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Pediatrics Clerkship > Aquifer - Neuro (Part 2) > Flashcards

Aquifer - Neuro (Part 2) Flashcards

1
Q

DDx - apnea in infants (CNS)

A
  1. Seizures (due to CNS bleeding, infection, structural abnormalities, metabolic disorders, electrolyte abnormalities, genetic syndromes, epilepsy)
  2. Breath-hold spells
  3. Increased ICP (bleed, trauma, tumor, infection) affecting the respiratory center
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2
Q

DDx - apnea in infants (Cardiac)

A
  1. Bradycardia secondary to congenital heart block or long QT syndrome
  2. Congenital heart disease (particularly ductal-dependent lesions), unrepaired Tetralogy of Fallot may have acute episodes of cyanosis associated with a drop in pulmonary blodo flow
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3
Q

DDx - apnea in infants (Pulmonary)

A
  1. RSV (most common respiratory cause)
  2. Pertussis
  3. Other lower respiratory infections
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4
Q

DDx - apnea in infants (GI)

A
  1. GER has been blamed, but a true correlation has not been proven - some experts think that apnea occurs first, leading to hypoxia, relaxation of the LES, and reflux; others believe reflux may cause choking, gagging, color changes, and laryngospasm
  2. Swallowing abnormalities
  3. TE fistula (chronic history of coughing or difficulty with feeds)
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5
Q

DDx - apnea in infants (Systemic)

A
  1. Systemic sepsis (apnea, pallor, tachycardia, tachypnea, fever, hypothermia, decreased feeding, change in tone)
  2. Inborn errors of metabolism
  3. Ingestions of medications and other toxins (respiratory depression, cardiac arrhythmias, seizures)
  4. Exposure to botulinum toxin (soil or honey -> hypotonia, constipation, paralysis, respiratory failure)
  5. Environmental exposure (CO -> mental status changes, hypoxia, respiratory distress)
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6
Q

What is a Brief Resolved Unexplained Event (BRUE)?

A

Event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now-resolved episode that includes one or more of the following:

  1. Cyanosis or pallor
  2. Absent, decreased, or irregular breathing
  3. Marked change in tone (hyper- or hypotonia)
  4. Altered level of responsiveness

Only used to define events when no underlying etiology is found and the infant has returned to baseline state of health

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7
Q

When infants deteriorate neurologically, they often stop breathing or seize. What initial steps should be taken?

A

Rapid response team
Ensure that CPR equipment and trained personnel are available
Obtain IV access

Once stable, head CT

Eventually call the pediatric critical care unit for transfer

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8
Q

Normal neurological findings in a 2-month-old?

A

Developmental: fix and follow easily with their eyes, exhibit a meaningful smile in response to voices, strong suck, beginning to coo

Lie flexed at the hips with good tone and move all 4 extremities well

Lack good head control when held upright

Cannot roll over because of persistence of the asymmetric tonic neck reflex

When prone, they can raise their heads from side to side

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9
Q

Infant Glasgow Coma Scale scoring?

A

15 possible points
>13 represents mild or no neurological compromise
<8 means severely impaired and in a coma

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10
Q

Causes of subdural hematomas?

A

Head trauma

Often found in infants who have experienced violent shaking as in abusive head trauma (may be associated with retinal hemorrhages)

Accidental trauma (MVAs)

Uncommon complication of delivery (especially vacuum extraction or forceps deliveries, resolve within 4-6 weeks of birth)

Do not occur as a result of CPR or seizures, or from short falls

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11
Q

___ accounts for 10-12% of all deaths among children who are victims of child abuse.

A

10-12

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12
Q

List skeletal survey findings that raise suspicion for abuse.

A
  1. Fractures or injuries inconsistent with reported mechanism of injury and/or developmental stage/abilities of child
  2. Multiple fractures/injuries in different stages of healing
  3. Toddler’s fracture (femur or tibia in a non-walking child)
  4. Posterior rib fractures (shaken baby syndrome due to squeezing of the thorax during shaking)
  5. Skull fracture ni an infant
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13
Q

Prognosis for victims of abusive head trauma?

A

Many babies with subdural hematomas and retinal hemorrhages have long-term developmental delays, seizures, and/or difficulty with vision

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14
Q

What is cerebral palsy?

A

Heterogenous group of non-progressive disorders, characterized by motor and postural dysfunction; these conditions, which range in severity, are due to abnormalities of the developing brain resulting from a variety of causes

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15
Q

Overall prevalence of cerebral palsy in western countries?

A

2/1000

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16
Q

List the 5 types of CP.

A
  1. Spastic quadriplegia
  2. Spastic diplegia
  3. Dyskinetic cerebral palsy (athetoid, dystonic)
  4. Spastic hemiplegia
  5. Ataxic cerebral palsy
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17
Q

General pattern of involvement for the 5 types of CP.

A
  1. Spastic quadriplegia - entire body
  2. Spastic diplegia - legs > arms
  3. Dyskinetic cerebral palsy (athetoid, dystonic) - variable, often entire body
  4. Spastic hemiplegia - arm and leg on one side
  5. Ataxic cerebral palsy - entire body
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18
Q

Class etiology of the 5 types of CP.

A
  1. Spastic quadriplegia - global brain abnormalities
  2. Spastic diplegia - Periventricular white matter abnormality
  3. Dyskinetic cerebral palsy (athetoid, dystonic) - Basal ganglia, cerebellum and/or thalamus abnormalities
  4. Spastic hemiplegia - unilateral UMN abnormalities
  5. Ataxic cerebral palsy - Cerebellar abnormalities
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19
Q

Examples of clinical scenarios for the 5 types of CP.

A
  1. Spastic quadriplegia - various
  2. Spastic diplegia - premature infants
  3. Dyskinetic cerebral palsy (athetoid, dystonic) - perinatal asphyxia, kernicterus
  4. Spastic hemiplegia - stroke
  5. Ataxic cerebral palsy - cerebellar hypoplasia, pontocerebellar hypoplasia
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20
Q

Risks for cerebral palsy?

A
  1. Prematurity (78%)
  2. Intrauterine growth retardation (34%)
  3. Chorioamnionitis (28%)
  4. Perinatal asphyxia (10%)
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21
Q

Assessment of the child with CP?

A
  1. H&P - determine that the condition is static rather than progressive or degenerative, classify type of CP
  2. Screening for developmental delays, ophthalmologic abnormalities, hearing impairment, speech and language disorders, and disorders of oral-motor function (problems commonly associated with CP)
  3. EEG - recommended when there are features suggestive of epilepsy
  4. Neuroimaging (MRI) - establish an etiology, prognostics
  5. Metabolic and genetic testing - if history/neuroimaging findings do not determine a specific structural abnormality, or if there are additional/atypical features in the H&P
  6. Developmental testing
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22
Q

3 core symptoms of ADHD?

A

Inattention, hyperactivity, impulsivity

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23
Q

Prevalence of ADHD in the US?

A

8-10% (most common neurobehavioral disorder of childhood)

24
Q

Dx - ADHD?

A

Presence of at least 6 symptoms (or 5 for individuals 17+ years old) + several present for at least 6 months and are inappropriate for the developmental age + several present before age 12 + evident in 2+ settings + interfere with individual’s functioning socially/at school or work + not attributable to another mental disorder

25
Q

Rx - ADHD?

A

Stimulants such as sustained-release methylphenidate

26
Q

Adverse effects of stimulants in children?

A

Appetite suppression most common (weight loss if present is typically minor)
Insomnia (common dose-related side effect, typically worse on first days of medication)
Decrease in growth velocity (1-2 cm)

27
Q

List purported adverse effects of stimulants in children.

A
  1. Risk of addiction (no signs of addiction at prescribe doses, may be addictive when abused or used for euphoric effect)
  2. Risk of substance abuse
  3. Personality changes (dull, overly restricted, over-focused -> signs of excessive dosing)
  4. CV risk (limited to children with known heart disease, may be higher for adults than children)
  5. Tics (do not cause tic disorders but may unmask them)
28
Q

DDx - School Failure

A
  1. Sensory impairment (hearing/vision impairment)
  2. Sleep disorder (formal sleep disorder like OSA, narcolepsy, or poor sleep hygiene)
  3. Mood disorder
  4. Learning disability
  5. Conduct disorder
29
Q

Childhood depression is marked by a high rate of conversion to ___.

A

Bipolar disorder

30
Q

Children with ADHD also have a higher rate of ___ disorders and ___.

A

Mood; learning disabilities

31
Q

What is a learning disability?

A

Disorder of cognition which manifests itself as a problem involving academic skills; most states require documentation of a discrepancy between IQ and academic achievement for dx

32
Q

Red flags for risk of learning disability?

A

History of maternal illness or substance abuse during pregnancy
Complications at the time of delivery
History of meningitis or other serious illness
History of serious head trauma
Parental history of LD or difficulty at school

33
Q

What is ODD?

A

Pattern of negativistic, hostile, and defiant behavior

34
Q

What is CD?

A

More severe disorder of habitual rule-breaking, characterized by a pattern of aggression, destruction, lying, stealing, and/or truancy

35
Q

What psychiatric condition has the highest comorbidity rates with ADHD?

A

ODD/CD

36
Q

True or false - research supports the popular notion that sugar causes overactivity or distractibility.

A

False - research does not support this.

37
Q

True or false - mood swings in adolescence are not usually indicative of depression.

A

True

38
Q

List symptoms of depression seen in adolescents and adults alike. Note one symptom only seen in adults.

A

Feeling down, doesn’t want to do his/her normal activities
Feels sad, often cries over small things
Doesn’t want to participate in friends’ activities
Thinks about suicide
Feels grouchy and flat all the time

Adults only: early morning waking, difficulty falling asleep at night

39
Q

Signs associated with anorexia?

A

Weight loss or failure to gain
Amenorrhea in females
Bradycardia (mostly asymptomatic, may lead to decreased CO severe enough to lead to postural hypotension)
Electrolyte abnormalities (hypoalbuminemia, hypoglycemia, hyponatremia [excessive water intake], all related to malnutrition, continued deficiencies of calcium and magnesium may lead to neurologic changes, increased reflex tone, and compromised cardiac function

40
Q

Signs associated with bulimia?

A

Lack of weight loss in early stages, dental decay (stomach acid), finger trauma (vomiting)

41
Q

Assess mental status in an infant?

A

How does the child interact with the caregiver and with you?

Is he alert, sleepy, arousable, etc.?

42
Q

Assess CNs in an infant?

A

Move your flashlight or a toy around and watch 3, 4, and 6
Look for facial symmetry as a marker for 7
Test 8 by making a sound to see if the child turns toward it
Look carefully at the palate (elevated symmetrically?) and the tongue (protrude)?
Listen to the child’s voice (9, 10, 12)

43
Q

Assess muscle tone in an infant?

A

Play with the child and move his arms/legs through full ROM

Note resting posture of extremities and trunk - symmetry?

44
Q

Assess muscle strength in an infant?

A

Watch as he plays
Look for resistance to physical-exam maneuvers
Look for asymmetry of muscle bulk

45
Q

Assess DTRs in infants?

A

Percuss the tendons
Note vigorousness
Look for asymmetry

46
Q

Assess cerebellum in infants?

A

Is his balance normal?
Does he have smooth, coordinated movements?
Look carefully for asymmetry

47
Q

What is the Babinski response and what does it test?

A

Tests L5 and S1 by stroking the lateral aspect of the sole from the heel to the ball

Babinski response is dorsiflexion of the big toe + fanning of the other toes

48
Q

Adult vs. infant Babinski?

A

Adult: normal = flexion of the toes, + Babinski indicates a CNS lesion in the corticospinal tract

Infants: normal = Babinski response (may persist until 2 years of age, usually absent by the time the child is walking)

49
Q

4 abnormal movements in young infants

A
  1. Seizures
  2. Jitteriness
  3. Myoclonic jerks
  4. Clonus
50
Q

Describe seizures typically seen in young infants.

A

Rarely have organized, generalized tonic-clonic seizures

often subtle, may manifest as jerking or horizontal deviation of the eyes, blinking or fluttering of the eyelids, drooling/sucking/lip smacking, tonic posturing of a limb, apnea

51
Q

What is jitteriness?

A

Distinct from seizure activity
Stimulus-sensitive movements that are generalized and symmetric
Can be diminished by gentle, passive flexion of the limbs

52
Q

What is clonus and when is it normal in infants?

A

Spasmodic alternation of muscular contractions between antagonistic muscle groups caused by a hyperactive stretch reflex from an UMN lesion

Ankle clonus up to ~210 beats should be considered normal in the newborn period if no other neuro signs are present and it is not distinctly asymmetric; normally disappears rapidly (>3 beats in a 1-2 mo old is abnormal)

53
Q

Large fontanelle?

A

Skeletal disorder (rickets, osteogenesis imperfecta), chromosomal abnormality (Down syndrome), hypothyroidism, malnutrition, increased ICP

54
Q

Small fontanelle?

A

Microcephaly, craniosynostosis, hyperthryoidism, normal varient

55
Q

Sunken fontanelle?

A

Dehydration

56
Q

Bulging fontanelle?

A

Increased ICP (meningitis, hydrocephalus, subdural hematoma, lead poisoning)

Pediatrics Clerkship (14 decks)

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