Ped 2 Flashcards
(215 cards)
1
Q
what is the most common reason why a baby is born prematurely
signs of this
A
sepsis from infection
cloudy or smelly amniotic fluid
2
Q
what constitutes a pre term baby
three conditions to be manage
A
<37 weeks
sepsis, thermoregulation, RDS
3
Q
what constitutes a term baby
four conditions to manage
A
37-42 weeks
sepsis, pneumonia, birth asphyxia, meconium aspiration
4
Q
post term baby
two conditions to manage
A
>42 weeks
asphyxia related complications and sepsis
5
Q
why are most others induced at 41-42 weeks
A
because the placent doesn’t function as well at this point and can injure the baby
6
Q
what does a gestational age assessment look at
A
neuromuscular and physical maturity
7
Q
components of neuromuscular maturity
A
posture
square window
arm recoil
popliteal angle
scarf sign
heel to ear
8
Q
what is the most important indicator of gestational age
how accurate is it
A
posture
accurate with in one week
9
Q
how would a preterm baby present posturally
A
full extension and no flexion
10
Q
what is the square window
how sshould this change as the baby gets older
A
the angle between the palm and the flexor surface of the arm when the hand is flexed
the angle should decreased as gestational age increases
11
Q
arm recoil test
how will this differ pretime to term
A
pull the arms down and se if the naturally recoil
a full term baby will naturally bring their arms back to less than 90, a preterm wont
12
Q
poplital angle
A
try to draw leg up to the ear, a preterm baby will allow more extension of the knee
13
Q
heel to ear
A
take both letgs to the ears without lifting the hips off the table, preterm will allow rhis
14
Q
scarf sign
A
when the preterm babies arm is pulled across their neck they wont fight
15
Q
what should cause an increased (bad) score on scarf test
A
obesity, chest wall edema, short humerus, shoulder girdle hypertonicity
16
Q
what would cause a spuriously low (good) score on scarf sign
A
brachial plexus injury or general hypertonicity
17
Q
what does the skin of an immatue baby look like
A
red, shiny, tacky
if 24028 weeks there will be venous patterns on the trunk, head, and neck
18
Q
lanugo
what does it mean in term of prognosis
A
fine hair on the baby
more lanugo means the baby is more viable
19
Q
how will the plantar surface of a preterm bbaby look like
A
preterm will have a more smooth foot
20
Q
eye fusing
A
eyes fused suggested a gestational of 26 weeks
21
Q
how will the ear look on a preterm baby
A
cartilage looks more firm on a term than a preterm baby
22
Q
maturity of male genitalia
female
A
presence of testis, degree of descent, developemtn of rugea on the scrotum
prominence of the clitoris, develpment of labia minora/majora
23
Q
neonate PE color
A
cyanosis of hands an feet is normal, jaundice is abnormal
24
Q
what typically causes jaundice ina neonate
A
infection or hemolytic process
25
neotnate PE vital signs
HR 120-140 preterm 140-160
heart sounds split s2 normal with no murmurs
RR 40-60
26
neonate PE eyes, nose, jaw
eyes should be 2-3cm apart
nose flattened bridge
pierre robin small jaw
27
pierre robin
issues with transport and intubation
babies with no lower jaw or very small one, commonly have stridor and tongue obstruction
easiest to transport prone and hard to intubate
28
what would abnormal red reflex indicate
glaucoma or cataracts
29
ear tags/ear pits are possibly indicative of what
kidney malformation because they are formed at the same time
30
how should the ears line up in relation to the eyes
the eye and the ear should be on a horizontal line, if the ear is low set it can be indicative of a chromosomal problem
31
how many vessesls hould be in the umbilical cord
two veins and one artery
32
neonate PE thorax
symettry, retractions, precordial activity
contour of the abdomen and number of vessels in the cord
33
neonate PE spine and extremities
curvatures, dimpling, bulging, exposed spinal cord
symmetry in appearance in movement, ROM, positioning
34
acrocynanosis
constriction of small arterioles that leads to cyanosis in the hands
35
four reflexs to note on neonate PE
root
suck
moro
grasp
36
root reflex
stroking the cheek will cause the baby to turn their head to ward the stimulus
37
suck reflex
issues with develipment
when the roof of the babies mouth is touched they wil begin to suck
usually doens;t present until 32 weeks and not fully developed until 36 weeks
38
moro reflex
how long is it present
a loud sound will cause the baby to throw back their head, extend their arms, cry, then pull the limbs back in
lasts about 5-6 months
39
grasp reflex
how long is this present
stroking the palm causes the babies hand to close
5-6 months
40
mongolian spots
why is it important to document
skin discoloation
can be mistaken for a bruise and lead someone to think there is abuse
41
what is the most important part of a apgar score
the progression or lack thereof (apgar 4 to 9 is ok, 4 to 4 is worrisome)
42
IURG (intrauterine growth restricted)
two types
what does this put them at risk for
assymterical: head too big for their body
43
neurochemical etiology of ADHD
deficiency of dopamine and norepinephrine
44
what is the gender bias in ADHD
how do they present differently
males more than females
men more hyperactive
women more inattentive
45
four centers in the brain associated with ADHD
frontal cortex (attention, organization, executive function)
limbic system (emotions)
basal ganglia (inattention, impulsivity)
reticular activating system (inattention, impulsiviity, hyperactivity)
46
genetic correlation of ADHD
prevalence
70-80% genetic
5 %
47
ADHD symptoms
inattention
hyperactivity
impulsivity
48
diagnostic conditions for ADHD
6+ symptoms under 16, 5+ symptoms over 17
present for at least 6 months
symptoms inappropriate or disruptive
symptoms are present in two or more settings
clear evidence that the symptoms interfere with social functioning
symptoms are not better explained by another condition (anxiety, dissociative disorder, schizophrenia)
49
two symtom categories for ADHD
inattention or hyperactivity/impulsiveness
50
inattention ADHD symptoms
often fails to give close attention to details
trouble holding attention on tasks
doesn't listen when spoken to
doesn't follow thoruh with instruction or fails to finish tasks
trouble organizing tasks
51
hyperactive ADHD symptoms
fidgets a lot
leaves seat often
unable to play quietly
talks alot
52
combined presentation of ADHD vs predominantly inattentive or hyperactive
allows for inattentive and impulsive criteria if there are enough present for six months
53
forms for ADHD
vanderbitl form
conners scale
54
comorbid conditions associated with ADHD
any mental, emotional, behavior disorders
behavior issues
anxiety
depression
autism spectrum
tourettes
55
DDX for ADHD
age approproate activity
mood disorders
anxiety disorders
ASD
substance abuse
56
ADHD treatment (pre school)
start with behavior therapy with positive reinforcement
add stimulants if therapy is ineffective
57
ADHD treatment (school aged)
types of medication
start with medication plus behavior therapy
methylphenidate
amphetamine
dextroamphetamine
58
nonstimulant treatment for ADHD in school aged children
atomexetine (strattera)
buproprion (wellbutrin)
guanfacine
59
behavior therapy for teachers and parents to implement with ADHD kids
keeping a schedule
keeping distractions to a minimum
having a place for all their things (toys, books, etc)
setting small, reachable goals
rewarding positive behavior)
60
presentation vs diagnosis of symptoms in ASD
symptoms usually present in the first 2 years but no diagnosed until age 4
61
hallmark features of ASD
altered communiations/interactions with others
repetitive movements
restricted interests
all these symptoms interfere with functioning at home/school/etc
62
DSM diagnostic criteria for ASD
presistant social communication and social interaction deficits
restrictive, repetative behaviors behaviors
symptoms present in early development
symptoms cause clincally signifcant impairment to function
disturbances are not explained by an intellectual disability
63
etiology of ASD
unknown, possible genetic or enviromental factors
64
risk factors for ASD
down syndrome, fragile X, rett syndrome
older parents
having a sibling with ASD
low birth weight
65
specific symptoms of ASD
little to no eye contact
abnormal response when someone tries to get their attention
unusual tone of voice
flat affect
echolalia
extreme focus
hyper/hyposensitive to sensory input
66
who diagnoses ASD
general practitioner makes initial screen
specialized evaluation by psych, speech pathology, pediatricians
hearing screens or lab tests to rule out other causes
67
DDx of ASD
childhood psychoses
fragile X
hearing loss
68
comorbid conditions with ASD
ADHD
depression
anxiety
frequent diarrhea
colitis
asthma
eczema
69
treatment of ASD
early treatment is important
involves therapy and medication
social service programs
life style modification
70
intellectual disability involved impairment in what two areas
intellectual ability (IQ \<75)
lack of adaptive behaviors (hard time learning but can communicate)
71
intellectual disability prevalence and gendrer bias
1% have it, 85% of those are mild
males affected more than females
72
etiology of intellectual disability
problems during pregnancy or child birth
genetic conditions
illnesses
injuries
73
preventable causes of intellectual disability
FAS
maternal drug use
maternal malnutrition
infection
74
T/F the etiology is intellectual disability is usually known
false, it is only known in 1/3 of patients
75
symptoms of ID
deficieits in intellectual functions (language development, reasoning, problem solving, planning, judgement)
deficits in adaptive learning (fails to become independent, limited functioning in daily activities)
76
diagnosing ID in children under 3.5
over 3
developmental testing
developmental testing, standardized tests, psych eval, vision and hearing test
77
specialized tests for diagnosing intellectual disability
genetic testing
brain imaging (micro/macrocephaly)
metabolic screen
78
comorbid conditions associated with intellectual disability
CP
epilepsy
ADHD
ASD
depression
79
DDx for ID
ASD
developmental delay
FAS
communication disorders
spoken language disorders
hearing loss
80
treatment for ID
speech therapy
OT/PT
special education
behavior therapy
counseling
medical therapy if needed
81
risk factors for pediatric depression
FHx of depression
family dysfunction
exposure to early difficulty (neglect, abuse)
low birth weight
TBI
gender dysphoria
substance abuse
82
symptoms of pediatric depression
depressed
decreased interest
change in appetite weight
sleep issues
psychomotor agitiation or retardation
fatigue
83
comorbid consitions for depression related to CV issues
diabetes
obesity
sedentary lifestyle
smoking
84
depression standardized tools for pediatrics
mood and feelings questionaire
beck depression inventory
child depression inventory (7-17)
reynolds adolescent depression (grades 7-12)
85
Dx of pediatric depression
HP
PE
mental status exam
labs (CBC, CMP, TSH, Urine)
86
DDx for pediatric depression
adjustment disorder with depressed mood
bipolar
sadness
87
treatment for pediatric depression
SSRI/SNRI (fluoxetine)
88
sideffects of SSRI (pediatric depression)
abdominal pain
diarrhea
nausea
headache
sleep changes
cardiac events
suicidal thoughts
89
T/F electroconvulsive therapy has been show to have no positive effect in treating pediatric depression
false
90
citalopram is associated with what risk for what (used to treat depression)
long QT syndrome and sudden cardiac death
91
clinical course for depression in children
adolescents
most end in 8-13 months with a 30-70% relapse
most end in 4-9 months, 90% within 2 years, 20-70% relapse
92
risk factors for recurrence of pediatric depression
presence of residual Sx
enviromental stressors
limited social support
93
what is the most common psychiatric condition across developmental stages
anxiety
94
five types of anxiety disorders
generalized anxiety
social anxiety
separation anxiety
OCD
phobias
95
symptoms of pediatric anxiety
overly tense and uptight
constant fears of safety
refusal to goto school
extreme worries about sleeping away from home
clingy
difficulty sleeping
96
clincal diagnosis of pediatric anxiety
HP
anxiety screen (screen for anxiety related emotional disorders)
labs
97
treatment for anxiety
therapy (cognitive behavioral therapy)
medications (SSRI)
98
typical onset of OCD
10, but can start as early as 6
99
what are the gender or racial bias of pediatric OCD
none in either category
100
OCD cycle
obesseion, anxiety, compulsions, relief
101
OCD defined
upsetting, recurrent thoughts leading to repetitive actions
feeling to urge to do repitive actions to soothe anxiety
difficulty stopping the reccurent thoughts until ritual is complete
102
etiology of OCD
precise cause is unknown
some genetic correlation
dysregulation of serotonin
103
risk factors for OCD
family Hx
stress
104
Dx of OCD
SCARED screen
childrens yale-brown obsessive compulsive scale
105
comorbid condition associated with OCD
other anxiety disorders
tic disorders
depression
ADHD
oppositional defiant disorder
106
DDx for OCD
depression
bipolar
eating disorders
body dysmorphic disorder
hoarding disorder
107
treatment for OCD
cognitive behavior therapy
medications (SSRIs, tricyclics)
108
oppositional defiant disorder
ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that interfere with daily function
109
PANDAs related to strep
some patients don't show signs of OCD until they have a strep infection
110
prevalence of ODD
gender, age, SE bias
up to 16%
no gender or SE bias
111
biological factors associated with ODD
parent with ADHD, ODD, CD
parent with depression or bipolar
parent substance abuse
chemical imbalance
exposure to toxins
112
psychological etiology of ODD
poor relationship with parents
neglectful or absent parents
difficultly forming social relationships
113
social etiology of ODD
poverty
chaotic environment
abuse
neglect
lack of supervision
114
symptoms of ODD
frequent temper tantrums
excessive arguing with adults
active defiance of adults
deliberate attempts to annoy upset people
frequent anger and resentment
115
comorbid conditions for ODD
ADHD
learning disabilities
mood disorders (depression, bipolar)
anxiety
116
treatment for ODD
therapy
medication at trating some of the more severe symptoms
treatment of comorbid conditions
117
treatment for parents and care givers
positve reinforcement
be a good role model
pick your battles
set up age appropriate limits with consequences
maintain a life away from your kid
118
how many/how long symptoms need to be present to diagnose ODD
\>4 symptoms for \>6months
119
lanugo
thin soft hair found on newborns
120
what is considered small for gestational age
large
10th percentile or less
90th perctile or more
121
ortolani manuver
PE of a new born that checks for hips dysplasia
122
capur succeduaneum
swelling of the scap of a neonate brought on by pressure of the being forced out of the vagina
123
cephalohemotoma
traumatic subperiosteal hemotoma that occurs under the skin
124
erbs palsy
brachial plexus injury of C5-6, makes a claw hand, related to birth trauma from shoulder dystocia
125
klumpke palsy
paralysis of the forearm muscles
126
syndactyl
fingers or toes that are attached to each other
127
polydactyly
multiple fingers and toes
128
meconium
the first newborn stool made of epithelium, hair, mucus, bile
129
TORCH infections
**T**oxoplasmosis
**O**ther (syphylis, chicken pox, parovirus)
**R**ubella
**C**ytomegalovirus
**H**erpes
130
nenonate
less than 4 weeks old
131
infant
birth to one year
132
acrocyanosis
cyanosis of the hands and feet
133
diastasis recti
separation of the rectus
134
hypospadias
opening of the urethra on the dorsal surface of the glans
135
fetal erythroblastosis
hemolytic anemia in the fetus caused by antibody incompatibility between the mother and fetus
136
mongolian spots
flat blue grey spots that can be confused for bruises
137
intrauterine growth retardation
a conditions where a baby does not grow to a normal size
138
kerion
abscess from a fungal infection
139
gastroschisis
baby's intestines are out side of the abdominal cavity
140
omphalocele
intestines and abdominal organs are formed out side the body
141
palmar grasp: defined
newborn closes fingers around object placed in hand
142
palmar grasp: duration
28 weeks gestation to 4 months
143
rooting: defined
touch a neonates cheek, head turns towards stimulus with an open mouth
144
rooting: duration
32 wks (incomplete gestation) or 36 wks (complete)
to 4 monts
145
moro (startle) reflex: defined
hold the baby supine, allow a head dropof 1-2 cm. arms will abduct and elbows flex with fingers spread
follwed by adduction with flexion
146
moro (startle) reflex: duration
28wks to 3 onths
147
suckle reflex
new born sucks when something is placed in the mouth
14 weeks
148
0-2 month milestones
gross
fine
social
language
**gross**: turns head to side
**fine**: clenched fist with eye contact
**social**: recognizes human face
**language**: vocalizes in play
149
2-3 month milestones
gross
fine
social
language
gross: lifts head
fine: tracks objects past midline, opens hands
social: smiles responsively
language: vocalizes in play
150
4-5 month milestone
gross: head steady in supported position
fine: hands together
social: shows displeasure through vocalization
language: looks for the source of sound
151
6-8 month milestones
gross: rolls over, sits foward on arms
fine: reaching and raking
personal: responsed to own name, holds bottle
language: imitates speech and voice
152
9-11 month milestones
gross stands while holding on
fine: passes object from hand to hand
social: feeds self, imitates waving
language: undestands no, says mama
153
12-14 month milestones
gross: stands alone for 2 seconds
fine: bangs object together, places pellet in bottle
social: hugs dolls, uses gestures to indicate needs
language: uses one or two words with meaning
154
15-17 month milestones
gross: stoops and recovers, walks well
fine: builds 2-3 cube tower
social: attempts to use sppon
language: waves bye, uses 4-5 words
155
18-21 month milestones
gross: runs well, kicks ball, walks backwards
fine: scribbles, turns book pages
social: drinks from cup, uses spoon, feeds self
language: follows simple commands, has 20-50 words
156
24 month milestones
gross: throws ball overhead, jumps
fine: turns door knobs, builds a 7 block tower
social: washes and ries hands, little spilling during feeding
language: two or three words combined, points to body parts
157
36 month milestones
gross: stands on one foot for 2 seconds
fine: copies circle
social: takes turns, toliet trained
language: uses pronouns, gives names
158
48 month milestones
gross: hops on one foot
fine: wiggles thumb, copies cross
social: dresses self
lanuage: knows colors, asks questions
159
5 yr milestones
skips using alternating feet
fine: holds a pencil correctly
social: brushes teeth without help
language: easily carries convestaion, counts, does ABCs
160
what is the peak time for SIDs
2-4 months in age, between 12am and 8 am
161
SIDs demographic bias and risk factors
more likley among minorities and low SES
RFs: low birth weight, teen mothers, drug addiction, multiparity, FHx
162
post mortem finding most consistent with SIDs
intraothoracic petiechiae with mild inflammation and congestion of the respiratory tract
163
reccomendations to decrease SIDs risk
sleep on back
firm surface
no bedding or pillows
share room, not bed
don't smoke
offer pacifier
avoid overwrapping, overheating, head coverings
encourage tummy time while awake
164
failure to thrive
weight curve fallen by two percentile channels from previously established rate
165
underlying causes of failure to thrive
inadequate nutrition
GI reflux
neglect
poverty
ignorance
166
what is the most common chronic disease of childhood
dental caries
167
when will primary teeth erupt
what factors can change this by one month
7 months
gestational age \<37 weeks or birthweight \<2500g increases that by one month
168
positive barlow manuver
hip dislocation brought on by adduction of a flexed hip while pushing down on the thigh
169
positive ortolani
dislocation of the hip by abducting the thigh that will elict a clunk or a spasm
170
positve barlow, ortolani, or hip click lasting more than one month should be referred
true
171
how will DTRs in an infant appear
brisk, possibly with clonus
172
three most common causes of hyperbilirubinemia in infants
physiologic jaundice, prematurity, breastfeeding jaundice
173
two causes of neonatal jaundice
excess production of bilirubin
decreased rate of conjugation
174
conditions associated with excessive bilirubin production in neonates
blood group incompatibility
spherocytosis
G6PD deficiency
sepsis
175
decreased conjugation of bilirubin in neonates is related to wha conditions
physiologic jaundice
gilbery syndrome
crigler-najar syndrome
176
kernicterus
at what level of hyperbilirubinemia will this occur
what will it cause
a conditon where bilirubin passes the blood brain barrier
20-25 mg/dL
encephalopathy
177
guidelines for phototherapy in neonatal jaundice
500-1000g
1000-1500g
1500-2500g
\>2500g
bilirubin 12-15 mg/dL
15-18
18-20
\>20
178
why are newborns predisposed to jaundice due to increased bilirubin load
decreased life span of RBCs
increased RBC volume
small amount of internal bleeding
179
why are newborns predisposed to jaundice due to immature hepatic circulation
decreased bilirubin uptake
decreased conjugation
180
three reasons why newborns are predisposed to jaundice
increased bilirubin load
increase entreoheaptic recirculation
immature hepatic metabolism
181
three phases of acute bilirubin encephalopathy
early, intermediate, advanced
182
signs of early phase acute bilirubin encephalopathy
severe jaundice
lethargy
hypotonic
poor nursing
183
signs of intermediate phase acute bilirubin encephalopathy
stupor
irritability
hypertonia of the neck and back
fever with high pitched cry
184
at what stage of acute bilirubin encephalopathy is the damage likely reversible
the intermediate stage if there is a blood transfusion
185
signs of advanced phase acute bilirubin encephalopathy
pronouced retrocollis-opisthotonos
shrill cry
no feeding
apnea
fever
stupor into coma
sz
death
186
signs of kernicterus
cerebral palsy
auditory dysfunction
dental enamel dysplasia
paralysis of upward gaze
intellectual handicaps
187
T/F most infants with kernicterus has show some sign of acute bilirubin encephalopathyq
true, but there are some with few clinical signs as well
188
treatment for breast feeding jaundice
nursing as soon as possible after delivery
frequent nursing for the first few days
do no limit nursing time
189
what causes breast milk jaundice in health infants
what is the treatment
familial tendency
active reabsorption of bilirubin
withhold breast feeding for 24 hours then resume
190
T/F phototherapy bleaches the skin and makes jaundice more prominent
false, it makes it harder to see and makes visual assessment of jaundice unreliable
191
risk factors for development of hyperbilirubinemia in infants older than 35 weeks gestation
predischarge TSB in the high risk zone
jaundice in the first 24 hours
blood group incompatibility
known hemolytic disease
gestational age 35-36 weeks
192
factors that indicate decreased risk for jaundice after discharge
TSB in the low risk zone
gestational age 41 weeks
exclusive bottle feeding
black
discharge after 72 hrs
193
what is the action of phototherapy for jaundice in neonates
to formation of lumirubin that will bind with water and does not need to conjugated to be excreted
194
T/F the use of homephototherapy or sunlight exposure in the treatment of jaundice in neonates is effective
false, it is reserved for those with optional phototherapy needs or excluded all together as a theraputic tool (sunlight)
195
what is the role of amniotic fluid
fetal breathing of amniotic fluid stimulates lung growth
if there isn;t enough fluid the baby gets pulmonaryt hypoplasia
196
what is the function of surfactant
decreases surface tension
maintains functions residual capacty
197
two conditions that might cause surfactant deficiency
prematurity
infant of a diabetic mother
198
four issues that would inactivate surfactant
pulmonary hemorrhage
pulmonary edema
alveolar capillary leak
meconium
199
pulmonary causes of respiratory distress
choanal atresia
transient tachypnea ofthe newborn
fluid aspiration (blood or meconium)
hyaline membrane disease
congenital pnemonia from rectal flora
200
PE findings that indicate RDS
cyanosis on room air
RR +60
grunting
sternal and intercostal retractions
201
hyperoxia challenge test
giving a neonate with RDS supplmental oxygen resolves cyanosis, indicative of pulmonary or noncardiovascular origin
202
increased risk factors for RDS
prematurity
male
familial dispositon
c section
chorioamnionitis
hydrops
maternal diabetes
203
decreased risk factors for RDS
chronic inttrauterine stress
maternal HTN
IUGR or SGA
corticosteroids
thyroid homone
tocolytic agents
204
RDS chest xray
ground glass appearance, hazy, air bronchograms
205
blood gas workup for RDS
high CO2, low O2
206
management of RDS
antenatal steroids
surfactant replacement
CPAP
mechanical ventiliation
ABx
sedation
207
acute or chronic hypoxia is indicative of what
meconium aspiration
208
risks of meconium aspiration
air leak of ball valving (atelectasis, pneumothorax)
chemical pneumonitis
pulmonary HTN
209
management of meconium aspiration
pulmonary toliet
umbilical lines
oxygen monitoring with mechanical ventilation
chest xray to rule out air leaks
ABx
surfactant
ECMO
210
pulmonary air leaks found with meconium aspiration
pneumothorax
pneumomediastinum
pneumopericardium
pulmonary interstitial emphysema
211
physical factors that contribute to SIDS
brain abnormalities
low birth weight
respiratory infeciton
212
environmental contributors to SIDS
side or stomach sleeping
sleeping on a soft surface
cosleeping
213
misc SIDS risk factors
sex
age
race
FHx
2nd hand smoke
gestational age
boys \> girls
most vulerable during the 2nd and 3rd month
black, native american, eskimo increased risk
FHx increases risk
2nd hand smoke increases risk
preature babies have a higher risk
214
maternal risk factors for SIDS
younger than 20
smokes
drugs or alcohol
inadequate prenatal care
215
specific causes that lead to failure to thrive
lack of appetite (anemia, CNS issues)
difficulty swallowing
unable to get food
vomitting
malabsorption
diarrhea
inadequate absorption of calories
increased metabolism
