Aquifer Pediatric Cases

Aquifer Pediatric Cases Growth Curve Terms: Weight age Age at which the pts weight would plot at the 50th %ile Growth Curve Terms: Height age Age at which the pts height would plot at the 50th percentile Core sxs of ADHD Inattention, hyperactivity, Impulsivity Important causes of school failure Sensory impairment (Hearing and vision), sleep disorder, mood disorder, learning disability, conduct disorder Objective vision screening should begin at which age? 3 y.o. Objective hearing screening should be performed in which age groups? All newborns (newborn screening) and 4 y.o. Difference in ADHD and Sleep Disorder ADHD children often have poor sleep hygiene but don't seem overtired in daytime True/False: Mood disorders may mimic OR accompany ADHD True Childhood depression is marked by a high rate of conversion to which psychological disorder? Bipolar Disorder What percentage of school age children and adolescents does depression affect? 1-2% of elementary school age children and 5% of adolescents True/False: Children with ADHD have a higher rate of mood disorders than control populations? True True/False: Most states require documentation of a discrepancy between IQ (in normal range) and academic achievement for the Dx of a learning disability True True/False: Comorbidity between LD and ADHD is common; many experts feel one Dx should not be made w/out evaluation for the other True Red flags for learning disabilities Hx maternal illness/substance abuse during pregnancy, complications of delivery, Hx of meningitis/other serious illness, Hx serious head trauma, Parental hx of learning disabilities What % of kids with ADHD respond to stimulant medications? 80% Adverse effects of ADHD Medications include: Appetite suppression, insomnia, decrease in growth velocity When is insomnia on ADHD meds usually the worst? First days of medication use Decreased growth velocity in ADHD medication use usually 1-2 cm and effects diminish by the 3rd year of tx Risk of developing substance abuse in tx for ADHD Some studies suggest a positive response to stimulant medication may reduce a pts likelihood of substance abuse & other high-risk behavior later on in life The probability of childhood obesity persisting into adulthood increases from 20% to what %age in adolescence? 80% What %age of 6-19 y.o. are at or 95th percentile for growth charts? 15% Genetic syndromes associated w/ obesity Prader-Willi, Bardet-Biedl, Cohen Prenatal/neonatal risk factors for obesity include: High birth weight and maternal DM Complications of obesity: Sleep apnea, dyslipidemia, HTN, slipped capital femoral epiphysis (SCFE), type II DM, steatohepatitis Slipped Capital Femoral Epiphysis (SCFE) Displacement of femoral head from femoral neck through the physeal plate. -Occurs at onset of puberty in obese pts w/ delayed sexual maturation -Typical sxs = antalgic gait due to pain referred from hip, thigh and/or knee w/ limited ROM on hip exam -Can be dx w/ plain x-rays of pelvis - shows widening of physis Steatohepatitis in childhood obesity Characterized by mild increase in liver transaminases, a hyperechoic liver on U/S, and evidence of fatty infiltration and fibrosis on biopsy Type II DM in kids -Between , 19% of all DM cases in kids were type II -New type II DM cases in adolescence has grown to 40% -Rare cases in kids as young as 5 y.o. Risk criteria to screen for type II DM at 10 y.o. and every 3 years after Overweight (85% BMI, 85% weight:height, 120% ideal for height), Family hx in 1st or 2nd degree relative, race/ethnicity (native american, AA, hispanic, asian), signs insulin resistance (acanthosis nigricans, HTN, PCOS, dyslipidemia), maternal hx gestational DM Classification of HTN in children: Motivational Interviewing for change: Get pt/caregiver to state their reason for wanting to change, set attainable goals, use external motivators, be cautious of preaching to the choir How much can holding adolescents arms down at their side raise systolic BP? 20 mmHg - 30 mmHg Screening for Secondary HTN in children -Umbilical arterial/Venous access (placement of umbilical arterial or venous line during prenatal period may predispose to renal vascular disease) -UTI = one of leading causes of HTN and renal insufficiency later in life (due to renal scarring) -Pheochromocytoma -Coarctation of aorta -Family Hx of renal disease Children with 90-95th %ile BP (PreHTN) mgmt Lifestyle changes, BP f/u in 6 months, only work up potential secondary causes if PE or Hx gives you a reason to Children w/ primary HTN (95 %ile) mgmt -Meds usually for Stage 2 (99 %ile) OR kids w/ end organ damage OR kids w/ secondary causes of HTN -Lifestyle modifications Criteria for ADHD Dx: 6 or more sxs in 2 or more settings for at least 6 months Several of these sxs must be present before the age of 12 Sxs fall w/in 3 categories of inattention, hyperactivity and impulsivity Coarctation of the Aorta Sxs include chest pain, cold lower extremities, dizziness, syncope, exercise intolerance, failure to thrive, poor growth, headache, and dyspnea -May also be associated w/ other congenital heart defects (bicuspid aortic valve in 50% pts) and chromosomal abnormalities (Turner syndrome) ADHD is usually dx before age: 7 y.o. Rett Syndrome X-linked pervasive developmental disorder seen only in females -regression of language and development -intellectual disability -ataxia -hand-writing -Dx around age 1-4 y.o. Sign of hypothyroidism in adolescence Cold skin, slowness, fatigue, preferring hot weather to cold, doing poorly at school, coarse hair Infectious Mononucleosis Infection of lymphocytes by EBV -Signs/sxs: extreme fatigue, pharyngitis, lymphadenopathy In regards to depression/suicide risk - all adolescents should be asked: Hx of self injury? Suicidal ideation? Suicide attempts? Difference between depression in adolescents and adults Adolescents don't usually experience early morning waking;difficulty falling asleep at night Dangerous electrolyte abnormalities in anorexia nervosa Deficiencies of calcium and magnesium may lead to neurological changes, increased reflex tone and compromised cardiac fx Age of puberty in females: 8-13 years of age Age of puberty in males: 10-15 years of age Male Tanner Stages: -Growth of testicles (12 yrs) -Pubic hair appears (12 yrs) -Growth of penis, scrotum (13-14 yrs) -First ejaculation (13-14 yrs) -Growth spurt (14 yrs) -Attainment of adult height (17 yrs) Female Tanner Stages: -Breast buds appear (10-11 yrs) -Pubic hair appears (10-11 yrs) -growth spurt (12 yrs) -periods/menarche (12-13 yrs) -attainment of adult height (15 yrs) Constitutional Short Stature: "Late bloomers," individual with delayed puberty, but will attain a normal adult height - just later than his/her peers von Willebrand's Disease (vWD) Epidemiology and Inheritance Pattern: -most common hereditary bleeding disorder -occurs in 1% population -AD inheritance w/ variable penetrance -Less common type 3 is AR -Type 1 is most common and mildest (non life-threatening bleeding) vWD Symptoms: -Ecchymoses (small hematomas in areas of trauma) -Epistaxis -Menorrhagia -Bleeding post-tonsillectomy/dental extractions -Gingival bleeds **In absence of major trauma: bruising in non-exposed areas (buttocks, back, trunk) need to be thought of as abnormal Dx of vWD -aPTT may be normal! -To confirm, check the vW factor antigen and/or platelet fxn analysis and factor VIII levels "HEEADSSS" After Family Hx and before ROS H=Home E=Education and employment E=Eating disorder screening A=Activities D=Drugs S=Sexuality S=Suicide risk and depression S=Safety (fights, care, weapons) What age should you begin to separate adolescents from parents/caregivers during part of their history? Early: 9-10 years old What %age of cases of anorexia nervosa occur in males? ~25% vWD Tx: -Intranasal/IV desmopressin -Human plasma-derived, virally inactivated vW factor concentrate -For menorrhagia: OCPS, IUD Differential Dx for Fatigue in Adolescent Female: -Anemia -Bleeding Disorder -Hypothyroidism -Depression -Substance Abuse (declining school performance may be an indicator) Menorrhagia Abnormally heavy/prolonged bleeding True/False: As may as 1 in 5 women with menorrhagia will have a bleeding disorder True Confinement to disorders of platelets and clotting factors: Bleeding disorders AD inheritance pattern Marfan syndrome, vWD, neurofibromatosis, Huntington's disease AR Inheritance Female and Male have 1/4 chance of being affected -Tay-Sachs, CF X-linked recessive Males more commonly affected -Duchenne's, hemophilia, fragile X syndrome Tanner I Female: No glandular tissue/prepubertal, no pubic hair at all ( = 10 y.o.) Tanner II Female: Breast bud formation and areola widening, small amnt of long, downy hair w/ slight pigmentation on labia majora Tanner III Female: Breast bud elevation but without secondary mound, pubic hair distributes more laterally than stage II but does not extend to mons pubis Tanner IV Female: Breasts increased in size and elevation and the areola and papilla form a secondary mound that projects from the contour of the rest of the breast, pubic hair extends across mons pubis and spares medial thighs Tanner V Female: Breasts reach adult size and areola returns to the contour of surrounding breast while central papilla remains projecting and the pubic hair extends to medial surface of thighs Desmopressin in vWD Causes release of von Willebrand's factor from vessel endothelial cells X-linked recessive Infectious Mononucleosis Vasovagal Prodrome: