USMLE Forum Archives - USMLE Step 3 - Step 3 HY
Step 3 HY
meduploader - 12-19-08 12:17
Precocious puberty: It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment.
Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis.
precocious pseudo-puberty is caused by a gonadotropin-independent process, typically an excess of sex steroids (severe cystic acne, significant growth acceleration). It can be caused by late-onset congenital adrenal hyperplasia.
Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. Sequential development of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth, and lastly, a growth spurt.
Benign premature thelarche: is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty. These other signs of precocious puberty include rapid increase in height, increase in bone maturity, appearance of axillary and pubic hair, and menstrual bleeding. The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months. Patients with benign premature thelarche have a normal hormone profile. Their final height is generally not compromised.
DD: 1. Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. Central precocious puberty is characterized by rapid acceleration of height, increase in bone age, thelarche, adrenarche, pubarche, and menarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. Majority of these patients will require treatment with a GnRH analog.
2. Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. This syndrome has similar clinical features as hypothalamic hamartoma, and is characterized by accelerated height and bone age, and menstrual bleeding. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Treatment is usually surgical.
3. McCune-Albright syndrome consists of "café au-lait" spots, fibrous dysplasia of the bone, and precocious puberty. This patient does not have any features to suggest McCune-Albright syndrome. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts.
Nocturnal enuresis can be categorized as primary or secondary, with secondary enuresis accounting for roughly Πof all cases. If the child was continent for at least 6 months prior to the onset of bed-wetting, then the enuresis is considered secondary. While psychological problems are very rarely the cause of primary nocturnal enuresis, they are quite frequently the cause of secondary nocturnal enuresis. Nocturnal enuresis is more common in boys. Prevalence declines slowly throughout childhood; almost Πof 5-year-old children (such as the boy in this case) continue to have nocturnal enuresis. Typically, the condition resolves of its own accord between the ages of 5 and 7. By age 10, prevalence of nocturnal enuresis has dropped to under 5% of all children.
To increase the likelihood of success, parents should maintain a caring, patient approach, and may wish to try behavioral modification with positive reinforcement. If the childs nocturnal enuresis persists for some time, alarm therapy or a prescription for desmopressin may be worth trying.
**First line management for primary nocturnal enuresis for children less than seven years of age is to reassure the patients parents that the child usually outgrows this phase and spontaneously recovers. Other options for treatment, however, are the use of alarms, along with behavioral therapy, such as limiting the childs fluid intake before bedtime. In the alarm method, a sensor is placed in the childs underwear or in the bed padding. Once the child voids and moisture is detected, the alarm is activated, waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use, the former is still more effective in preventing relapses. Alarms are more effective than treatment with tricyclics during and after treatment.
When giving an opinion about a patients diagnosis, the physician must be cautious and try to avoid giving false reassurance or a premature diagnosis that cannot be supported by adequate clinical evidence. In cases wherein the patients history or physical findings do not point to a specific diagnosis, the physician can correctly state that it is "probably a medical condition", and then begin the work up in order to arrive at a more specific diagnosis.
Chronic adrenal insufficiency: It must be suspected in patients with the corresponding signs and symptoms: fatigue, weight loss, myalgias, increased pigmentation, and a decreased amount of axillary and pubic hair. Hyponatremia, hyperkalemia and hyperchloremic metabolic acidosis are characteristic laboratory findings. The most common etiology of this condition is primary adrenal insufficiency (Addisons disease). Diagnosis can be made through the ACTH stimulation test, or by the measurement of early morning serum cortisol level (A level less than 10 mg/dl indicates a high probability of the disease). DD: Hyperthyroidism shares some similar clinical manifestations with Addisons disease (weight loss, asthenia,); however, the presence of other findings, such as fatigue, androgen deficit signs, hyponatremia and hyperkalemia, cannot be explained by hyperthyroidism alone. Hypothyroidism, not hyperthyroidism, is usually related to fatigue and hyponatremia (although the other symptoms still cannot be explained by hypothyroidism).
Sickle cell disease: In children, the most common initial symptom of sickle cell disease is dactylitis, which develops in 40% of patients. Splenic sequestration is the second most common, and occurs in about 20% of patients. Other complications, such as ischemic events, are not as frequent, and are seen mainly in the adult population.
Salmonella is an uncommon cause of hematogenous osteomyelitis in the general population; however, it is the most common cause of osteomyelitis in patients with sickle cell disease. Long bones are usually affected, and multiple foci are often present. Sickle cell anemia should be strongly suspected in child who has a history of anemia and an episode of Salmonella osteomyelitis. Interestingly, only about 30% of cases of sickle cell anemia are diagnosed at the age of 1 year. Hemoglobin electrophoresis will confirm the diagnosis.
Acute otitis media: The most common complication after an episode of acute otitis media is another episode of otitis media. Approximately 75% of early recurrences are due to different bacteria, while other recurrent episodes are caused by the same agents (usually Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Children who have had more than two episodes are especially at risk. Some authors recommend prophylactic antibiotic therapy in such cases.
Contrary to popular belief, pneumonia is not a complication of acute otitis media. Both conditions can coexist, but one is not a risk factor for the other.
** While adults have wide, steeply angled Eustachian tubes, infants have shorter, almost horizontal Eustachian tubes. This fact makes fluid accumulation and infection quite common in young children; however, not all children develop acute otitis media (AOM). Recurrent episodes require further exploration by the clinician.
Exposure to cigarette smoke has been shown to alter mucosa, cilia, and adenoid structures, in addition to increasing the risk of developing AOM and upper respiratory tract infections. An increase in the level of smoke exposure is paralleled by an increase in the number of AOM episodes. Exposure to cigarette smoke is one of the most important risk factors for developing acute otitis media. Parents should be urged to quit smoking.
Current recommendations for AOM patients with an initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who has not received antibiotics in the month prior to the initiation of treatment are high doses of amoxicillin/clavulanate or certain second or third generation cephalosporins. The rationale is to enhance activity against penicillin-resistant S. pneumoniae (drug resistant S. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US.
Discontinue amoxicillin, begin IM ceftriaxone, and refer the boy to an otolaryngologist for urgent tympanocentesis. This would be an appropriate choice if the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. (Prior antibiotics in the month preceding AOM increases the likelihood that AOM is due to DRSP.) Under these conditions, the patient would also have been initially treated with high dose amoxicillin, high dose amoxicillin/clavulanate, or certain second or third generation cephalosporins. These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. IM ceftriaxone is even more effective against DRSP. Moreover, immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment.
Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months, or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole). It might be considered in AOM if the TM bulging, earache, fever, vomiting, and/or diarrhea were unusually severe or persistent.
**Post OM management: A normal appearing tympanic membrane with decreased mobility on pneumatic otoscopy is suggestive of an effusion in the middle ear. An effusion commonly persists up to three months after an acute episode of otitis media (OM) has been treated. If no other symptoms are present in such cases, watchful waiting is all that is necessary. If other symptoms are present, the effusion is bilateral, or has persisted for more than three months, further therapy should be considered.
Switching to a second-line antibiotic should be considered if there is inadequate improvement of symptoms or appearance of the tympanic membrane, or when there is persistence of a purulent nasal discharge. According to the CDC, three drugs can be used as alternatives. These are amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone.
Tympanocentesis or myringotomy with culture are indicated in children in whom the clinical response to a second-line treatment has been unsatisfactory.
Hearing should be assessed if effusion has persisted for more than three months.
Myringotomy and insertion of tympanostomy tubes should be considered for patients with otitis media and effusion after antibiotic therapy and an ample period of watchful waiting.
Gynecomastia is very common (up to 70%) in pubertal males. Its occurrence during puberty is associated with the relative excess production of estrogens from the testes. In majority of subjects, gynecomastia regresses in about 18-24 months; however, this may persist in some patients, and although rare, it could be cosmetically disfiguring.
Surgical resection is required in very large, cosmetically disfiguring gynecomastia which has not responded to medical therapy.
Liver cirrhosis is associated with gynecomastia. This is mainly due to an increased aromatization of circulating androgens.
Methamphetamine (MF): therapy is associated with decreased weight and height. Sadness and irritability can be seen in up to 22% of children at therapeutic doses. MF overdose has similar effects as dextroamphetamine, that is: anorexia, nausea, vomiting, tachycardia, increased blood pressure, palpitations, dizziness, headache, nervousness, euphoria, agitation, and aggressive or violent behavior.
It is very important to remember that MF cannot be stopped abruptly because of the high prevalence of psychological dependence to the drug. MF must therefore be slowly tapered.
DD: MF use in childhood has been associated with an increased probability of drug abuse problems in adulthood. Illicit drug overdose, especially cocaine, may be difficult to differentiate from MF or amphetamine overdose. A urine toxicology test may be useful in most cases.
Exercise-induced bronchoconstriction is usually seen after strenuous activities or exercises. Bronchodilation initially occurs during exercise, followed by bronchoconstriction, which begins after 3 to 5 minutes, and rapidly peaks within 10 to 15 minutes of cessation of exercise. This is extremely common in patients with a history of symptomatic asthma, and the patient"s response correlates with the degree of airway hyperresponsiveness.
The first step in the management of patients with exercise-induced bronchoconstriction is to control the underlying asthma effectively.
Patients with well-controlled asthma and a history of exercise-induced bronchoconstriction should have prophylactic treatment with inhaled beta-2 agonists (e.g., albuterol) approximately 5 to 10 minutes before the initiation of exercise. Patients with less severe or less frequent attacks, along with their close contacts, must be taught how to recognize and treat the acute attack with inhaled beta-2 agonists.
It is important to realize that exercise is not the cause of asthma, but it induces bronchoconstriction in patients with underlying asthma. The patient should not be instructed to avoid exercise. In contrast, exercise should be encouraged to reduce the minute ventilation for any given level of exercise, and to prevent the recurrence of exercise-induced bronchoconstriction.
Capillary (strawberry) hemangioma: superficial, bright, red, strawberry-like round lesion is a benign vascular lesion. Most capillary hemangiomas are evident at birth. They may undergo subsequent growth for a period of several months (proliferation phase). Spontaneous regression usually follows (involution phase). It is estimated that 70% of superficial lesions will disappear by seven years of age, although residual skin changes may be left.
For lesions that are small, do not affect normal functioning, and do not constitute a significant cosmetic problem, observation is the best approach.
Laser treatment should be considered in patients with lesions on the face, and at sites of potential functional impairment (orbital area).
Imaging studies are usually indicated in infants with multiple superficial lesions to exclude visceral involvement.
Oral corticosteroids, and sometimes subcutaneous interferon, are indicated for the treatment of rapidly growing lesions.
Anorexia nervosa : Anorexia nervosa is a complex medical condition, which is difficult to treat. There are some indications to admit a patient with anorexia nervosa to the hospital. The Society for Adolescent Medicine (SAM) has developed some guidelines. The indications for admission are: dehydration, electrolyte abnormalities (hypokalemia, hyponatremia), bradycardia (less than 50 beats per minute), hypotension (BP < 80/50 mmHg), hypothermia (under 96șF), orthostatism, acute food refusal, severe malnutrition (weight < 75% of the average for her age, height and sex), acute medical or psychiatric emergencies (pancreatitis, seizures, syncope, suicidal ideation, psychosis), and cardiac arrhythmia. If the patient meets any of these criteria, she must be admitted immediately. All other medical and psychiatric evaluations may be done after the patient is admitted to the hospital.
Hypocalcemia is common in patients with anorexia nervosa because of the presence of hypoalbuminemia.
Refeeding syndrome can develop during the second or third week of nutritional therapy of patients with anorexia nervosa. It is characterized by edema and heart failure, and can lead to delirium and cardiac arrest. Phosphate must be replaced immediately, and the patient should be managed in the intensive care unit.
Neonatal sepsis: The diagnosis of neonatal sepsis is suspected when an infant has poor appetite, decreased reactivity to external stimuli, diminished oral intake, and lassitude or depressed sensorium. The most common etiologic agents are Group B Streptococcus, Escherichia coli, Klebsiella and Enterobacter species. Although Listeria infections are rare in the United States, ampicillin is recommended as part of the antibiotic regimen. Cefotaxime, ceftriaxone or antipseudomonal penicillins are used in combination with the aforementioned drug. The type of bilirubinemia involved also affects the approach in management of septic infants. Indirect hyperbilirubinemia is usually physiologic in nature and persists, while direct hyperbilirubinemia is probably induced by sepsis-related cholestasis.
Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of bilirubin. Moxalactam and sulfonamides are not recommended due to their capability of increasing indirect bilirubin levels.
Sydenhams chorea (SC; also known as Saint Vitus dance), one of the classic manifestations of rheumatic fever. SC is more common in girls, especially between 5 and 13 years of age. SC is usually preceded by a period of emotional lability, manifested by a tendency to cry or laugh, as well as deterioration of school performance. SC starts with distal hand movements, later progressing to facial jerking and grimacing, as well as abnormal feet movement. Chorea usually develops several (one to eight) months after the onset of acute rheumatic fever, whereas carditis and arthritis typically develop within 21 days. The presence of carditis is diagnostic. Approximately one third of the patients have carditis; mitral regurgitation is the most common cardiac finding. Patients may not remember a prior sore throat, and cultures are also usually negative. Patients usually have hypotonia, and the relaxation phase of the patellar reflex is usually delayed. When the patient is examined with the arms stretched out, the arms move from the prone to the supine position (positive pronator sign).
DD: 1. Gilles de la Tourette syndrome starts between 2 and 15 years of age, and is four times more frequent in boys. Pronator sign, carditis and hypotonia are not present.
2. Attention deficit disorder is a chronic condition with no abnormal findings on physical examination.
Sydenhams chorea (SC) should be treated immediately with oral penicillin for ten days. If patient adherence is an issue, an alternative is a single dose of intramuscular Benzathine penicillin. In patients who are allergic to penicillin, weight based erythromycin, divided in 2-4 doses, should be given. SC usually resolves within 12 to 15 weeks; however, prophylaxis should be continued into adulthood.
If the motor function is severely compromised, valproic acid, phenobarbital or haloperidol can be started, and the patient must be referred to a neurologist.
meduploader - 12-19-08 12:17
Precocious puberty: It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment.
Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis.
precocious pseudo-puberty is caused by a gonadotropin-independent process, typically an excess of sex steroids (severe cystic acne, significant growth acceleration). It can be caused by late-onset congenital adrenal hyperplasia.
Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. Sequential development of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth, and lastly, a growth spurt.
Benign premature thelarche: is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty. These other signs of precocious puberty include rapid increase in height, increase in bone maturity, appearance of axillary and pubic hair, and menstrual bleeding. The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months. Patients with benign premature thelarche have a normal hormone profile. Their final height is generally not compromised.
DD: 1. Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. Central precocious puberty is characterized by rapid acceleration of height, increase in bone age, thelarche, adrenarche, pubarche, and menarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. Majority of these patients will require treatment with a GnRH analog.
2. Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. This syndrome has similar clinical features as hypothalamic hamartoma, and is characterized by accelerated height and bone age, and menstrual bleeding. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Treatment is usually surgical.
3. McCune-Albright syndrome consists of "café au-lait" spots, fibrous dysplasia of the bone, and precocious puberty. This patient does not have any features to suggest McCune-Albright syndrome. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts.
Nocturnal enuresis can be categorized as primary or secondary, with secondary enuresis accounting for roughly Πof all cases. If the child was continent for at least 6 months prior to the onset of bed-wetting, then the enuresis is considered secondary. While psychological problems are very rarely the cause of primary nocturnal enuresis, they are quite frequently the cause of secondary nocturnal enuresis. Nocturnal enuresis is more common in boys. Prevalence declines slowly throughout childhood; almost Πof 5-year-old children (such as the boy in this case) continue to have nocturnal enuresis. Typically, the condition resolves of its own accord between the ages of 5 and 7. By age 10, prevalence of nocturnal enuresis has dropped to under 5% of all children.
To increase the likelihood of success, parents should maintain a caring, patient approach, and may wish to try behavioral modification with positive reinforcement. If the childs nocturnal enuresis persists for some time, alarm therapy or a prescription for desmopressin may be worth trying.
**First line management for primary nocturnal enuresis for children less than seven years of age is to reassure the patients parents that the child usually outgrows this phase and spontaneously recovers. Other options for treatment, however, are the use of alarms, along with behavioral therapy, such as limiting the childs fluid intake before bedtime. In the alarm method, a sensor is placed in the childs underwear or in the bed padding. Once the child voids and moisture is detected, the alarm is activated, waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use, the former is still more effective in preventing relapses. Alarms are more effective than treatment with tricyclics during and after treatment.
When giving an opinion about a patients diagnosis, the physician must be cautious and try to avoid giving false reassurance or a premature diagnosis that cannot be supported by adequate clinical evidence. In cases wherein the patients history or physical findings do not point to a specific diagnosis, the physician can correctly state that it is "probably a medical condition", and then begin the work up in order to arrive at a more specific diagnosis.
Chronic adrenal insufficiency: It must be suspected in patients with the corresponding signs and symptoms: fatigue, weight loss, myalgias, increased pigmentation, and a decreased amount of axillary and pubic hair. Hyponatremia, hyperkalemia and hyperchloremic metabolic acidosis are characteristic laboratory findings. The most common etiology of this condition is primary adrenal insufficiency (Addisons disease). Diagnosis can be made through the ACTH stimulation test, or by the measurement of early morning serum cortisol level (A level less than 10 mg/dl indicates a high probability of the disease). DD: Hyperthyroidism shares some similar clinical manifestations with Addisons disease (weight loss, asthenia,); however, the presence of other findings, such as fatigue, androgen deficit signs, hyponatremia and hyperkalemia, cannot be explained by hyperthyroidism alone. Hypothyroidism, not hyperthyroidism, is usually related to fatigue and hyponatremia (although the other symptoms still cannot be explained by hypothyroidism).
Sickle cell disease: In children, the most common initial symptom of sickle cell disease is dactylitis, which develops in 40% of patients. Splenic sequestration is the second most common, and occurs in about 20% of patients. Other complications, such as ischemic events, are not as frequent, and are seen mainly in the adult population.
Salmonella is an uncommon cause of hematogenous osteomyelitis in the general population; however, it is the most common cause of osteomyelitis in patients with sickle cell disease. Long bones are usually affected, and multiple foci are often present. Sickle cell anemia should be strongly suspected in child who has a history of anemia and an episode of Salmonella osteomyelitis. Interestingly, only about 30% of cases of sickle cell anemia are diagnosed at the age of 1 year. Hemoglobin electrophoresis will confirm the diagnosis.
Acute otitis media: The most common complication after an episode of acute otitis media is another episode of otitis media. Approximately 75% of early recurrences are due to different bacteria, while other recurrent episodes are caused by the same agents (usually Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Children who have had more than two episodes are especially at risk. Some authors recommend prophylactic antibiotic therapy in such cases.
Contrary to popular belief, pneumonia is not a complication of acute otitis media. Both conditions can coexist, but one is not a risk factor for the other.
** While adults have wide, steeply angled Eustachian tubes, infants have shorter, almost horizontal Eustachian tubes. This fact makes fluid accumulation and infection quite common in young children; however, not all children develop acute otitis media (AOM). Recurrent episodes require further exploration by the clinician.
Exposure to cigarette smoke has been shown to alter mucosa, cilia, and adenoid structures, in addition to increasing the risk of developing AOM and upper respiratory tract infections. An increase in the level of smoke exposure is paralleled by an increase in the number of AOM episodes. Exposure to cigarette smoke is one of the most important risk factors for developing acute otitis media. Parents should be urged to quit smoking.
Current recommendations for AOM patients with an initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who has not received antibiotics in the month prior to the initiation of treatment are high doses of amoxicillin/clavulanate or certain second or third generation cephalosporins. The rationale is to enhance activity against penicillin-resistant S. pneumoniae (drug resistant S. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US.
Discontinue amoxicillin, begin IM ceftriaxone, and refer the boy to an otolaryngologist for urgent tympanocentesis. This would be an appropriate choice if the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. (Prior antibiotics in the month preceding AOM increases the likelihood that AOM is due to DRSP.) Under these conditions, the patient would also have been initially treated with high dose amoxicillin, high dose amoxicillin/clavulanate, or certain second or third generation cephalosporins. These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. IM ceftriaxone is even more effective against DRSP. Moreover, immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment.
Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months, or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole). It might be considered in AOM if the TM bulging, earache, fever, vomiting, and/or diarrhea were unusually severe or persistent.
**Post OM management: A normal appearing tympanic membrane with decreased mobility on pneumatic otoscopy is suggestive of an effusion in the middle ear. An effusion commonly persists up to three months after an acute episode of otitis media (OM) has been treated. If no other symptoms are present in such cases, watchful waiting is all that is necessary. If other symptoms are present, the effusion is bilateral, or has persisted for more than three months, further therapy should be considered.
Switching to a second-line antibiotic should be considered if there is inadequate improvement of symptoms or appearance of the tympanic membrane, or when there is persistence of a purulent nasal discharge. According to the CDC, three drugs can be used as alternatives. These are amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone.
Tympanocentesis or myringotomy with culture are indicated in children in whom the clinical response to a second-line treatment has been unsatisfactory.
Hearing should be assessed if effusion has persisted for more than three months.
Myringotomy and insertion of tympanostomy tubes should be considered for patients with otitis media and effusion after antibiotic therapy and an ample period of watchful waiting.
Gynecomastia is very common (up to 70%) in pubertal males. Its occurrence during puberty is associated with the relative excess production of estrogens from the testes. In majority of subjects, gynecomastia regresses in about 18-24 months; however, this may persist in some patients, and although rare, it could be cosmetically disfiguring.
Surgical resection is required in very large, cosmetically disfiguring gynecomastia which has not responded to medical therapy.
Liver cirrhosis is associated with gynecomastia. This is mainly due to an increased aromatization of circulating androgens.
Methamphetamine (MF): therapy is associated with decreased weight and height. Sadness and irritability can be seen in up to 22% of children at therapeutic doses. MF overdose has similar effects as dextroamphetamine, that is: anorexia, nausea, vomiting, tachycardia, increased blood pressure, palpitations, dizziness, headache, nervousness, euphoria, agitation, and aggressive or violent behavior.
It is very important to remember that MF cannot be stopped abruptly because of the high prevalence of psychological dependence to the drug. MF must therefore be slowly tapered.
DD: MF use in childhood has been associated with an increased probability of drug abuse problems in adulthood. Illicit drug overdose, especially cocaine, may be difficult to differentiate from MF or amphetamine overdose. A urine toxicology test may be useful in most cases.
Exercise-induced bronchoconstriction is usually seen after strenuous activities or exercises. Bronchodilation initially occurs during exercise, followed by bronchoconstriction, which begins after 3 to 5 minutes, and rapidly peaks within 10 to 15 minutes of cessation of exercise. This is extremely common in patients with a history of symptomatic asthma, and the patient"s response correlates with the degree of airway hyperresponsiveness.
The first step in the management of patients with exercise-induced bronchoconstriction is to control the underlying asthma effectively.
Patients with well-controlled asthma and a history of exercise-induced bronchoconstriction should have prophylactic treatment with inhaled beta-2 agonists (e.g., albuterol) approximately 5 to 10 minutes before the initiation of exercise. Patients with less severe or less frequent attacks, along with their close contacts, must be taught how to recognize and treat the acute attack with inhaled beta-2 agonists.
It is important to realize that exercise is not the cause of asthma, but it induces bronchoconstriction in patients with underlying asthma. The patient should not be instructed to avoid exercise. In contrast, exercise should be encouraged to reduce the minute ventilation for any given level of exercise, and to prevent the recurrence of exercise-induced bronchoconstriction.
Capillary (strawberry) hemangioma: superficial, bright, red, strawberry-like round lesion is a benign vascular lesion. Most capillary hemangiomas are evident at birth. They may undergo subsequent growth for a period of several months (proliferation phase). Spontaneous regression usually follows (involution phase). It is estimated that 70% of superficial lesions will disappear by seven years of age, although residual skin changes may be left.
For lesions that are small, do not affect normal functioning, and do not constitute a significant cosmetic problem, observation is the best approach.
Laser treatment should be considered in patients with lesions on the face, and at sites of potential functional impairment (orbital area).
Imaging studies are usually indicated in infants with multiple superficial lesions to exclude visceral involvement.
Oral corticosteroids, and sometimes subcutaneous interferon, are indicated for the treatment of rapidly growing lesions.
Anorexia nervosa : Anorexia nervosa is a complex medical condition, which is difficult to treat. There are some indications to admit a patient with anorexia nervosa to the hospital. The Society for Adolescent Medicine (SAM) has developed some guidelines. The indications for admission are: dehydration, electrolyte abnormalities (hypokalemia, hyponatremia), bradycardia (less than 50 beats per minute), hypotension (BP < 80/50 mmHg), hypothermia (under 96șF), orthostatism, acute food refusal, severe malnutrition (weight < 75% of the average for her age, height and sex), acute medical or psychiatric emergencies (pancreatitis, seizures, syncope, suicidal ideation, psychosis), and cardiac arrhythmia. If the patient meets any of these criteria, she must be admitted immediately. All other medical and psychiatric evaluations may be done after the patient is admitted to the hospital.
Hypocalcemia is common in patients with anorexia nervosa because of the presence of hypoalbuminemia.
Refeeding syndrome can develop during the second or third week of nutritional therapy of patients with anorexia nervosa. It is characterized by edema and heart failure, and can lead to delirium and cardiac arrest. Phosphate must be replaced immediately, and the patient should be managed in the intensive care unit.
Neonatal sepsis: The diagnosis of neonatal sepsis is suspected when an infant has poor appetite, decreased reactivity to external stimuli, diminished oral intake, and lassitude or depressed sensorium. The most common etiologic agents are Group B Streptococcus, Escherichia coli, Klebsiella and Enterobacter species. Although Listeria infections are rare in the United States, ampicillin is recommended as part of the antibiotic regimen. Cefotaxime, ceftriaxone or antipseudomonal penicillins are used in combination with the aforementioned drug. The type of bilirubinemia involved also affects the approach in management of septic infants. Indirect hyperbilirubinemia is usually physiologic in nature and persists, while direct hyperbilirubinemia is probably induced by sepsis-related cholestasis.
Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of bilirubin. Moxalactam and sulfonamides are not recommended due to their capability of increasing indirect bilirubin levels.
Sydenhams chorea (SC; also known as Saint Vitus dance), one of the classic manifestations of rheumatic fever. SC is more common in girls, especially between 5 and 13 years of age. SC is usually preceded by a period of emotional lability, manifested by a tendency to cry or laugh, as well as deterioration of school performance. SC starts with distal hand movements, later progressing to facial jerking and grimacing, as well as abnormal feet movement. Chorea usually develops several (one to eight) months after the onset of acute rheumatic fever, whereas carditis and arthritis typically develop within 21 days. The presence of carditis is diagnostic. Approximately one third of the patients have carditis; mitral regurgitation is the most common cardiac finding. Patients may not remember a prior sore throat, and cultures are also usually negative. Patients usually have hypotonia, and the relaxation phase of the patellar reflex is usually delayed. When the patient is examined with the arms stretched out, the arms move from the prone to the supine position (positive pronator sign).
DD: 1. Gilles de la Tourette syndrome starts between 2 and 15 years of age, and is four times more frequent in boys. Pronator sign, carditis and hypotonia are not present.
2. Attention deficit disorder is a chronic condition with no abnormal findings on physical examination.
Sydenhams chorea (SC) should be treated immediately with oral penicillin for ten days. If patient adherence is an issue, an alternative is a single dose of intramuscular Benzathine penicillin. In patients who are allergic to penicillin, weight based erythromycin, divided in 2-4 doses, should be given. SC usually resolves within 12 to 15 weeks; however, prophylaxis should be continued into adulthood.
If the motor function is severely compromised, valproic acid, phenobarbital or haloperidol can be started, and the patient must be referred to a neurologist.
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#1
Re: Step 3 HY
meduploader - 12-19-08 12:19 Atopic dermatitis: The characteristic (red, oozing) rash may involve the face and the scalp in children. Scaly, dry cheeks, especially in the winter, are also typical. Atopic dermatitis is believed to have a strong allergic/immunologic component because many patients demonstrate allergies to food and inhalant allergens. 80-85% of patients have elevated IgE levels, and there is a strong family predisposition to the disease. The condition promptly responds to topical steroids and calcineurin inhibitors such as topical tacrolimus and pimecrolimus.
Diarrhea diet: In a child with diarrhea and no clinical signs of dehydration, preferred intake includes fluids low in sugar and the resumption of a normal, age-appropriate diet with plenty of complex carbohydrates with limited fats and sugars. Foods containing excessive sugar can increase the osmolarity of the stool in the intestinal lumen, and fatty foods are known to delay gastric emptying. Both can worsen diarrhea.
The previously popular BRAT diet is no longer recommended for refeeding children with diarrhea because it is quite low in calories and protein. Moreover, the bananas and applesauce in the BRAT diet add excessive sugar.
Of greater concern is loperamideâs linkage with paralytic ileus, toxic megacolon, CNS depression, coma, and death in children.
Rabie prophylaxis: In a case of exposure to bats, immediate vaccination is recommended if the person was not aware of the presence of the animal. Postexposure prophylaxis consists of the administration of one dose of anti-rabies immunoglobulin and five doses of anti-rabies vaccine. If treatment is postponed for no more than five days (if the patient did not immediately report the exposure), effectiveness will be the same, although there have been reports of rabies in persons not vaccinated in the first 72 hours when the bite was in the head or the neck.
Ethics: Permission to treat a child can only be granted by the parent or legal guardian. As an exception to this rule, adolescents are typically allowed to give consent for their own care in regards to pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness.
When providing medical care, clinicians must seek to balance the autonomy of the family with the welfare of the child. In true emergency situations requiring imminent treatment of a child, most medical teams choose to proceed with treatment despite the parental refusal of care. Very rarely do courts uphold charges against physicians in such cases.
Homosexual parents: Homosexuality was classified as a sexual disorder in the DSM I and II, but was removed from the revised DSM III.
Multiple studies of both biological and adopted children of homosexual parents have been performed, and the general consensus is that these children experience normal childhood development. Among children of homosexual parents, adolescent concerns about identity and peer approval are becoming less intense as variance in the American family unit grows more common and socially accepted.
The majority of children adopted by homosexuals consider themselves to be heterosexual, though some do describe themselves as homosexual or bisexual.
Homosexual parents have not been proven to be more passive than heterosexual parents, and there is no documentation of increased violence or antisocial behavior in their children. Studies of domestic violence suggest it is similarly prevalent in homosexual and heterosexual relationships.
Although at least one study has suggested that certain learning disabilities (e.g., dyslexia, stuttering) are more common in homosexuals than in heterosexuals, there is no evidence that this tendency translates to increased learning disabilities in the children of homosexual parents.
Bacterial conjunctivitis: Characterized by redness and copious, purulent discharge. No fever or blurred vision. Examination shows conjunctival erythema and yellow exudates. It is usually a self-limited disease; however, it must be treated because there is a small, but real risk of keratitis, which can lead to visual impairment.
Erythromycin ointment or sulfa drops are the first line of therapy for uncomplicated bacterial conjunctivitis, as they cover most organisms.
Fluoroquinolone eye drops are preferred for contact lens wearers and cornel ulcers because of the activity against pseudomonas. They should not be used in uncomplicated bacterial conjunctivitis as first line therapy because of the risk of the emergence of resistance.
Primary care physicians should not prescribe corticosteroids, as they can cause sight-threatening complications in patients with bacterial conjunctivitis and herpes keratitis.
Bacterial conjunctivitis is very contagious. The best thing to do is to keep the child at home until the discharge is cleared. However, in many patients who work outside, this may not be feasible. In those patients, at least 24-hours of topical antibiotic therapy should be applied before returning to work.
Delayed puberty: The earliest sign of puberty is nocturnal increase in the LH surge. This is followed by a daytime increase in the levels of gonadotrophins, and increase in testosterone levels. On physical examination, enlargement of testes is one of the earliest signs of onset of puberty.
A patient is diagnosed with delayed puberty if he does not have testicular enlargement by 14 years of age, or if his testicles are 2.5 cm or less in diameter. Another criterion is a delay in the development for 5 years or more from the onset of genitalia enlargement. The most common cause of delayed puberty is constitutional delay. The initial evaluation involves the use of an imaging test to determine bone age. Bone age that is older or equal to the chronological age warrants further testing to rule out chromosomal abnormality and endocrine causes.
DD: Constitutional pubertal delay is characterized by delayed puberty, retarded bone age, and a positive family history without any evidence of systemic disorder. These patients develop puberty without any intervention. The development of secondary sexual characteristics can be enhanced in patients with constitutional pubertal delay by using small doses of testosterone for a short time. The use of testosterone for a short period of time does not compromise the final adult height.
Kallmanâs syndrome consists of anosmia with hypogonadotropic hypogonadism, and sometimes there are associated midline facial defects. This syndrome is due to a genetic defect which leads to the defective migration of GnRH-secreting and olfactory neurons to their final adult positions.
Neurofibromatosis: To meet the diagnostic criteria NF 1, two or more of the following are required: a first degree relative with NF 1, the development of more than six CALS of 5 mm in greatest diameter (if children) or 15 mm (if adult), or the presence of more than two neurofibromas, Lisch nodules, optic glioma, bone dysplasia, or axillary freckling. If the patient is a child, there is a 15% possibility of development of optic nerve gliomas. Current recommendations include having a detailed ophthalmologic evaluation for early detection of this problem and for search of Lisch nodules (iris hamartoma). As primary care physicians have a lack of expertise in such an evaluation, immediate ophthalmologic referral is advised.
If there are any ophthalmologic or neurologic abnormalities, other tests such as MRI, head CT scan, EMG, or neurosurgery evaluation may be needed.
DD: Hypopigmented spots, in combination with a family history of bilateral deafness, strongly suggest neurofibromatosis type 2 (NF-2), an autosomal-dominant disorder. The spots described actually represent café-au-lait spots that are usually hypopigmented (unlike the hyperpigmented café-au-lait spots found in NF-1). Deafness is caused by bilateral acoustic neuromas, a characteristic neurologic manifestation of the syndrome.
#2
Re: Step 3 HY meduploader - 12-19-08 12:22 Herpes zoster or varicella: The diagnosis of herpes zoster or varicella is made clinically. No further laboratory tests are needed.
In immunosuppressed patients (e.g., HIV), the rash can be atypical and can be confused with herpes simplex. If the patient is critical and antiviral therapy needs to be started, lesions can be scraped for PCR or immunofluorescence studies.
Vaccination: There are two true contraindications for DTaP vaccination: 1) anaphylaxis within seven days of administration of a previous DTP or DTaP vaccine, and 2) encephalopathy within seven days of administration of a previous DTP or DTaP vaccine. If high fever (>104.8F), shock, inconsolable crying for three or more hours, or seizure occur within 24 hours of receiving a dose of DTaP vaccine, then subsequent doses should be given with caution. Temporary contraindications to receipt of the DTaP vaccine include moderate or severe illness, with the vaccine administered as soon as the illness resolves. Mild acute illness with or without fever is not a contraindication to vaccine administration. There are no significant contraindications to receipt of vaccinations against Hib, poliovirus, and pneumococcus; therefore, a four-month-old child with otitis media should be vaccinated against DTaP, Hib, IPV, and PCV.
**Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended by the American Association of Pediatrics (AAP). It is advisable for all patients to receive pre-transplantation immunization, although this is not always possible and durable protection is reached in less than 50% of patients. Transmission of vaccine-associated VZV is not typical, except for some cases when post-vaccination rash appears; therefore, this child should be monitored for the appearance of a rash and isolated if a rash appears
TB:
All patients with sputum-positive pulmonary or laryngeal tuberculosis can transmit the infection to other household contacts or healthcare workers via infectious aerosols containing Mycobacterium tuberculosis bacilli. The acts of coughing, sneezing, singing, and even speaking can all produce microscopic aerosols containing the organism. All such patients should be placed in respiratory isolation until they are confirmed to be non-infectious. Patients are rendered non-infectious if they are receiving effective antituberculous therapy and have had three consecutive negative results on sputum acid-fast smears performed on different occasions. Non-infectivity should be documented by serial negative acid-fast smears, and not by the duration of therapy. A patient can still be infectious after prolonged drug therapy if he has a drug-resistant infection. Resolution of chest x- ray findings in patients with pulmonary tuberculosis typically lag behind the clinical response. Chest radiograph changes can persist for longer periods of time after the patient has been rendered non-infectious, and may even become permanent.
**Multi-drug resistant TB: is an emerging problem in the USA. If the organisms are resistant to both rifampin and INH, we call it a multi-drug resistant TB (MDR-TB). In case of exposure to MDR-TB, chemoprophylaxis with pyrazinamide and ethambutol or quinolone with anti-mycobacterial activity, like ofloxacin or levofloxacin is recommended. But, if it is resistant to INH only, then the standard recommendations are to give the chemoprophylaxis with Rifampicin alone for four months or Rifampicin plus PZA for two months. The problem with the rifampin plus PZA combination in an immunocompetent host is liver toxicity. The patient needs careful monitoring.
**Tuberculous meningitis: is one of the forms of extrapulmonary tuberculosis. It is associated with high morbidity and mortality rates. Patients usually present with an insidious onset of symptoms such as malaise, headache, and low-grade fever. If left untreated, these symptoms can rapidly progress to persistent headaches, vomiting, cranial nerve involvement, confusion, seizures, coma, and eventually, death within six to eight weeks of the onset of illness. All patients with suspected tuberculous meningitis (based on initial history and CSF examination) should be immediately started on empiric antituberculous therapy, pending the results of confirmatory tests. The prognosis of the patient with tuberculous meningitis greatly depends on the stage in which the treatment is initiated. Early diagnosis and treatment of the patients is critical to prevent adverse clinical outcomes.
All patients with tuberculous meningitis should be initially treated with a combination of isoniazid, rifampin, and pyrazinamide (bactericidal agents) for the first two months, followed by treatment with INH and rifampin for the succeeding months. These three agents have good CSF penetration, and can achieve adequate therapeutic levels in the cerebrospinal fluid. Based on the current guidelines, all infants and children with drug-sensitive tuberculous meningitis should be treated for at least 12 months. In a patient with drug-resistant infection, the therapy may be extended to 18-24 months, depending on the clinical response and severity of the illness.
Summary: 1. Specific antituberculous therapy should be initiated early in all patients with clinically suspected tuberculous meningitis.
2. Infants and children with tuberculous meningitis, miliary TB, and tuberculous osteomyelitis should receive 12 months of antituberculous therapy.
kyphosis:
a) Flexible:
Scenario: Physical examination shows a postural round back that is corrected by voluntary hyperextension. Forward bending reveals no lateral deformity and no angulation. Neurological examination of the lower extremities is normal. You order x-ray of the spine that shows a convex alignment of the thoracic spine at 35 degrees.
It is typically noticed by parents or teachers who observe adolescents sitting or standing in a slouched position. On lateral radiographs, the angle of thoracic kyphosis is normal or slightly increased (normal 20-40 degree). Interestingly, contrary to common belief, there is no evidence that flexible kyphosis leads to adverse physical effects or permanent deformity.
b) Scheuermann disease (structural kyphosis )
Scenario: Physical examination reveals thoracic curving of the spine that is not corrected with voluntary hyperextension of the spine. On forward bending, sharp angularity is observed in the thoracic region, but no lateral deformity is present. Neurological examination of the lower extremities is normal. X-ray of the spine shows a convex alignment of the thoracic spine at 55 degrees.
Unlike flexible kyphosis, structural kyFphosis is not corrected with voluntary efforts, and a sharp angulation is commonly seen on forward bending. The typical treatment for structural kyphosis that is not severe (less than 70-80 degrees) includes the use of a Milwaukee brace. In more severe cases (significant angulation, intractable pain, neurological abnormalities), surgical correction is used.
Turner syndrome (45,XO): dorsal feet and hands edema, short webbed neck, and a cardiac murmur) is typical for Turner syndrome. It represents monosomy for the X chromosome (45, X), that is why no Barr body is revealed on the buccal smear. Less common chromosomal abnormalities that can be present in patients with Turner syndrome include X chromosome mosaicism and Xp deletion. Interestingly, the risk of having an infant with monosomy for the X chromosome does not increase with advance maternal age, unlike Downâs syndrome and Klinefelterâs syndrome (47, XXY). Moreover, no increased recurrence risk is present after having an infant with Turner syndrome.
All patients who are initially diagnosed must be screened for the presence of other associated somatic abnormalities. The most important of these are the cardiac defects, which include coarctation of the aorta, bicuspid aortic valve, mitral valve prolapse, and hypoplastic heart. Since some of these defects cannot be picked up by clinical examination, an echocardiogram is necessary. The other associated defects are: visual and hearing deficits, kidney malformation (including horseshoe shaped kidney), and an increased predisposition for autoimmune endocrinopathy (especially primary hypothyroidism); therefore, in addition to an echocardiogram, all patients initially diagnosed with Turner syndrome require visual and hearing assessment, renal ultrasound, and TSH level measurement.
Patients with Turner syndrome develop moderate to severe insulin resistance and diabetes when they are older. Blood sugar screening is performed based on the patient"s clinical manifestations.
Patients with Turner syndrome have hypogonadism, and eventually require estrogen replacement; however, if estrogen therapy is given at an early age, there may be premature fusion of the epiphysis, which will potentially decrease the patient"s final height. Most physicians begin prescribing hormone replacement therapy when the patient reaches 14 years of age. Growth hormone is approved for use in patients with Turnerâs syndrome to improve their final height.
Imaging studies in UTI:
Imaging studies are recommended in the following patients:
1. children under the age of five years with a febrile UTI
2. males of any age with a first UTI
3. females under the age of three years with a first UTI
4. children with UTI who do not promptly respond to antibiotic therapy
5. children with recurrent UTI
Voiding cystourethrogram is routinely recommended, and is considered by most authors as an important imaging study to demonstrate vesico-ureteral reflux (VUR).
Infantile hypertrophic pyloric stenosis (IHPS): usually presents in infants who are three to six weeks old. 83% of affected patients are boys. Postprandial, non-bilious vomiting is characteristic. Peristaltic waves can sometimes be detected just before vomiting. These occur as wavy movements traveling from left to right across the upper abdomen. A palpable "olive-like" mass in the right upper quadrant is pathognomonic of the disease, but is actually detected by only 49% of physicians, since most cases are diagnosed at an early stage (usually between the third and fourth week).
Historically, laboratory evaluation will show hypokalemia and a hypochloremic, metabolic alkalosis secondary to the loss of gastric hydrochloric acid, although electrolyte imbalances are seen less often now that the diagnosis is made earlier. The imaging modality used most commonly to diagnose IHPS is ultrasound, though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers.
Electrolyte derangements and dehydration must be corrected before proceeding with surgical correction of infantile hypertrophic pyloric stenosis. Studies have shown that children who undergo surgery without first correcting the electrolyte imbalances are at increased risk for postoperative apnea.
Rx: pyloromyotomy
Endoscopically guided balloon dilation has been studied, but is not often used because of inconsistent success in opening the muscular ring of the pylorus. This approach is typically reserved for patients who are not otherwise good surgical candidates.
Studies have documented an association between the development of infantile hypertrophic pyloric stenosis and the usage of oral erythromycin, which is typically given as postexposure prophylaxis for pertussis. In addition, there is some indication that the usage of macrolides in breastfeeding women is linked to the development of infantile hypertrophic pyloric stenosis, especially in infant girls.
Constipation: The normal frequency of passage of stools in the infant is around six to eight times daily. This approximates to one stool passage per episode of breastfeeding. On the fourth week of life, the pattern changes. The stool frequency decreases to one or two episodes daily or even less, such as three episodes per week. This has to be differentiated from true constipation in order to avoid exaggerated concern.
DD: Hirschsprungâs disease usually presents earlier in life (failure to pass meconium in first 48 hours) as intestinal obstruction or enterocolitis. Notwithstanding, some patients will be diagnosed later, but will have a history of chronic constipation and failure to thrive. For this reason, observation is required to determine if the constipation persists.
**While constipation can signify a serious disorder (e.g., Hirschsprungâs disease, cystic fibrosis, hypothyroidism) in select circumstances, most children who are constipated are normal. Children with a history of resisting toilet training are at increased risk for developing constipation, as are those children whose dietary intake is high in dairy products and low in fiber. If dietary modification fails to relieve constipation, usage of a laxative is the next best step. Once the childâs bowel begins to operate properly on its own, the laxatives should be discontinued gradually.
Magnesium hydroxide, also known as milk of magnesia, is a mild saline laxative that causes the osmotic retention of fluid in the gut lumen. It can be titrated to produce soft, but non-liquid stool, and is safe for use in young children. In a child experiencing moderate constipation and no encopresis, magnesium hydroxide is an excellent treatment choice.
Bisacodyl suppositories are powerful stimulant laxatives that cause increased peristalsis. Usage of these suppositories commonly results in abdominal cramping, diarrhea, and nausea, and is best reserved for short-term "rescue therapy" in children with severe constipation.
Phosphate enemas are highly effective at relieving impaction, and act by distending the rectum and stimulating the muscles of the colon; however, frequent use of these enemas can cause electrolyte imbalances, and is therefore discouraged. This form of treatment is best reserved for relieving impaction. or for bowel preparation prior to medical procedures.
#3
Re: Step 3 HY meduploader - 12-19-08 12:23 Tick bite: The risk of acquiring Lyme disease after being bitten by a tick is less than 1.5%. The most common complication of tick bites is local inflammation or infection.
In order to be infected with Lyme disease, the patient must have been exposed to the tick for more than 36 hours, because the transmission of the infectious agent - Borrelia burgdorferi - takes place only after the tick is firmly attached to the skin and has suctioned a certain amount of blood which gives it an engorged appearance. If a tick is found and it is not engorged with blood, there is no risk of Lyme disease, as ticks take at least 24 hours to firmly attach to their victims.
The majority of patients have a transitory skin reaction in the first 24-72 hours on the site of contact with the tick; this lesion must not be confounded with erythema chronicus migrans, which develops later.
The tick that transmits Lyme disease is brown, while the one that transmits RMSF is black
Epiglottitis: With the introduction of the Haemophilus influenzae type b vaccine in 1985, epiglottitis has become much less common in recent years. When it does occur, it causes an inflammatory edema of the epiglottis that impinges upon the airway. Respiratory arrest is easily provoked at this stage, and treatment should be focused on relieving any airway obstruction and treating the infection. The threshold for performing intubation should be very low. Since the outpatient setting is inadequate for such procedures, it is imperative that an ambulance be called so the childâs condition can be properly addressed by emergency personnel.
Frequently, epiglottitis is diagnosed solely by the clinical presentation. However, if a lateral neck radiograph is deemed necessary, it will reveal a swollen epiglottis (the "thumbprint sign") in classic epiglottitis. Endotracheal intubation should be performed before the radiograph is obtained, because patient is at great risk for respiratory arrest.
Lead intoxication: Lead intoxication remains a common preventable environmental hazard, although its prevalence is declining in developed countries. Early recognition of lead poisoning helps to prevent the development of long-term irreversible neurological sequelae. The two main factors contributing to lead poisoning in industrialized countries are exposure to old, lead-based paints which are usually found in old houses, and non-nutritive hand-to-mouth activities of young children.
Children with a blood lead level greater than 10 ĂŹg/dL should be comprehensively evaluated by obtaining a CBC, serum electrolyte levels, and urinalysis. Environmental/behavioral interventions are crucial in the management of patients with lead intoxication. Ideally, these include identifying the source of exposure, removing the family from the lead-containing dwelling, cleansing of the environment, and educating the family in an effort to reduce hand-to-mouth activitiesof the children.
High-risk populations must be screened for lead intoxication. This includes children who live in or frequently visit old houses, and children whose sibling was diagnosed with lead poisoning. Measurement of the blood lead level is the gold standard in lead intoxication screening. A blood lead level greater than 10 ĂŹg/dL is diagnostic. Venous sampling is always preferred to capillary sampling because the former is more accurate.
**Mild lead poisoning (blood lead level < 45 ”g/dL) can be treated by DMSA or d-penicillamine, although this approach is not evidence-based. Moderate lead poisoning (blood lead level between 45 and 70 ”g/dL) requires the treatment with EDTA IV or oral DMSA. Continuous IV infusion of EDTA is preferred to IM injection
Severe lead intoxication (blood lead level > 70 ”g/dL and/or acute encephalopathy) is a medical emergency and prompt chelation therapy with dimercaprol and EDTA is necessary.
Afebrile pneumonia syndrome (APS): Causative organisms of APS include Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma, CMV, RSV, Parainfluenza virus, Adenovirus, and Pneumocystis carinii. The fever may either be absent or low grade. Other symptoms include cough, tachypnea, irritability, and poor feeding. Because of the lack of specificity of symptoms and radiologic findings, the causative organism cannot be determined solely by the clinical presentation. However, some organisms have characteristic features which may aid in the differential diagnosis and direct the necessary work-up of the patient.
The age of onset (between 2 and 19 weeks) and the presence of staccato cough are suggestive of Chlamydia pneumonia. This diagnosis can further be supported if there is a history of conjunctivitis in the neonatal period. Conjunctivitis is present in half of cases and may present either in the neonatal period or be concurrent with the pulmonary infection. Additional characteristics include auscultatory and radiologic findings that are out of proportion to the overall healthy appearance of the infant. Chest-x ray shows hyperinflation, peribronchial thickening, and bilateral, symmetrical, interstitial infiltrates. The WBC count is usually normal, but the eosinophil count is elevated. The diagnosis can be confirmed by tissue culture isolation of the organism from nasopharyngeal specimens, direct fluorescent antibody tests, enzyme-linked immunoassays, or polymerase chain reaction.
Delayed speech development: may indicate an underlying hearing impairment and should prompt referral of the patient for audiologic assessment. Other candidates for hearing evaluation include children with a family history of hereditary childhood hearing loss, history of meningitis, history of recurrent or persistent otitis media with effusion for more than three months, documented intrauterine infections, craniofacial anomalies, and use of ototoxic medications such as aminoglycoside.
Hearing loss early in life, even mild or unilateral, may affect speech and language development, social and emotional development, and academic achievements. Early identification is thus mandatory for a better prognosis; hence, screening programs have been widely and strongly advocated. Although the American Academy of Pediatrics endorses universal screening, at present, systematic screening is implemented in 32 states only.
The etiology of hearing impairment depends on whether the hearing loss is conductive or sensorineural. The most common cause of conductive hearing loss in children is presence of fluid in the middle ear. Other causes include tympanic membrane perforation (trauma or infection), ossicular discontinuity (infection, cholesteatoma, and trauma), tympanosclerosis, and congenital anomalies of the external ear canal or middle ear components. As for sensorineural hearing loss (SNHL), it may be congenital or acquired. The most common infectious cause of congenital SNHL is CMV. Other less common congenital infectious causes include toxoplasmosis, syphilis, and rubella. Postnatal infectious causes include group B streptococcus and bacterial meningitis. Hearing loss can also be genetically determined; it may be autosomal dominant or recessive, isolated or in a syndromic association with other anomalies.
Downs syndrome: Endocardial cushion defect is the most common congenital heart lesion in patients with Downâs syndrome. Other malformations that are frequent in Downâs syndrome include duodenal atresia, Hirschsprungâs disease, atlanto-axial instability, and hypothyroidism. Echocardiography is the most useful test for diagnostic evaluation of this condition. Cardiac catheterization is evidently more accurate than echocardiography for diagnostic evaluation, but this modality is reserved for cases in which the size of the shunt is uncertain, laboratory data and clinical findings are equivocal, or when pulmonary vascular disease is suspected.
Patients with Downâs syndrome are at increased risk of developing acute leukemia later in life. Other conditions which occur with a higher frequency in Down"s syndrome include Alzheimer-like dementia, autism, ADHD, depressive disorder, and seizure disorder.
Infectious mononucleosis: Suspect IM in any adolescent who presents with fever, pharyngitis, tonsillitis, lymphadenopathy, splenomegaly, and rash. The recognition of "atypical lymphocytes" in the peripheral smear can be a clue to its identification, but these can also be seen in toxoplasmosis, CMV infection, or lymphocytic leukemia.
**It is infrequent to find posterior cervical adenopathy in a case of common bacterial pharyngitis. The development of rash after administration of amoxicillin is also one of the characteristics of the disease. Even though the spleen and liver are not always palpable, the former is constantly increased in size and friable. Since there is an increased risk of splenic rupture, especially if the patient is actively involved in sports, a patient who is highly suspicious for IM must be recommended to avoid practicing sports while waiting for the test results. Despite this fact, almost 50% of the cases of splenic rupture associated with IM can occur spontaneously, without evidence of previous trauma or excessive exercise.
Smoking cessation: Nicotine is a highly addictive drug. It is extremely difficult for even the highly motivated to stop smoking. Numerous factors may elicit the urge to smoke. Studies have shown that smokers who attempt to quit while working or living with people who continue to smoke are much more likely to relapse.
Smoking cessation is difficult to accomplish if the smoker remains subject to environmental triggers, including friends and family who continue to smoke.
Parents who want their children to stop smoking should quit themselves.
Prescriptions for nicotine replacement (e.g., nicotine patch, nicotine gum) should be offered to those smokers interested in quitting.
Rash: Due to the success of immunization campaigns, infection with the rubella virus (Choice B) is now very rarely seen in the United States; cases today typically arise in non-immunized foreign born populations. Infection with rubella is most often asymptomatic, but can cause German measles, a mild illness classically characterized by low-grade fever, lymphadenopathy involving the posterior cervical and occipital lymph nodes, and a maculopapular rash that begins on the face and spreads caudally. The rash is similar in appearance to that caused by measles, but patients are usually much less sick upon presentation with rubella. Supportive treatment is sufficient when the illness is self-limited. Of primary concern is the congenital rubella syndrome, which has devastating effects on the unborn child, especially when a non-immune pregnant woman is exposed to the virus in the first trimester.
Varicella, commonly known as chickenpox, is an illness characterized by a low-grade fever, malaise, and a macular rash that appears in crops which progress through several stages, including papules, vesicles, pustules, and crusts. The rash is considered distinctive because it includes a variety of lesions at different stages.
Rubeola, commonly known as measles, is an illness characterized by the three Câs: cough, conjunctivitis, and coryza. Fever and photophobia are also common. The blue-white Koplik spots found on the buccal mucosa precede the appearance of the maculopapular rash, which starts on the face and spreads caudally to the trunk and extremities.
Roseola is a mild illness characterized by a high fever that rapidly resolves. The fever is followed by the eruption of a characteristic rosy nonpruritic rash originating on the trunk and spreading to involve the extremities.
Rocky Mountain Spotted Fever is a rickettsial disease transmitted by tick bite. It is characterized by fever, myalgias, headache, and a petechial rash. Classically, the rash first involves the distal extremities (especially the palms and soles) and subsequently spreads to involve the trunk.
Henoch-Schönlein purpura Classical clinical manifestations of Henoch-Schönlein purpura include abdominal pain, arthralgias, skin lesions, and renal involvement. An antecedent upper respiratory infection is present in 50% of patients. Abdominal pain is a presenting symptom in 10-15% of patients. The skin lesions are symmetric, involve dependent parts of the body, and classically progress from an erythematous, macular rash to papular purpura. The joints and kidneys are also commonly involved.
Thrombotic thrombocytopenic purpura (TTP) is a serious disorder characterized by the following classical pentad:
1. Severe thrombocytopenia
2. Microangiopathic hemolytic anemia (RBC fragments)
3. Fluctuating neurological signs
4. Renal failure
5. Fever
Patients with TTP generally present with fever, pallor, petechiae, and confusion. The peripheral smear shows RBC fragments. PT and PTT are usually normal. The LDH is elevated due to hemolysis. Hemolytic uremic syndrome (HUS) and TTP comes under a spectrum of diseases. If a patient has more neurologic symptoms and less renal failure, the disease is considered TTP. On the other hand, if a patient has significant renal failure and less neurologic symptoms, the disease is considered HUS. Both TTP and HUS are very serious conditions, and require emergent plasmapheresis.
Idiopathic thrombocytopenic purpura Platelet-specific autoantibodies are the presumed pathogenesis of idiopathic thrombocytopenic purpura. In children, the condition is typically characterized by a sudden onset of bleeding, manifested as petechiae, purpura, epistaxis, and gingival bleeding. More severe bleeding is rare. Commonly, there is a history of infection in the several weeks prior to presentation. Symptomatic patients with moderate to severe thrombocytopenia
#5
Re: Step 3 HY meduploader - 12-19-08 12:24 Diaper rash (diaper dermatitis): is a type of irritant contact dermatitis that is caused by a combination of factors: overhydration, friction, maceration and prolonged contact with excretions. The appearance of the rash after an episode of diarrhea is very characteristic. Management includes keeping the diaper area of the skin as dry as possible. This involves: frequent changing of diapers, avoiding tight-fitting diapers, exposing the skin to air, using diapers with super absorbent surfaces, and applying barrier creams such as zinc oxide or petrolatum. An uncomplicated diaper rash resolves quickly if the abovementioned measures are performed. Otherwise, a low-potency corticosteroid ointment may be prescribed.
DD: Candidal diaper rash: Tomato-red plaques and satellite papules are characteristic of candidal intertrigo and perineal infection. This infection is common in infants who have recently received antibiotic therapy because the decrease in the normal bacterial flora favors yeast proliferation. The condition can be confounded with diaper dermatitis, which affects the same area but usually spares the crural folds. Treatment of candidal diaper rash involves the application of an antimycotic cream such as clotrimazole or nystatin, while zinc oxide is the preferred treatment for diaper dermatitis.
Intestinal parasitosis: due to Helminths (hookworms, roundworms, pinworms, or whipworms) is the most frequent cause of chronic diarrhea, iron-deficiency anemia, and eosinophilia in patients coming from endemic countries. The prognosis is excellent with adequate therapy. Since the disease is easily transmitted, prophylactic treatment should be given to the rest of the household members.
Hemophilia: is an X-linked recessive disorder that occurs almost exclusively in males. Females are usually the carriers of the disease. A female may acquire hemophilia, an extremely rare possibility, only when her father is a hemophiliac, and her mother is a carrier who transmits the abnormal allele to her.
When a father is a hemophiliac, he will transmit his abnormal X gene to all his daughters, and consequently, they will all be carriers of the disease. When the mother is a carrier, her daughters have 50% chances of being carriers and her sons have 50% chances of getting the disease.
Childhood absence epilepsy (CAE): age of onset (4-8 years), no neurologic signs, typical EEG pattern, and no myoclonic activity. This condition is usually responsive to ethosuximide or valproate, although high doses may be required to control it effectively. Interestingly, many traditional anti-epileptic drugs are not effective in absence epilepsy, and can even exacerbate the condition (e.g. gabapentin). The prognosis in patients with CAE, especially if generalized tonic-clonic seizures are absent, is good. Staring spells will disappear in the teenage years. The risk of persistence of the condition is higher in patients who develop generalized tonic-clonic seizures. Unlike CAE, juvenile myoclonic epilepsy (JME) is characterized by a late onset of absence seizures with myoclonic activity, and is associated with life-long seizures.
Candidiasis: The first-line therapy for oral candidiasis is a topical antifungal - nystatin suspension or clotrimazole troches. Oral fluconazole can be used in resistant cases.
Child abuse: Always maintain a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, especially if the family has an unstable economic background or if the child"s parents have a history of drug/alcohol abuse.
**Whenever you suspect child abuse, it is strongly recommended that you inform the social services of your hospital or to call the child protection agency. Even if you are proved wrong later on, you do not owe any liability legally and, perhaps, it is the most important step in the management of suspected child abuse.
Allergic rhinitis: Dog or cat dander is one of the most common identifiable allergen in patients with allergic rhinitis. Allergen avoidance is traditionally considered the first step in the management. If the allergen is not identified or the symptoms persist after the avoidance measures, nasal corticosteroids should be the first-line therapy. Second-generation antihistamines and cromolyn are less effective than topical steroids. Nasal decongestive sprays are not recommended because tachyphylaxis usually develops and rebound phenomena may result.
Thalassemia major: Patients with this disorder usually die early in life due to relentless anemia and catastrophic expansion of erythroid precursors. Hypertransfusion therapy has a great role in treated patients (i.e. the child may survive several years after the diagnosis). Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant iron overload and resultant organ damage.
Failure to thrive (FTT): is not a diagnosis in itself; rather, it is a term used to describe failure to gain weight in children younger than two years old. Children categorized as FTT weigh less than the 5th percentile for their age; more severe cases involve a slowing of linear growth and head circumference as well. The three causes of FTT are inadequate calorie intake, inadequate calorie absorption, and increased calorie requirements. Newborn infants need 110 kcal/kg/day, while children up to twelve months need 100 kcal/kg/day to grow at a normal pace. Psychosocial factors are very commonly involved in cases of FTT; this is why the clinician must explore whether there are stressors in the home environment. Organic causes of FTT, while less common, may include feeding problems, milk-protein intolerance, inborn errors of metabolism, infection, cystic fibrosis, gastroesophageal reflux, or renal tubular acidosis.
Dietary modification is the first-line of treatment in an otherwise well-appearing child with FTT.
The anxiety caused to the family by admitting the child to the hospital should not be underestimated. Although admitting a child with FTT for hyperalimentation was a common practice in the past, it is now considered unnecessary unless the child is severely malnourished, or if the child is at risk for neglect or abuse. If oral feedings do not result in appropriate weight gain within four to six weeks, supplemental feeding by nasogastric tube is preferred to the intravenous route.
If the history and physical examination are suggestive of an organic cause for the childâs FTT, then laboratory evaluation is warranted. Appropriate tests include urinalysis and culture, hematocrit, blood urea nitrogen, calcium, electrolyte levels, HIV ELISA test, and Mantoux tuberculin skin testing. Note that unless there is clinical evidence suggestive of thyroid disturbance, thyroid hormone levels are not typically tested.
Cat bites: get infected most of the time. Furthermore, the lesion is usually deeper than when produced by a dog, because the catâs teeth are smaller and sharper. Pasteurella multocida, the major causative organism, is transmitted by the catâs bite. However, this is often a polymicrobial infection. Adequate prophylaxis can be obtained by using amoxicillin and clavulanic acid. In adults, especially those allergic to penicillin, the second alternative is doxycycline. More ill patients can be treated with intravenous ampicillin-sulbactam combination.
** The incidence of infection complicating a cat bite is close to 50%; therefore, antibiotic prophylaxis is usually recommended, especially in high-risk situations (a hand bite is considered a high-risk situation) wherein the potential infection could extend to the bone and joint. The first dose of antibiotics (e.g. ampicillin/sulbactam) is usually given parenterally, and covers a broad spectrum of cat mouth flora, including Pasteurella multocida. An oral antibiotic (e.g. amoxicillin/clavulanate) is administered subsequently for 3-5 days.
Cat-scratch disease: is an infection that usually affects the young immunocompetent population. It is produced by Bartonella henselae. Around 10% of the patients with cat-scratch disease can develop suppuration of the lymph nodes. Other complications are: visual loss due to neuroretinitis, encephalopathy, fever of unknown origin, and hepatosplenomegaly.
#6
Re: Step 3 HY meduploader - 12-19-08 12:25 Gastroesophageal reflux (GER) is a clinical diagnosis. Reassurance should be offered to the mother that the "spitting up" is a normal occurrence in infants up to 24 months old. It typically requires no intervention if the child is otherwise healthy and developing appropriately (the "happy spitter"). Children with mild GER symptoms, should be initially addressed with reassurance and thickening of formula with cereal, which usually results in decreased emesis, decreased cry, and better weight gain.
Prone positioning is another conservative treatment that may alleviate symptoms; however, this treatment method is of some concern, because of the correlation between prone positioning and SIDS. Formula thickening should be attempted first.
H2 receptor antagonists such as ranitidine are appropriate in those infants with a more severe GER presentation and who have failed conservative treatment.
Surgery is reserved for cases of GER that do not respond to medical management.
Pneumonia: It can be difficult to distinguish between bacterial and viral pneumonia, and indeed viral pneumonia is very common in previously healthy children and adults.
Classically, bacterial pneumonias are sudden in onset, associated with high fevers, and cause the child to look very ill if not toxic. Auscultatory findings are typically focal and distinctive. Chest radiographs may demonstrate a lobar consolidation. In contrast, viral pneumonias are gradual in onset and cause the child to look mildly ill. Auscultatory findings are more diffuse and bilateral. Chest radiographs may also demonstrate a more diffuse, bilateral infiltrate. Both forms of pneumonia are frequently preceded by an upper respiratory tract infection.
Community-acquired bacterial pneumonia in children is most commonly caused by S. pneumoniae. Amoxicillin is the drug of choice for the outpatient treatment of patients younger than five years of age.
Group B streptococcus pneumonia occurs most often in neonates.
Mycoplasma causes respiratory infection most often in school-aged children and young adults. The clinical presentation is usually gradual (although it may be abrupt) and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to lower respiratory symptoms.
Pneumocystis carinii pneumonia (PCP) is seen in patients with defects in cell-mediated immunity, especially in HIV-infected patients. It is usually seen in HIV patients when the CD4 cell count decreases to less than 200 cells/cubic mm. It has an insidious onset, and usually presents with low-grade fever, cough, dyspnea, and tachypnea. Chest x-ray results of patients with PCP reveal diffuse, bilateral ground-glass opacity.
Trimethoprim-sulfamethoxazole is the initial drug of choice for treatment in patients with suspected or proven Pneumocystis carinii pneumonia.
Respiratory syncytial virus is the most important respiratory pathogen of early childhood, and the major cause of bronchiolitis and pneumonia in children < 1 year. The illness manifests in annual outbreaks, appearing in winter with peaks in January, February, or March. Although this disease affects all age groups, lower respiratory symptoms appear mainly in children. Apnea is an important clue for this condition, as up to 25% of infants presenting with RSV infection will have this. How it causes significant apnea is not clearly known. The illness tends to be more severe, with a higher frequency of complications in preterms and infants with chronic medical conditions such as congenital heart disease, chronic lung disease, and immune deficiencies.
Diagnosis of RSV is quickly made by detection of RSV antigen in nasal or pulmonary secretions by ELISA.
**In healthy infants and young children, bronchiolitis is usually a self-limited disease; however, patients who are hypoxic or cannot feed because of distress should be hospitalized. These children should be kept in respiratory isolation. Therapy in most cases consists of supportive measures. Humidified oxygen and tube or intravenous feedings are indicated. Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis, it is a routine practice to administer these (nebulized albuterol or epinephrine) and observe the patient for any effect. If no prompt clinical response is seen, most clinicians discontinue these drugs.
Although ribavirin is a nucleoside analogue with good in vitro activity against RSV, studies examining its effect in children have been conflicting, and the cost for a course of therapy is substantial. It is usually reserved for patients with severe disease.
A secondary bacterial infection of the middle ear and future risk of bronchial hyperreactivity are the most common complications of RSV bronchiolitis.
Congenital toxoplasmosis: The consumption of undercooked meat during pregnancy may be associated with congenital toxoplasmosis, which can manifest as microcephaly or other abnormalities, such as chorioretinitis, mental retardation, deafness, and seizures. Domestic cats are definite hosts for T. gondii. Humans can acquire the infection by: (1) the consumption of raw or undercooked meat of infected animals (including lamb, beef, or game), or (2) contact with cat feces. Other congenital infections of the TORCH group can also result in microcephaly.
Rehumatic disease prophylaxis: The benefits of antibiotic therapy in a child with acute pharyngitis include: (1) reduction of the severity and duration of the symptoms, (2) prevention of rheumatic fever, and (3) prevention of local suppurative complications.
Interestingly, antibiotic therapy does not decrease the risk of acute glomerulonephritis because cutaneous (not pharyngeal) infection is typically implicated as its cause.
Disease associations: Meconium ileus is usually the earliest manifestation of cystic fibrosis (CF), and is almost pathognomonic for the disease. Uncomplicated meconium ileus is characterized by distal intestinal obstruction, wherein the terminal ileum is dilated and filled with thick, tar-like, inspissated meconium. Plain abdominal x-ray findings (dilated, gas-filled loops of small bowel, absent air-fluid levels, and a meconium mass within the right side of the abdomen) are usually suggestive of the diagnosis. Since CF is inherited in an autosomal recessive pattern, a family history of recurrent respiratory infections (or other manifestations of CF) is an important clue to the diagnosis of this patient.
Duodenal atresia is associated with Downâs syndrome and polyhydramnios.
A family history of severe constipation is sometimes present in patients with Hirschsprungâs disease.
Patients with pyloric stenosis are typically firstborn males.
Even though most cases of muscular dystrophy such as Duchenneâs, Beckerâs, or myotonic dystrophy present around 10-12 years of age, some cases can be diagnosed when the child is 2-3 years old. Limb-girdle or facioscapulohumeral muscular dystrophies can be detected at this age; while congenital dystrophies and glycogen-storage diseases are evident soon after birth, and have early mortality.
Muscular dystrophy can be a cause of inability to walk or limping in the infant or toddler, even though the more common cause of this problem is spasticity, a condition amenable to rehabilitation therapy. Hypothyroidism, MSUP and phenylketonuria must be screened for at birth, and are almost always accompanied by mental retardation and global delays in development.
Neonatal screening for hypothyroidism is performed by obtaining a small sample (few drops) of blood from the heel pad and using a piece of filter paper to absorb the blood sample. This test may be done within two to five days following delivery. It is performed after the first 24 hours of life because there is a normal physiologic TSH surge following delivery. After 24 hours, the TSH levels gradually drop to normal levels or may remain slightly elevated for the next few days. It is very important to avoid any delays in the diagnosis and treatment to avoid permanent neurological deficits.
Most centers in the United States use total T4 measurement as a primary tool for screening for neonatal hypothyroidism. If the total T4 levels are low, TSH levels of the same sample is measured, and if the TSH levels are over 20 U/L, repeat testing (measurement of both Free T4 and TSH levels) is performed from a regular blood draw to confirm the diagnosis. Some programs use TSH as a primary screening tool.
Once the diagnosis of neonatal hypothyroidism is confirmed by measuring the Free T4 and TSH levels from a regular blood draw, other ancillary procedures such as thyroid ultrasonography, radioactive iodine scanning and urinary iodide levels are performed to investigate the etiology of the hypothyroid state. Radioactive iodine uptake and scanning are useful to determine the location, size and function of the thyroid gland.
Levothyroxine is the treatment of choice for hypothyroidism, and the dose in the neonate is higher than the adult dose; however, levothyroxine therapy should be started once the diagnosis is confirmed with a regular blood draw. The clinical features of hypothyroidism in neonates can be subtle and unreliable. Levothyroxine therapy in neonates is therefore started once the biochemical confirmation is obtained, even if the clinical features of hypothyroidism are not present.
Febrile seizures
The generally accepted criteria for febrile seizures are:
1. Age less than six years
2. No past history of afebrile seizures
3. Temperature greater than 38 C
4. No evidence of CNS infection / inflammation
5. No metabolic disturbances present which may produce seizures
Febrile seizures may be subdivided into 2 forms: simple and complex.
A simple febrile seizure is characterized by the absence of focal features, a duration of less than 15 minutes for an isolated event, and for seizures occurring in series, a cumulative duration of less than 30 minutes. This form of seizures is more common, and is associated with only a mild elevation of the risk for subsequent epilepsy (i.e. afebrile seizures) in latter life, compared to the general population,contrary to previous thinking.
It is important to note that the question specifically asks about prognosis, and not recurrence. If the question particularly asks about the recurrence of febrile seizures during childhood, then the answer would be âsignificantly elevated riskâ, regardless if this case was a simple or complex febrile seizure for the first time.
Febrile seizures often occur on the first day of a mild illness as the childâs temperature is rising, and may be the first manifestation of illness. Generally, studies are not necessary for the evaluation of the simple febrile seizure, although it may be appropriate to explore the cause of the fever in children with other symptoms (e.g., severe diarrhea). Parents should be reassured that it is not an indication of future neurologic dysfunction or disease.
Complex febrile seizures, on the other hand, are characterized by focal features (i.e. postictal paresis), a duration of more than 15 minutes, and if occurring in series, a cumulative duration of greater than 30 minutes.
Congenital adrenal hyperplasia (CAH) is a group of disorders characterized by a deficiency in one of the enzymes involved in steroid synthesis. In 90% of cases, the deficiency concerns 21-hydroxylase, which is necessary in mineralocorticoid and glucocorticoid synthesis. In addition to a low production of mineralocorticoids and glucocorticoids, the deficiency of 21-hydroxylase results in an excess of its substrates. These excess substrates are shunted towards androgen synthesis, resulting in ambiguous genitalia and virilization in females, and precocious puberty in males. ACTH levels are also evidently elevated, and lead to hyperplasia of the adrenal glands, further contributing to the increased production of androgens.
Salt wasting syndrome occurs in severe deficiencies. It presents in the first 2-4 weeks of life with emesis, dehydration, and shock. Laboratory work-up reveals hyponatremia and hyperkalemia (from lack of aldosterone), and hypoglycemia (from lack of cortisol).
Diagnosis confirmation of 21-hydroxylase deficiency is carried out by documenting the elevation of 17 alpha-hydroxyprogesterone, a substrate of 21-hydroxylase. Other biologic disturbances occuring in 21-hydroxylase deficiency include elevated corticotropin and renin levels, and a serum aldosterone level that is inappropriately low for the renin level.
The treatment principle for 21-hydroxylase deficiency is based on supplementation of deficient hormones (mineralocorticoids and glucocorticoids). This supplementation will decrease corticotropin (ACTH) production, and consequently correct androgen levels.
11-hydroxylase deficiency is a far less frequent cause of CAH than 21-hydroxylase deficiency. It is characterized by: (1) decreased aldosterone and cortisol, and (2) increased androgens and deoxycorticosterone. A deficiency in 11-hydroxylase results in an excess in its substrate, 11-deoxycorticosterone. This substrate has mineralocorticoid activity. Patients with this condition present with hypertension, hypernatremia, and hypokalemia.
3-beta-hydroxysteroid dehydrogenase is a rare cause of CAH. It involves: (1) a decrease in testosterone, mineralocorticoids and glucocorticoids, and (2) an increase in DHEA-S. Consequently, males fail to acquire normal external genitalia because of a lack of testosterone, and females are slightly masculinized because of DHEA-S excess.
#7
Re: Step 3 HY meduploader - 12-19-08 12:25 Marfan syndrome (MFS): a disease characterized by arachnodactyly, increased arm span relative to height, and valvular (mitral or aortic) insufficiency. Dural ectasia is the most common finding, although frequently overlooked (present in more than 90% of patients), and usually requires an MRI of the lumbar spine for the confirmation of the diagnosis. Other characteristics that can affect up to 80% of the patients with MFS are ectopia lentis, aortic dilatation (more frequent in adults), and mitral valve prolapse.
The risk of aortic dissection is high in patients with MFS. For this reason, corrective surgery is recommended when the aortic root reaches 45 mm. About 80% of the patients will have mitral insufficiency, which can lead to CHF. These patients will benefit from mitral valve replacement.
Diaphragmatic paralysis in a newborn usually results from phrenic nerve injury. The two most common causes of phrenic nerve injury are birth injury and cardiothoracic injury . It is typically accompanied by the signs of brachial plexus injury, like Erbâs palsy. Other causes of diaphragmatic paralysis, (e.g., diaphragmatic hypoplasia, neural and neuromuscular disorders) are very rare.
Myelomeningocele: In 80% of myelomeningocele cases, the lumbar region is involved. Almost all these patients will have bladder dysfunction, which can ultimately lead to upper urinary tract involvement and renal dysfunction. Children with S2-S3 involvement can have external anal sphincter dysfunction that can lead to fecal incontinence. This is a much less common complication than bladder involvement, and is specifically associated with S2-S3 involvement.
Giardiasis has several routes of transmission: person-to-person, food-borne and waterborne. Person-to-person transmission occurs in two settings: (1) in institutions where there is fecal incontinence and poor hygiene (e.g., some daycare centers), and (2) in male homosexuals. Symptomatic patients with giardiasis should receive appropriate treatment.
Asymptomatic carriers of Giardia lamblia are not usually treated, except in specific instances such as in outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis.
Severe malnutrition: remains as one of the major health problems in developing countries.
The initial treatment of patients with severe malnutrition should address the following issues: temperature control (warming), possible infection, dehydration and malnutrition (feeding). Dehydration should be treated with oral rehydration whenever possible.
Posterior urethral valves are predominantly found in males and are the most common cause of severe obstructive uropathy in children. The abnormal development of the valves in utero can obstruct urinary flow, leading to detrusor hypertrophy and, eventually, vesicoureteral reflux and hydronephrosis. Hallmarks of PUV include a distended bladder and a weak urine stream.
Voiding cystourethrogram (VCUG) is a radiographic examination of the bladder and lower urinary tract. The bladder is filled with contrast material by catheter and multiple radiographic images of the bladder and urethra are obtained as the patient empties the bladder. VCUG is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves.
Foreign body aspiration:
Never forget your ABCs of resuscitation no matter what the nature of emergency is.
The Heimlich maneuver is recommended in kids older than one year. Below that age, give blows on the back with chest thrusts.
If the child is unconscious, do it while the patient is lying down. After the abdominal thrusts, examine the airway for a foreign body. If visualized, it should be removed.
Transient synovitis (also known as toxic synovitis) is a common condition that causes pain in the hip, thigh, or knee in boys aged 3-10 years old. Up to 25% of children with transient synovitis will have bilateral effusions. The disorder may be preceded by a respiratory infection, although the erythrocyte sedimentation rate (ESR) and white blood count (WBC) are typically normal. If the clinical presentation suggests transient synovitis and plain radiographs are unremarkable, an ultrasound should be performed. Ultrasonography is the preferred technique for identifying small joint effusions, and may demonstrate widening of the joint space of the hip. This modality is also useful in guiding aspiration of the joint, a procedure that is warranted in a febrile child with hip effusion.
Breastfeeding: Every primary care physician should encourage breastfeeding. It is recommended that the infant be fed at least every four hours. The mother should be able to identify early signs of hunger, like suckling of the hand or fingers or arm movements towards the mouth, as preterm or debilitated infants may not be able to cry vigorously or show agitation.
It is a good practice to feed the newborn using both breasts, as complete emptying of the breast will increase the milkâs nutritional qualities. Unfortunately, sometimes there may be a decreased production of milk, and the baby has to be fed using artificial formula. Feeding the baby using both breasts will therefore not guarantee the infantâs satiety.
Neonatal jaundice appearing in the first 24 hours of birth is always pathologic. Immune or non-immune hemolysis is frequently present in such patients.
G-6-PD deficiency is the most common red cell enzymopathy that can lead to hemolysis. It is an X-linked disorder, and should be suspected in a male infant of African, Mediterranean, or Asian descent. No triggering agent is usually present, although those infants who develop severe jaundice with G6PD deficiency usually have Gilbert"s syndrome as well.
Physiologic jaundice manifests 24 hours after birth.
Enterovirus and Arbovirus infections are the most common cause of viral meningitis or encephalitis in the pediatric population. These infections are more frequent during summer, late spring, and early fall. Most arbovirus infections are zoonosis (transmitted through animal vectors); for this reason, these infections are more common in the rural areas. Herpes simplex virus is the most common cause of viral meningitis in the adult population, not in children.
Sickle cell disease is an inherited disorder that results from the presence of hemoglobin S. The most severe and common form is sickle cell anemia, in which only hemoglobin S is present (HbSS). Clinical manifestations rarely present prior to 6 months of age, when fetal hemoglobin levels decline and functional asplenia typically develops. Dactylitis (pain in the hands and feet) is common in the first 18 months of life. The best diagnostic test is hemoglobin electrophoresis because it precisely determines which form of sickle cell disease is present.
Acute severe anemia may be superimposed on chronic anemia in patients with sickle cell disease. When this occurs, it is a life-threatening condition. Clinical manifestations include weakness, pallor and lethargy. The three typical causes of acute anemia are splenic sequestration crisis, aplastic crisis, and hyperhemolytic crisis.
Aplastic crisis represents a transient failure of erythropoiesis with an abrupt reduction in the blood hemoglobin and the number of erythroid precursors in the bone marrow. A very important finding during a crisis is the virtual absence of reticulocytes. The typical cause is an infection; parvovirus B19 infection is the most common cause in children.
Intussusception occurs when a part of the small bowel is telescoped into itself. The most frequent vicinity is the ileocecal region. Almost 60% of the cases occur in children younger than 1 year of age, while 80% present before 2 years of age. The classic presentation is a sudden onset of colicky abdominal pain followed by vomiting, and the vomitus rapidly changes from alimentary to bilious. The child usually draws up his legs towards the abdomen because of the pain. Hematochezia is present in 70% of the cases; 15% of the patients have the characteristic "currant jelly" stools. Initially, the child is irritable, but he may eventually become apathetic when he is no longer able to eat, and he gets dehydrated. Palpation of a sausage-shaped abdominal mass on the right side is characteristic. Abdominal x-ray reveals generalized distension of the bowel loops or another evidence of obstruction. An enhanced density that projects into the air level of the large bowel can be identified in 25% of the cases. This density represents the invaginated bowel loop, and is known as the "crescent sign."
DD: Acute gastroenteritis (AGE) presents with fever that precedes abdominal pain and diarrhea. AGE will not explain the presence of the abdominal mass and the massive bowel distention seen in the abdominal x-ray of this patient.
Meckelâs diverticulum usually presents in toddlers and older children, generally between five and ten years of age, and in young adults. The most common location of pain is in the right lower quadrant. Hematochezia is also present, but the stool is non-mucoid, and there is no palpable abdominal mass.
Erbâs palsy: The classical scenario of Erbâs palsy is described. It is the most common form of obstetrical brachial plexus injury and involves the upper roots (C5, C6, and sometimes C7) of the plexus resulting in an adducted and internally rotated right arm with forearm pronation and flexed wrist. A serious complication is diaphragmatic paralysis due to phrenic nerve involvement. Symmetric palmar grasp reflex indicates that lower roots of the brachial plexus are intact and is a good prognostic sign. The prognosis of Erbâs palsy is typically good with an 80% chance of full or near-full recovery. Hornerâs syndrome may be associated with the injury of lower roots of the brachial plexus.
Gastrointestinal foreign bodies occur typically in toddlers, because exploring objects by putting them into the mouth is a characteristic behavior pattern in that age group. Coins are the most common GI foreign bodies. Foreign bodies can become lodged in any of the areas of esophageal physiologic narrowing. They require attention and frequently removal in that case. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty. Pyloric obstruction is rare and manifests as persistent vomiting.
Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty; therefore, no intervention is usually necessary.
Cellulitis: is characterized by its irregular and elevated borders, as well as increased local temperature, tenderness, and erythema. It is an infection located between the subcutaneous tissue and the fat, therefore local anesthesia will not be useful in this situation. Pain can be treated by oral analgesics.
Cleft lip with or without cleft palate is typically a multifactorial disorder but can have autosomal dominant, autosomal recessive, and X-linked inheritance, as well as be associated with teratogenic agents. Reconstruction of a cleft lip is generally performed at approximately three months of age according to the rule of â10:â 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin.
The reticulocyte count is an index of RBC production by the bone marrow. Increased destruction of RBCs (hemolytic anemia) prompts the normal bone marrow to compensate for the loss by increasing the rate of erythropoiesis, which results in an increased reticulocyte count. On the other hand, nonhemolytic anemias, due to a decreased production of RBCs, will result in a low reticulocyte count. The reticulocyte count is therefore increased in hemolytic anemia, and decreased in nonhemolytic anemia.
Diabetic ketoacidosis (DKA) must be suspected in any child with dehydration, metabolic acidosis, nausea, vomiting, tachypnea without oxygenation problems, abdominal pain, and hyperglycemia. Patients must be immediately admitted to the Intensive Care Unit for correction of the metabolic acidosis and dehydration. Treatment involves intravenous fluids and insulin administration, as well as adequate potassium supplementation (to avoid hypokalemia).
Botulism: Giving honey to the child is the main clue to the diagnosis. Constipation is typically the first manifestation of the disease, and is followed by lethargy, poor sucking and weak crying. Gag reflex is frequently impaired. This may result in aspiration if airways are not protected.
Chlamydial infection This newborn most likely has conjunctival and pulmonary chlamydial infection. Chlamydia may have been transmitted from the mother during the neonate"s passage through the birth canal. Cervical carriage in the mother has been associated with a higher incidence of preterm labor, PROM, and late post-term endometritis.
Chlamydia is the most common causative agent of infectious neonatal conjunctivitis. Infected infants have a 25-50% risk of developing conjunctivitis and a 5-20% risk of developing pneumonia. Chlamydial conjunctivitis develops a few days to several weeks after birth and manifests with conjunctival congestion, edema, and mucoid or frank purulent discharge. Pneumonia usually appears 3-19 weeks after birth, and symptoms include cough, tachypnea, rales, and absence of fever. Wheezing is rare. The latter two features differentiate chlamydial pneumonia from RSV bronchiolitis.
Neonatal disease is best prevented by early detection and treatment in pregnant women. Screening is recommended in high-risk individuals such as single mothers, adolescents, patients with low socioeconomic status, and promiscuous patients. Erythromycin is the drug of choice in pregnancy and should be given to both the patient and her sexual partner. Another test should be performed later in pregnancy, and a positive result warrants a second course of antibiotics. Infants should also be treated with oral erythromycin for 14 days, as topical agents are ineffective. Colonization takes place during delivery, when the newborn comes in contact with the vaginal secretions of the mother.
#8
Re: Step 3 HY meduploader - 12-20-08 09:48 OBG
Preconception: All women who wish to get pregnant should take 400 micrograms of folic acid daily at least one month before the projected date of conception. Oral contraceptive pills (OCPs) can be stopped at any time; however, conception may be delayed because the patient may continue to have anovulatory cycles immediately after discontinuation.
Screening: Alpha-Feto-Protein (AFP) is produced by the yolk sac and fetal liver and a certain amount of it crosses the placenta to the maternal circulation. AFP production is altered in the presence of fetal anomalies, and its measurement in maternal serum can be used to screen for these anomalies.
Increased levels are seen in the presence of neural tube defects, abdominal wall defects (Gastroschisis, Omphalocele), as well as âfalse positiveâ causes such as fetal demise, multiple gestation, and inaccurate gestational age. In the case of an increase in MSAFP levels, the physician should first perform an ultrasonography to rule out the false positive causes, and to detect the presence of any anomaly that may be seen by ultrasound. Amniocentesis has to be ordered afterwards for confirmation by measuring amniotic levels of AFP and Acetylcholinesterase (AChE). AChE is a protein that is increased only in neural tube defects.
Low levels of MSAFP are frequently associated with chromosomal anomalies, especially Downâs syndrome. The screening can be rendered more accurate when MSAFP is coupled with beta-hCG and Unconjugated Estriol (UE3) levels; it is then called triple test. A combination of a decreased MSAFP, increased beta-hCG and decreased UE3 levels is typical of Downâs syndrome, whereas in trisomy 18, all three parameters are decreased. Likewise, Ultrasonography has to be performed to rule out inaccurate dates and fetal demise, then amniocentesis to confirm the diagnosis. MSAFP and triple test should be performed between the 16th and 18th week of gestation, and it must be noted that their reliability in screening depends greatly on the accuracy of the gestational age.
Amniocentesis is indicated in cases of abnormal levels of MSAFP or triple screen, but after ultrasonography has ascertained gestational age accuracy, and ruled out fetal demise and multiple gestation. It is best performed between 16 and 20 weeksâ gestation.
Chorionic villous sampling (CVS): Chorionic villus sampling is indicated in women with known genetic diseases, or previously affected children. It is performed between 10 and 12 weeksâ gestation, and therefore offers the advantage of a first trimester termination of pregnancy in case the fetus is affected.Transverse limb abnormality is one of the complications of chorionic villous sampling (CVS). The risk of this complication depends upon the age of gestation; the risk is greatest when the age of gestation is less than 9 weeks, and is lowest when it is greater than 11 weeks.
Cordocentesis or Percutaneous Umbilical Blood Sampling (PUBS) is used for rapid karyotype analysis, or when fetal blood dyscrasias, such as fetal anemia and Rhesus isoimmunization, are suspected. In the present case, ultrasound has to be performed first to rule out the other causes of MSAFP elevation beside genetic anomalies.
Serum estriol levels can be measured in pregnancy along with MSAFP and beta-hCG (Triple test) as a screening tool for chromosomal anomalies in the fetus.
#9
Re: Step 3 HY meduploader - 12-20-08 09:49 Down syndrome: is the most common autosomal abnormality among live births and the most common cause of mental retardation in children. Most cases are caused by total trisomy 21, which typically arises from maternal meiotic nondisjunction. Since advanced maternal age (defined as 35 years of age or older) is associated with an increased risk of having offspring with Down syndrome, accurate prenatal screening for the condition is in high demand. At this time, the integrated test is considered the best overall screening test for Down syndrome, with a detection rate of 85% and a false positive rate of 1.2%. The integrated test is comprised of ultrasound measurement of nuchal translucency thickness at 10 weeks in combination with measurement of serum markers from the first trimester (PAPP-A) and the second trimester (alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and dimeric inhibin-A); however, the actual diagnosis of Down syndrome can only be made by examining the fetal karyotype, which requires chorionic villus sampling or, more commonly, amniocentesis.
BioPhysical Profile: BPP is a scoring system to evaluate baby's well being. Its indicated when there is Decreased movement or a non-reactive NST. It includes NST in addition to 4 things, 1-Fetal tone, 2-Movment, 3-Breathing(30/10min), 4-Amniotic fluid inxed(5-20). Each has a score of 2, when present and 0 when absent. 8-10 is normal, and should be repeated once or twice weekly, until term.In presence of OlygoHydramnions (AFI
#10
Re: Step 3 HY meduploader - 12-20-08 09:49 Preeclampisa/Eclampsia: A history of preeclampsia in the past increases the risk of developing this complication during a subsequent pregnancy. The risk is higher if the preeclampsia presented earlier (age of delivery was less than 32-33 weeks), or if the patient has renal disease or chronic hypertension.
Patients at term and with severe preeclampsia should be promptly managed with hydralazine (or labetalol) to lower the blood pressure, and MgSO4 to prevent progression to eclampsia. Once initial stabilization has been obtained, delivery should be carried out. For patients with mild preeclampsia, vaginal delivery is the preferred mode of delivery. For patients with severe preeclampsia, the preferred mode of delivery has not been evaluated. Cesarean section should be decided on an individual basis.
Patients with severe preeclampsia and who are remote from term are best managed in a tertiary care center or by referring them to obstetricians who specialize in the management of high-risk pregnancies.
Patients with severe preeclampsia are at greater risk of developing eclampsia. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Anticonvulsant medications can be administered after placing two large-bore needles in the patient. The most effective agent used in these cases is magnesium sulfate; however, the most effective treatment to prevent further complications is to accelerate delivery. Eclampsia can cause several other complications besides seizures, such as disseminated intravascular coagulopathy, acute renal failure, hepatocellular injury, liver rupture, intracerebral hemorrhage, etc. Magnesium sulfate prevents seizures, but it will not stop the pathologic process.
So if Qs asks Which of the following is the most effective strategy to decrease this patient"s risk for developing further complications?
Ans: Speed vaginal delivery or termination of pregnancy
if the question asks about the next step in the management?
Magnesium sulfate, because the hemodynamic stability and seizure control are important before attempting delivery.
So the bottom line is If the patient is in the third trimester, especially in the last six weeks, termination of pregnancy is advised in order to stop the pathologic process. There is no pharmacologic therapy more effective than this intervention.
Anti-seizure prophylaxis in a patient with eclampsia has been a topic of prolonged debate. Recently, some studies have confirmed that magnesium sulfate is not only the best anticonvulsant medication for patients with eclampsia, but it is also the more effective agent to prevent further seizures. Diazepam or phenytoin can be added to the therapy if seizures persist, even though the use of diazepam is limited because of depressant effects on the fetus.
In pregnant patients with a hypertensive crisis, either hydralazine or labetalol are the antihypertensive drugs of choice. Methyldopa is preferred for oral therapy in mild to moderate hypertension in a pregnancy.
Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia/eclampsia.
Eclampsia is diagnosed when unexplained convuslions occur in the setting of preeclampsia.
HELLP syndrome is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and abnormal liver function tests. Magnesium sulfate is the standard of care for patients with severe preeclampsia and HELLP syndrome, because it significantly reduces the risk of seizure and is relatively safe. Although 50% of all cases of eclampsia occur prior to term, the risk is significant within the first 24-48 hours after delivery. Magnesium sulfate infusion should cover this period. Antihypertensive agents may be indicated to control elevated blood pressure if it exceeds 160/105 mmHg. Plasma exchange transfusion is useful in patients with persistent HELLP syndrome.
#11
Re: Step 3 HY meduploader - 12-20-08 09:50 Preterm pregnancy: Respiratory distress syndrome (RDS) is a common complication in preterm infants. It occurs when fetal lung maturity has not been reached yet. Other complications of preterm birth include intraventricular hemorrhage, sepsis, necrotizing enterocolitis and kernicterus. The mortality rate in preterm infants is greatly influenced by the gestational age. For instance, it is similar to that of full-term infants when birth occurs at 36 weeks and attaining 50% when it occurs at 24 weeks.
The patient in advanced stage of labor should be managed more aggressively and tocolysis has to be instituted at once. Magnesium sulfate is now the drug of choice for tocolytic therapy because of its fewer side effects such as feeling of warmth and flushing. However, it is not FDA approved for this use. It is particularly useful in the presence of contraindications to beta 2 agonists, such as diabetes and heart disease. It acts by competing with calcium ions for entry into the cell.
Among tocolytic agents, Ritodrine (beta 2 agonist) is the only agent approved by FDA for management of preterm labor. Terbutaline is also widely used in the US and exists in the oral, subcutaneous and intramuscular forms. Most side effects of beta-agonist result from their concurrent b1 activity, and include increase in heart rate, rise in systolic pressure, decrease in diastolic pressure, chest pain secondary to MI, and arrhythmia. Beta agonists may also cause fluid retention secondary to decrease in water clearance, which when added to the tachycardia and increased myocardial work, may result in cardiac failure. In addition, they increase gluconeogenesis in the liver and muscle, resulting in hyperglycemia, which increases insulin requirements in diabetic patients. The passage of beta-agonists through the placenta does occur and may be responsible for fetal tachycardia, as well as hypoglycemia or hyperglycemia at birth.
Other tocolytic gents include prostaglandin synthetase inhibitors, such as indomethacin, and calcium channel blockers. Indomethacin is quite effective but it can result in oligohydramnios and premature closure of ductus arteriosus. It also decreases fetal renal function and increases the risk of necrotizing enterocolitis and intracranial hemorrhage. Calcium channel blockers are promising agents and nifedipine may gradually replace I.V. b-agonists. Its only side effects are headache, hypotension, tachycardia and cutaneous flushing. Tocolytic therapy does not decrease the incidence of preterm births but prolong gestation, increasing thus, birth weight and decreasing complications related to prematurity. Contraindications include chorioamnionitis, pre-eclampsia, placenta abruptio, severe placenta previa bleeding, fetal demise and fetal anomalies incompatible with life.
Cervical cultures should also be performed to detect urinary or genital infections, as well as the presence of group B streptococcus. It is reasonable to administer prophylactic antibiotic therapy since it has been proven to prolong pregnancy even in the absence of ruptured membranes. Steroids are also necessary at this stage of pregnancy. When administered between 24 and 34 weeksâ gestation, they accelerate fetal lung maturity and thus decrease the incidence of RDS. They also reduce mortality and the incidence of intraventricular hemorrhage.
Post-term pregnancy: Post-term pregnancy is defined as a pregnancy age more than 42-weeks gestation. Perinatal mortality is 2-3 times higher in post-term pregnancies and it is related most commonly to post-maturity syndrome, which occurs consequently to aging and infarction of the placenta. Post-mature infants typically have a loss of subcutaneous fat, long fingernails, dry and peeling skin, and abundant hair. In 70-80% of cases, fetuses are not affected by placental insufficiency and continue to grow past 42-weeks gestation, resulting in macrosomia. The cause of post-term pregnancy is unknown; however, some associated syndromes have been noted such as anencephaly and trisomy 18.
In terms of diagnosis of post-term pregnancy, the importance of accurate dating cannot be stressed enough. In fact 20-30% of pregnancies have uncertain dates, which may mislead to another diagnosis or cause it to be overlooked.
The management of post term pregnancy is principally based on the well being of the fetus. The non-stress test and biophysical profile should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished. If on the contrary, those parameters are reassuring, as in this case, labor should not be induced unless the cervix is favorable, the infant is macrosomic or in the presence of obstetrical indications for delivery. If the pregnancy is more than 43 weeks, delivery is mandated. If the pregnancy is more than 42 weeks, the cervix is favorable and fetal head is into the pelvis labor should be induced. Patients with uncertain dates should be managed expectantly as long as fetal assessment is reassuring, and the possibility of preterm pregnancy should be considered as much as that of post-term pregnancy.
Expectant management is more appropriate since fetal heart tracing is reassuring and there is no oligohydramnios. Moreover, the cervix is not favorable for induction of labor.
The patient does not have oligohydramnios (AFI of 5 or more), so amnioinfusion is not necessary.
C. Section is indicated in the presence of signs of fetal distress. The fetal heart activity of this fetus is normal.
Fetal lung maturity is not a concern here since it occurs in preterm not post-term infants. The respiratory condition most frequent in post term fetuses is meconium aspiration.
Premature rupture of membranes (PROM): Premature rupture of membranes (PROM) is a rupture that occurs before labor at any time of gestation. Preterm PROM (PPROM) is the rupture of membranes that occurs before term, whether there are uterine contractions or not. The origin of PROM or PPROM is not clear yet. Several etiologic factors, however, have been supposed to contribute to its occurrence. Such factors include infection, abnormal membrane physiology, incompetent cervix and nutritional deficiencies of copper and ascorbic acid. The diagnosis of rupture of membranes is mainly clinical. The patient usually complains of either a gush or continual leakage of clear fluid from the vagina. Differential diagnoses include urinary incontinence, vesicovaginal fistula and leukorrhea. On examination, amniotic fluid may be noted in the vagina or leaking through the cervix when Valsalva maneuver or slight fundal pressure is applied. When the patient is not in labor, and whether the pregnancy is at term or not, the hand of the examiner should not be inserted into the vagina because of the increased risk of infection, and the examination should be performed with a sterile speculum. The amniotic origin of the fluid is confirmed by Nitrazine paper, which turns blue when in contact with amniotic fluid. It can be confirmed by demonstration of arborization, or âferningâ when the fluid is air-dried on a slide and examined at low magnification. In the case of PPROM, amniotic fluid sampling to measure fetal lung indices is mandatory. Also, ultrasound examination should be performed to detect fetal anomalies, determine gestational age and measure amniotic volume, which will all influence the management decision. In the case fetus with a severe congenital anomaly incompatible with life labor should be allowed to proceed.
Intra Uterine Fetal Demise (IUFD): Intra Uterine Fetal Demise (IUFD) is the death of a fetus in utero that occurs after 20 weeks gestation and before the onset of labor. It can be caused by a multitude of conditions such as hypertensive disorders, diabetes mellitus, placental and cord complications, antiphospholipid syndrome, congenital anomalies, and fetal infections (TORCH, Listeria). The cause remains, however, unknown in 50% of cases. A search should be undertaken to determine the cause after the first episode of IUFD. The work up should include: serology testing and cultures of TORCH, Listeria and Parvovirus infections, an autopsy, complete body radiographs and chromosomal studies of the fetus, testing for anticardiolipin antibodies and Kleihauer-Betke test to detect a fetomaternal hemorrhage. It is very important to try to diagnose the cause of the demise after the first episode and to correct it, in order to prevent recurrence in the following pregnancy. IUFD is suspected when the patient reports the disappearance of fetal movements, a decrease or stagnation in uterine size, and/or when fetal heart sounds are no longer heard. The most appropriate test to confirm this diagnosis is Real Time Ultrasonography, which will demonstrate a lack of fetal movement and absence of fetal heart activity. Beta-hCG serum levels are not useful because they remain usually elevated because of an ongoing placental production. After the diagnosis is confirmed, the coagulation profile has to be determined to detect an eventual disseminated intravascular coagulation, which is a serious complication of IUFD, early in its course.
IUGR: IUGR is defined as birth weight below the 10th percentile for a given gestational age, and refers to fetuses and neonates whose growth potential has been restricted by pathologic processes in utero. These fetuses are particularly prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia, and mental retardation.
Once IUGR diagnosed, fetal well-being has to be closely monitored with NST and BPP twice weekly. The mother can also contribute to this monitoring by assessment of a kick count.
Decision to deliver depends on fetal well-being and lung maturity. Delivery is usually indicated at 34-weeks or later, or at any gestational age when fetal lung maturity is reached. If there is an associated oligohydramnios, delivery should be strongly considered. In addition, IUGR fetuses are more susceptible to asphyxia, and the threshold to perform a C. section should be lower than that of normal fetuses. In fact, some signs on fetal heart tracing that may be considered reassuring in a normal fetus, are ominous in a fetus with IUGR and may indicate distress.
At birth, neonates with IUGR are very prone to hypothermia, and hypoglycemia. Respiratory distress syndrome also frequently occurs because of reduced surfactant synthesis and release caused by asphyxia and resultant acidosis.
#12
Re: Step 3 HY meduploader - 12-20-08 09:50 Labor: Labor is defined as the progressive cervical effacement, dilatation, or both resulting from uterine contractions, which occur at least every 5 minutes and last 30 to 60 seconds.
Labor progresses through four stages:
The first stage extends from the onset of labor until full dilation of the cervix, and includes two phases: a latent phase, during which dilation progresses at a slow rate until reaching 2-3cm, followed by an active phase, during which the dilation is more rapid. The length of the latent phase is highly variable but is considered prolonged when it exceeds 20 hours in the primiparous and 14 hours in the multiparous. The progression of the active phase is evaluated by the rate of cervical dilation. At this phase, the cervix normally dilates at a rate of at least 1cm/hr in the primiparous and 1.2cm/hr in the multiparous.
The second stage of labor extends from complete dilation of the cervix to delivery of the baby. It usually lasts 30 min to 3 hours in the primiparous, and 5 to 30 minutes in the multiparous. The third stage of labor starts with the delivery of the baby, and ends with the delivery of the placenta. The fourth stage extends from delivery of the placenta until 6 hours postpartum. The mother should be closely observed during this stage because of the risk of postpartum hemorrhage.
Prolonged latent phase can be caused by hypertonic uterine contractions, hypotonic contractions, or premature or excessive use of anesthesia or sedation. Hypertonic contractions, although intense, are ineffective. They are more painful and are associated with increased uterine tone. Hypertonic activity of the uterus usually responds to therapeutic rest with morphine sulphate or an equivalent drug. Hypotonic contractions are less painful and are characterized by an easily indentable uterus during the contraction. Sometimes, patients diagnosed with prolonged latent phase may actually be still in false labor. Contractions of false labor are usually painless and sporadic, but can be rhythmic, occurring every 10 to 20 minutes. Their main characteristic, however, is that they are not accompanied with cervical changes. Patients with hypocontractile dysfunction are best treated with a diluted infusion of oxytocin.
Anesthesia may reduce uterine activity if administered in the latent phase (such as in this case). In the active phase, it has either the opposite effect, or no significant effect. The only treatment when it is the cause of a prolonged latent phase is to allow the responsible drug to be evacuated; the uterus usually resumes its normal activity afterwards.
Twin pregnancy: Recent studies have indicated that if the fetal heart rate is reassuring, the second twin does not have to be delivered within a fixed time frame after the first twin. Expectant management suffices for the spontaneous deliveries of most twins, but electronic fetal monitoring and ultrasound are of significant help in promptly recognizing fetal distress when it does occur.
Once the first twin is delivered, the positioning and heart rate of the second twin must be assessed with ultrasound. If labor has halted, oxytocin should be administered.
Arrest disorders: Hypotonic uterine contractions is the most common cause of arrest disorders in the active phase of labor. Patients with such conditions should undergo an augmentation of labor using amniotomy and/or oxytocin infusion.
False Labor: Characterized by painless and irregular contractions for 5hrs or more. In the last month these contractino may become rhythmic occuring every 10-20 minutes mimicking contraction of real labor. The main characteristic is however they are not accompanied with progressive cervical changes, so cervix is closed shut. All the pt needs is reassurance.
Deccelereaions: Early decelerations defined as decrease in fetal heart rate by 15 beats/sec from baseline for at least 15 seconds, occuring at the same time as the uterine contraction.
Fetal sleep presents with decreased long-term variability.
Fetal cord compression presents with variable decelerations. Such decelerations are not related to uterine contractions, are variable in form and may be non-repetitive. The first step in the presence of variable deceleration is oxygen administration and change in maternal position to the left or right side. Placing the patient in the Trendelenburg position and elevating the presenting part may be tried thereafter, if the anomaly is persistent. Amnioinfusion can be used when variable decelerations occur after the membranes have ruptured, in order to relieve cord compression. However, regardless of membranesâ status, it is not a first-line measure and the change in position plus mask oxygen is more appropriate.
Uteroplacental insufficiency presents with late decelerations.
Intrauterine infection presents with tachycardia, which may be associated with other signs of fetal distress.
Scalp pH is performed if the abnormal fetal heart pattern persists after all initial measures (i.e.; position change, mask oxygen and discontinuation of oxytocin) have been tried.
Cesarean section is indicated when fetal distress is confirmed.
Preterm labor: Antenatal corticosteroid therapy has been proved to be effective in reducing perinatal morbidity and mortality associated with preterm labor. It reduces the risk of infant respiratory distress syndrome by stimulating phospholipids synthesis (surfactant!) and accelerating morphologic development of the lungs. Besides that, antenatal corticosteroid therapy appears to reduce the risk of intraventricular hemorrhage in infants. It should be given to any pregnant woman from 24 to 34 weeks of gestation with intact membranes at high risk for preterm delivery. Two regimens of therapy are available: betamethasone and dexamethasone (some authors believe that betamethasone is preferred over dexamethasone). Intramuscular administration of steroids provides stable and predictable concentration of the drug in the blood that is required to achieve desired fetal effects. Intravenous administration results in peaks and troughs in the blood concentration of the drug and, therefore, is not recommended. One study that compared an oral regimen to intramuscular administration of dexamethasone found increased risk of intraventricular hemorrhage and sepsis in the oral dexamethasone group.
Shoulder dystocia: Shoulder dystocia is commonly defined as a failure of the fetal shoulders to pass through the maternal pelvis once the fetal head has been delivered. It is diagnosed when the anterior shoulder cannot be delivered with mild, downward pressure. Risk factors for the development of shoulder dystocia include macrosomia, maternal diabetes mellitus, operative vaginal delivery, shoulder dystocias in previous deliveries, postdate pregnancies, male fetal gender, advanced maternal age, obesity and excessive weight gain, and disproportion between the fetal shoulders and maternal pelvis. However, more than 50% of cases of shoulder dystocia are not associated with any known risk factors. When shoulder dystocia occurs, appropriate support staff (eg, nursing, anesthesia, obstetrics, pediatrics) should be summoned. The mother should be told not to push while attempts are made to reposition the fetus. Suprapubic pressure directed downward and laterally should then be applied by an assistant. If that fails to deliver the anterior shoulder, then typically the McRoberts maneuver is attempted, though many other techniques work as well (eg, Rubin maneuver, Woods screw maneuver, delivery of posterior arm).
The McRoberts maneuver requires that two assistants grasp both of the motherâs legs and flex the thighs back against her abdomen. This maneuver has been shown to relieve the shoulder dystocia in 42% of patients. Before the maneuver is implemented, however, the mother should be told to stop pushing until everything is in place.
The Zavanelli maneuver replaces the fetal head in the pelvis before performing a cesarean section. It is generally accepted that the physician has up to seven minutes to deliver a previously well-oxygenated infant before there is an increase in the risk of damage due to asphyxia. Therefore, the Zavanelli maneuver is normally employed when other methods have failed and the "safe" period of seven minutes is dwindling.
Breech presentation: If prior to 37 must be left alone. After that External cephalic version may be attempted PRIOR TO onset of labor, given no CI (Hypertension).
Post partum hemorrhage (PPH): The most common cause of post partum hemorrhage (PPH) is uterine atony, and the first step in the management of all patients with PPH is to do a pelvic examination to identify retained placental fragments. If the retained placental products are not identified, manual uterine massage should be started. Uterine massage stimulates the uterus, uterine contractions start, and bleeding stops.
If bimanual uterine massage fails to control bleeding, uterotonic drugs (like IV oxytocin) are used to control bleeding.
If bleeding does not stop with the medical measures, surgical measures are taken. Uterine artery ligation is one of the surgical measures for the treatment of PPH.
Uterine Rupture: Presents with intense abdominal pain asso w vaginal bleeding, ranging from spotting to massive hemorrhage.
Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more children, total hysterectomy is the Tx of choice. If she wants more kids then Debridment and closure is indicated. Difficult to ddx from abrupta placenta. UR is preceeded by agitation, rapid breathing, tachycardia.
Postpartum endometritis: It is a polymicrobial infection of the decidua (the pregnancy endometrium) characterized by fever, uterine tenderness, foul-smelling vaginal discharge, and leukocytosis. As the infection is often produced by both aerobes and anaerobes from the genital tract, any treatment regimen must include broad-spectrum antibiotics that also cover beta-lactamase producing anaerobes. At this time, the gold standard of treatment for endometritis is clindamycin and gentamicin.
Metronidazole is contraindicated in breastfeeding mothers.
Endometritis occurs after 3% of vaginal births, but after 15-30% of cesarean deliveries (especially those performed after labor commences or after the rupture of membranes). Studies show that the most important risk factor in the development of endometritis is the route of delivery. Several causes contribute to this finding, including contamination of the uterine cavity, prolonged rupture of membranes, and presence of sutures or other foreign objects.
Chorioamnionitis: Chorioamnionitis is the infection of the amniotic fluid surrounding the fetus. It is frequently associated with preterm or prolonged rupture of membranes but can also occur with intact membranes. Patients with chorioamnionitis exhibit fever greater than 38°C(98.7F), uterine tenderness and irritability, elevated WBC count and fetal tachycardia. Maternal infection of any origin can cause fever, elevated WBC count as well as fetal tachycardia. So, a careful examination to detect any other foci of infection is necessary. Fetal tachycardia may also be congenital or consequent to beta 2-agonist administration to the mother, for example for tocolysis. Elevation of maternal WBC also occurs at the onset of labor or can be caused by corticosteroid administration. Amniotic fluid cultures are the gold standard for diagnosis if any doubt remains.
Once chorioamnionitis is diagnosed, broad-spectrum antibiotic therapy should be instituted, but not before samples for culture are taken. Ampicillin and gentamicin are the drugs of choice. Labor should thereafter be induced or augmented if contractions have already begun. If the cervix is unfavorable and fetal heart tracing is alarming, a C- section may be necessary.
#13
Re: Step 3 HY meduploader - 12-20-08 09:51 Diabetes: All pregnant patients are generally screened for gestational diabetes between the 24th and 28th weeks of pregnancy using the 50 gm glucose tolerance test. This test does not require fasting. Blood glucose levels are checked one hour after the ingestion of 50 gm of glucose. Patients with blood glucose values of 140 mg/dL or higher should be subjected to a 3-hour glucose tolerance test after the ingestion of 100 gm of glucose on a fasting state. Two or more blood glucose values greater than 105, 190, 165 and 145 mg/dL at 0, 1, 2 and 3 hours, respectively, are diagnostic of gestational diabetes. Some workers have proposed lower cutoff values for the diagnosis of gestational diabetes. The American Diabetes Association is recommending the use of a 75-gm glucose tolerance test, with different cut-off values, for use in non-pregnant women and for diagnosing gestational diabetes.
The recommended fasting blood glucose values in pregnant diabetic patients should range between 60-90 mg/dL, and postprandial blood glucose values should be less than 120 mg/dL. NPH in combination with regular or lispro insulin is generally recommended if diet and exercise are not able to adequately control the blood sugar. Oral hypoglycemics are not indicated in pregnant patients. The use of glargine insulin is not considered safe during pregnancy.
UTI: In pregnant patients with signs and symptoms suggestive of urinary tract infection, begin empiric antibiotic therapy immediately with cephalexin, amoxicillin, or nitrofurantoin for a period of 3-7 days. Some experts also advocate obtaining a urine culture to allow for later modification of the treatment regimen based upon pathogen sensitivity and patient response to pharmacotherapy. Trimethoprim-sulfamethoxazole is not advised in the first or third trimester of pregnancy.
Acute pyelonephritis is usually characterized by costovertebral angle tenderness, fever, chills, dysuria, nausea, vomiting, and respiratory discomfort. Pregnant women are particularly susceptible to experiencing adverse outcomes secondary to pyelonephritis (eg, septic shock syndrome, preterm birth, low birth weight). Traditionally, pyelonephritis in the pregnant woman is treated with hospitalization and intravenous antibiotics such as ceftriaxone or ampicillin and gentamicin until she is afebrile for 24-28 hours and experiencing an improvement in symptoms. Some providers will consider outpatient treatment if the pyelonephritis is otherwise uncomplicated. Whether the treatment is provided on an inpatient or outpatient basis, the treatment course should last for 10-14 days. For the remainder of the pregnancy, low-dose antibiotic prophylaxis with nitrofurantoin or cephalexin should be accompanied by occasional urinary evaluation for infection.
If the symptoms of pyelonephritis do not respond to antibiotic therapy within 48 hours, then a renal ultrasound to assess for perinephric abscess or renal calculi should be performed.
Repeat: Traditionally, pyelonephritis in the pregnant woman is treated with hospitalization and intravenous antibiotics such as ceftriaxone or ampicillin and gentamicin until she is afebrile for 24-28 hours and experiencing an improvement in symptoms. She should then be discharged on oral antibiotics, with the entire treatment course lasting for 10-14 days.
Ultrasound is the test of choice for suspected nephrolithiasis in a pregnant patient.
Helical CT scan is the test of choice for suspected nephrolithiasis; however, a CT scan is associated with radiation exposure, and is not the best test in pregnant patients.
Asymptomatic bacteriuria must be treated promptly in the pregnant female as it can quickly progress to cystitis and pyelonephritis. Although Streptococcus agalactiae (Group B Streptococcus) is a less common cause of cystitis and pyelonephritis in pregnancy than Escherichia coli, its presence is indicative of significant genital colonization with Group B Streptococcus, which is associated with an increased risk of preterm labor and premature birth.
positive urine culture for Group B Streptococcus in a pregnant female should be treated immediately with a 10-day course of antibiotics. The antibiotic may either be penicillin G or cephalexin; both antibiotics are considered safe for the fetus. After the treatment course is completed, it is important to document that the patientâs urine is sterile.
Thyroid disease: As soon as pregnancy is confirmed in hypothyroid patients who are receiving hormone replacement therapy, the dose of L-thyroxine should be increased. During pregnancy, the requirement in levothyroxine increases by 25 to 50%. The causes of the increased requirement for L-thyroxine during pregnancy include increases in thyroxine-binding globulin (TBG) and the volume of distribution of T4, and an increase in body mass. The serum TSH level is a sensitive marker of the hypothyroid state, and should be checked each trimester. The dose of L-thyroxine should be adjusted accordingly.
Due to an increase in serum concentrations of TBG, pregnant women have high levels of T3 and T4. In order to determine if a patient has true hyperthyroidism, free T4, total T4 and TSH levels need to be determined.
In order to diagnose a pregnant woman with hyperthyroidism, she must meet the following criteria:
1. high serum free T4
2. serum TSH value < 0.01 mU/L
On the other hand, gestational transient thyrotoxicosis (GTT) is diagnosed if the woman meets the following criteria:
1. mildly increased free T4
2. slightly decreased TSH levels at the end of the first trimester
GTT is a medical condition that occurs approximately in 10% of women. It usually presents between 8 to 11 weeks of gestation, and does not occur after 14 weeks. It is due to the elevated levels of human chorionic gonadotropin (hCG), which has thyroid-stimulating properties.
Sickle-cell disease: Patients with sickle-cell disease are at a very high risk for complications during pregnancy. The possible complications include acute crisis, endometrial infection, pyelonephritis, and thromboembolic events. Up to 46% of sickle-cell patients have complications during pregnancy. Such patients therefore need a safe and very effective method to prevent undesirable pregnancies. Therefore, patients with sickle-cell disease need a safe and reliable method for contraception to prevent undesired pregnancies. The use of oral contraceptive pills in patients with sickle-cell disease is controversial despite the fact that no studies show any associated increased side effects with OCP use. Depot medroxyprogesterone appears to be safe and effective in preventing pregnancies in patients with sickle-cell disease.
Syphilis: Any pregnant woman that has positive treponemal tests should be considered infected until proven otherwise. Untreated syphilis is associated with a very high prevalence of adverse fetal outcomes (up to 80%), including stillbirth, neonatal death, and mental retardation. Appropriate therapy should be promptly instituted. Penicillin remains the drug of choice (gold standard) for the treatment of syphilis. In patients with a penicillin allergy, penicillin desensitization is recommended. It is typically accomplished using incremental doses of oral penicillin V.
Cardiology in pregnancy: Women who have congenital heart disease and become pregnant are at risk for significant maternal and fetal deterioration. Pregnancy is associated with a number of physiologic changes, including expansion of intravascular volume, changes in the cardiac output, and systemic vascular resistance. The risk of complications in such patients is even higher if the patient has Eisenmenger syndrome (i.e., severe pulmonary hypertension and shunt reversal). Pregnancy in these patients is associated with a 30-50% risk of mortality. Majority of the maternal deaths occur during the first week after delivery; however, death can also occur during gestation, labor, or delivery since the sudden drop in systemic vascular resistance after delivery increases the right-to-left shunt, which may precipitate maternal cyanosis. Unfortunately, a sudden increase in systemic vascular resistance can also lead to adverse effects due to the decreased cardiac output, which can cause syncope. Furthermore, there is an associated higher incidence of spontaneous abortions, pre-term delivery, and fetal mortality in these patients. Due to these reasons, all pregnant patients with Eisenmenger syndrome should be advised to have an elective termination of pregnancy.
Anticoagulation: The goal is to prevent thrombotic or embolic complications in the pregnant patient, while avoiding fetal or maternal harm due to anti-thrombotic agents. The most common indications are the presence of mechanical prosthetic heart valves or the history of venous thromboembolism. Because warfarin is teratogenic and can freely cross the placental barrier, a patient on anticoagulation therapy who plans to get pregnant should replace warfarin with subcutaneous unfractionated heparin or low-molecular-weight heparin in the first trimester.
Pruritus: Pruritus is a very common complaint during pregnancy. It is reported to affect up to 20% of pregnant women. The symptom may be a manifestation of pregnancy-associated dermatosis, although there is usually no pathologic process present in most cases. Common pruritic locations are the scalp, anus, vulva, and abdomen (during the third trimester). Pregnancy-induced pruritus may be related to dermographism or urticaria, which are common in the last half of pregnancy. Topical steroids, antihistamines, oatmeal baths, emollients, and UVB are used to treat the condition.
Herpes gestationis (also called pemphigoid gestationis) is an uncommon blistering dermatosis that is associated with pregnancy. It typically starts during the second or third trimester, or postpartum period. It may first manifest as abdominal pruritis, a relatively common benign condition during pregnancy, with later development of a rash. The rash is localized around the umbilicus, and is characterized by papules, urticarial plaques, and vesicles, although bullae may also form. Contrary to its name, herpes gestationalis is not caused by a viral infection, and is believed to be an autoimmune disorder.
Herpes gestationis is an autoimmune disease of pregnancy. Autoantibodies are detected in the skin as well as in the circulation. Corticosteroids are the mainstay of therapy. In early and mild cases, topical mid-potency steroids (e.g., triamcinolone) are used. In more advanced cases or if topical steroids are not effective, systemic steroids are employed.
Note: Topical steroids and antihistamines are widely used to treat many pregnancy-associated dermatoses, including papular urticarial papules and plaques of pregnancy (PUPPP); therefore, these are typically the correct choices for questions asking about the treatment of pregnancy-associated dermatoses!
#14
Re: Step 3 HY meduploader - 12-20-08 09:52 Rh â incompatibility: Hemolytic disease of the newborn due to Rh-incompatibility is possible only when the mother is Rh-negative and the father is Rh-positive.
Hemolytic disease is very unlikely in the first pregnancy, as the mother is not sensitized. The mother becomes sensitized as a result of fetomaternal hemorrhage at or near the end of pregnancy. This risk of sensitization can be reduced by a RhoGAM injection within 72 hours of the delivery.
Anti-D immune globulin should be administered intramuscularly at 28 weeksâ gestation to all Rh (D) negative women if no anti-D isoimmunization is detected by antibody screening. Antenatal prophylaxis is not necessary only if the father of the child is known with certainty to be Rh (D) negative . Antenatal prophylaxis helps to reduce significantly the risk of Rh (D) isoimmunization during pregnancy. Peripartum anti-D immune globulin is also indicated to reduce the risk of isoimmunization due to fetomaternal transfusion during the delivery. Early antenatal anti-D immune globulin prophylaxis is indicated in case of the events and procedures that can increase the risk of isoimmunization (e.g., spontaneous abortion, ectopic pregnancy, and amniocentesis). Otherwise, the risk of isoimmunization before the 28th week of pregnancy is very low.
Failure to adjust the dose of anti-D immune globulin after events that are associated with excessive feto-maternal hemorrhage (e.g., placental abruption) may result in maternal alloimmunization.
Events that are associated with feto-maternal hemorrhage (such as placental abruption) may require adjustments in the dosage of anti-D immune globulin; therefore, the presence and the amount of feto-maternal transfusion should have been determined in this patient during her first pregnancy.
The rosette test is a qualitative test that helps determine the presence of feto-maternal hemorrhage. If negative, the standard dose of anti-D immune globulin should be administered. If positive, the amount of hemorrhage can be evaluated using Kleihauer-Betke stain or fetal red cell stain using flow cytometry, and the dose of anti-D immune globulin should be corrected accordingly.
Pregnancy Facts:
Screening for gourpB strep should be done 36-37 week gestation and positive cases should be tx with Penicilline G during labor, even in the absence of risks.
Low back pain is very common in thrid trimester. Its caused by lumbar lordosis and relaxation of ligament to the joints.
Both Graves dis and Migrain will improve in Pregnancy.
Excessive use of oxytocin may cause water retention (acts like ADH), hyponatremia and seizures (water intoxication).
ACE inhibitors and Oral hypoglycemic agents (Glibenclamide) are CI in pregnancy. Stop them and give Insulin for DM, and Methyldopa(most comonly used), Hydralazine and Labetalol for HT control in pregnancy.
Pregnancy hasa protective efect on both MS and PUD.
In pregnancy both BUN and Creatinin are decreased to half of prepregnancy levels. Amoxicilin has no effect on them.
Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli is the cause 70% of the times. tx is 7-10 days of Nitrofurantoin, Ampicillin or first gen Cephalos.
Neonates of pts with graves dis treated with with surgery are at risk for Thyrotoxoicosis.because of the passage of throid stimulating immunoglobin across the placenta.
Hypotension is a comon se of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling.
In pregnancy its recommended to CONTINUE excercise as you were doing before, like an aerobic instructor.
Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria, no need to do ECG or DVT (presents unilateral and fever).
Oxytocin is like ADH so it causes water retention and Water toxicity due to decrease in Na concentration ( 123 ). So it could cause seizure post partum.
Screening cultures should be performed at week 36-37 and positive cases should be treared with IV penicillin therapy during labor to prevent the new born from getting infected.
If hypertension sets in before 20 weeks, its either Mole or CHRONIC hypertension. If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT hypertension (not accompanied by proteinuria,
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