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  1. Cervical cancer:
    99% due to HPV
    75% of poeple are infected w/HPV
    peak late 20s, early 30s
    Risk factors: sex prior to 20, >3 partners, smoking
    CIN can revert to N w/in 5-6 yrs w/o intervention
  2. Cervical ca screening:
    Takes 7 yrs to develop
    First PAP @ 21 yrs or 3 yrs after sexual debut
    Between 21-30 q 1-2 yrs, 30-65 q 2-3 yrs
    After 65--d/c if 3 normal PAPs + no abn PAP X10 yrs
    post hyster--d/c if no prior Hx of high-grade CIN
  3. Slide Method--room for error
    Liquid--more expensive, blood doesn't alter
    --ThinPrep better
  4. Bethesda Class. System since 1991
    1. State. on specimen adequacy--endo cervical cells?
    2. Categ.--interpretation results
    negative (or benign)
    epithelial cell abnormalities
  5. Pap is only screening for CA not infection
  6. Trichomonas--do a wet mount
    Yeast (normal finding/don't always tx)--Kolt mount
    BV--shift in flora
    Actinomyces--associated w/IUD strings,?tx
    Cell changes consistent w/herpes--IGM or culture if lesion is present
  7. PAP interpretation:
    *reactive cell changes--inflammation, radiation, IUD
    *glandular cells s/p hysterectomy
    *atrophy--often see inflammation
  8. PAP squamous cell abn.:
    *Atypical cells--1st level of change, if present do HPV
    *Low-grad (LSIL)--HPV, mild dysplasia, CIN1
    *High-grade (HSIL)--mod-severe dysplasia, CIS, CIN2, CIN3
    *Squamous cell carcinoma
  9. HPV>100 types: low, medium & high-risk
    *low-risk--type 6 & 11condylomata (warts)
    --type 16 most common cause of squamous ca
    --type 18 most common viral type in adenocarcinoma
  10. PAP normal--repeat annually or as indicated
    **unsatisfactory SPECIMEN--repeat in 8-12 weeks
    **w/older women put on estrogen cream BID X6 wks then repeat PAP in 6 wks
  11. **ASC-US=Atypical Squamous cells of undetermined significance:
    --repeat in 6 months, if ASC-US or higher, colposcopy is indicated
  12. Low & high grade SIL:
    **colposcopy & cervical biopsies with endocervical curettage (ECC) is indicated
    **low-grade sesions monitor w/Pap & colposcopy q 6 months if ECC is negative
    **common tx=cryotherapy, large loop excisions of transformation zone (LLETZ), laser vaporation
  13. **endometrial cells in post-menopausal women not on ERT must have endometrial biopsy
    **AGUS (AGS)=atypical glandular cells of undetermined significance need colposcopy, ECC, endo biopsy, fractional D&D, or hysteroscopy
  14. Amnio for fetal hemolytic dx
    **done by spectrophtometric analysis
    **done when indirect Coombs test is + and AAT indicate poss. of severe hemolytic disease
  15. Risks of amnio:
    *reduced after 20 weeks
    *perforation of placenta or pl. vessels
    *PTL or PROM
    *fetal trauma
    *Rhogam indicated for RH- moms
    • *monitor 20-30 min. post-amnio
    • *caution re: S&S of complications
  16. Fetal movement counts:
    Lie in quiet darkened room
    *10 episodes of mm in 12 hrs
    *> or = to 10 mm w/in 2 hours
    *4-5 mm within 1 hour
    Count at least 3X in 1 week
  17. NST: monitors FHT in response to fetal movement
    *Reactive (positive NST)
    --FHT accels by 15 BPM above baseline & lasts 15 sec (15x15)
    --2 accels in 10 min or 5 in 20min.
    --account for fetal sleep-wake cycles...if no rxn in 20 min go to 40 min
    • Equivocal: decels (not late) are present
    • Unsatisfactory: not able to interpret tracing

    • **Reactivity depends on GA
    • --90% @32 wks
    • --85% @28 wks
    • --40% @24 wks
  18. NST: side-lying position
    --FHR baseline X 3 min
    --monitoring for min. of 20 minutes
    • Shake test:
    • --FHT accels
  19. FHT accels 15 BPM over baseline X 15 sec for 3 episodes of shaking fetus thru mom's belly
  20. NST reactive---repeat q 1-2 weeks if post-term
    NST nonreactive after 40 min OR reactive w/variable decels of FHR:
    *if first NST, order BPP then repeat NST w/in 24 hours or extend test period to 8o min.
    *perform CST
    *if previous NSTs reactive--deliver
    Bradycardia: assess AF volume, deliver if fetus mature
  21. Biparietal diameter--done 14-28 weeks
    *accurate w/in 10-11 days of EDC
    *>9.2 = fetal lung maturity
    *BPD >9.2 w/ grade II placenta= lung maturity & L/S ratio not needed.
    *use in combo w/femur length to dx IUGR
    • *Femur length--estimate gestational age
    • *Abd. circumference--est. fetal weight not dating, used for fetal well-being
    • *Placental maturation: 4 phases, grades 0-4, grade 4 most mature
  22. Before 36 wks use:
    *abd circumference
    *femur length
    • After 36 wks use:
    • *head circumference
    • *abd circumference
    • *femur length
  23. AFI (amniotic fluid index) by U/S
    *oligo: AFI < or = 5 (IUGR, postterm, PPROM, placental insufficiency
    *polyhydramnios: AFI > or= to 24-25 (fetal GI abn., maternal DM
  24. BPP (biophysical profile)=NST, fetal breathing movements, fetal tone, & AF volume

    Score 2 pts for each normal results
    *0-2: (abn.) high incidence of perinatal mort, not shown to improve
    *4-6: (equivocal) can improve if maternal condition improves
    *8-10: (normal)
    Good to use after -NST or +CST
  25. Modified BPP: combine NST with AFI
    --most commonly used tool for antenatal testing
    --NST reflects fetal well-being @ time of testing
    --AFI is long term predictor of uteroplacental function
    If NST & AFI are normal--repeat 2x/week
  26. Preeclampsia is gestation HTN with proteinuria (>300mg/24hr or > or= to 1+)

    mainly primigravidas & adolescents & >35 y/o

    complicate~12-22% of pgs
    Risk factors: nulliparity, mult. pg, hx of pre-eclampsia, HTN, DM, renal dx, thrombophilias, obesity

    WARNING SIGNS: unusual or severe HA, extreme swelling of face & hands, blurred vision, epigastric pain
  27. Gest. HTN= increase SBP of at least 30 mm
    --increase of DBP of at least 15 mm or DBP of 90 or above
    --Proteinuria (>300 mg/24 hrs
    --2 occasions at least 6 hrs apart within 1 week (baseline of previous known BP)
    --degree of elevation more important than absolute values
    --Sit w/arm supported in horizontal position at heart level
    • Final dx of gest. HTN made PP:
    • --if BP returns to normal w/in 12 hrs PP
    • --if persists after 12 weeks=chronic HTN
  28. Etiology of gest. HTN:
    --inadequate blood volume so body responds as if hemorrhage
    --kidneys secrete renin to constrict blood vessels, increase volume by retaining water & salt, increases reabsorption of water
    • Fluid leaks into tissues=pathological edema
    • --not enough albumin & salt to hold fluid in blood volume
    • --increased BP late sign
    • --monitor HTN, proteinuria (& edema
  29. Criteria of pre-eclampsia:
    --SBP>= 140, DBP >= 90 after 20 wks, on 2 occasions, at least 4 hrs apart within 1 week
    --proteninuria > 300 mg/24 hrs or > or = 1 on dipstick
    • Severe Pre-eclampsia
    • --SBP >=160, DBP >=110 on 2 occasions 6 hrs apart w/in 1 week
    • --proteinuria >=5 g/24, >-3=on random urines 4 hrs apart
    • --Oliguria, visual/cerebral disturbances, epigastric/RUQ pain, pulmonary edema or cyanosis, impaired liver fx, thrombocytopenia, IUGR
  30. HELLP--atypical variant of pre-eclampsia, acute & progressive
    **10-20% pre-eclamptics develop HELLP
    **76% dx 28-36 wks
    **20% dx >36 wks
    **28% dx PP
    • H=hemolysis
    • EL=elevated liver enzymes
    • LP= low platelets
  31. HELLP caused by ?apresoline & aldomet?

    **LDH >600=HELLP
    **SGOT > or = 40 = HELLP
    Tx: Apresoline---aldomet--albumin infusion

    42% risk of reoccurance of PIH, 19-27% recurrence of HELLP
  32. Placenta Previs: painless bleeding, fundal height > 28 cm, FHT WNL, fetus transverse or breech, not engaged, uterus soft
  33. Placental abruption: HTN (predisposing factor), concealed bleeding, abd hard or board-like, marked pain & tenderness, low back pain, rising fundus. Fetus brady or tachy or absent FHT
  34. Vasa previa: cord vessel traversing fetal membranes before inserting into the placenta.
  35. PROM:
    **leaking or gush
    **+nitrazine paper (alkaline 7) (can be false+ if bloody)
    **+fern test
    **fluid visualized in vagina
    Before term: BR, avoid vag exam, increase fluids, pelvic rest

    Term: Most induce after 12 hours, can wait 48h, infection risk increases after 24h
  36. Chorioamnionitis is inflammation chorion, amnio & amniotic sac
    **maternal fever & tachy
    *fetus tachy
    *uterine tenderness
    *warm vaginal walls
    *elevated WBC
    *foul smelling, purulent amniotic fluid
    • >= 34 wks--deliver & GBS antibiotics
    • 32-34 wks--steriods, BGS, antibiotics, delivery if + FLM
    • 24-32 weeks--accelerate FLM

  37. IUGR is fundal height > 2 cm below gestation before 34 wks
    --U/S q 3 weeks
    --single amniotic pocket of 1 cm or less assiciated w/90% chance of IUGR
  38. GBS (group B streptococcus agalactiae)
    --10-40% of pg woman GBS+
    --80-85% GBS infection is early onset
    --frequent cause of newborn pneumonia, sepsis & meningitis
    --vaginal/rectal cx @ 35-37 wks on all woman
    • GBS treatment:
    • **PenG 5 million units IV then 2.5 mil q4h until delivery
    • **Ampicillin 2 gm IV then 1 gm q4h until delivery
    • **May use Cefazolin, clindamycin, or EES
  39. Maternal BP of 140/90 or greater before 20 wks is chronic HTN
  40. BPP measures fetal tone, gross body movements, fetal breathing frequency, reactive HR, amniotic fluid volume
    8 or less requires delivery or more frequent testing
  41. Toddler
    **gains 5-6 # during 2 & 3rd years
    **decreased appetite, more lean & muscular
    **head circ increases 2 cm during 2nd yr
    **brain reaches 80% of size of adult brain
    14-16 teeth by end of 2nd yr
    875-900 cals/day at 2 years old
  42. Toddlers
    **major accomplishment--walking & increased fine motor
    **vision 20/40
    **can jump, hop on one foot, pedal a bicycle & stop a ball between ages 2-3
    **can climb stairs one at a time
    • --can draw stick figures
    • --pics more like real life
    • --by age four, can copy figures
  43. Toddler language:
    **18 months--vocab of 10-12 words
    **age 2-3--vocab of 300-900 words
    **speaking concurrent w/walking
    **can say first & last name, identify colors & recognize size difference
    **recognize pictures in books by 18 months
    • **temper tantrums
    • **magical thinking--if they think it, it will happen
    • **solitary play
    • **no significant interaction w/other kids
  44. Toddler toliet training--begin at 18-24 months.

    Sleep--11 hours/night by 2 years old

    MV safety--rear seat only
  45. Cardiac murmurs (toddler)
    >50% infants
    >80% ages 3-4
    innocent/pathologic 10:1
  46. Preschoolers, ages 3-5
    **4-5 lbs per year
    **2.5-3.5 inches per year
    **less lordosis in stance/protuberant abd disappears by age 4
    **20 teeth
  47. Preschooler neuro development--3 year old
    **alternates feet going upstairs
    **jumps from bottom step
    **rides trike using pedals
    **holds crayon w/fingers
    **pincer grasp
    • Language--uses plurals, names action in picture books, gives sex and full name, obeys 2 prepositional commands ("on" & "under")
    • **teach phone # & address
    • **feeds self well
    • **puts on shoes
  48. Neurodevelopment, 4 year old
    **walks down stairs alternating feet
    **does broad jump
    **throws ball overhand
    **hops on one foot
    • Language development: names one or more colors correctly, obeys 5 prepositional commands (on, under, in back, in front, & beside)
    • ** washes & dries face & hands
    • **brushes teeth
    • **laces shoes
    • **distinguishes front from back of clothes
  49. Neurodevelopment, 5 year old
    **skips, alternating feet
    **stands on one foot more than 8 seconds
    ** catches & bounces a ball
    Language--knows 4 colors, names penny, nickel, dime
    **dresses w/o assistance
    **asks meanings of words
    **prints some letters
    • Sleep--requires 12 hours/night w/1 nap per day
    • Caloric intake for 3 &4 year olds is 1000-1100/day.
    • Limit TV to 1 hour/day
  50. Tinea cruris.
    --rare in peds a puberty
    --does not affect scrotum or penis
    --may appear as vesicles
    • Tinea versicolor
    • --well-marginated lesions of varying colors
    • --rare itching
    • --common in axilla, shoulders, chest & back
  51. Diagnostic studies for tinea:
    --KOH scraping
    --Wood's lamp exam
    • Treatment:
    • capitis--griseofulvin orally, pg C, liver fx tests, recheck in 2 weeks & 6 weeks
    • Tx X 4-6 weeks

  52. Tinea corporis/cruris/pedis treatment (creams):
    **ketoconazole X 2 wks (6 wks--pedis)
    **econazole X 2 wks (6 wks--pedis)
    **terbinafine X 2 wks
    • Tinea versicolor tx:
    • 1)ketoconazole shampoo (Nizoral) to damp skin X 5 min, 1 app enough
    • 2)selenium sulfid 2.25% shampoo to skin 10 min X 7 days
    • Consult/referral for non-responsive cases
  53. Tinea cure:
    4 weeks for capitis
    1-2 weeks for corporis
    1-2 weeks for cruris
    Pedis--controlled NOT cured, frequent recurrences

    Versicolor--frequent recurrences esp. in spring
  54. Complications of tinea:
    capitis--permanent alopecia or scarring
    corporis & cruris--bacterial secondary infection
    pedis--frequent recurrences
  55. Pediculosis--lice, ectoparasites that feed on human blood, nits may survive up to 3 weeks removed from human hosts

    Incubation period--about a month

    Head lice less likely in African Amer.
    • Body lice
    • --papules 2-4 mm in dia
    • --found on axilla, trunk, & groin

    DD: lice, mite, dandruff
  56. Diagnosis of lice:
    --Wood's lamp, live nits fluoresce white, empty are gray
    --microscopic, open vs filled nits

    Nonpharmacological--mayonnaise, petrolatum, vinegar soak--empty nits will remain on hair shafts for months after eradication
    • Tx: 1% permethrin (Nix) most effective (to dry hair 10")
    • --synergized pyrethrins (0.33% piperonyl butoxide 4% (Rid) to dry hair X 10" then wash
    • --malathion 0.5% (ovide) apply to affected areas X 8-12 hours then wash

    May need to repeat tx
  57. Pubic lice--may use Rid or Nix or Kwell (lindane)
    --no Kwell for pg women or infants
    --don't use for eyelash infestation
    --instead use manual removal of nits & petroleum jelly 3-4X per day X 1 week

    Consult/referal: school personnel/parents/dermatol is unresponsive to tx
    • F/u
    • --may return to school if empty nits but not live lice
    • --recheck head after treatment
  58. Scabies (sarcoptes scabiei) burrowing mite causes small, itching blisters in a line (scaling, erythema, vesicles, papules)

    DX: examine skin w/magnifying lens, Burrow ink test, recover mite from burrow
    TX: wash all clothing, bedding, toys in hot soapy water

    sealed bags X 3-5 days for items cannot be washed

    Can use Kwell--not on pg women
  59. Varicella-zoser virus (chickenpox)--latency in dorsalroot ganglion then reactivates as shingles

    "dewdrop on rose petal"
    peak age 5-9
    infectious 2 days before appearance of rash and until all lesions have crusted over
    For immunocompromised--varicella zoster immune globulin with in 4 days of exposure

    Consider acyclovir in adolescents/adults more likely to have serious illness
  60. Acyclovir ( 20 mg/kg/dose2-16 yrs) max 800 mg qid X 5 days

    Famvir (adults) 500 mg tid X 7-10 days
    Valacyclovir (adults) 1 gm tid X 7-10 days

    NO ASA!!
    • **Fetal infection following maternal infection is 25%
    • **5% get congential defect in 1st or 2nd trimester

    Refer: infected newborns, immunocompromised, pg, severe cases

    Complications: pneumonia, encephalitis, Reye's syndrome, disseminated infection
  61. Pityriasis Rosea--idiopathic self-limiting skin dosorder
    **papulosquamous lesion--trunk & extremities
    **males=females, all ages (most common 10-35)
    **"herald patch"precedes ge. rash, present 40-70% of time, fine scales 1-10 cm in diameter
    **gen rash appears 1-2 weeks after herald patch
    **Christmas tree pattern, salmon-colored oval plaques
    DD: syphilis, tinea corporis--versicolor, viral exanthums, drug rash

    • Tx: antipruritics e.g. Calamine, oral antihistamines e.g. Atarax or loratadine
    • F/U benign, usually none, resolves in 2-6 weeks but up to 14 weeks
  62. Roseola--viral illness of high fever X 3-5 days, fever disappears then a blanching maculopapular rash lasting 1-2 days
    **usually self-limited, no sequelae
    **human herpes virus 6, common in daycare & preschoolers, most common age 6 months to 3 years
    ** contact w/saliva/feces during fever phase or during 5-15 days incubation period

    Presentation: sudden fever, not ill-appearing, mild URI, sudden resolution of fever and onset of rash, rash blanches w/pressure, TM inflammation, lymphadenopathy--DO NOT USE ASA!!

    Can use HHV-6-IgM but not needed unles questionable dx
  63. Rubella (german measles, 3-day measles, Third disease)
    <1000 reported annually
    Risk factors--lack of vaccination, incubation 7-21 days, most contagious when rash is erupting

    Presentation: mild catarrhal sx, conjunctivitis, low-grade fever, occipital lymph nodes diagnostic!!, maculopapular rash, poss desquamation, arthralgia & arthritis
    • DD: scarlet fever, roseola, Fifth Disease, drug reactions, viral exanthems
    • DX: titer of 1:10 or higher immune
    • Immunize at 12-15 months then age 4-6 years, not during pg!, communicable in breat milk!
    • TX: NSAIDS for arthralgia, Tylenol for fever
  64. Fifth Disease--common viral infection w/eruptive rash, parvovirus B19
    Incidence: common in 4-12 year olds in late spring (also infants & adults)
    Incubation period 4-28 days, nasal secretions & respiratory droplets transmit
    • Prodrome: low fever, malaise, sore throat, lethergy
    • Rash: phase I--intense red rash w/circumoral pallor; phase II--macular & lacy rash on body & extremities
    • final phase--pruritic, can last up to 21 days
    • palms & soles may be affected

    DD: Rubella, enterovirus, lupus, drug rashes, vial exanthems

    Danger to fetus due to severe anemia due to RBC destruction, PG women avoid exposure (10% fetal death prior to 34th week).

    • TX: supportive, rest, NO ASA!!
    • Expected course: rash may last up to 3 weeks, fade or intensify w/heat, sunlight, exercise
  65. RUBEOLA--(measles, 9-day measles, First disease)acute, highly contagious viral disease
    **characteristic rash, sig. morbidity/mortality worldwide
    **morbillivirus (paramyxoviridae family)
    **significant outbreak 1989-1990, decrease since then
    Risk factors: lack of vaccine, waiting rooms, incubation 10-12 days, contagious from 1-2 days prior to onset of symptoms until 4 days after rash appears
    Prodromal state (2-3 days before rash): URI, fever to 104, 3-C's=cough, coryza, conjunctivits, Koplik's spots, malaise

    Rash phase: maculopapular rash & fever occur simultaneously, pharyngitis, cervical lymphadenopathy and splenomegaly, rash on forehead & behind ears first then neck & arms in 24 hours then trunk, thighs & hips in 24 hours--after 3-4 days, rash begins to clear
  66. Roseola DD: roseola, scarlet fever, viral rashes, drug rashes, Kawasaki Dx, Stevens-Johnson syndrome

    Report all cases to public health department
    Measles specific IgG titers--detectable 3 days after rash onset, 4-fold increase between acute & convalescent phase
    Immunize at 12-15 months then 4-6 years

    • Can vaccinate w/live virus within 72 of exposure
    • Immunoglobulin within 6 days of exposure

    TX: water miscible vitamin A for children 6 months to 2 years reduces morbidity and mortality (vit A deficiency predisposes to keratitis & vision complications)
  67. Roseola

    Significant increase in fetal morbidity & mortality during pg

    Immunoglobulin recommended for exposed pg women
    • Refer:
    • all severe cases
    • pg women
    • immunocompromised

    Complications: OM, bronchopneumonia, pneumonitis, diarrhea, keratitis, encephalitis, laryngotrachetitis
  68. SCARLET FEVER (Scarletina)--sore throat, fever, & "sandpaper rash", group A Beta-hemolytic strep pyrogenes
    **6-12 years most common
    FINDINGS: sore throat, exudative tonsillitis, HA, fever, chills, vomiting, petechiae on palate, strawberry tongue, fine sandpaper rash, Pastia's lines, desquamation (Pastia's lines=classic red streaks underarms)
    DD: pharyngitis, measles, rubella, durg rash, viral exanthems, toxic shock, scalded skin syndrome

    • Diagnostics: throat culture, rapid strep, antistreptolysin O (confirms infection but not helpful for diagnosis)
    • Antibiotics within 10 days of onset effective in preventing rheumatic fever.
  69. Scarlet fever:
    **bleach or replace toothbrush, supportive care, maintain hydration
    **PCN is DOC, can use Cephalosporins, EES or macrolides for PCN allergic, DO NOT USE tetracyclines/sulfonamids for strep infections!!
    Complications: sinusitis, OM, rheumatic fever, glomerulonephritis
  70. Immunizations: Need only 3 IM hep B vaccines

    DTaP--a stands for acellular pertussis(less likely to cause fever & severe rxn)--give only to children < 7 years old
    **Td or Tdap for ages 7 and older--need primary series for booster to work
    Valid DTaP contraindications: severe allergic rxn e.g. high fever, encephalopathy within 7 days, temperature > 105 within 48 hours of vaccine not due to other causes, collapse or shock-like state, persistent inconsolable crying> 3 hours, convulsions with or without fever

    TB testing has noeffect of MMR but MMR may suppress response to PPD if not given at same time.
    Options for administering:
    **apply PPD first, read, then give MMR
    **apply PPD & give MMR at same time
    **delay PPD for 4-6 weeks after MMR
  72. Varicella vaccine must be frozen with special freezer
    **can't refreeze!!
  73. PCV-pneumococcal vaccine, give 4 doses

    PPSV-pnumococcal polysccharide vaccine, give 1 dose at least 8 weeks after final dose of PCV to high-risk children age 2 years & older (give 2 dose 3-5 years later for immunocom, sickle cell, asplenia)
    • Influenza vaccine--all children aged 6 months to 18 years
    • **children aged < 9 years getting the vaccine for the first time should receive 2 doses 4 weeks apart for TIV (injected flu vaccine)

    **can use intranasal live, attenuated flu vaccine
  74. Rotavirus (RV)--give 2-3 injections (if given at 2 & 4 months, dose at 6 months is not indicated)

    ** give final dose by 8 months
  75. HPV vaccine--need 3 doses
    **first dose at age 11-12 (minimum age 9)
    **second dose--1-2 months after 1st dose
    **third dose--6 months after first dose
    **gets more painful as series goes on
    **HPV 4 (Gardasil approved for males ages 9-26)
    **should get vaccinated even if pt has disease
    • **type 6 & 11--cause 90% anogenital warts
    • **types 16 & 18--cause 70% cervical cancers
  76. School-aged children:
    **organ development is complete
    **tonsilar hypertrophy
    **don't usually have sinusitis
    **grow 2.5 inches/year
    **weight increases 5-7 lbs/year
    **brain-adult size by 12 years old
    • **spine become straighter--improvesknock-knee or bowleg
    • **lymphatic system is most active & tonsils are largest
  77. School-aged VS:
    --HR 60-100/min
    --RR 18-30
    --BP 90/60 to 108/60
    • First permanent teeth after 6 years
    • Primary teeth shed in same order as arrived
    • 4 teeth/year shed and replaced
  78. School-aged nutritional recommendations:
    --each meal should have 1 high quality protein
    --milk/low-fat dairy each meal
    --veg and fruits high in A&C in 2 meals/day
    --meat 4X/week
    --fish/poultry 1-2X/week
    --dark green, leafy or deep yellow veg daily or at least 4X/week
    --max of 4 eggs/week
  79. Additional assessment for BMI between 85th & 95th %tile if:
    *BMI increased by 2 or units in the past 12 months
    *family hx of heart disease, obesity, HTN, or DM
    * child is concerned
    *elevated serum chol. or BP
    • If additional assessment is negative:
    • *give general dietary advice, exercise counseling & monitor annually
    • *assess kids with low BMI for eating disorders
    • *if eating pattern doesn't change promptly w/intervention--refer
  80. Overweight=BMI> or = 95th percentile for age & gender

    Underweight=BMI<= 5th percentile for age & gender

    Both should be referred for dietary & health assessment
  81. School-aged neurodevelopment:
    *concrete operational stage
    *differentiate right from left hand
    *handedness is developed by age 6
    • *ages 6-7 eye-hand coordination improves, can dress self
    • *can hop, skip, jump, run, climb, wrestle & ride bike
    • *ages 7-8 improved conscious & cognitive skills, improved physical coordination
    • *ages 8-10 increased strength, endurance, precision w/hand movements
  82. AAp policy of lipid screening:
    Screen for any of the risk factors:
    *Family hx of high chol or heart disease
    *Family hx unknown
    * obesity, HTN, DM
    • Screen:
    • *after age 2 but no later than age 10
    • *best method--fasting lipid profile
    • *if normal repeat in 3-5 years
    • *kids over 8 years w/high LDL--consider cholesterol-reducing medication
    • *kids less than 8 with elevated chol should focus on weight reduction and increase activity
    • *start treating @ 100-140 LDL
  83. Puberty begins in boys 11-14, in girls 10-13

    Schoolage children should get 10 hours/sleep per night
  84. Congenital calcaneovalgus foot
    --very common neonatal deformity
    --banana shaped sole
    --dorsiflexes easily--long heel cord
    --deviates laterally
    No intervention is beneficial
  85. Metatarsus adductus
    --most common congenital foot deformity
    --sole is kidney bean shaped (medial deviation)
    --easily dorsiflexed

    Foot & leg deformities--common, up to 10% of infants
    Treatment: foot exercises
  86. Excessive femoral anteversion
    *entire leg turns in
    *both patella and foot are facing medially
    TX: normal activity
  87. Talipes equinovarus (clubfoot)
    **inability to dorsiflex foot
    **heel varus (bowed)
    **sole kidney-bean shaped
    **tight heel cord
    TX: serial casts or surgery
  88. Flexible flatfeet
    **when bearing weight--no arch
    ** when not weight-bearing, arch is present
    TX: normal activity
  89. Internal tibial torsion:
    **entire foot points inward
    **patella points straight ahead
    TX: normal activity
  90. Developmental dysplasia of hip
    **partial or complete subluxation/dislocation of femoral head from pelvic acetabulum (congenital hip dislocation)
    **occurs postnatally not congenitally
    • Etiology:
    • --generalized laxity of ligaments
    • --maternal estrogen & relaxin--pelvic relaxation
    • --breech
    • postnatally adducted, extended position vs natural abducted, flexed position
  91. Incidence of hip dysplasia:
    --1/60 to 1/1000
    --30-50% develop in breech positions
    --20% positive family hx
    Risk factors: breech, adducted position, neuromuscular disorder, + fam hx,, muscular torticollis, metatarsus adductus, down syndrome.
  92. Menopause--"climacteric refers to period of physiologic change before onset of menopause.
    *FSH rises to stimulate estrogen production in ovaries
    *before 30 years is premature meno
    *early meno. before 40 y/o genetic or autoimm.
    *peri-menopause 7-10 yrs prior to onset of menopause
    *peri-meno. =onset of menstrual changes thru 1st year of meno (average length 4-5 years)
    Cardinal sx: irregular menses, heat intolerance/hot flashes, vaginal dryness

    • Average age of perimeno onset is 47.5
    • Smokers have earlier menopause

    Menopause=12 mo. of amenorrhea--average age in US is 51 to 52.
  93. Menopause physiology
    *decreased estrogen, decrease negative feedback thus increased FSH & LH--never return to pre-menopausal levels
    *if no hormone therapy FSH=30 mlU/ml is diagnostic
    *if on combined oral contraceptives do annual FSH on day 5,6,7 of placebo-pill week (if progesterone only--anytime)
    Atrophic changes--diuretics & CCB inhibits the parasympathetic nervous system & contribute to incontinence

    • 85% women have vasomotor instability
    • mood swings--estrogen receptors in the brain
    • 35-60% of women have sleep disturbances
  94. Menopause: HRT--if no uterus--don't need progestin
    Benefits of HRT:
    *decreases meno symptoms
    *protects against RA
    *protects against dementia
    • HRT risks:
    • *increase in gallbladder disease, breast ca, CV dx, thromboembolic dx, worsen migraines, worse hepatic failure

    **NEED ADEQUATE PROGESTERONE IN WOMEN W/UTERUS--otherwise risk endometrial ca
  95. Absolute contraindications for HRT:
    *breast ca
    *estrogen dependent neoplasm
    *undiagnosed abn. genital bleeding
    *thromboembolic dx
    *recent MI
    *unopposed estrogen for women w/uterus
    • Relative contraindications:
    • Estrogen:
    • *malignant melanoma
    • *gallbladder dx
    • *HTN
    • *migraines
    • Progesterone: can raise seizure threshold
    • --liver dysfunction
    • --seizure disorders
  96. Menopause diagnostics:
    --chol, lipids
    --U/A, chemistry, serum FSH & LH, LFTs
    --screen for colorectal ca
    --bone density
    --thyroid profile--need a diagnosis for insurance to pay
  97. Menopause--HRT/WHI women's health initiative:
    --stopped study r/t increase in breast ca
    --increase risk for CHD, Stroke & PE

    Lowered risk for colon ca and hip fx
    • HRT/WHI--estrogen only, stopped r/t increase in stroke
    • --no relationship to CHD
    • --no effect on breast ca

    In study: estrogen=0.625 & medroxyprogesterone= 2.5

    Lowered risk for hip fx
  98. TX: risk/benefit analysis--lower doses w/alternative methods of administration e.g. creams & patches applied above the waist

    **skin based formulations avoid "first pass"of liver & have fewer side effects
    **vaginal rings worn for 3 w/little systemic absorption
    --systemic vaginal therapy--Femring--systemic vaginal estrogenX3 months.
  99. SERMS--selective estrogen receptor modulators (tamoxifen analogs e.g. Evista(raloxifene))

    --decreases bone remodeling & used to prevent and treat osteoporosis in women who cannot take estrogen
    • Other drugs for vasomotor symptoms:
    • --clonidine
    • -methyldopa
    • -bellergal
    • --propranolol
    • --naloxon
    • --SSRIs
    • --Gabapentin
  100. Bone mineral density testing
    **all women at age 65
    --T-score on DEXA of 1-2.5=osteopenia

    femoral neck score better than spine score
  101. Menopausal health promotion:
    --diet w/1000-1500 mg of Ca+ and Vit D
    --exercise--daily wt bearing
    --contraceptive protection for at least 1 yr after cessation of menses
    --dental health r/t cardio & osteo reasons
    • Immunizations:
    • --Tdap
    • --flu
    • --Pneumovax
    • --Zoster vaccine for >60
    • --catch up
  102. IUD teaching: early warning signs---PAINS
    Abdominal pain or pain w/intercourse
    Not feeling well
    String missing--shorter or longer
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