NR 602 Week 4 Midterm Template{GRADED A}

1

1. Asthma – all levels of severity
What are s/s of asthma?
 Wheezing
Continuous/persistent cough
Long expir. phase
Diminished breath sounds
Signs of resp. distress
Tachypnea
Retractions
Nasal flaring
Accessory muscles Your text here 1
Apprehension
Drowsiness
Tachycardia
Cyanosis of lips
How is asthma dx'd?
 O2 sat
PFT:
-Spirometry
-FEV1: normal >75%, mild 60-75%, mod 50-59%, severe <49%.
-FVC: normal 80-120%, mild 70-79%, mod 50-69%, severe <50%.
What are mild asthma s/s?
 Wheezing @ end of expiration or no wheezing
No/min intercostal retraction along post. axil. line
Slight prolongation of exp. phase
Normal aeration in all lung fields
Can talk in sentences
What are moderate asthma s/s?
 Wheezing throughout expiration
Intercostal retractions
Prolonged expiratory phase
Decreased breath sounds at base
What are severe asthma s/s?
 Use of accessory muscles plus lower rib/suprasternal retractions
Nasal flaring
Inspir/expir. wheezing or no wheezing heard w/poor air exchange
Blepharitis
What is blepharitis?
Inflammation/infection of the lid margins (chronic problem)
What are the two types of blepharitis?
 Seborrheic (non-ulcerative)
 Ulcerative
What can cause seborrheic blepharitis?
Irritants (smoke, makeup, chemicals)
What are s/s of seborrheic blepharitis?
 Chronic inflammation of eyelid
 Erythema
 Greasy scaling of anterior eyelid
 Loss of eyelashes
 Seborrheic dermatitis of eyebrows/scalp
What usually causes ulcerative blepharitis?
 Infection w/staph or strep
What are s/s of ulcerative blepharitis?
 Itching

,2

 Tearing
 Recurrent styes
 Chalazia
 Photophobia
 Small ulceration at eyelid margin
 Broken/absent eyelashes
 Most frequent complaint: ongoing eye irritation, conjunctiva redness
What is the treatment for blepharitis?
 Clean w/baby shampoo 2-4 times/day
 Warm compresses
 Lid massage (right after warm massage)
How are infected eyelids with blepharitis treated?
 Antistaph abx: bacitracin, erythromycin 0.05% x1 wk and quinolone ointments
How is blepharitis infection resistant to topical abx treated?
 Tetracycline 250mg PO x4
 Doxy 100mg PO x2
Café au lait spot
What are cafe au lait spots?
 Smooth, regular borders of darkened patch
If a child has >5 cafe au lait spots that are >1.5cm, what should be suspected?
 Possible Von Recklinghausen's dz (90-100%)
LEOPARD syndrome:
-Lentigines
-Electrographic abnormalities
-Ocular hypertelorism
-Pulmonary stenosis
-Abnormalities of genitalia
-Retardation of growth
-Deafness
In kids <5yo with 5 or more cafe au lait spots of at least 0.5cm, what should be suspected?
 Neurofibromatosis
What is a rare but diagnostic sign of neurofibromatosis?
 Smaller 1-4cm diameter cafe au lait spots in axillae (axillary freckling or Crow's sign)
Celiac Disease
 Malabsorption syndromes can be caused by many different genetic, congenital, and acquired conditions
and usually lead to an initial decrease in weight followed by a deceleration in height velocity.
 Celiac disease is an immune-mediated systemic disorder triggered by dietary exposure to wheat gluten
and related proteins in barley and rye.
 It is characterized by the presence of a variable combination of gluten-dependent clinical manifestations,
celiac disease–specific antibodies, HLA-DQ2.5 or HLA-DQ8 haplotypes, and enteropathy.
 Celiac disease has a worldwide distribution with overall prevalence of 1%
Risk factors
o Demographic changes
o Increased gluten exposure
o infants born by cesarean section;
o The most typical presentation occurs between 6 months and 2 years old.
Parent reported gastroenteritis occurring at the time gluten was introduced into the child's diet does not appear to be
associated with celiac disease.
Clinical Findings
• Chronic or intermittent diarrhea, persistent or unexplained GI symptoms (e.g., nausea and vomiting),
sudden or unexpected weight loss, and prolonged fatigue.
• Delayed puberty can coexist with malabsorption, Impaired growth, FTT, unexplained iron deficiency
anemia, abdominal distention, bloating or cramping pain

,3

• May have no symptoms at all despite evidence of small bowel changes;
 maintain a high suspicion for celiac disease in children with metabolic bone disease (such as rickets or
osteomalacia), low-trauma fractures, or those with dental enamel defects.
 An estimated 85% to 90% of individuals with celiac disease are undiagnosed
• Pallor, fatigue, hair and dermatologic abnormalities, digital clubbing, dizziness, cheilosis, glossitis,
peripheral neuropathy (symptoms of vitamin deficiency seen with malabsorption), Skinfold thickness and
lean body mass
Diagnostic Studies
• See chronic diarrhea tests
Specific Tests for Celiac Disease
• Serologic testing should be done if there is clinical suspicion of celiac disease, the child has an associated
disorder, or there is a first-degree relative with celiac disease.
• Gluten should be eaten in more than one meal every day for 6 weeks prior to testing.
• Recommended serologic tests include IgA tissue transglutaminase antibody (tTGA) and IgA endomysial
antibody (EMA) because of their high sensitivity and specificity
• EMA is more expensive and less accurate in children younger than 2 years old
• Home blood testing is not recommended
• If serologic testing is positive, refer for endoscopy with biopsy for a definitive diagnosis, although
colonoscopy may not be necessary if the tTGA level is greater than 100 units/mL
• Careful follow-up of growth parameters, tTGA testing after 6 months of gluten-free diet (GFD), and then
yearly
• Bone density testing (bone problems may be first symptom of celiac disease).
Management
Celiac Disease
• A strict GFD for life is currently the only effective treatment for celiac disease.
• The standard for being gluten-free is a limit of 20 ppm of gluten
• Adding pure oats to a GFD can improve palatability and increase fiber and vitamin B intake without
causing a systemic or autoantibody response
Complications and Prognosis
• Growth failure is the primary complication of celiac disease.
• risk for fractures and osteoporosis (due to reduced bone mineral density), lymphoma, autoimmune
diseases (e.g., type 1 diabetes, thyroid disorders), primary biliary cirrhosis, and primary sclerosing
cholangitis.
• Sensory peripheral neuropathy may be related to gluten
• Celiac crisis consisting of abdominal distention, explosive watery diarrhea, dehydration with
hypoproteinemia, electrolyte imbalance, hypotensive shock, and lethargy, although rare, can be the first
indication of celiac disease.
Chalazions
What is a chalazion? Benign, chronic lipogranulomatous inflammation of the eyelid
What causes a chalazion? Blockage of the meibomian gland
What puts a person at risk for a chalazion?
 Hordeolum or any condition which may impede flow through the meibomian gland.
Mite species that reside in lash follicles.
What are physical exam findings for a chalazion?
 Painless
Does NOT involve lashes
Lid edema or palpable mass
Red or grey mass on inner aspect of lid margin
What is prevention for chalazion? Good eye hygiene
What is treatment for chalazion? Warm, moist compresses 3x a day
If secondarily infected: sulfacetamide or erythromycin
What is the follow-up for chalazion?
 In 2-4 weeks
If still present after 6wks, follow up w/ophthalmologist
Clostridium difficile

, 4

Incubation UNKNOWN
S/S
• Variety of symptoms and severity are seen: mild to explosive diarrhea, bloody stools, abdominal pain,
fever, nausea, vomiting
• Mild to moderate illness is characterized by watery diarrhea, low-grade fever, and mild abdominal pain
DURATION
• During or after several weeks of antibiotic use; can occur without being associated with such treatment
TRANSMISSION:
• Acquired from the environment or from stool of other colonized or infected people by the fecal-oral route
DIAGNOSTICS
• Stool cultures;
• enzyme immunoassay for toxin A, or A and B;
• positive gross blood,
• leukocytes;
• CBC: ↑ WBCs;
• ESR normal
TREATMENT
• Discontinue current antibiotic (any antibiotic, but notably ampicillin, clindamycin, second- and third-
generation cephalosporins).
• Fluids and electrolyte replacement are usually sufficient. If antibiotic is still needed or illness is severe,
treat with oral metronidazole (drug of choice in children) or vancomycin for 7 to 10 days.
• Supplement with probiotics. Lactobacillus GG, Saccharomyces boulardii are recommended
• Complications include pseudomembranous colitis, toxic megacolon, colonic perforation, relapse,
intractable proctitis, death in debilitated children.
Coarctation of the aorta
 Congenital birth defect that presents with narrowing within the aorta can be due to the following factors :
 Occurs as a single defect caused by a disturbance in the development of aorta or 2ND to PDA
 abnormal genetic development of embryo,
 decreased blood flow within the uterine through the aorta resulting in underdevelopment of the aorta, and
 abnormal arterial duct tissue in the wall of aorta which inhibits blood flow to the aortic vessel
 Coarctation usually occur at the lower end of left subclavian artery at the site where arterial duct closes
 Narrowing leads to higher pressure closer to the obstruction and hypoperfusion distal to the defect or
coarctation
 The increase pressure and overload eventually results in enlargement of left ventricles and heart failure
 Apparent in the first 6 weeks in newborns
Epidemiology
 CoA occurs in 4 out of 10,000 live births in the US
 CoA accounts to 6 to 8 percent of all congenital defects of the heart
 Genetic predisposition
 Prevalent in male more than female
 Affects 30 %percent of female with Turner syndrome
Signs & symptoms:
 Tachypnea
 Poor feeding
 Cool lower extremities
 In children 3-5 yrs of age COA may go unnoticed until htn or a murmur is detected
 Retrospective children with COA may c/o of leg pain with exercises and headaces.
Physical Examination:
 Upper extremity hypertension with lower extremity hypotension ,
 poor lower extremity perfusion with mottling or pallor can be present in severe cases
 delayed timing and absent or weak arterial and other distal arterial pulses
 Bounding brachial , radial , and carotid pulses may occur
 Signs of CHF may be evident