh that blanches dramatically with pressure. Over the past few months it has increased in size. I'm other ask you what you think it is. You respond
It may be a hemangioma
When advising parents about injectable influenza immunization, the clinician considers the following about the vaccine
Its use is recommended for member so household of high risk patients
Diagnostic tests for Candidiasis?
KOH shows pseudo hyphae
Onset of high fever (up to 104°F) and enlarged lymph nodes on the neck. Bright red rash (more obvious on groin area). Conjunctivitis (dry, no discharge), dry cracked lips, "strawberry tongue." Swollen hands and feet. After fever subsides, skin peels off hands and feet. Treated with high-dosed aspirin and gamma globulin. Most cases (75%) occur in children under the age of 5 years. Resolves within 4 to 8 weeks but may have serious sequelae, such as aortic dissection, aneurysms of the coronary arteries, and blood clots. Close follow-up with pediatric cardiologist done for several years because effects may not be apparent until child is older (or adult).
Kawasaki Disease/Syndrome
What is S3
Ken-tuck-y = increased fluid states
What is genu valgum
Knock knees - normal variant in preschooler (knock knees, knees stick)
What kind of 'play' is characteristic of preschool age?
Associative, cooperative, dramatic, physical
When should PPD be done?
At least before entrance into school
Poorly controlled asthma and children can lead to
Attenuated lung development
What does ASCUS mean?
Atypical squamous cell of undetermined significance
Autism A developmental disorder that affects the normal development of communication and social skills. The exact cause is unknown. Autism affects more boys than girls. There are several theories about the cause, but they are unproven (thimerosal, mercury, vaccines,etc.). Autism is hard to diagnose before the age of 18 months. Classic Case Child who is extremely sensitive to noises, touch, smells, and/or textures. Will refuse to wear tight or rough textured clothes because they feel "itchy." Prefers to be alone. Poor eye contact. Does not interact with others. Slow to poor language development. Repeated body movements such as flapping arms. Some may appear to be progressing normally but suddenly regress at ages 1 to 2. Language and social skills disintegrate. Treatment Plan ■ Refer to psychiatrist or psychologist for testing and evaluation. ■ Intensive rehabilitation at younger ages (i.e., OT, PT, speech therapy). ■ Medications: risperidone (Risperdal) is an antipsychotic that is prescribed for some patients.
Autism
By the end of the first year of life, normal infants demonstrate interest in a object that a caregiver points out. Absence of this behavior is associated with which disorder?
Autism
Disorder? may appear as early as 18 months. Usually, autism becomes more apparent in early childhood (ages 2 to 6 years). Five behaviors to look for: ■ Does not point/wave/grasp by 12 months. ■ No babbling or cooing (by 12 months). Does not say single words (by 16 months). ■ Does not say 2-word phrases on his own (by 24 months). ■ Any loss of language or social skills (by 24 months). ■ Does not gesture (waving, grasping, pointing) at 24 months. Safety Education ■ Use rear burners. Turn pot handles away from reach. ■ Child should be supervised at all times. ■ Hold child's hand when crossing the street or when shopping. ■ Keep tools and sharp objects out of reach. Inspect toys for loose parts or breakage. ■ Water safety education. Fences around pools. Never leave child alone in the pool.
Autism
What stage are toddlers (1 to 3 years) in, according to Erik Erikson?
Autonomy vs shame and doubt (children are beginning to explore the world around them - if parent lets them then they develop autonomy, if parents are restrictive then they may doubt themselves)
Marfan's
Autosomal dominant mutation: defect in connective tissue protein; affected tall lanky, joint laxity, long digits, myopia, arched palate; complications: pneumo, MVP, aortic root dilation, aortic insufficiency, aneurysm: eye problems
What advice would the provider give to a patient newly prescribed COC containing progestin drospirenone (Yasmin, Yaz)?
Avoid using potassium-containing salt substitutes
The preferred treatment option for a 6-year-old boy with pertussis is
Azithromycin
1. Which of the following best depicts Hegar's sign? A. Cervical cyanosis B. Softening of the cervicouterine junction C. Amenorrhea D. Softening of the cervix
B
16. When are Leopold maneuvers first able to be performed? A. 15 weeks B. 20 weeks C. 25 weeks D. 34 weeks
B
22. An ultrasound examination for fetal survey is typically performed at: A. 10-12 weeks B. 18-20 weeks C. 20-22 weeks D. 22-24 weeks
B
29. Syncopal episodes are most likely to occur in which trimester? A. First trimester B. Second trimester C. Third trimester D. Postpartum
B
33. When should fetal heart tones be able to be first detected? A. Between 8 and 10 weeks of pregnancy B. Between 10 and 12 weeks of pregnancy C. Between 12 and 14 weeks of pregnancy D. Between 14 and 16 weeks of pregnancy
B
34. As a nurse practitioner, you know that an intrauterine pregnancy typically presents with the following specific indications in the first trimester except: A. Amenorrhea B. Change in skin pigmentation C. Urinary frequency D. Breast tenderness
B
39. A patient who is 32 weeks pregnant is hospitalized for severe preeclampsia. Based on your knowledge of this condition, you know that she should initiated on which type of therapy to stabilize her condition? A. B-methasone B. Magnesium sulfate C. Lumirubin D. Calcium gluconate
B
4. How often should prenatal checks be traditionally scheduled for a patient who is 30 weeks pregnant? A. every week B. every 2 weeks C. every 3 weeks D. Every 4 weeks
B
Softening of the cervix and the vagina indicates which sign? A. Chadwick's sign B. Goodell's sign C. Braxton-Hicks sign D. Hegar's sign
B
Yes or No: Does this patient has a reactive TST? A. 45-year-old woman with type II diabetes mellitus and a chest radiograph finding consistent with previous TB and a 7 mm induration B. 21-year-old man with no identifiable TB risk factors and a 10 mm induration C. 31-year-old man with HIV and a 6 mm induration D. A 45-year-old woman from a country where TB is endemic and has been 11 mm induration E. 42-year-old woman with rheumatoid arthritis who is taking etanercept (Enbrel) who has a 7 mm induration
A. Yes B. No C. Yes D. Yes E. Yes
According to WHO guidelines, who is a COC candidate? A. 22-year-old smokes 1 ppd B. 29-year-old with PID C. 45-year-old with tension type headache D. 32-year-old breastfeeding a 6-month-old infant E. 28-year-old with Type 1 DM
A. yes B. yes C. yes D. yes E. yes, in the absence of advanced cardiovascular disease
What is the cardinal sign of endometrial cancer?
ABNORMAL UTERINE BLEEDING
Contraindications to Hormone replacement therapy (HRT):
ABSOLUTE CONTRAINDICATIONS: pregnancy active venous thrombosis or embolism undiagnosed vaginal bleeding active liver disease active breast or endometrial cancer active CVD
WHO Precautions for Use of copper containing IUD: Category 3, exercise caution
AIDS-defining illness Cirrhosis with severe decompensation Postpartum <4 weeks
What is ASCUS? What causes it? As a provider what should u do with these results?
AS-CUS = atypical squamous cells of undetermined significance, obtained from a PAP test. CAUSES: HPV infx, low hormone levels What to do (pt ages 30 - 65 yrs, PAP testing only) PREFERRED: HPV testing for high risk strains (16 & 18) ALTERNATIVE: repeat cytology in 1 yr if HPV comes back positive, get COLPOSCOPY if HPV comes back negative, back to routine screening protocol (for a woman approaching or past menopause: u can give her a topical estrogen cream to apply to cervix for a few weeks, this may clarify the cause of the ASCUS)
How soon after unprotected sex must emergency contraception be used to be effective?
ASAP is ideal. Recommended within 72 hr (3 days), but effective up to 120 hr (5 days)
Bethesda Grading (best to worst)
ASC-US: HPV cotest, colposcopy if + LSIL: HPV cotest, colposcopy if + ASC-H: colposcopy HSIL: coplposcopy or electrosurgical excision AGC: colposcopy + endometrial sampling CIN1: cotest in 1 yr CIN 2 & 3: colposcopy, refer AIS: hysterectomy
What is the treatment for hip dysplasia
Abduction
What does Pap test for ?
Abnormal cervical cells
You suspect autism in the young child of a client of yours, but they say he is just shy. For diagnosis of Autism, you know there are 3 requirements that must be present. Which of these would lead you to suspect autism in a young child?
Abnormal verbal and nonverbal communication
Patient presents at 29 weeks with severe abdominal pain and bright red vaginal bleeding s/p low impact MVC. Suspect?
Abruptio placentae - also related to chronic hypertension, drug and alcohol use EMERGENT DELIVERY
What is primary amenorrhea?
Absence of menarch by age 16
Trisomy 21
"Downs" Prescence of a third #21 chromosome Occurs 1:660 births
What is the weight gain progression birth to school age?
(Rapid decelerating growth followed by consistent growth) -Initial 10% loss -Regained in 7-14 days -doubles by 5 months of age -Triples by 1 year of age -quadruples by 2 years of age -3yrs old-school age; gain 2.5 inches annually -School age children gain 5-7 lbs annually
Which medications decrease the effectiveness of COCs?
(from practice questions) antibiotics, antacids, anticonvulsants, barbituates
Signs of deficient estrogen in BCP
(menopause sx) hot flashes night sweats depression irritability weight gain
Signs of excessive estrogen in BCP
(pregnancy sx) dysmennorhea nausea cholasma (mask-like) cardioembolic events telangiactasias breast changes
Some OTC progesterone creams contain sterols that the body is unable to use
***
Pregnancy Induced Hypertension (PIH)
*BP: >140/90 or >30/15 over baseline with readings 6hrs apart* RF: HTN, DM, multiple gestation, primigravida, very young, >35 Dx: monitor BPs, baseline CBC, LFTs, US, nonstress test, fetal kick counts Tx: bedrest in *left lateral* position
XO Karyotype (Turner's syndrome)
*Females* sex chromosome abnormality Occurs in 1:2,000 births 95% don't survive in utero "Puffy babies" in utero
HELLP Syndrome
*Hemolysis, Elevated Liver Enzymes, Low Platelets* Looks like liver failure and may bleed May occur before or after eclampsia Sx: preeclampsia, jaundice, fatigue, RUQ tenderness, ascites, platelets <50k, highly elevated AST and ALT, decr. clotting factors Tx: referral, hospitalization, delivery ASAP
S/S of Trichomonas?
*Malodorous, frothy, yellowish-green discharge, pruritus, vaginal erythema, *strawberry patches on cervix and vagina, dyspareunia, dysuria
Preeclampsia
*PIH + proteinuria + edema* May occur from 20wks gestation to 4 wks postpartum Sx: sudden wt. gain, peripheral edema (can't put on shoes or take rings off), HA, visual disturbances, oliguria, N/V may indicate encephalopathy Dx: check urine at every visit, BPs, labs, US, nonstress test, kick counts Tx: referral, bedrest, weekly steroid injections if <34 weks for lung development
Eclampsia
*Preeclampsia + tonic clonic seizure* Usually stage 2 HTN Dx: CBC, CMP, coag panel for DIC concern Tx: Refer, hospitalization, anticipate delivery asap
XO Karyotype (Turner's syndrome) physical features
*webbed neck* Lymphedema low hairline learning disabilities *"Sheild"* shaped chest (wide spaced nipples) Hypertension (coart) Head/neck abnormalities
Acute HIV infection
- *maculopapular rash* - fever - mild pharyngitis - ulcerating lesions - diarrhea - diffuse lymphadenopathy
Juice recommendation
- 100% juice w/o added sugar - not introduced no earlier than *6 mons* - 6 oz/ day for 6 mons to 5 yo
Weight gain & caloric requirement: 0-3 mons
- 26-31 g/ day - 100-120 kcal/day
Red flags in young children
- 6 mons: no big smiles or other warm, joyful expressions - 9 mons: no back & forth sharing of sounds, smiles, or other facial expressions - 12 mons: lack response to name, no babbling, no back and forth gestures (pointing, showing, reaching, or waving) - 16 mons: no spoken words - 24 mons: no meaningful 2-word phrases that don't involve imitating or repeating
Breastfeeding
- Breastfeed newborns a minimum of 8, preferably 12 times / 24 hrs - infants only get 1% or less of drug dose and only a few drugs are contraindicated - pumping & discarding the milk need to cont for 3-5 drug free half lives of the med
Signs an infant is ready for solids
- Double birthweight & 4-6 mons old - eats more than 32 oz (936 ml) formula/day or > 8-10 feedings (breast or bottle/d)
Gastroenteritis
- Duration: usually 3-5 days, often as short as 24 hours - Hydration status: ask about the last urination - gatorade, soda, most fruit juices are inappropriate d/t containing inappropriate glucose & electrolyte composition - blood or pus stools, fever, malaise= bacterial (r/o shigellosis)
Risk of HRT:
- ENDOMETRIAL CA (estrogen only, with uterus). - DVT and STROKE (less risk w/patch or cream. in women within 5 years of menopause there was no statistically significant increase in stroke risk) - GALLBLADDER/ GALLSTONES - DEMENTIA (if started after 10 yrs of menopause)
Lead Poisoning
- Elevated blood levels= >/= 5 mcg/dL - diets low in calcium, iron, zinc, magnesium, copper, high in fat enhances oral lead absorption - s/s: abd pain, cramping, aggressive behavior, anemia, constipation, difficulty sleeping, HA, irritability, loss of previous dev skills in young children, low appetite & energy, reduced sensations - Tx: < 44: removal of source, nutrition, iron tx. > 45: chelation tx (binds to toxins in blood)
Klinefelter syndrome (XXY male)
- Only males - developmental issues, mostly *language impairment* - Low testicular vol, hip & breast enlargement
Car Safety Seat Use
- Rear facing till 2 yo - vehicle seat belt fits when a child is 4 ft & 9 inches and btw 8-12 yo - all children < 13 should sit in the back
Influenza
- Uncomplicated cases resolve in about 1 wk, cough & malaise often go for 2 or more weeks - children remain infectious for 10 or more days after the onset of symptoms - immunocompromised can remain infectious up to 3 wks - in general pts age 2-50 tend to be well protected - given usually in Oct or Nov - when a child *< 8* is receiving the vaccine for the 1st time, 2 doses 4 wks or more apart should be given. - trivalent (standard dose; given to pts < 18 yo; IM), low-dose TIV (intradermally), high-dose TIV (IM) -LAIV: nasal spray, contains 3 diff viruses, for healthy pts 2-40 yo, s/e: nasal irritation, d/c, muscle aches, sore throat, fever - *ppl w/ an egg allergy can receive the vaccine*
Varicella
- Varicella immunity should be confirmed w/ pregnant woman, immunocompromised persons, and healthcare workers. - pts who have not received the vaccine should get the 1st dose and 2nd dose *4-8 wks after* - healthy children > 12 mons exposed, should get vaccinated within *3-5* days - greatest varicella mortality: 30-49 yo.
Combined OC
- avoided until the baby has been nursing for at least 6 mons (since it could affect milk flow) - if not breastfeeding, can be started 21 days postpartum
CAP in children: Tx
- bacterial: usually start w/ amoxicillin 90 mg/kg/d in 2 doses. alt. Augmentin. - atypical: azithromycin. alt: clarithromycin, erythromycin, doxycycline for > 7 yo. - influenza pna: tamiflu, zanamivir (>/= 7 yo)
Pertussis
- bordetella pertussis - incubation period: up to 3 weeks - dx tests: nose or throat cultures (can take 2 weeks to be +; gold standard) and PCR (faster and more sensitive) both needed esp if pt has a cough > 3 wks - s/s: paroxysmal cough, early signs resemble the common cold - tx: preferred azithromycin (clarithromycin & erythromycin- risk for infantile hypertrophic pyloric stenosis in infants < 1 mon). sensitivity to macrolides- Bactrim.
Feeding Frequency during months 1 & 2
- breastfed: 10 mins at each breast q1.5-3 hrs - bottlefed; 2-3 oz (60-90 ml) q2-3 hrs
Fragile X Syndrome
- chromosomal alteration causes intellectual disability - *most common* known cause of *autism* - males: large testicles after puberty, large body, learning & behavioral differences, large forehead, ears, prominent jaw, tendency to avoid eye contact
Hemangioma
- congenital vascular malformation - grows rapidly in the first yr, eventually regresses - 90% disappear by age 9 - tx PCP: oral propranolol commonly used
ABRS
- considered if >/= 1: worsening URI (double sickening= acute worsening of symp or new fever at day 6-7), persistent URI w/o improvement after 7-10 days (nasal d/c, daytime cough, bad breath, fatigue, HA, decreased appetite), acute onset: tempt > 102.2, purulent dc, ill appearing for 3-4 days - *usually tx after URI initially improves then gets worse and persistent URI w/o improvement after >/=10 days* - tx: amoxicillin or Augmentin. if no improvement= clindamycin AND cefixime or linezolid AND cefixime or levofloxacin
Hepatitis B
- contraindicated in pts w/ hx of anaphylactic reaction to *baker's yeast* - 2nd & 3rd dose should be separated by an interval of at least *8 weeks* - it is NOT necessary to restart the series if a dose is missed - infants perinatally infected have a 25% change of dev liver CA or cirrhosis - neonate born to a mother w/ HBV should receive vaccine & hep B immune globulin (HBIG)
CAP in children: S/S
- cough, tachypnea (most sensitive), dx of lower resp tract dz considered w/ RR > 50/min < 1 yo, > 40/min in children > 1 yo - less likely to complain of dyspnea, sputum production, pleuritic chest pain
Precocious puberty: Boys
- dev of secondary sexual characteristics before 9. - usually a benign normal variation - other causes: gonadal & adrenal tumors, or genetic dz
Precocious puberty: Girls
- dev of secondary sexual characteristics btw 6-8. thelarche as early as 7, pubarche as early as 8. Common reason: early onset of normal puberty. - usually just monitored, unless other causes - < 6 yo= health problems (ie ovarian or adrenal tumor)
Theophylline
- effective bronchodilator - for children >/= 5 yo - requires laboratory monitoring
Port-wine stain
- flat hemangioma - usually appears on the face, deepen in color as time goes, and grow proportionally w/ the child.
Progestin-only pill (POP)
- for lactating women who want OC - disadvantage: bleeding irregularity, from prolonged to amenorrhea. - can be started immediately postpartum if *not breastfeeding* or 3 wks postpartum if breastfeeding
AOM: Watchful waiting criteria
- for pt >= 6 mons w/ nonsevere illness, unilateral AOM w/ decision making w/ parent - f/u 2-3 days for abx tx if symptoms do not improve
Atopic dermatitis: Tx
- hydration! - on the face of infants and children >/= 3 mons, may use hydrocortisone 1% (low potency)
OME
- if > 8 wks, the presence of communication problems and other symptoms dictates the need for further eval & tx - chronic bilateral OME (>/= 3 mons), may need tympanostomy w/ documented hearing diff and recurrent AOM
When is jaundice concerning?
- if there is an increased in *conjugated* bilirubin or jaundice in the &first 24 hrs* of life, pathological etiologies should be considered ie ABO incompatibility.
UTI: Tx
- initial: amoxicillin, bactrim (high resistance though) or *third generation* cephalosporin. ciprofloxacin is approved by the FDA for children starting age 1 for UTI tx (but usually not given for other conditions for children < 18 yo). - duration of tx: 7-14 days
Milia
- likely cause is maternal androgenic effects on the sebaceous glands - resolves w/o tx by 4 wks-6 mons of life
Acne neonatorum
- likely d/t maternal androgens - resolves 4-8 wks but occasionally up to 1 yr.
Rehydration therapy
- minimal to none: < 10 kg: 60-100 ml for each loss, > 10 kg: 120-240 ml for each loss. - mild to moderate: 50-100 ml/kg over 3-4 hours
AOM: Diagnosis
- mod or severe bulging of TM or new onset otorrhea not r/t OE w/ otalgia - milk bulging of TM and recent (</= 48 hrs) onset of ear pain (in nonverbal child- tugging, holding, rubbing) or intense TM erythema w/ otalgia
AOM: Causes
- most common: streptococcus pneumonia (least likely to resolve w/o tx and causes the most sig symptoms; d/t alteration of intracellular protein binding sites, *also most common cause of childhood *ABRS*) - haemophilus influenza (most commonly isolated from mucoid middle ear effusion) - moraxella catarrhalis (high rate of beta lactamase production)
Delayed puberty
- no evidence of sexual maturation (tanner I) in girls > 13 and boys > 14 yo. - can be d/t the being healthy but maturing slowly (constitutional delay in puberty; often runs in the family) or hypogonadism (ie brain or pituitary tumor, infection, radiation, chromosomal anomalies) or poor diet or girls undergoing intense physical activity.
AOM: nonsevere vs severe illness
- nonsevere: mild otalgia < 48 hrs or fever < 102.2/ 24 hrs - severe: moderate to severe otalgia, otalgia > 48 hrs, fever >/= 102.2
Bronchiolitis
- peaks in children < 2 yo btw Nov and April - dx: rapid antigen tests of nasal washings - s/s: tachypnea, mild fever, conjunctivitis, pharyngitis, rhinorrhea, decrease in appetite, cough, sneezing, wheezing - usually for 2-3 wks
Physiologic jaundice
- presents btw *3-5* days - d/t normal breakdown of fetal hgb & immature liver metabolism - *unconjugated* bilirubin is elevated
Hyperlipidemia management
- pts *8 or older* w/ LDL >/= 190 (lower for those w/ FH of cardiac dz, 2 or more RF, DM), medication tx should be considered.
Cholesterol levels for aged 2-19 yo
- should be *<170* mg/dL - should be retested in 3-5 years if the values fall within the reference range.
BP
- should be measured annually starting @ 3 (also when children should be screened for FH of CVD).
BMI
- should be measured beginning at 2 - @ 5, if BMI >/= 85th %, intensity diet and act changes
Asthma: clinical effects of inhaled steroids & leukotriene modifier
- take at least 1-2 wks to be seen.
Diphtheria & tetanus
- tetanus: c/b clostridium tetani, an anaerobic, gram +. Causes painful muscle weakness & spasm ("lockjaw") - diphtheria: c/b c. diphtheriae, gram - bacillus, transmitted person to person or through contaminated liquids, pseudomembranous pharyngitis - contraindications: life-threatening allergic reaction or has suffered a brain or nervous system disease within 7 days after a dose - single dose of Tdap is recommended for pts 11-64 yo - catch up in children 7-18 yo, should get * one Tdap* and *two Td* in 1 & 6 mons. - preg woman should also get Tdap w/ each of their pregnancies in the 3rd trimester (btw 27-36 wk)
Hepatitis A
- the likelihood of having symptoms is r/t age; children < 6 yo (>70%). s/s typically last < 2 mons. - <1% can lead to acute liver failure
Mongolion spots
- typically fade by 7 yo
Middle ear effusion: LOT
- typically persists for 4-6 wks and often up to 3 mons
Erythema toxicum neonatorum
- unknown etiology, occurs in 50% of full-term infants, usually in the first 10 days of life - look like flea bites, widely distributed (not on palms or soles) - tend to fade 5-7 days after eruption
Polio
- viral infection that can cause *paralysis* - transmitted by fecal-oral route - most do not have symptoms. 4%-8% show fever, fatigue, nausea, HA, flulike symptoms, stiff neck & back, pain in the limbs (often resolve). <1%= permanent paralysis, usually the legs. - 5-10% die when paralysis strikes the resp muscles - contraindications: life threatening reaction to vaccine and abx such as *neomycin, streptomycin, or polymyxin B*
Milk recommendation
-12 to 24 mons: whole cows' milk (after 12 mons limit milk to a total of 16-24 oz/ day (480-720 ml) or reduced fat milk for whom overweight or obesity is a concern or FH of obesity, dyslipidemia, CVD - after 24 mons: switch to skim milk or 1% milk
what are the recommendations for iron supplementation?
-For exclusive breast fed babies, approx 1 mg/kg/day of iron after 6 months of age -Bottle feeding should contain iron supplementation -Ideally the iron should come from fortified cereals -Elemental iron supplements can be given if iron intake from diet not adequate
What are the vitamin supplementation recommendations?
-Vit D supplements (400 IU per day) at 2 months to adolescence -Vit B12 for breastfeeding mothers who are strict vegetarians to prevent neurological abnormalities
Suffix for estrogen?
-diol
Prefix for progesterone?
-nor
UTI: S/S in children
-younger children: irritability, lethargy, fever (no obvious focal infection) -older children: abd pain, unexplained fever, or both -as children approach puberty, flank pain becomes more common - UTI considered in infants and < 2 mons-2 yo w/ unexplained fever
How much influenza vaccine is given in children 6 months - 35 months
.25 mL IM
How much influenza vaccine is given in children greater than 3 years?
.5 mL IM
How is the hepatitis B vaccine series spread out?
0-2-6 months
What is the typical schedule of prenatal visits?
0-28 wk = q4 weeks 28-36 wk = q2 weeks >36 wk = q1 week TOTAL OF 15 VISITS
scheduling of prenatal visits
0-28wks: every 4 wks 28-36: every 2wks 36-delivery: every wk
First dental exam should occur by age...
1
How many doses of Hep B are administered and when?
1 at birth other ages is high risk
The rate of spontaneous fetal loss related to amniocentesis is approximately:
1 in 200 procedures
Prevalence of breast cancer
1 in 8! 90% with no family history
What signifies adequate weight gain in first 3 mo. (daily)?
1 oz/day or 30 grams/day
Tetanus, diptheria, acellular pertussis (Tdap) is a series of how many vaccines?
1 with booster of Td every 10 years
How long does night time toilet training control lag behind day time
1 year
What Age? Supports own weight. Walks with hands held. Parallel play. Separation anxiety. Abnormal: Unable to support own weight. Lack of babbling. No response to smiles, poor eye contact, loss of previously learned skills (autism).
1 year
Naegele's rule
1 year -3 months + 7days from LMP
MMR is given when
1 year and by 12 years
When does birth weight triple?
1 year of age
Hep A is given when
1 year to 2 years, 6 months apart
incubation period for the flu in immunocompetent adult
1-4 days (avg of 2)
When should 1st Meningococcal vaccine be given? Booster? What if no vaccine was given until 16 years old?
1. 11-12 and a booster dose should be given at age 16 years. 2. 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 through 18 years, 3. Adolescents who receive their first dose of at or after age 16 years do not need a booster dose.
Trimesters
1. <13 wks: N/V, breast tenderness, amennorhea 2. 13-28 wks: abd discomfort, incr. fetal movement 3. 28 wks +: Braxton Hicks
Contraindications for depo?
1. Abnormal uterine bleeding 2. Pregnancy 3. Allergy to DMPA
Absolute contraindications with IUD placement?
1. Active, recent or recurrent pelvic infection, such as GC/Chlamydia, 2. Pregnancy
Signs / symptoms of a vertebral compression fracture:
1. Acute onset back pain after a fall, sneeze or heavy lifting 2. Tenderness to palpation at the affected level 3. Decreased spinal mobility 4. Neurologic deficits - i.e. numbness, weakness - after low level insult (rare) *** Often asymptomatic ***
Following is the most appropriate way to relieve fever and discomfort in a child with Varicella
Acetaminophen
What is first line for fever
Acetaminophen
What is the most appropriate antipyretic for a 4 month old and how often is it given?
Acetaminophen, every 6 hours
This is not among the proposed mechanisms of action of emergency contraception pills
Acts as an abortifacent
Fast growing cancer of the lymphoblast, which are immature lymphocytes. CBC will show very high WBC count (greater than 50,000 cells per cubic millimeter). Girls have slightly higher chance of cure compared with boys. African American and Hispanic children tend to have a lower cure rate compared with children from other races.
Acute Lymphocytic Leukemia
Fast growing cancer of the bone morrow that affects immature or precursor blood cells, such as myeloblasts (WBCs), monoblasts (macrophages, monocytes), erythroblasts (red blood cells), and megakaryoblast (platelets). Children with Down's syndrome who have AML tend to have better cure rates, especially if the child is younger than age 4 years.
Acute Myelogenous Leukemia (AML)
What is Kawasaki disease?
Acute febrile syndrome causing vasculitis - the leading cacuse of CAD in children of an infectous etiology
What is intussusception
Acute prolapse (Telescoping) of one part of the intestine into another adjacent segement, causing mesenteric ischemia
what are the sensorimotor development stages of an infant?
Adaptation of reflexes to environment Simple problem-solving without trial and error
When does humor and formal thought begin?
Adolescent stage
What age is Erikson's theory of identity vs. role confusion referring to?
Adolescents
Developmental warning signs in adolescents
1. Change in school performance, friendship, sleeping, eating, 2. Personality change 3. Difficulty accepting failure, 4. Talk of suicide, 5. Withdrawl
What is tanner stage V in girls
Adult breast - areola recedes, nipple retracts
What is pubic hair tanner stage IV
Adult in character but not as voluminous
What is pubic hair tanner stage V
Adult pattern, thighs
What is tanner stage V in boys
Adult shape and appearance
Fine Motor skill at 3 y.o.?
1. Copies circle 2. Builds a tower
Developmental warning signs at age four:
1. Does not listen to story 2. Does not talk in sentences 3. Engages in head banging/rocking 4. Is not toilet trained 5. Does not draw human figure
Developmental warning signs at age two:
1. Does not make eye contact 2. Does not feed self with spoon 3. Does not squat spontaneously
Therapies to reduce breast cancer risk
1. EXERCISE (4+ hours weekly) 2. Hormone therapy with SERMS or aromatase inhibitors 3. PROPHYLACTIC MASTECTOMY 4. BREASTFEEDING 5. PREGNANCY
Management with PDD?
1. Early screening, detection 2. Refer for community resources, family support
What are the three subtypes of ADHD?
1. Inattentive 2. Hyperactive-impulsive 3. Combination of both (most common)
Disadvantages of nuva ring?
1. Increased discharge and vaginal infections 2. Depression 3. No STI protection
Disadvantages of implanon?
1. Informed consent=higher cost with risk/benefit counseling 2. Invasive, visible 3. Irregular menses
Developmental warning signs at age three:
1. Is not aware of external environment 2. Is not using 2-3 word sentances 3. Is not noticing cars, animals 4. Uses only baby talk 5. Does not imitate adult activities
What is venu valgum? What age is it normal?
1. Knock-knee 2. normal in preschool age kids
Number one cancer killer in Men and Women?
1. Lung 2. Colorectal
Developmental warning signs at age five:
1. Magical thinking is still dominent 2. Lack of impulse control
What should a lost tooth be put in for transport?
1. NS 2. Milk
What is Rett's disorder? When is it seen?
1. Neurodegenerative developmental regression following a period of normal functioning 2. Through the first five months of life
Developmental warning signs at age one:
1. No sound imitation 2. Not pulling to stand 3. Not indicating desire via pointing or gesturing
Management of PID?
1. Oflaxacin + levofloxacin with/without Metronidazole 2. Cefoxitin + probenicid + doxycycline with or without Metro 3. Ceftriaxone + doxycycline + with or without Metronidazole
To diagnose ADHD
1. Onset <7 y.o. 2. Symptoms for > 6 months 3. Symptoms interfere with functioning in two areas: a. Home, School or Play
What is diagnostic criteria for a Pervasive developmental disorder (PDD) diagnosis?
1. Onset before age 3 2. Six behaviors from 3 categories: (motor language, communication or social)
What is Stage 4 Tanner boys?
1. Penis enlarges in *breadth 2. Development of glans 3. Rugae appear
contagious period with the flu
Adults are infectious 1 day before onset of symptoms and continue to remain infectious for 5 days after onset of illness Children are infectious for 10 or more days after the onset of symptoms and can shed the virus before the onset of symptoms. People who are immunocompromised can remain infectious for up to three weeks
What are the advantages of breastfeeding?
1. Perfect food for humans, can't be duplicated 2. Decreased illness in infants 3. Maternal antibodies are transferred to infants 4. Decreased GI problems such as GERD 5. Breast feeding during painful procedures provides analgesia 6. The longer the mother breastfeeds, the less chance of the child to be overweight independent of education and socioeconomic status
Exam findings with PID?
1. Positive CMT 2. Adnexal tenderness, 3. Abdominal tenderness 4. Fever >38 degrees
When can BMI be calculated?
After 2 years old.
When are developmental screening tests such as the Denver ll used?
After 6 mo-6 years
Management of primary dysmenorrhea?
1. Prostaglandin sythetase inhibitors: Ibuprofen, Naproxen, Indomethacin 2. OCP 3. Exercise 4. High fiber diet, decrease sugar, caffeine, and salt
Primary Series of Vaccination: Missing or Not Done
After seventh birthday (never been vaccinated): ■ Td (three doses primary, then every 10 years) ■ IPV (three doses) ■ Hepatitis B (three doses) ■ MMR (two doses) ■ Varicella (two doses) if no history of chickenpox ■ HPV (three doses; give if younger than age 26 years)
Bartholin Gland Cyst and Abscesses
Age 20-29 Usually mixed flora: Gonorrhea, Chlamydia, E.coli Very painful vulvar mass at 4 and 8 o'clock of introitus Tx: sitz baths, I/D, Word catheter placement Rocephin + clindamycin x 7 Refer to surgeon for excision to r/o carcinoma if >40 If rapidly growing (over 24 hr), likely MRSA
When are nightmares common
Age 3
Freud classified this age group under the "latency stage." The major task for this age group is to succeed in school and to interact with their peer group. May have a "best" friend(s).
Age 7 to 11 Years (Middle Childhood)
What is considered precocious puberty
Age 8 in girls and 9 in boys
When should scoliosis screening begin
Age 9
WHO Precautions for Use of Combined Oral Contraceptive pills - Category 2, advantages outweigh risk:
Age >= 40 Severe headache with oral contraceptive use DM type 1 or type 2 without vascular disease Major surgery without immobilization Sickle cell disease Hypertension (140/100-159/109 mm Hg) Undiagnosed breast mass Cervical cancer Age >50 Nonadherence factors Family history lipid disorders Family history premature MI BMI >= 30 Lactation >= 6 months
WHO Precautions for Use of Combined Oral Contraceptive pills - Category 1, no restriction:
Age menarche to 40 Postpartum >21 days without breastfeeding Smoking age <35 Post therapeutic or spontaneous abortion History gestational DM Varicose veins Mild headache PID, STI history HIV Benign breast disease Family history breast, cervical, ovarian cancer Cervical octropion Uterine fibroids Past history ectopic pregnancy Obesity Thyroid disease Depression Minor surgery without immobilization
Immunizations Tips
Age of 12 to 15 months, the following vaccines are usually completed (for most infants): ■ Hepatitis B vaccination (three doses). ■ Hib (hemophilus type B; four doses). ■ PCV (pneumococcal vaccine; four doses). ■ RV (rotavirus; three doses). ■ DTaP, MMR, varicella, IPV (inactivated polio vaccine).
Peak incidence of bulimia, and anorexia?
Ages 14-18
Treatment option for patients with comdyloma acuminatum is
Aldara (imiquimod)
Diagnostics with PID?
1. STD testing 2. ESR and CRP 3. Ultraound to R/O ovarian cyst
What are hallmarks of Asperger's (4)
1. Social impairment 2. Repetitive patterns 3. OCD 4. *without language delay
Fine Motor skill at 2 y.o.?
1. Stacking tower of 8 blocks 2. Turns doorknob
What diagnostics / clinical presentation gives a definitive dx of osteoporosis?
1. T-score (obtained from DXA) ≤ -2.5 2. Clinical fragility fracture (regardless of bone density) 3. Incidentally discovered vertebral compression frx
Instructions for taking oral bisphosphonates?
1. Take with full glass of water 2. NPO for 30-60 minutes 3. Sit upright for 30-60 minutes
Who should get progestin only pills?
1. Those who are breastfeeding, 2. History of migraine 3. Contraindications of estrogen
Management of stress incontinence?
1. Timed voids to prevent full bladder 2. Pessary 3. Surgery 4. Avoid caffeine
Management of urge incontinence?
1. Urge suppression/distraction 2. Kegels 3. Medication 4. Weight loss 5. Avoid caffeine
Non-pharmacological interventions for osteoporosis:
1. Weight bearing exercise (30 min daily) 2. Stop smoking 3. Limit etoh (1 drink / day) 4. Adequate daily intake of Calcium (1200 mg daily) & Vit D (800 -1000 IU) for women over 50 yrs (max daily vit D = 4000 units) **Supplementation carries risk of kidney stones & CVD, but still recommended for patients w/est osteoporosis & high frax risk *** 5. Fall risk reduction a. Physical therapy (improve balance & gait) b. Occupational therapy for home safety evaluation c. Assistive mobility devices (cane, walker, etc) d. Modify home environment (good lighting, remove cords & throw rugs, etc)
Management of a suspected or confirmed vertebral compression fractures:
1. X-ray (esp if pain has lasted 4 - 6 weeks) 2. Order physical therapy 3. Pain management 4. Back brace for stabilization 5. Also consider malignancy or metastasis
How do u screen / diagnose osteoporosis?
1. bone mineral density (BMD) testing: using dual-energy X-ray absorptiometry (DXA) of the hip & lumbar spine. PROVIDES T SCORES USED FOR DX 2. FRAX assessment tool: used to determine 10 year risk of fracture using age, BMI, history of prior fracture, tobacco use and alcohol use. Assess risk for African-American, Asian and Hispanic women, who typically have a lower risk than Caucasians.
These two tests are standard of care at 18 to 20 weeks for all pregnant patients?
1. fetal ultrasound of anatomy 2. One hour glucose tolerance test at 20 weeks IF + family history of diabetes or weight >200 lbs. ((GTT at 28 weeks for all pregnant patients.))
Common symptoms of menopause: Average age of menopause in North American women:
1. hot flashes (vasomotor symptoms) 2. bone density loss 3. dyspareunia 4. DEPRESSION 5. fat redistribution 6. vaginal atrophy avg menopause age: 51 yrs
What are the USPSTF screening guidelines for osteoporosis?
1. osteoporosis screening for all women 65 and older 2. screening for younger women whose 10 year risk of bone fracture is equal to that of a 65 year old Caucasian woman (=9.3% or higher)
Medications that can contribute to osteoporosis:
1. steroids 2. Methotrexate 3. Anticonvulsants 4. PPIs 5. SSRIs 6. Depo provera 7. Thiazolidinediones
Labs to order for osteoporosis:
1. vit D 2. Calcium 3. Phosphate 4. Creatinine 5. CBC 6. liver fnx tests
According to the U.S. Medical Eligibility Criteria for Contraception Use, who is a category 1 or 2 COC candidate? yes or no 1. ___ a 22 year old woman who smokes one pack per day 2. ___ a 29 year old woman with PID 3. ___a 45 year old woman with tension like headache 4. ___ a 32 year old woman breastfeeding a 6 month old infant 5. ___ a 28 year old woman with type 1 diabetes
1. yes 2. yes 3. yes 4. yes 5. yes, in the absence of advanced vascular disease
When are children ready for toilet training
1.5-2.5 years
How much empty space should be left at the tip of the condom?
1/2 inch
The typical HT regimen contains ____ or less the estrogen in a combined oral contraceptive
1/4
What is the dose range of ibuprofen
10 mg/kg every 6 hours
DM: Screening starts at...
10 or at the onset of puberty and done q2yrs until adulthood.
At which of the following ages in a young child's life is parental anticipatory guidance about temper tantrums most helpful?
10 to 12 months
How much weight is loss by infants initially?
10%
What is initial weight loss in infant?
10%
When does baby mark on paper
10-12 months
When can fetal heart tones be heard?
10-12 weeks
When can fetal heart tones first be detected?
10-12 weeks
The incubation period for measles caused by the rubeola virus is
10-14 days
What is the dose range of acetaminophen
10-15 mg/kg every 4-6 hours
Caloric requirements for ages seven months - 1 year
100 kcal/kg/day
Caloric requirements for ages two to 10 years
100-70 kcal/kg/day
fht heard by
10wks
When is Jean Piaget's formal operational thought stage?
11 - 15 years
When does baby stand alone
11-12 months
When is Tdap given?
11-12 years
When is meningococcal vaccine given
11-12 years and a booster at 16
When is HPV given
11-12 years, second dose given 1 month after first dose, then third dose is given 6 months after the initial dose
When does baby stand alone/walk
11-14 mo.
What age are kids in Piaget's formal operational thinking?
11-15 years
What are calcium recommendations by age?
11-24=1200-1500 mg/day 25-49=1000mg/day 50-64=1500mg/day *(NOT taking ERT)* 50-64=10>65 yo. 1000mg/day *(taking ERT)* >65 =1500 mg/day
Menopause diagnosed after ___ months of amenorrhea 6 8 12 18
12
How long does the sponge provide protection?
12 hours
okay to drink cows milk
12 mo
At what age can a baby usually say 2- 3 words with meaning ?
12 months
At what age is it appropriate to recommend dietary changes to parents if overweight or obesity is a concern
12 months
Varicella (1 dose)
12 months after 13 y/o needs 2 doses
At what age should children first be screened for lead toxicity
12 months old
MMR (2 doses)
12 months, 4-6 years
Tamika has an appointment for a well baby checkup. The clinician knows that she will be due for her measles mumps and rubella immunization at age
12 months.
1st trimester
12 weeks amenorrhea, n/v, fatigue, breast tenderness, urinary frequency
At which age should a child be expected to remember a string of 6 numbers and repeat them backward?
12 years
Average age of menarche
12 years (normal range 10-16yr)
Condom failure rate
12% (1 in 8-9!)
WCC schedule for toddlers
12, 15, 18, 24, 30, 36
What is the schedule of well visits in toddlers?
12, 15, 18, 24, 30, and 36 months
When does baby walk
12-14 months
Caloric requirements for ages birth - 6 months
120 kcal/kg/day
Caloric requirements in 0-6mo ?
120 kcal/kg/day
2nd Trimester
13-27 weeks fetal movement, abdominal discomfort, changes in skin, syncopal episodes
What is the usual regimen for PID treatment in terms of days of treatment?
14 days
How much weight gain should take place during 3-6 months of age?
15 to 20 g/day
When should utensils be encouraged at meals?
15-17 mo.
When do you introduce a spoon to a child
15-17 months
When does baby point to body parts?
15-18 mo.
When does baby point to body parts
15-18 months
When is amniocentesis indicated if positive family history of chromosomal abnormalities or advanced maternal age?
15-20 weeks IUP
What is the age limit to get emergency contraception OTC?
15yo+
What HPV types are most often associated with cervical cancer?
16 and 18
Heather is scheduled for a well-child visit. Her mother asked how much milk should she be drinking now? The clinician states that the recommendation for milk intake after 12 months of age is
16 ounces per day
The "quad screen" should be obtained at about how many weeks of pregnancy?
16 to 20
When is the quad screen indicated with IUP?
16-20 weeks
When does baby stack 3 blocks
17-18 months
Edwards syndrome is the clinical manifestation of trisomy
18
brush teeth
18 mo
potty train
18 mo
time out
18 mo (1 min per year of life)
When does baby stack three blocks?
18 mo.
At which goes would a child likely start to imitate housework?
18 months
At which of the following ages in a young child life is parental anticipatory guidance about toilet training readiness most helpful?
18 months
At which of the following ages in a young child's life is parental anticipatory guidance about using "time out" as a discipline method most helpful?
18 to 24 months
Notable fetal movement is typically observed between ___ to ___ weeks IUP?
18-20
Fetal movement by
18-20wks
When does baby have 2-word sentences
18-22 months
Universal infant vaccination against HBV was recommend in what year
1991
Routine adolescent vaccination against HBV was recommended in what year?
1996
How prevalent is Marfan's
1:20,000 births
What is the occurrence rate of congenital hypothyroidism
1:3,600-5,000
How prevalent is down syndrome
1:660 births
What is a woman's lifetime risk of breast cancer?
1:8 Unless a 1st degree relative has had breast cancer, increases by 2-4x
What is normal lymph node enlargement in toddler/preschooler?
1cm inguinal/cervial
How much should the fundus grow per week?
1cm/wk
How soon can you take a pregnancy test after unprotected sex?
1st day of missed period OR 21 days after u had the unprotected sex
How to rule out pregnancy
1st: urine hCG If negative, must be ruled out with serum hCG May do transvag US if >6wks since LMP
loss of mucus plug
1wk before labor
Hep A is a series of how many vaccines
2
Measles, mumps, and rubella (MMR) is a series of how many vaccines
2
Meningococcal vaccine is a series of how many vaccines
2
Varicella is a series of how many vaccines
2
■ Speech of a______ year-old is understood mostly by family member.
2
How long after breast buds is menarche expected?
2 Years
What Age? Language ■ Speaks in two- to three-word sentences (intelligible mostly by family). ■ Understands simple commands. ■ Knows first name. Fine Motor ■ Stacks six cubes. ■ Can copy straight line. Gross Motor ■ Goes up stairs using same foot. ■ Runs, jumps, and climbs. ■ Very active and energetic. Behaviors ■ Temper tantrums are common at this age. ■ Easily frustrated and says "no" often. Oppositional behaviors. ■ May have a favorite stuffed toy (transitional object). ■ Toilet training is now in process. ■ Report loss of speech, social skills, or previously learned skills; flapping hands. Avoids social interaction (rule out autism).
2 Years Old
milestones with journal
2 mo
When is vitamin D supplementation needed? How much?
2 months through adolescence, 400 IUs per day
IPV (Polio) 3 doses
2 months, 4 months, 4-6 years
TDap (5 doses)
2 months, 4 months, 6 months, 15 months, 4-6 years
How long after contact do clinical manifestations of syphilis typically occur?
2 to 4 weeks
Recommended frequency of prenatal visits in weeks 28 to 32 of pregnancy is every:
2 weeks
roles, feed/sleep schedule
2 weeks
Influenza vaccine - time till effective
2 weeks to produce antibodies to vaccination Do not give before 6 months because it will not be effective due to immature immune system.
According to Bright Futures Guidelines the schedule for well child checks for an infant is
2 weeks, 2 months 4 months 6 months 9 months (the only time they don't get a vaccine) 12 months
What is the schedule for well visits during infancy
2 weeks, 2 months, 4 months, 6 mmonths, 9 months, 12 months
Sally and June report the news of their upcoming international adoption. The clinician should discuss the babies need for a follow-up exam within how long after arrival in the United States?
2 weeks.
When does baby use 2-word sentences?
2 words at (around) 22 mo.
When does baby stack 6-7 blocks?
2 y.o.
When is daytime control in toilet training achieved on average?
2 y.o.
How long do we measure head circumference for
2 years
What Age? Walks. Runs. Climbs stairs using hand rails. Speech mostly understood by family. Copies a line. Abnormal: Unable to speak meaningful 2-word "sentences." Does not understand simple commands. Loss of speech, social skills, previously learned behaviors. Does not say words by 16 months (autism).
2 years
When does birth weight quadruple?
2 years of age
When does baby jump?
2 years old
When does baby walk up and down stairs?
2 years old
When should hematocrit be done in toddlers?
2 years or once between 1-5 years
When is a Hematocrit checked
2 yo (once between 1 and 5 years)
When does baby have a *vocabulary* of 30-50 words?
2 yo.
When is cholesterol screening done?
2 yo.
When is lead screening done?
2 yo.
cough and malaise from the flu can last for how long?
2+ weeks
PCV (pneumococcal conjugate vac.) 3 doses
2, 4, 6 months do not give after 7 years old
Hib (3 doses)
2, 4, 6 months - do not give any after 7
What is the average height gain in a school age child?
2-3 inches/year
When does baby grasp and shake a rattle
2-3 months
When does baby have good head control?
2-3 months
When does baby smile, coo
2-3 months
When does good head control occur
2-3 months
When does the posterior fontanel close
2-3 months
When is Jean Piaget's preoperational/preconceptual stage?
2-4 years
When is Piaget's pre-operational and pre-conceptual stage?
2-4 years
When is the pneumococcal series given?
2-4-6 months and 1 booster
When is the polio vaccine given?
2-4-6 months and 6 years
When is the Hib series given?
2-4-6 months and booster at 12 months
When are night terrors common
2-6 y.o.
At what age should kids be able to 1. Up and down steps 2. Kicks ball 3. Runs
2.
How much height do children 3 years old - school age gain annually?
2.5 inches
How much height do school agers gain annually, how much weight
2.5 inches, 5-7 pounds
Preeclampsia is noted after what week of pregnancy?
20
When to do triple or quad screen for Down's
20 weeks
When is cholesterol screening done initially?
20 y.o
Approximately what percentage of all clinically recognized pregnancies end in spontaneous abortion
20%
After what amount of change in weight must a woman get her diaphragm or cap resized?
20% or 10-20lbs (contraindicated first 6 weeks postpartum)
When is clinical breast exam recommended?
20-39 yo. USPSTF: Not recommended
Visual acuity in school age child?
20/20
What should visual acuity be by 5 years
20/30
What is visual acuity at age 5 y.o.?
20/30 (near-sighted)
Leopold maneuvers posible at
20wks
fundus palpable at umbilicus at
20wks
When does baby have a 30 to 50 word vocabulary
22-24 months
When does baby stack 6-7 blocks
22-24 months
When does baby walk up and down stairs
22-24 months
When does the sponge NEED to be taken out?
24 hours--increase risk of TSS after 24 hours
personality dev
24 mo
Viability and limit to elective abortion
24 weeks
When does baby jump
24-28 months
When is blood glucose tested in low-risk mothers?
24-28 weeks
Infants who have been infected perinatally with HBV have an estimate ___ % lifetime chance of developing hepatocellular carcinoma or cirrhosis
25 %
What percentage of sexually active adults has serological evidence of human herpesvirus 2 (HHV-2) herpes simplex type 2?
25%
Recommended weight gain during pregnancy for woman with a desirable or healthy BMI is:
25-35 lbs
When does an unsensitize mother receive RhoGAM?
28 weeks
Rhogam at
28 wks
3rd Trimester
28-40wks abdominal growth, braxton hicks, urinary frequency, increased respiratory effort
1hr GTT at
28wks
When does baby smile and coo?
2mo.
Hepatitis B vaccine is a series of how many vaccines
3
Human Papillomavirus vaccine (HPV) is a series of how many vaccines
3
Rotavirus is a series of how many vaccines
3
■ Speech of a _______ -year-old can be understood by strangers.
3
■ _________old can copy a circle.
3
What Age? Fine Motor ■ Copies a circle (but not a cross). ■ Can throw a ball overhead. ■ Can stack 9 cubes. Gross Motor ■ Pedals a tricycle ■ Knows 3 numbers and 3 colors. ■ Walks up (ascends) stairs with alternating feet Language ■ Speaks in complete sentences using three to fi ve words. ■ Speech is understood by most strangers. ■ Knows full name, age, sexual identity. ■ Magical thinking is prominent at this age (between ages 3 and 5 years). May have an imaginary friend. A girl may think that she is a fairy with special powers. Behaviors ■ Freud classified this age as the "Oedipal stage," (phallic stage). The child expresses the desire to marry the parent of the opposite sex. Occurs between the ages of 3 and 5 years (preschool). ■ Plays with other children, (group play) but does not like to share toys or to take turns. ■ Imagination is becoming more active (pretends that a broom is a "horse").
3 Years Old
HPV Vaccine dosing
3 doses 0 month, 1-2 months after first dose, 6 months after 1st dose
After Varicella, no pregnancy for
3 months
Expect breakthrough bleeding if COCs are used for > ____ continuously?
3 months
At which age are testes fully descended and can Gynecomastia/galactorrhea can be noted up to
3 months of age
What pneumococcal vaccine is a series of how many vaccines?
3 primary and 1 booster
The Diptheria/Tetanus/Pertussis vaccine (DTaP) is a series of how many vaccines?
3 primary and 2 boosters
The Hib vaccine is a series of how many vaccines?
3 primary and one booster
What percentage of children have an episode of pneumonia before the age of five
3 to 4%
When does pyloric stenosis typically occur
3 weeks to 4 months
According to AAP what is earliest age that visual acuity screening in primary care practice should be included in the overall well child assessment?
3 years
Children begin to develop real friendships at the age of
3 years
How long does implanon last?
3 years
What Age? Speaks 3-4 word sentences; understood by strangers. Rides tricyle. Knows 3 colors/3 numbers/3 body parts. Group play. Knows other gender. Abnormal: Speech hard to understand. Unable to understand simple commands.
3 years
Molly has an appointment to see you for her annual well child physical the client clinician knows the blood pressure screening is recommended at every preventative healthcare visit beginning at age
3 years old.
nightmares normal
3 yo
When does assessment of BP start?
3 yo.
When does baby reach?
3-4 mo.
When does baby reach for objects
3-4 months
A woman who has used emergency contraception pills should be advised that if she does not have a normal menstrual period within ___ weeks, a pregnancy test should be obtained.
3-4 weeks
lightening happens
3-4 wks before labor
When should baby's first visit be if discharged from the hospital prior to 48 hours
3-5 days
At what age should kids be able to 1. Hops on one foot 2. Tricycle (3 wheels)
3.
How much weight gain should take place during the first 3 months?
30 g/day (1 oz/day)
Caloric requirement of Adults?
30 kcal/kg/day
When to do a Group B beta-hemolytic strep genital culture?
34-36 weeks
What Age? Smiles. Able to coo. Good eye contact. Can recognize parents. Abnormal: Inability to hold head up. Avoids eye contact. Floppy.
3rd month
Anywhere from 28 to 40 weeks IUP is considered?
3rd trimester
Polio vaccine is a series of how many vaccines
4
Fine Motor ■ Can copy a cross. ■ Draws a person with two parts. Gross Motor ■ Rides a bicycle. Hops on one foot. ■ Dresses with little assistance. Other ■ According to Piaget, children between 1 and 4 years are at the preoperational stage. ■ Child is ready to learn the alphabet, spelling/reading short words, and basic math concepts.
4 Years Old (Preschool)
introduce liquid foods
4 mo - rice cereal, veg, fruit
When is head control achieved by?
4 months
When should baby have head control
4 months
At which of the following ages in an infants life is parental anticipatory guidance about teething most helpful?
4 to 6 months
After MMR, no pregnancy for
4 weeks
At what age can children use scissors successfully and fasten and unfasten simple buttons?
4 years
What Age? Draw a cross. Draws person with 3 parts. Abnormal: Unable to speak in full sentences. Inability to skip, run, hop. Cannot put on clothes without help. Unable to play with other kids.
4 years
When are phrases and analogies seen during language development?
4 years old
When does baby laugh?
4-5 mo.
When does baby laugh
4-5 months
What age are kids in Piaget's Intuitive/preoperational stage
4-7 years
When is Jean Piaget's preoperationaol/intuitive stage?
4-7 years
At what age should kids be able to 1. Draws a person with FOUR-six parts 2. Tower of ten blocks
4.
At what age should kids be able to 1. Go up stairs with alternating feet 2. Bicycle with training wheels (4 wheels)
4.
What age to begin Mammography? What age to end?
40 y.o. USPSTF: 50 y.o. and every two years until 74
Health care providers have _% immunization rate against influenza in US?
40%
What percentage of fever occur in infants less than 4 weeks of age?
40%...and 40% of those fevers are viral
Before what age would menopause be considered "premature"?
40yo
Caloric requirements for adolescents
45 kcal/kg/day
Caloric requirements of Adolescent?
45 kcal/kg/day
Where is the PMI in toddler/preschooler?
4th ICS,
What Age? ■ Copies a square. ■ Can partially dress self. ■ Can identify and draw 4 body parts. Good balance with skipping, hopping.
5 Years Old
Gross Motor ■ Can ride a bicycle (use bike helmet). ■ Likes to help parent with certain household chores. Child at this age likes to help adults. Other According to Piaget, this age group is in concrete operations stage (early abstract thinking starts at about age of 11 years).
5 Years Old (Kindergarten)
When does birth weight double?
5 months of age
At what age is Hib no longer indicated?
5 years
When should IUD be placed when being used for Emergency contraception?
5-6 days after intercourse
When does baby make hand-to-hand transfer?`
5-6 mo.
When does baby babble
5-6 months
When does baby do hand-to-hand transfer
5-6 months
When does baby roll back to front
5-6 months
How much weight do school age children gain annually?
5-7 pounds
What is the approximate annual weight gain of a school age child?
5-7 pounds
What is the average weight gain in the school age child?
5-7lbs per year
At what age should a child be able to 1. Copies a square 2. Copies shapes 3. Prints letters 4. Ties shoe
5.
When should kids be able to 1. Skips 2. Jump rope 3. Plays ball
5.
The classic clinical triad of ectopic pregnancy is found in no more than what percentage of women presenting with this condition?
50%
What is the average age at which menopause occurs? 45-50 50-55 50-51 40-41
50-51
When should you start doing rectovaginal exams and stool occult blood on women?
50yo
What is the average age of menopause?
51 years (45-55)
How is the rotavirus vaccine series spread out?
6 - 32 weeks at 4 week intervals
Which HPV types are most likely to cause condyloma acuminatum?
6 and 11
How far before and after ovulation can conception occur?
6 days before, 1 day after
How long does diaphragm get left in the vagina after intercourse?
6 hours
When does the sponge get inserted prior to intercourse? Left in place afterward?
6 hours: 6 hours
When does baby babble?
6 mo
teething
6 mo
When do primary teeth begin to develop? When do permanent teeth begin to develop?
6 mo 6 yrs
introduce solid foods
6 mo - beans, eggs, yogurt, meat
When should fluoride be added to diet
6 mo of age--check with health dept for levels
When does baby roll from front to back?
6 mo.
At which of the following ages should screening begin for a child who has significant risk of lead poisoning?
6 months
How long should breastfeeding be done exclusively?
6 months
When does stranger fear occur?
6 months
What is the time frame when primary tooth eruption occurs?
6 months - 2 years
When should baby have no lag when pulled sositting
6 months - lag may be first sign of palsy
When is iron supplementation needed?
6 months of age (we start to introduce solid food), 1 mg/kg/day, for breastfed infants
Can ride a bicycle at the age of
6 to 7 years.
Postpartum visit occurs at
6 weeks postpartum
At what age does a child usually develop the ability to mentally reverse actions that have been completed?
6 years
Most children display a clear tendency for right or left handedness by what age?
6 years
What is the time frame when permanent teeth erupt?
6 years - 13 years
exercise/PE
6-11 yo
separation from parents with safety teaching (stranger danger, good touch bad touch)
6-11 yo
When should hematocrit be checked
6-12 months
What Age? ■ Copies a triangle (age 6). Copies a diamond (age 7). ■ Ties shoes. ■ Rides a bicycle.
6-7 Years Old
When does baby have a raking grasp
6-7 months
Kawasaki disease is the leading cause of acquired heart disease in children in the developed world. The clinician should be aware that the minimum length of treat with low dose aspirin is
6-8 weeks.
Approximately what percentage of spontaneous abortions result from chromosomal defects?
60%
What Age? Sits up without support. Rolls front to back. Says "baba/dada." Abnormal: Lack of babbling. Inability to turn head past midline (180 degrees).
6th month
When does baby sit alone?
7 mo
When does baby sit alone
7 months
At what age is DTaP no longer indicated?
7 years of age
When is the period of Piaget's concrete thinking?
7-11 (School age)
When is Jean Piaget's concrete thinking stage?
7-11 years
When is the infant's weight re-gained?
7-14 days
Infants born at term, are expected to sit well without support by what age
7-8 months
When does baby have a finger grasp
7-9 months
Who is likely to be a mouth breather?
Allergic rhinitis
The influenza is what % effective in preventing or reducing the severity of influenza?
70%-80%
When does separation anxiety occur
8 months
In healthy children the scone and third doses of of the HBV vaccine should be separated by at least how much time?
8 weeks
When is H/H done in school years?
8 years old
Recommended amount of sleep per night in school age child?
8-10
When does baby do pincer grasp?
8-10 mo.
When does baby have a pincer grasp
8-10 months
How much should infants sleep
8-12 hours per night, two to three naps daily
What is the average hours of sleep a child has per night between the ages of 2 months to 1 year?
8-12 hours with 2-3 naps daily
When does baby say Mama-Dada?
8-9 mo.
When does baby wave "bye-bye"
8-9 mo.
Sue takes her young son Michael to day care every day. He has begun to cry loudly and try to cling to her when she leaves. Michael is likely at what age?
8-9 months
When does baby say mama-dada
8-9 months
When does baby wave bye-bye
8-9 months
When does object permanence develop?
8-9 months
balance diet (all intro done)
9 mo
choking
9 mo
■ Rolls both directions and plays peek-a-boo and pat-a-cake by
9 months.
When does scholiosis screening start?
9 y.o.
At what age should a normally developing child be able to use a pincer grasp and pick up small cereal pieces, raisins, and finger foods?
9-10 months
When does baby pull to a stand
9-10 months
When does baby understand no
9-10 months
What is the vocabulary of a 3 year old
900 words
Approximately what percentage of fetuses are in vertex position by the 36th week of pregnancy?
95%
What percentage of anogenital and cervical cancers can be attributed to HPV infection?
95% or greater
What Age? Pincer grasp (fine motor). Plays "pat a cake" peek-a-boo. Cruises. Rolls both directions. Says "bye bye". Abnormal: Infantile refl exes strong. Persistence of primitive reflexes (startle, fencing, etc.). Head lag.
9th month
What is the weight constraint for the patch?
<180 lbs
Recommended amount of television per day in school age child?
<2 hours
Medical abortions are indicated over surgical abortions up until what time?
<49 days (mifeprex, prostaglandin)
Too much wt. gain in pregnancy
> 2lb/wk, > 6lb in 1 mo
What are T score results?
>-1.0 SD=Normal -1.0-2.5=Osteopenia -2.5=Osteoporosis
Language development (How many words by age 5 y.o.)? How many Colors?
>2000 words 4 colors
Contraindications with nuva ring?
>35 y.o Smoking HTN (uncontrolled- or controlled and smoking) History of thromboembolic events
When can ibuprofen be used?
>6 months of age
When are bone density scans recommended?
>65 y.o. Family history Smoking, Excessive excersise, alcohol, corticosteroid use Hyperthyroidism Slender Postmenopausal women with fractures Women on HRT for extended amount of time
When to stop pap screening?
>65 y.o. with no history of abnormal pap or 20 years after treatment
More than how many days menses is considered abnormal?
>7 days, mean duration is 4 days
When is a school age child considered obese?
>95 percentile in weight.
10. Which of the following conditions is least associated with causing spontaeous abortions in the second trimester of pregnancy? A. Chromosomal abnormalities B. Cervical incompetence C. Infection D. Uterine abnormalities.
A
What is Allis's sign test for? What is Galeazzi sign test for?
Allis Sign examines unequal leg length and is also known as Galeazzi sign which observes for Unequal knee height as an indication for congenital hip dislocation or femoral shortening
23. Which of the following is NOT typically performed either during the first trimester of pregnancy or upon a new visit? A. Quantitative human chorionic gonadotropin blood titer B. Sexually transmitted disease screening C. Hepatitis B surface antigen screening D. Dating ultrasound
A
25. Which of the following poses the greatest risk of ectopic pregnancy among the general population? A. History of infertility B. Previous ectopic pregnancy C. Use of an intrauterine device D. Tubal surgery
A
3. A patient who is in her 28th week of pregnancy arrives to your clinic with concerns of vaginal bleeding. Upon questioning, she tells you that the bleeding is not accompanied with any pain and that the bleeding occurred after vaginal intercourse. Based on these signs, you should screen the patient for the following conditions? A. Placenta previa B. Premature labor C. Spontaneous abortion D. Abruptio placentae
A
32. Vacuum curettage and dilation may usually be used to perform an induced or selective abortion until what week of pregnancy? A. Up to 12 weeks B. up to 14 weeks C. up to 20 weeks D. up to 22 weeks
A
6. Which of the following is more likely to cause a pregnancy loss in the second trimeter? A. A patient with uterus didelphys B. Implantation of the fertilized eff in the Fallopian tubes C. The fetus is missing a second X chromosome D. The placenta is located in the lower uterine segment
A
9. All of the following factors are associated with an increased incidence of placenta previa except: A. Chronic hypertension B. Previous uterine surgery C. Multiparity D. Malpresentation
A
Which of these language behaviors would be cause for concern at a primary care visit?
A 3 year old does not use 3-5 word sentences.
A good candidate for a progesterone only pill (POP) is:
A 32-year-old woman breastfeeding a 4-week-old infant
What is Ortolani's click
A click is heard or flet as hip dislocation is reduced
Osgood-Schlatter Disease
A common cause of knee pain in young athletes. Caused by overuse of the knee. Repetitive stress on the patellar tendon by the quadriceps muscle causes pain, tenderness, and swelling at the tendon's insertion site (the tibial tuberosity). Usually affects one knee, but can be bilateral. Most common during rapid growth spurts in teenage males who are physically active and/or play sports that stress the patellar tendon (i.e., basketball, soccer, running). Classic Case A 14-year-old male athlete undergoing a rapid growth spurt complains of a tender bony mass over the anterior tubercle of one knee. The pain is worsened by some activities (squatting, kneeling, jumping, and climbing up stairs). The knee pain improves with rest and avoidance of aggravating activity. Reports the presence of bony mass on the anterior tibial tubercle that is slightly tender. Almost all cases resolve spontaneously within a few weeks to months. Rule out avulsion fracture (tibial tubercle) if acute onset of pain posttrauma (order lateral x-ray of knee).
What does rheumatic fever typically follow
A group A strep infection of the upper respiratory tract
"Mature Minor Rule"
A mature minor is an unemancipated minor (from 15 to 17 years of age) with the mental capacity (and intelligence) to understand the consequences of a decision (such as refusing a surgical procedure or medical treatment). The mature minor has the right to refuse or to request treatment (even if the parents disagree with this decision). There are statutory and/or common laws at the state level. Each state has its own laws and statutes. Example A 17-year-old male who is scheduled for a procedure calls the NP and tells her that he does not want to have the procedure. After the NP speaks with the patient and listens to his rationale (the patient understands the consequences), she decides to call the hospital's patient liaison/advocate (or ombudsman) to speak with the patient first (instead of calling the parents first).
When treating a 3-year-old well child with community acquired pneumonia the NP realizes that the most likely cause of pathogen is
A respiratory virus
What is a VSD typically associated with?
A thrill
Byron is 36 months old. His mother asks you what toys he should have for him to lay with at home. Your suggestions to her could include
A tricycle and a Wiffle ball and bat.
Warning Signs of bad side effects of COCs
A- abdominal pain (severe) C- chest pain (severe), cough, SOB, sharp pain with inspiration H- headache (severe), neuro signs, esp if one sided E- eye (visual blurring or loss), speech problems S- severe leg pain
According to WHO guidelines, the only one of the following who is not a candidate for a copper-containing IUD is: A. 45-year-old with fibroids with uterine cavity distortion B. 33-year-old smokes 2 ppd C. 25-year-old with hypertension D. 33-year-old with low-grade squamous intraepithelial lesions noted on Pap test
A. 45-year-old with fibroids with uterine cavity distortion
Head Circumference
Also known as the occipitofrontal circumference (OFC). Use paper tape (cloth tapes stretch) and place above the ear. ■ Average head circumference at birth is 13.7 inches (35 cm). ■ Head circumference is measured at each wellness visit until the age of 36 months (3 years). ■ In newborns, chest is about 1 to 2 cm less in size than the head circumference. ■ Head circumference will increase by 12 cm during the fi rst 12 months. ■ Fastest rate of head growth is the during the fi rst 3 months of life (2 cm per month).
A 33-year-old woman works in small office with a man recently diagnosed with active pulmonary TB. Which of the following would be the best plan of care for this woman? A. She should receive TB chemoprophylaxis for TST is a 5 mm or more and induration B. Because of her age TB chemoprophylaxis is contraindicated even in the presence of a positive TST result C. If the TST result is positive the chest radiograph is normal no further evaluation or treatment is needed D. Further evaluation is needed only if the TST result is 15 mm or more and induration
A. She should receive TB chemoprophylaxis for TST is a 5 mm or more and induration Chemoprophylaxis with isoniazid (for 6-9 months depending on dosing regimen) and other agents (Rifampin) and considered for patients with latent TB (positive skin test, neg CXR, no suspicion of disease). Beware of liver toxicity.
Classic sx of ectopic pregnancy
Amennorhea, Abdominal Pain, Abnormal bleeding (usually dark tarry) Usually also has cervical motion tenderness May have shoulder pain as in cholecystitis May become shocky with signs of peritonitis
What you're following is the most appropriate antimicrobial for treatment of community acquired pneumonia in a 2-year-old who is clinically stable and able to be treated in the outpatient setting
Amoxicillin
Management for lower UTI in pregnancy? How long?
Amoxicillin, nitrofurantoin, cephalexin *10 days of treatment during pregnancy
Which of the following statements is true regarding infant car seats?
An infant car seat should be placed facing backward until the infant weighs 20 pounds.
In the treatment of asthma leukotriene modifiers should be used as
An inflammatory inhibitor
Freud's Toddler stage?
Anal (potty training)
What stage are toddlers in, according to Freud?
Anal stage
Category X drugs
Androgens, Warfarin, Diethylstilbestrol, Penicillamine, Isotretinoin, Live vaccines, "Statins", Methotrexate, Evista, RU-86, Depo- Lupron, Dutasteride, Finasteride, Misoprostol, Iodides, Thalidomide, Lithium
Development delay, lack of speech, seizures, walking and balance disorders, and a happy demeanor characterized by frequent smiling laughter, and excitability describes which of the following syndromes?
Angelman's syndrome
WCC schedule for pre-schoolers
Annually after 3 yo.
When are well visits during preschool age?
Annually at 3, 4, and 5 years
When do you need to re-screen newborns for newborn screening?
Any infants who appear symptomatic, if screening was done when newborn was less than 24 hours old
What is transposition of the great arteries?
Aorta and pulmonary arteries are switched, cyanotic defect.
What cardiac anomalies are associated with marfan's?
Aortic regurgitation, mitral valve prolapse
What is S2
Aortic/pulmonic (semilunar) valve closure
What are developmental warning signs in an infant?
Apparent visual delay Doesn't raise head when lying on stomach by 3 months No reaction to noise/voice Doesn't laugh Doesn't seek interpersonal contact Doesn't sit up
What is Stage 4 Tanner girls?
Areola and nipple project as secondary mound
What is tanner stage IV in girls
Areola and nipple project as secondary mound
When do boys have nocturnal emissions? Spermarche?
Around stage 3
Donna is breastfeeding her 3 month old infant exclusively. She expresses concern to you that the baby's growth seems to be slowing down and she wonders if she should supplement the diet with other foods. What would be your response?
As long as you are well nourished, the baby will get what she needs. Her growth pattern is normal for an exclusive breastfed baby.
PID
Ascending infection and inflammation most commonly from Chlamydia or Gonorrhea Most commonly age 16-25 Classic triad: lower abd pain, adenexal tenderness, cervical motion tenderness May also have fever, discharge, N/V, dysurea, dyspareunia Dx: STIs with wet prep and HIV, hCG, r/o ectopic Tx: Rocephin + doxycycline 100 PO x 14. May add Flagyl 500 bid x 14. May also use quinolones +/- Flagyl Treat all partners Complications: infertility, ectopic gestations, chronic pelvic pain
What syndrome can an IUD prevent?
Ashermans (adhesions)
Good interviewing (open-ended) questions for adolescent interview?
Ask what typical days is? What is the best part of your day? What is the worst part of your day?
Expected outcomes with he use of varicella vaccine include a reduction in the rate of all of the following EXCEPT
Aspirin sensitivity
Definition of pregnancy induced hypertension?
BP >140/90 or ( >30mmHg SBP, >15 DBP above and established baseline on at least two occasions, six hours apart)
What is the assessment of severe dehydration
BP is normal or decreased, pulse is decreased? cap refill is prolonged, skin turgor is decreased, fontanel is sunken, urine output is < 1 ml/kg/hr
What is the assessment of mild dehydration
BP normal, Pulse normal, cap refill normal, skin turgor normal, tontanel is normal, urine output is slightly decreased
What is the assessment of moderate dehydration
BP normal, pulse normal, cap refill normal, skin turgor decreased, fontanel slightly sunken, urine output < 1 ml/kg/hr
PIH
BP>140/90
Use of combined estrogen-progesterone HRT increases risk of what kind of cancer?
BREAST CANCER (when used for longer than 3-5 yrs. Breast CA risk goes back to baseline once HRT is stopped)
What is the most common vaginal infection?
BV
In an infant, when you flex the hips and knees at 90 degrees and attempt to slip the femur heads into the poster tip of the acetabulum you are testing for normal hip movement. This test is known as
Barlow's test
What is the 'gold standard' test to diagnose developmental delay in infants-toddlers to 42 mo. of age?
Bayley-lll
When is the onset of developmental delay in pervasive developmental disorders (PDD) such as Autism, Aspergers, and Rett's?
Before 3 y.o.
When should PPD testing be done in school agers
Before school entry at 4-6 years once, or annually if risk factors (low SES, residence in area where TB is prevalent, known exposure, immigrant status)
What characterizes the preoperational/intuitive stage?
Beginning of causation
When does menses occur? Which tanner stage?
Between 3 and 4, usually 4.
What blood work is done on an infant?
Bilirubin if indicated Hematocrit between 6, 9, 12 months unless otherwise indicated.
What is the primary pharmacological tx for osteoporosis? Important pt teachings for this medication? Contraindications?
Biphophonates FOSAMAX (alendronate) 10 mg daily OR 70 mg weekly BONIVA (ibandronate) ACTONEL (risedronate) 1. Take on an empty stomach with lots of water 2. Remain upright for 30-60 min after ingesting 3. Take first thing in the am 4. do NOT crush, split or chew. May cause esophagitis if lodged in the esophagus Contraindication: chronic kidney dx
Advantages of OCP?
Birth control, decreased cramps, decreased bleeding, decreased acne, Protects against ovarian/endometrial cncer, PID, ovarian cysts, fibroids
When is Jean Piaget's sensorimotor stage?
Birth to 2 years
When is Piaget's *Sensorimotor stage*? Characterized by trial and error learning.
Birth-2 years
Current treatment options for osteoporosis and preventing fractures in postmenopausal women
Bisphosphonates, SERMs (selective estrogen receptor modulators), calcium, vitamin D, calcitonin, monoclonal antibodies, hormonal medications, estrogen therapy (consider as second line therapy)
What is Metorrhagia?
Bleeding between cycles
Tay-Sachs Disease progression
Blindness, Deafness, seizures, vege state....death
What responses indicate newborn vision?
Blink reflex and pupil constriction (accommodation)
Laboratory findings and Kawasaki disease include all the following EXCEPT
Blood cultures positive for offending bacterial pathogen
Somatic S/S of PMS?
Body aches, breast tenderness, bloating, HA, food cravings,
School age
Booster seats (belt-positioning booster seats).
What are the X-ray findings in ToF
Boot-shaped heart, no cardiomegaly or pulmonary vascular markings
First Tooth (Primary Teeth)
Both the left and right teeth erupt bilaterally at the same time (symmetrical). Symptoms are drooling, chewing on objects, irritability, crying, and fever. ■ 6 to 10 months of age: Lower central incisors (lower front teeth). ■ 2½ years of age: Has complete set of primary teeth (20 teeth).
What is Genu varum?
Bow legged, normal in toddlerhood
What is genu varum
Bowed legs - normal variant in toddlerhood (drinking too much rum)
S/S of excess progesterone?
Breaset tenderness HTN Depression Fatigue Decreased libido Decreased duration of bleeding Increased appetite
Which cancers are linked with estrogen?
Breast Liver adenoblastoma d/t coagulation
What is tanner stage II in girls
Breast buds with areolar enlargement
What is Stage 2 Tanner girls?
Breast buds, with areolar enlargement
What are contraindications for using hormonal therapy in women?
Breast cancer, CAD, MI, Uterine cancer, thromboembolic events
What happens in Tanner stage 3 for girls?
Breast enlargement without separate nipple contour
What is tanner stage III in girls
Breast enlargement without separate nipple contour
How does breastfeeding decrease allergies
Breast milk contains anti-inflammatory agents to decrease atopy (a syndrome characterized by being "hyperallergic")
Common symptom of intrauterine pregnancy in the first trimester?
Breast tenderness (N&V)
S/S of fibrosystic breast disease?
Breast tenderness (cyclic), nodularity, breast discharge-occasionally-but is clear
What is fibrocystic breast dx? Signs and symptoms:
Breast tissue becomes engorged & TENDER d/t monthly menstrual cycle. Lumps increase & decrease in size / tenderness disappears once menstruation begins PHYS EXAM: tender, rubbery, mobile masses in BOTH BREASTS Pertinent negatives: NO SKIN CHANGES, NIPPLE CHANGES, DISCHARGE OR ENLARGED LYMPH NODES
What self exams should boys start in adolescent years?
Breast, testicular
What criteria should be met to determine that a woman does not need additional contraceptives while breastfeeding?
Breastfeeding with <15% supplemented <6mo postpartum amennorhea
What are the fine motor skills of a 2 year old
Builds a tower of 8 cubes, turns a doorknob
When is the first dental visit?
By 1 year of age
When should baby have first dental visit
By 1 year of age
When should lead screening be done
By 2 years
When should a woman have her first pap test?
By 21
How is adequate nutrition confirmed?
By weight gain -30 g/day (1oz/day) for 1st 3months -gain of 15-20 g/day during subsequent 3 months
11. You are examining a patient whose complaints include pelvic cramps and heavy vaginal bleeding that she says is "dark". She says she thought she was pregnant because she missed her period the month prior, and that this is the first time she has seen any bleeding in 8 weeks. When asked if she has any other pain, she says, "Come to think of it, my shoulder's been hurting since the cramps began." The exam indicates an adnexal mass. Considering that the patient is likely pregnant these findings most indicate which of these? A. Spontaneous abortion B. Preeclampsia C. Ectopic pregnancy D. Eclampsia
C
13. Considering that age is a risk factor for some pregnancy-related complications, a 16 year old and a 45 year old who are pregnant are both at risk of developing which complication due to their ages? A. Ectopic pregnancy B. Spontaneous abortion C. Premature labor D. Placentia previa
C
15. In cases of abruptio placentae, separation of the placenta from the uterine wall usually occurs at which point in pregnancy? A. First trimester B. First or second trimester C. Second or third trimester D. third trimester
C
17. A patient in the third trimester of pregnancy presents with a swollen face and complaints of nausea and headaches that she says originate at the back of her head. You note that the patient's skin is slightly yellow, which is most likely a sign of what pregnancy-related complication? A. Preeclampsia B. Eclampsia C. Hemolysis, elevated liver enzymes, and low platelets syndrome D. Pregnancy-induced hypertension
C
18. Which of the following tests is most useful in providing a specific diagnosis of ectopic pregnancy and ruling out other conditions? A. Clinical examination B. Serum quantitative human Chorionic gonadotropin C. Ultrasound D. Biophysical profile
C
21. Sandra, a patient who is 34 weeks pregnant, arrives at your clinic with complaints of bleeding. She does not report any pain. Given your concern regarding possible placenta previa, which of the following should NOT be performed at this time? A. Biophysical profile B. Vaginal rest C. Bimanual exam D. Hospitalization
C
26. Which major pregnancy-related complication is known to occur in no ore than 2% of the general population? A. Spontaneous abortion B. Pregnancy-induced hypertension C. Ectopic pregnancy D. Abruptio placentae
C
27. What two drugs are typically prescribed to induce an elective abortion withing the first 49 days of pregnancy? A. Mifepristone and B-methasone B. B-methasone and magnesium sulfate C. Prostaglandin and mifepristone D. Prostaglandin and B-methasone
C
30. Which of the following statements is not true regarding abruptio placenta? A. An abruption is most likely to occur in the second or third trimester B. The recurrence rate increases after it occurs more than once C. It is most often precipitatied by a previous uterin surgery D. Cocain, alcohol, and cigarette use contribute to the incidence of abruptio placentae
C
31. The first day of your pregnant patient's last normal menstrual period was on March 24. Using Naegele's rule, you estimate the date of confinement to occur on: A. December 18 B. December 24 C. December 31 D. January 1
C
35. Which of the following is least useful as an initial test for providing a dianosis of suspected placenta previa? A. Complete blood count B. Ultrasound C. Rh blood test D. Electronic fetal monitoring
C
37. Which of the following tests would usually be performed during a prenatal exam for a patient who is 28 weeks pregnant? A. Human chorionic gonadotropin test B. Ultrasound C. Glucose tolerance test D. Tripl/quad screening
C
7. At which point during pregnancy should women expect to see the most significant abdominal growth? A. 20 weeks B. 24 weeks C. 28 weeks D. 32 weeks
C
8. In following your patient who is 32 weeks pregnant who is admitted to the hospital for convulsions, you note that her medical record shows that she has preeclampsia. Which of the following drugs is most likely to be ordered in the plan of care to stabilize the patient at this time? A. B-methasone B. Diazepam C. Magnesium sulfate D. Phenytoin
C
Which of the following typically occurs in the first trimester but may also return in the third trimester? A. Abdominal growth B. Back pain C. Urinary frequency D. Breast tenderness
C
