PNP-PC Part 2 Flashcards by Alexis B

If a child’s 0.9 g/dl, hematocrit is 32%, and serum ferritin is 25 mcg/L, what should her iron supplementation start at?

3 to 6 mg/kg/day of elemental iron until her hemoglobin (Hgb) reaches above 11 g/d

Once hemoglobin normalized, continue 2 to 3 mg/kg/day of elemental iron for 4 months

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_________ ensures that NPs are qualified to provide safe health care, meet professional standards and minimal levels of acceptable performance, and comply with federal and state laws relating to NPs

privileging or credentialing

Credentialing

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most definitive tools for confirming intussusception

Radiography and barium enema

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which anemia is normocytic and normochromic

Anemia of chronic disease

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microcytic and hypochromic anemias

iron-deficiency anemia
thalassemia
lead poisoning anemia

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Which two vaccines should not be given to those allergic to streptomycin, neomycin, and polymyxin B?

IPV (polio)

Varicella

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Which vaccines should not be given to immunocompromised patients as these are live vaccines that can cause them to become severely ill?

MMR

Varicella

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Which vaccine should be not given to people who are allergic to eggs?

Influenza

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A 12-month-old infant is brought to the nurse practitioner’s (NP) office because her left foot is turned inward. What is her probably condition?

Clubfoot

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What are the necessary abilities to be able to give informed consent?

reason, differentiate, and communicate

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Patchy infiltrates and pleural effusion on chest x-ray suggestive of pneumonia

Escherichia coli

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lobar consolidation rather than patchy infiltrate on chest x-ray suggestive of pneumonia

Klebsiella and Streptococcus pneumoniae

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diffuse interstitial, infiltrates that are apical or in the upper lobe on chest-ray suggestive of pneumonia

Pneumocystis pneumonia

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You meet your new patient, Ali, in the exam room. You see that Ali has drawn a picture of her mother that includes a face, body, legs, arms, and hair. Based on this behavior, how old do you suppose Ali is?

4 years old

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the leading cause of death among infant

Developmental and genetic disorders

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Sudden head extension produced by light drop of head

Moro

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Week of gestation that moro reflex appears

34-36 weeks

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When does moro reflex resolve

5-6 months

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Rotation of infant’s head to one side for 15 seconds

Asymmetric tonic neck reflex

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When does asymmetric tonic neck reflex appear

38-40 weeks

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When does asymmetric tonic neck reflex resolve

2-3 months

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Scratching the skin of infant’s back from shoulder downwards, 2-3 cm lateral to spinous processes

Tunk incurvation/

Galant

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Week gestation that trunk incurvation/Galant reflex appear

38-40 weeks

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when does trunk incervation/galant resolve

1-2 months

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placing index finger in palm of infant

palmar grasp

week gestation that palmar grasp appears

38-40 weeks

when does palmar grasp resolve

5-6 months

pressing tumb against sole just behind the toes in the foot

plantar grasp

week gestation that plantar grasp reflex appears

38-40 weeks

when does plantar grasp resolve

9-10 months

infant's head turns toward cheek that is stroked to suck

rooting

week gestation that rooting reflex appears

38-40 weeks

when does the rooting reflex resolve

2-3 months

arms and legs extend in protective fashion when suspected in prone

parachute reflex

when does parachute reflex appear

8-9 months

when does parachute reflex resolve

it persists

In supine position with hip and knee flexed at 90 degrees, the patient has pain with extension at the knee

Kernig sign

While in supine position, patient flexes lower extremities during passive flexion of neck

Brudzinski sign

Headaches in occipital or consistently localized could mean what?

Underlying pathology

``` Worse in the morning upon awakening Nocturnal awakening Projective vomiting without nausea Seizures Fever VP shunt, hydrocephaly ``` Primary or Secondary Headache

Secondary headache

Commonly bilateral in young children, in adolescents, and young adults Gradual in onset, crescendo pattern; pulsating; moderate to severe intensity; aggravated by routine physical activity Patient prefers to rest in a dark, quiet room 2-72 hour duration Nausea, vomiting, photophobia, phonophobia, aura (visual, but can involve other senses)

Migraine

Bilateral Pressure/tightness that waxes and wanes Patient may remain active or may need to rest Variable duration

Tension-Type Headache

Always unilateral, usually begins around eye/temple Pain begins quickly, reaches crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality Patient remains pain Duration: 30 minutes to 3 hours Ipsilateral lacrimation and redness of eyes; stuffy nose; rhinorrhea; pallor; sweating; Horner syndrome; focal neurologic symptoms rare; sensitivity to alcohol

Trigeminal autonomic cephaloagia

Which is the most common migraine-type? With or without aura

Without aura

What is the standard of care for migraine management?

Lifestyle modification and behavioral factors - Adequate sleep - Eating routine meals, not skipping - Adequate exercise and physical activity - Adequate hydration (at least 64 ounces of water/day) - Limit screentime - Avoid triggers or stressors

What is acute migraine medication management?

NSAIDs, acetaminophen, triptans, antiemetics

What are the approved migraine medications from the FDA?

Almotriptan, rizatriptan, sumatriptan/naproxen, zolmitriptan TRIPTANS

What is the preventative medication for migraines?

Topiramate 25-100 mg/d for 12 years and up

Sudden and stereotyped alternation in motor activity, sensation, behavior, or consciousness due to abnormal electrical discharge of neurons

Seizure

Chronic neurological condition characterized by recurrent seizures (2 or more >24 hours apart) which are not provoked by systemic or acute neurologic insults

Epilepsy

Carbamazepine/Tegretol and valproic acid/Depakote can cause which side effects

Bone marrow suppression | Liver damage

Phenytoin/Dilantin can cause what side effects

Gingival hypertrophy

Oxcarbazepine/Trileptal can cause what side effects

Significant hyponatremia | Stevens-Johnson syndrome

What is the common age for febrile seizures?

6 months to 5 years

Bried, generalized seizures and associated with concurrent febrile illness

Simple febrile convulsion

Which antibiotics should you want to prescribe with caution with antiepileptics drugs?

Erythromycin, Azithromycin, Doxycycline

Prolonged (>15 minutes) seizure, focal, or repeated episodes within 24 hours that are associated with fever Usually genetic predisposition

Complex febrile convulsion

Treatment for simple febrile seizure

Reduce fever with ibuprofen (>6 months) or acetaminophen

Manifested by both motor and phonic tics with onset during childhood

Tourette Syndrome

Coprolalia

Obscene words tic

Echolalia

Repetition of words tic

Palilalia

Repetition of phrase or word with increasing rapidity tic

Management for tics

Educating patient and family, teachers

Non-epileptic, paroxysmal event; occurs between ages 6 months and 4 years Peak age 18 months Start with provoking factors (frustration, anger, fright) and minor trauma (crying or emotionally upset) leading to a noiseless state of expiration (silent scream) with color change and eventually loss of consciousness and tone (briefly)

Breath-holding spells

What should be ruled out for breath-holding spells?

Iron-deficiency anemia (serum ferritin level)

Upper trunk nerve injury to C5 and C6 nerve roots from stretching of brachial plexus Occurs usually unilaterally, weakness of deltoid and infraspinatus muscles and biceps

Neonatal brachial plexus palsy (Erb's)

Upper arm adducted and internally rotated, forearm extended, hand/wrist movement preserved

Neonatal brachial plexus palsy (Erb's)

Who would you refer a patient to for neonatal brachial plexus palsy (Erb's)?

Physical Therapy for passive ROM

Heterogenous group of conditions involving permanent non-progressive central motor dysfunction that affect muscle tone, posture, and movements

Cerebral Palsy

Non-degenerative, non-progressive, chronic motor disorder

Cerebral Palsy

Muscle stiffening and tightness Muscles cannot relax on their own Can be hemiplegic or global

Spastic CP

Involuntary, purposeless movements

Athetoid CP

Affects balance and coordination

Ataxic CP

What is management referrals should be made for cerebral palsy patients?

Neurology Nutrition Auditory/Speech Vision

Many anti-seizures medications are _________

Teratogenic

Genetic disorder of nervous system that primarily affects development and growth of nerve cell tissues; tumors grow on nerves and cause skin changes and bone deformities

Neurofibromatosis type-1

Multiple hyperpigmented skin macules (cafe au last spots), axillary or inguinal freckling, multiple skin neurofibromas, and iris hamartomas (Lisch nodules)

Neurofibromatosis type-1

Genetic disorder resulting in the development of bilateral acoustic neuromas; pressure on vestibulocochlear or facial nerve; typical first appearance in adolescent or early 20s

Neurofibromatosis type-2

Impaired/loss of hearing, tinnitus, unsteadiness, or facial weakness

Neurofibromatosis type-2

Raised, pigmented hamartomas of the iris

Lisch nodules

Lisch nodules are characteristic of Neurofibromatosis type 1 or Neurofibromatosis type 2?

Neurofibromatosis type 1

Cognitive impairment is associated with Neurofibromatosis type 1 or type 2?

Type 1

6 or more cafe au lait macules > 5 mm (0.5 cm) in greatest diameter in prepubertal children and >15 mm (1.5 cm) in postpubertal individuals 2 or more neurofibromas of any type or 1 plexiform neurofibroma Axillary or inguinal freckling Optic glioma 2 or more Lisch nodules Distinctive bony lesions (sphenoid dysplasia or medullary narrowing and cortical thickening) 1st degree relative with disease

Neurofibromatosis type 1

Bilateral 8th nerve masses seen on neuroimaging OR 1st-degree relative Multiple spinal tumors (schwannomas, meningiomas) Cutaneous schwannomas Sporadic vestibular schwannoma in individuals younger than 30 Solitary meningioma or non-vestibular schwannoma in individual younger than 25

Neurofibromatosis type 2

Neurofibromatosis type 1 management

Monitor for hypertension (renal involvement) Monitor for enlargement of plexiform Examining skin routinely to see if there are new lesions Yearly eye exam Observing skeletal system for any changes

Ashleaf spots, adenoma sebaceum, shagreen patches, forehead fibrosis plague Seizures, cognitive delay, learning disabilities

Tuberous Sclerosis Complex

Management for tuberous sclerosis complex

Monitor for seizures Brain MRI every 1 to 3 years (up to 25 years old) Neuropsychiatric assessment for aggressive behaviors Annual skin examination Periodic dental and oral inspections or examinations Baseline echocardiography (repeat 1-3 years) and electrocardiography(every 3-5 years) for those <3 years

Diagnosis for tuberous sclerosis complex

2 major clinical features or 1 major and 2 minor

Diagnosis for possible tuberous sclerosis complex

1 major or | 2 or more clinical

Headache, nausea/vomiting, neck pain, light sensitivity, noise sensitivity Vision problem, hearing problems/tinnitus, balance problems, dizziness Confusion, difficulty concentrating, difficulty remembering, answers questions slowly, repeat questions Irritable, more emotional than usual, sadness, nervous/anxious Drowsiness/fatigue, trouble falling asleep, sleeping too much, sleeping too little

Concussion

Most common cause of head trauma in infants and toddlers

Fall and non-accidental trauma

Most common cause of head trauma in young children

Falls and bicycles

Most common cause of head trauma in adolescents

MVA, sport-related injuries, assaults

Treatment for minor head trauma

Observation in ED, clinic, or home Physical rest for 24-48 hours followed by a gradual and progressive return to non-contact, supervised physical activity Athletes should follow return to play protocol Acetaminophen or Tylenol can be used briefly

Treatment for moderate head trauma

Admit for prolonged observation in ED

Indications for neuroimaging with head trauma/TBI

``` Age <2 Recurrent vomiting Loss of consciousness Severe mechanism of injury Worsening headache Amnesia Glasgow Coma Scale <15 Suspicion for skull fracture Non-frontal skull hematoma ```

Typical symptoms of migraine headache in 14 year old usually include recurrence and: A. Unilateral forehead pain, nausea, photophobia B. Bilateral temporal pain, cyclical vomiting, and vertigo C. Unilateral forehead pain, ataxia, and photophobia D. Bilateral forehead pain, nausea, and an aura

Unilateral forehead pain, nausea, and photophobia

How is bone age measured on a radiograph?

Left hand and wrist

Growth spurts start at which tanner stage in girls?

Tanner 2

Growth spurts start at which tanner stage in boys?

tanner 3

When does long bone growth stop?

~2 years after menarche or damage to the epiphysis

What are unique bone fractures in childhood?

Buckle fracture | Greenstick fracture

Growth plate injuries

Salter fractures

Salter fractures cause?

Growth arrest leading to shortening or angular deformity

Trendelenburg gait signals

weakness of hip abductors

Gower sign signals

weak hip extensors and abductors

Trendelenburg gait and Gower sign are common in which condition

Duchene Muscular Dystrophy

Equine gait

toe-walking or toe-to-heel

Equine gait is common with which conditions

Heel cord contracture | Limited dorsiflexion

Radial head subluxation/annular ligament displacement | Commonly occurs in age 1-4 years

Nursemaid's Elbow

Nursemaid's Elbow reduction maneuvers

Hyper-pronation | Supination/flexion

Support child's arm at elbow, place moderate pressure with finger on radial head, examiner grips distal forearm with other hand and hyper-pronates forearm until click felt over radial head when reduced

Hyper-pronation

Supports child's arm at the elbow, exerts moderate pressure on radial head, apply gentle traction, supinate forearm fully and flex elbow

Supination/flexion

Evaluations for scoloisis

Adams forward bend test Scoliometer Radiographs

Differences in shoulder/scapula height Waist, truncal, or rib asymmetry Asymmetry in distance that arms hands S- or C- shape curve of the spine

Scoliosis

Red flags for scoliosis

Cutaneous lesion over spine Weakness, atrophy, abnormal reflexes Progressively worsening low back pain

When is observation ok for scoliosis

Cobb angle less than 20 degrees

When is bracing necessary for scoliosis

Cobb angle between 20-40 degrees

When is surgery necessary for scoliosis

Cobb angle greater than 50 degrees

Acute/gradual onset Sharp, darting, dull pain Point tenderness of costal cartilages along sternal border coughing, sneezing, deep inspiration, movements can exacerbate pain

Costochondritis

Maneuvers to evaluate costochondritis

Horizontal arm traction/Crowing rooster

Management for costochondritis

NSAIDs

Idiopathic avascular necrosis of hip

Legg-Calve-Perthes Disease

Peak age incidence for Legg-Calve-Perthes Disease

5-7 years

Acute/chronic onset Unilateral pain that is activity related Insidious onset limp with groin, thigh, or knee pain Pain with weight-bearing Decreased abduction, internal rotation of hip

Legg-Calve-Perthes Disease

Which x-ray should you order for Legg-Calve-Perthes disease

AP and lateral pelvis

AP and lateral pelvis x-ray for Legg-Calve-Perthes disease

Cresent sign

Management for Legg-Calve-Perthes DIsease

Non-weight bearing | Referral to orthopedist

Femoral neck displaces at physis causing bone impingement

Slipped Capital Femoral Epiphysis (SCFE)

Peak age incidence for Slipped Capital Femoral Epiphysis (SCFE)

10-14 years

``` Knee, groin, and thigh pain Limping **Obesity (boys), delayed puberty External rotation fo thigh when hip is flexed Limited *abduction/extension ```

Slipped Capital Femoral Epiphysis (SCFE)

What type of Salter-Harris fracture is Slipped Capital Femoral Epiphysis (SCFE)?

Salter-Harris type I

risk factors for Slipped Capital Femoral Epiphysis (SCFE)

malnutrition endocrine disorders hx of displaced hip chemotherapy/radiation exposure

What radiographs should you order for Slipped Capital Femoral Epiphysis (SCFE)?

AP pelvis, frog-leg lateral view

Management for Slipped Capital Femoral Epiphysis (SCFE)

Placement on crutches or wheelchair | Immediate referral to an orthopedist

How to decide if Slipped Capital Femoral Epiphysis (SCFE) is stable or unstable?

Ability to weight bear

Micro-trauma in deep fibers of patella tendon at its insertion on tibial tuberosity Painful swelling caused by repetitive stresses (basketball, sports) Seen after growth spurt Boys > Girls

Osgood-Schlatter Disease

Increased pain with activity Resolves with rest ** Pain can be reproduced with extension of the knee under pressure Focal swelling and point of tenderness of tibial tuberosity

Osgood-Schlatter Disease

Classic prominent tibial tubercle above physis

Osgood-Schlatter Disease

Management for Osgood-Schlatter Disease

``` Avoid activities that cause pain Ice/cold therapy Stretching Knee immobilizers NSAIDs (with limited use due to prolonged nature of disease) ```

Inflammation of joint due to infection (staph and strep most common)

Septic Arthritis

``` Acute onset Hx of antecedent URI Knee/hip pain Redness, swollen, warm High fever, limp, refusal to bear weight, anorexia, **appears ill ```

Septic Arthritis

Confirmation of septic arthritis

CT or ultrasound-guided aspiration

Management of septic arthritis

referral for surgical draiange | IV antibiotic

Solid tumor of bone

Osteosarcoma

Common age for osteosarcoma

15-19 years

``` Local pain, local swelling, and/or tenderness at rumor site Decreased ROM Soft tissue mass at end of long bone Fever Increased pain with activity, limp ```

Osteosarcoma

Stretch or tear in ligaments or other connective tissue

Sprains

Stretch or tear in muscle or tendon

Strains

Pain/limp, tenderness to palpation, swelling, discoloration (ecchymosis or erythema)

Sprain

Minimal stretching of ligament with microscopic tears Mild swelling and tenderness No joint instability, patient is able to bear weight and ambulate with minimal pain

Grade I sprain

More severe injury involving an incomplete tear of ligament Moderate pain, swelling, tenderness, ecchymosis Mild to moderate joint instability with some ROM restriction and loss of function; weight-bearing and ambulation are painful

Grade II sprain

Complete tear of ligament Severe pain, swelling, tenderness, ecchymosis Significant mechanical instability, significant loss of function and motion; unable to bear weight/ambulate

Grade III sprain

PRICE for sprain management

Protect with splint/brace; limit weight bearing Rest for 24-73 hours or until pain resolves Ice Compression with elastic bandage to decrease bleeding or swelling until edema is resolved Elevation at or above heart level

When can you start passive ROM and stretching with sprains?

After 1-2 days of rest

Tennis, cheer

sports common with overuse syndrome

Fractures suggestive of abuse

Ribs, long bone, skull, fingers, clavicle/scapular, vertebral

Most common causes of fractures

Abuse, sports, falls, MVA, pedestrian/bicycle events

Pain, *point tenderness*, swelling, ecchymosis/erythema, loss of function, obvious deformity

Fracture

Management for fracture

``` Immobilization/splinting, compression, ice, elevation Pain medication (initially narcotic) Emergent referral to a pediatric orthopedist ```