ELDERL BODY AND METABOLIC CHANGES ➢ Skin and Hair – atrophies, less elasticity due to less subdermal fat and collagen. Fragile and slower to heal. Xerosis (dry skin) due to ³ sebaceous and sweat gland activity (± risk dehydration, heat stroke). ³ in vitamin D synthesis.Fewer melanocytes which contributes to gray hair. o Seborrheic keratoses – soft wart-like skin that appear pasted on; found mostly on back; color can range from tan, brown to black; benign o Senile Purpura – bright colored patches with well demarcated edges. ➢ Eyes – presbyopia – loss of elasticity of lenses and difficulty in focusing on objects up close. Onset mid 40’s – reading glasses. Need more illumination, increased sensitivity to glare, washing out of colors. o Arcus Senilis – opaque gray to white ring in margin of cornea or on periphery of iris, develops gradually and not associates with visual changes. Caused by deposit of cholesterol and fat. If less than 40 – chest fasting lipids. o o Cataracts – cloudiness and opaque lens of eye. Gradual onset with decreased night vision. Red reflex disappears. Most common cause of blindness in developing countries. Lentigines – 5 o Immature liver cannot get rid of bilirubin fast enough; breakdown of RBC; Bili deposited under skin. Concerns for kernicterus NUTRITION ➢ Breastfeeding up to 6 months ➢ Delay complementary foods until 4-6 months o Single ingredient – iron rich rice cereal o Cow’s milk at 12 months ➢ Vitamin D for breastfed babies M PEDIATRIC ASSESSMENT ➢ Musculoskeletal o Scoliosis – risk greatest during puberty o 10-degree curvature of spine o Adams forward bend o Scoliosis series (full length PA/Lateral) o More curvature at a young age indicates worse problem TANNER STAGING ADOLESCENCE ➢ Identity vs Role Confusion ➢ Early (10-14) o Egocentric! Concrete thinking with early moral struggles, progression of sexual identity, body image o Emotional separation from parents, identify as a person, peer identification, early exploration of harmful health behaviors such as substance abuse; engage in risky behavior – wear seatbelts ➢ Middle (15-17) o Peer groups more important than you. Increased abstract thinking, 13 nutrition with low weight (eating disorders, gymnast, genetic) Normal onset puberty Male 9-14 o Refer pedi endo for early onset PEDIATRIC IMMUNIZATIONS ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ Spacing of Vaccines o 4 days before due is ok – 5 days prior is INVALID Hepatitis A o Universally recommended age 1 o 2 dose series at least 6 months apart Hepatitis B o 3 dose series: 0, 1-2 months, 6 months DTaP (< 7 years) – minimum age 6 weeks o #1 at 2 months o #2 at 4 months o #3 at 6 months o #4 at 15-18 months o #5 at 4-6 years Tdap > 7 years o 11-12 o Td booster every 10 years o Every pregnancy 3rd trimester Hib o 2, 4, 6 and 12-15 months o For unvaccinated 15+ months administer only one dose Pneumococcal vaccine (PCV13) o 2, 4, 6 and 12-15 months o Vulnerable populations also get PCV23 Polio (IPV only) o 2, 4, 6-18 months and age 4-6 o Contraindicated for allergies to neomycin, streptomycin or polymyxin B o No more oral polio due to live vaccine Flu vaccine o Every year Meningococcal Conjugate vaccine (MCV4) o o All children age 11-12 BOOSTER age 16 ➢ HPV-9 o Age 9-14 – 2 dose series at 0 and 6-12 months o Avoid in pregnancy, ok if breastfeeding LIVE IMMUNIZATIONS ➢ ➢ ➢ ➢ Must replicate to reproduce immunity – run fever and/or rash Avoid before age 1 MMR o 12-15 months and age 4-6 Varicella o 12-18 months and age 4-6 o If given at age 13 or later, 2 doses are required at least 1 month apart o Contraindicated if allergic to neomycin or gelatin Must wait 28 days between live vaccines ➢ ➢ Local (redness), systemic (fever) or allergic Syncope with HPV, MCV4 and Tdap ➢ ➢ 10mm is enlarged Exceptions o Epitrochlear > 5mm o Inguinal > 15mm o Cervical > 20mm ➢ ADVERSE REACTIONS TO IMMUNIZATIONS PEDIATRIC Pulse BP Respiration Mucosa Anterior fontanel Eyes Skin turgor Skin Urine output Systemic signs Mild Moderate Normal Rapid Normal Normal to low Normal Deep, ± rate Sticky Dry Normal Sunken Normal Sunken Normal Reduced Normal Cool Normal Reduced Thirsty Irritable Severe Rapid and weak low Deep, ± rate Parched Very sunken Very sunken Tenting Cool, mottled None Lethargy Can they hold fluids down? UNDESCENDED TESTES ➢ ± risk of testicular cancer ➢ Cryptorchidism – undescended ➢ Retractile testes –moves between scrotum and inguinal ring ➢ Refer if not descended by 6 months PINWORMS ➢ Enterobiasis ➢ Scotch tape test in the morning to look for eggs o Worms come out at night and lay eggs in anal area o Check several days in a row since females do not lay eggs every day ➢ Usually happens 4-8 weeks after exposure ➢ Treat with Albendazole ➢ CONGENITAL HEART DISEASE ➢ Innocent Murmur Clues: o Grade < 2 o Softer when sitting than when supine o Not holosystolic o Minimal radiation o Musical or vibratory quality ➢ Pathologic Murmur Clues: o Grade > 3 o Holosystolic o Max intensity at LUSB o Harsh or blowing o Systolic clicks o Diastolic murmur o ± intensity in upright position o Gallop rhythm o Friction rub PEDIATRIC Name Cause Jaundice Physiologic jaundice occurs in absence of liver disease; jaundice arise from problems with liver Galactorrhea Maternal hormonal influences Chlamydial (inclusion) conjunctivitis Exposure to Chlamydia Signs/Symptoms Diagnostics Usually seen in face and progress caudally to trunk and extremities Breast milk production in the absence of lactation, usual onset day 3-4 of life. Breast engorgement will resolve without intervention within first 2 months of life. Concerns Prevention: encourage breastfeeding every 2-3 hours daily Physiologic jaundice occurs after 24 hours of life Jaundice within first 24 hours of life typically involves liver problems Some cultures think this is a curse so be sure to ask how if this has any effect on the family. Oral erythromycin x 2 WE eks due to pneumonia risk Prevention: 3rd trimester STI screening Signs and symptoms 5-14 days post exposure. Bilateral lid swellin g, chemosis, mucoid drainage Fever, sore throat, malaise, nasal discharge, diffuse maculopapular rash lasting about 3 days. Posterior cervical and postauricular lymphad enopathy begin ning 5-10 days prior to onset and present during rash; arthralgia in about 25% Fever, nasal discharge, cough, coryza, generalized lymphadenopathy, conjunctivitis (clear copious discharge), photophobia – Koplik spots, pharyngitis, maculopapular rash 3-4 days and may coalesce to generalized erythema, starts on head and neck Treatments Lab confirmation of serum rubella IgM Notifiable condition – droplet transmission – public health dictates when child goes back to school Mask patient until she gets home Prevention with MMR vaccine Lab confirmation of serum rubeola IgM Notifiable condition Prevention with MMR vaccine Rubella (German measles, 3-day measles) Rubella virus Rubeola (measles) Rubeola virus Roseola Infantum HPV 6 High fever for 2-4 days follo wed by maculopapular rash on body (body pink – roses are pink)– face not affected Self-limiting Usually around 7-13 months Erythema Infectiosum 6 months; Be evident in 2 different settings (school and home) Document > 6 symptoms of inattention Use rating scale (Child behavior checklist, Conners’ rating scales, Vanderbilt ADHD rating scales, others) If co-morbidities are present – refer Commonly treated with Schedule 2 meds Do not confuse with someone who has sensitivity to decongestants; hyperthyroidism; pinworms Same as adults except: Leukotriene receptor – Singular (1 in 3) Nebulizer or spacer Most common chronic disorder in children Asthma Disease of inflammation Pneumonia Commonly viral If bacteria – Strep pneumo Cystic Fibrosis Autosomal recessive Excessive loss of sodium through sweat (cannot transport sodium and chloride – making mucous thick and tenacious); Recurrent sinus and pulmonary infections, mucous can block ducts of pancreas and cause weight loss and greasy stools Leukemia Most common form of cancer Fever in the evening, bruising, bleeding, frequent nosebleeds, bone pain, recurrent infections, lymphadenopathy, fatigue, poor appetite, hepatosplenomegaly. Failure of bone marrow Pyloric Stenosis Narrowing of pyloric sphincter due to hypertrophy of pyloric muscle Projectile vomiting, first-born males, nonbilious vomiting. Olive like mass palpated in RUQ ultrasound LES immatu re to 9-12 months Frequent regurgitation in absence of anything pathological; occurs 30+ times in healthy infant – irritability during a reflux episode indicated GERD rather than GER Red flags: choking with eating, coughing with eating, forceful vomiting, GI bleed, poor weight gain, refusal to feed, constipation or diarrhea, abdominal tenderness, fever Intestinal obstruction Sudden onset intermittent, crampy, progressive abdominal pain – acts normal between painful episode. Cries and pulls knees up to chest. Current jelly stools, sausage shaped mass Gastroesophageal reflux (GER) Intussusception Same as adults Most sensitive finding is ± respiratory rate Chest x-ray CBC High dose amoxicillin 90 mg/kg/day Multisystem disease – pulmonary, GI, sweat glands European descent Sweat test ³ WBC ³ H/H ³ Platelets Peripheral smear: malignant cells Bone marrow: infiltration with blast cells KUB, ultrasound Most common age 2-8 ALL – 77% AML – 11% Differential diagnosis: GERD, milk protein intolerance, intestinal obstruction Surgery Typically occurs at 4-6 weeks; Usually preventative measures – continue to breast feed, place supine to sleep, small frequen t, thickened feedings, consider non-cow ’s milk protein formu la for 1-2 weeks, soy-based formula, 1-2-week trial of hypoallergenic formula Barium enema Possible surgical correction Typically, less than age 2 PEDIATRIC Name Cause Legg-Calve Perthes Disease Avascular necrosis of proximal femoral head Slipped Capital Femoral Epiphysis (SCFE) Femoral head slips out of hip joint Signs/Symptoms Limp; pain to hip and/or knee Diagnostics Trendelenburg’s (stand on affected side causes pelvic tilt) Hip x-ray (AP and frog leg) Several weeks or months of hip/knee pain with intermittent limp Trendelenburg’s (stand on affected side causes pelvic tilt) Hip x-ray (AP and frog leg) Fragile X syndrome Males: Large forehead, ears, prominent jaw, tendency to avoid eye contact, large testicles (macroorchidism) large body habitus, hx of learning and behavioral differences Females: less common with fewer prominent findings Blood testing for carrier state Klinefelter syndrome XXY male Low testicular volume, hip and breast enlargement, infertility. Mostly developmental issues, most commonly language impairment Blood testing for carrier state Turner syndrome XO Short stature (less than 5 ft.) wide, webbed neck, broad, shield-shaped chest, absent menses, infertility; born without ovaries, high narrow arched palate, retrognathia, low-set ears, edema of hands and feet – mosaic Turner’s have milder features Blood testing available; High rate of pregnancy loss Osgood Schlatte Common in grow Tx: Rest, activity Tolerated; RICE Treatments Concerns Refer to ortho Ages 3-12 Affects males > females Refer to ortho – surgical repair with internal fixator Common in adolescents Most common known cause of autism