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Pediatrics - sb

a 9 year old boy comes in complaining of heavy vomiting, lethargy, confusion, headaches, but no fever... of note he has a virus the other day and mom gave him aspirin reyes syndrome
Of the kiddo with reyes syndrome what might you find on physical exam enlarged liver
What tests would you do to confirm reyes syndrome CT, LP, ammonia levels (elevated), ALT/AST (x3 elevation), amylase and lipase (elevated), PT/aPTT (prolonged)
how do you treat reyes syndrome IVF, anti-epileptics, treatments to prevent bleeding, NO MORE ASPIRIN
Pt has projectile non-bilious vomiting and FTT what anatomical problem should you evaluate them for pyloric stenosis
Bilious vomiting makes you worried for what condition obstruction
most common reason for vomiting in a kiddo gastroenteritis (norovirus, rotovius, adenovirus, or astrovirus)
intermittent abdominal pain, vomiting, bloody stool that looks like jelly(?), fever. what do you worry about them having intussusception
after how many days is it considered chronic diarrhea 14
most common cause of acute diarrhea infectious usually viral
which diarrhea will be more bloody bacterial or viral bacterial (invades the intestinal wall)
Dysenteric diarrhea acute bloody caused by invasive microbial infection
Dehydration in a kid is more common because they have a higher metabolic rate, increased body surface area to mass index, higher body water content
at what stage of dehydration do you get skin tenting moderate
sucken eyes, pulse increased but barely palpable, sucken fontanelle all point to what stage of dehydration severe
what question would you ask a mom with an infant you suspect has dehydration how many wet diapers has she/he had in the last 24 hours
what finding on UA is consistent with dehydration ketones and/or protein in the urine
treatment of moderate dehydration 20mL/kg NS bolus repeat until better
maintenance fluids in a kiddo with dehydration D5 + 1/2 NS +/- 20 meq KCl
History questions you should ask a patient with a head injury mechanism, LOC, HA, seizures
When would you suspect meningitis in a newborn fever and nonspecific symptoms, stiff neck or bulging fontanel, irritable, restless, or lethargic
When would you suspect meningitis in an older child sudden fever, headache, nausea, vomiting, confusion, stiff neck, photophobia
Phsyical exam findings with meningitis cyanosis, disturbed consciousness, meningeal irritation (Kernig, brudzinski)
A 2 week old baby comes into the ER with a fever. what diagnostic procedure should you do LP
When treating meningitis Do LP then initiation of empiric antibiotic therapy
What bacteria do you think you with a neonate and mengitis Group B strep, E. coli, Listeria
what pathogens do you suspect with older children with menigitis S. pneumoniae, N meningitis, staph (Hib if not vaccinated)
Findings on CSF with bacterial Elevated white count mostly PMNs, glucose decreased, protein elevated
Findings on CSF with viral Normal WBC (could be elevated with lymphocytes), normal glucose, normal protein
Treatment of meningitis/sepsis (?) with newborns Amp + Gent
Treatment of meningitis/sepsis (?) with children Ceftriaxone + Vanc
Drowning treatment management of hypoxia, ET tube and mechanical ventilation may be indicated
How high is the fever with febrile seizures usually >102
simple febrile seizures < 15 minutes, generalized, once during a 24 hour period, febrile child, no signs of intracranial infections, metabolic distrubances or history of febrile seizures
Complex febrile seizures prolonged >15 minutes, focal, more than once in 24 hours
Treatment of febrile seizure in the ER Tylenol or Motrin, LP if first one and young, monitor for return to baseline mental status, PT EDUCATION
Ca Blockers poisoning symptoms Hypotension, bradycardia, N/V, stupor, confusion
Ca blockers treatment IV access, telemetry PO activated charcoal, aggressive tx if bradycardia with IVF, pressors, Ca, possible ECMO
Beta blockers poisoning symptoms Hypotension, arrhythmia, bradycardia, CNS depression/coma, seizures, hypoglycemia, bronchospams
Beta blockers poisoning treatment admit for 24 hour obs activated charcoal if <1hr post ingestion IVF, pressors, antidote is glucagon with NS
Sulfonylureas poisoning symptoms hypoglycemia, agitation, confusion, tachycardia, seizures
Sulfonylureas poisoning treatment MUST ADMIT for 24h q1hr blood glucose check, give food, dextrose, or if really bad octreotide
Tylenol poisoning symptoms transaminases start to increase 12 hr post ingestion, liver necrosis in 72-96h
Tylenol poisoning treatment check lytes, LFTs, coags, UA and recheck qhr antidose- NAC within 8hr
Antidepressant poisoning symptoms CNS depression, seizures, arrhythmias, hypotension (TCA) hypertension (SSRI)
Antidepressant poisoning treatment ECG and telemetry activated charcoal gastric lavage sodium bicarb if arrhythmia
Iron poisoning symptoms Stage1 abd pain, V/D, Gi hemorrhage, dehydration Stage 2 asx Stage 3 coma seizures shock hepatic dys, hypoglycemia stage 4 hepatic failure stage 5 GI tract strictures bowel obstruction
Iron poisoning treatment follow abdominal radiograph, lytes, CBC do NOT use activated charcoal whole bowel irrigation if iron tablets seen antidote- desferoxamine if severe, AG acidosis, lots of pills seen
Ethylene glycol poisoning symptoms Elevated anion gap metabolic acidosis CNS toxicity, tachycardia, hypoxia, CHF, ARDS, acute tubular necrosis, renal failure
Ethylene glycol poisoning treatment Airway, telemetry, ethylene glycol levels, renal function, dialysis? antidote- domepizole
Methanol poisoning symptoms normal or inebriated AG metabolic acidosis blindness death (6-36 hours)
Methanol poisoning treatment Airway, supportive, dialysis? antidote- fomepizole
Poor prognosis post drowning -Prolonged submersion(>10 min) -Delay in effective CPR -Severe met acidosis (<7.1) -Asystole on arrival to ED -GCS <5 -Fixed, dilated pupils in ED
early diagnosis of aspiration respiratory distress, stridor
Late diagnosis of aspiration wheezing, coughing, decreased breath sounds, fever
Evaluating aspiration plain chest x-ray, inspiration/expiration xray, left and right decubitus x-ray, chest fluorscopy
you think a kid swallowed captain planet.. but you cant see earth wind or fire on a chest xray.. what do you do GI endoscopy
How can you tell if the child is eating enough growth charts
initial post-natal loss average weight loss 3-6% in first 2 weeks after birth
when does a baby regain the initial post-natal loss by day 10-14
infants double birth weight by 5-6 months
infants triple birth weight by 1 year
Constipation infrequent stooling, dry hard or small stools, uncommon in breast fed infants
Constipation of treatment ensure proper diet and formula prep, feed water after each feeding, 2oz of juice, ensure potty training is not forced
Diarrhea causes excessive fruit juice and fluid intake, low fat diet, sugar free candies
Diarrhea treatment appropriate diet, whole milk, minimal fruit juice
When can you add cereal into the babies diet ~6 months
When can you add mashed foods, fruits, veggies, grains 6-8 months
When can you add foods with fine lumps, foods with soft texture 8-10 months
When can you add bite sized foods 10-12 months
is baby getting enough with breast feeding audible swallowing, 6-8 wet diapers a day, 2-3 stools per day, appear satiated, breast softer after feeding
contraindications to breast feeding infants with galactosemia, mother with HIV, TB, drug use, chemo/radiation, on antiretrovirals, or has human T cell lymphotropic virus
components of a nutritional assessment in a child anthropometrics, biochemical analysis, history, dietary data, PE
Transcription DNA to RNA
Translation RNA to protein
Clinical presentation of down syndrome (Trisomy 21) (6/10) Flat facies, slanted palpebral fissures, anomalous auricles, excess skin on back of neck, hypotonia, poor moro reflex, hyperflexibility, dysplasia of the mid phalanx 5th digit, pelvic dysplasia, single transverse palmar crease
Trisomy 18 (edwards syndrome) IUGR, clenched hand with index overlapping 3rd and 5th overlapping 4th, inguinal or umbilical hernia, cardiac defects, low set ears, micrognathia, rocker bottom feet, apnea (90% die by 1 year)
Trisomy 13 holoprosencephaly, polydactyly, seizures, deafness, sloping foreheads, cleft lip/palate, abnormal ear, microphthalmia, single umbilical artery, cardiac and urinary tract defects (70% die within 1 year)
Klinefelter syndrome features (XXY) Normal to tall stature, delayed speech, behavior or learning problems, thin with long legs, hypergonadotropic hypogonaism (also gynecomastia and elbow dysplasia)
Klinefelter syndrome treatment developmental or behavioral counseling, testosterone therapy
Turner syndrome Single X chromosome
What does turner syndrome look like congenital lymphedema, webbed neck, short stature, broad chest, triangular face, ptosis, strabismus, posteriorly rotated ears, cubitus valgus
horseshoe kidney seen in what genetic conditon turner syndrome
Heart defects seen with downs syndrome AV canal, VSD, ASD
Heart defects seen with turners syndrome coarctation of the aorta, bicuspid aortic valve
Turner syndrome treatment growth hormone at age 2-5, estrogen replacement, thyroid replacement, repair of coarctation
Fragile X presentation mental retardation, autism, macrocephaly, large ears, prognathism, macroorchidism, tall stature
Marfans syndrome presentation TALL, low upper-to-lower segment ration, pectus excavatum or carinatum, Archnodactyly, joint laxity, scoliosis, lens subluxation, glaucoma, aortic aneurysm, mitral valve prolapse, inguinal or femoral hernias
Marfans heart defect mitral valve prolapse
Congenital adrenal hyperplasia due to a deficiency in 21-hydroxylase (so no cortisol or aldosterone so high ACTH and adrenal androgens)
how does congenital adrenal hyperplasia look ambiguous genitalia, pt in a salt crisis
Management of congenital adrenal hyperplasia glucocorticoids +/- mineralocorticoids
Symptoms of an inborn error of metabolism in neonates anorexia, lethargy, vomiting, seizures
pt has galactose in urine could indicate what disease severe renal disease
PKU deficiency of phenylalanine hydroxylase
PKU babies look fair haired, blue eyed, developemental delays by 6months, can have ezcema seizures, and weird smelling urine (phenylacetic acid)
FISH is used for detection of submicroscopic deletions and duplications
Perodicity table guidelines for screening history, physical, labs, immunizations at each well visit
checklist for autism M-CHAT-R/F
When do you attempt the eye chart 3 years
When do you attempt audiometry testing (not counting new borns) 4 years
Measurements of the well child visit Length, weight, BMI, FOC, blood pressure (after age 3)
Screening for congenital and heritable disorders in otherwise normal infants happens when 24-48 hours, second screen at 1-2 weeks old
newborn screenings include 29 disorders in what categories Cystic fibrosis, 6 amino acid disorders, 6 fatty acid oxidation, 8 organic acid disorders, G1PD, Biotinidase deficiency, 3 sickling disorders, 2 endocrine disorders, SCID
when do you do anemia screenings 12 months, 18 months, 12 years in females
When do you do TB screening if pt at low risk questionnaire at 12 months, if risk then PPD
when do you do TB screening if pt at high risk PPD once at 12 months, 4-6 years, and 11-17 years, questionnaire annually at age 2
THSteps recommends lead screening at 12 months and 24 months, if none prior up to 72 month
What kind of carseat... birth to 35lbs infant rear-facing seat
What kind of carseat... toddlers/preschoolers forward facing seat with 5 point harness at or above shoulder
What kind of carseat... school aged children >40lbs booster with shoulder/lap belt, back seat only
when can a kid ride in the front seat older than 13
valid contraindication to all vaccines anaphylactic reaction to vaccine, moderate or severe illness
Tdap contraindicated when after last vaccine encephalopathy within 7days, fever >105 within 48 hours, collapse/shock, seizure within 3 days, crying inconsolably >3hrs within 2 days
Valid contraindications for any attenuated live virus vaccines such as MMR, Varivax anaphylaxis to eggs, immunodeficiency, recent immunoglobulin
How would you assess development in kids (tools) Denver, PEDS, ASQ, M-CHAT, growth charts
At 1 month movements are reflexive
between 1 and 3 months movements are intentional, hands to mouth, able to raise head, grasp toys
when can a baby roll over 4-7 months
can sit without assistance, pulls up, crawls on belly, first steps, pincer grasps 8-12 months
Can respond to requests 8-12 months
walks alone, begins to run, climb, know names of people, short sentences 12-24 months
Colic food sensitivity, late pm feedings, and lasts a few hours
Colic treatment try diet change, motion, pacifier, swaddle
What do you do at well child visits for newborn weight check, labs, feedings, safety including car seat, warnings about fever, cord care
What do you do at well child visits for 2 months diet, stimulation, safety- bed roll over, immunizations, fever
What do you do at well child visits for 4 months new foods, sleep changes, safety, stimulation
What do you do at well child visits for 6 months diet, safety with hands to mouth
What do you do at well child visits for 9 months Diet- introduce cup, poison control, behavioral management
What do you do at well child visits for 12 months diet- whole milk, no bottle, stimulation-reading, discipline, immunizations
What do you do at well child visits for 18 months child proofing, prepare for terrible twos, talk about toilet training
otitis media is most commonly viral or bacterial viral (RSV, rhinovirus, coronavirus, parainfluenza, adenovirus, enterovirus)
Treatment for acute otitis media amoxicillin 80-90 mg/kg/day divided by 2 or 3
pathogens with otitis externa pseudomonas, enterobacteriacae, proteus species, fungi
Treatment for otitis externa topical eardrops, wick bactrim, polymyxin b/neomycin/hydrocortisone
Pharyngitis- adenovirus fever, acute follicular conjunctivitism, myalgia, malaise, GI issues
pharyngitis- bacterial usually caused by group A beta hemolytic strep
pharyngitis- bacterial sx fever, sore throat, *petechiae on soft palate*
pharyngitis- bacterial treatment Pen VK or amoxicillin
your patient with strep throat starts complaining of worsening symptoms.. you look at their throat the the uvula is leaning to one side.. whats your worry peritonsillar abscess
Hand foot mouth disease is caused by coxsachie virus
Hand foot mouth disease symptoms low grade fever, URI, *ulcerative pharyngitis* rash on palms and soles
Herpes simplex stomatitis symptoms fever, body aches, *ulcers on lips, gums, buccal mucosa*
Herpes simplex stomatitis treatment they hurt to they dont want things touching them... so dehydration common so give them popsiles or the maalox:benadryl:lidocaine cocktail
mononucleosis caused by EBV
mononucleosis symptoms fever, malaise, lymphadenopathy *posterior cervical*, hepatosplenomegaly
mononucleosis testing monospot (IgM), or EBV serum antibody titers
what must you check when someone has mono if they also have strep
Diphtheria membraneous pharyngitis, bull neck (can lead to respiratory obstruction)
pt comes in looking toxic, high fever, muffled voice, unable to swallow, and tripod stance Epiglottitis
Epiglottitis caused by H. flu
on xray you see a thumb print sign epiglottitis
on xray you see a steeple sign croup
epiglottitis treatment intubation 3rd gen cephalosporin
Croup symptoms mucosal inflammation, increased secretions with edema, URI, seal like bark
Croup treatment if mild just manage at home, systemic steroids, epinephrine (big gun)
Bronchiolitis caused by RSV
Bronchiolitis symptoms coryza, dry cough, respiratory distress, fine end-inspiratory crackles, high pitched wheezing
bronchiolitis x-ray findings hyperinflation, atelectasis, hilar bronchial markings
Pertussis caused by bordetella pertussis
pertussis stages catarrhal (1-2 wks)- non-specific, paroxysmal (3-6 wks)- cough, whoop, post-tussive emesis, apnea, convalescent (1-2 wks) gradual resolution
Pertussis treatment erythromycin, azithromycin, clarithromycin
high fever, seizures, diarrhea shigella
shigella treatment ceftriaxone, azithromycin, FQ
fever, conjectival infection, *red cracked lips*, rash, swollen red peeling hands and feet Kawasaki disease
kawasaki disease treatment echocardiogram (coronary aneurysms), IV immunoglobulin will decrease coronary aneurysms
dew drop on a rose petal varicella
low grade fever, mac/papular rash on day 1 faded by day 2-3, post auricular post cervical and occipital nodes rubella
measles (rubeola) cough *rhinitis* conjunctivitis, koplick spots, *rash on day 3* starts on neck face then downward
mumps fever, malaise, parotitis, *rash starts unilateral then bilateral* pain when eating
fifths disease "slapped cheek syndrome" parvovirus B19
fifths disease symptoms mild URI, low grade fever, headache then 1 week later "slapped cheek"
roseola caused by human herpesvirus 6 and 7
roseola symptoms high fever for 3-4 days, defervescence rash- small pink blanchable mac/papules on trunk and neck
genu varum bow legs
genu valgum knock knees (normal for under 3)
when do you worry about genu valgum if older than 3, unilateral, pain or limp, or if >2ins
toe walking you should check for tightness of achilles, mild CP, duchennes
Risk factors for SIDS <1, low birth weight, siblings with SIDS, recent infection, smoking during pregnancy, drug use, poor prenatal care, low education level, single mom, multiparty
cystic fibrosis abnormal ion transport across epithelial cells of exocrine glands in respiratory tract and pancreas causing think sticky build up
test of CF sweat test (will show abnormally high salt)
CF symptoms in infancy meconium ileus, prolonged chest infection, pancreatic exocrine insufficiency cause steatorrhea and FTT
CF symptoms in children persistent loose cough, viscid mucus in small airways leads to chronic infection, *nasal polyps*, chronic pseudomonas, cirrhosis
CF management regular spirometry, physiotherapy, prophylactic antibiotics, high calorie diet, daily exercise
Pneumonia symptoms cough, fever, sputum production, SOB, tachypnea, tachycardia, apnea, retraction/flaring/grunting, abd pain
manifestations of respiratory distress retractions (supraclavicular, intercostal, subcostal) nasal flaring, grunting, wheezing, stridor
asthma exacerbation treatment B2 agonists (3 back to back treatments), Atrovent (3 back to back treatments), steroids
Transient tachypnea tachypnea within 2 hours of delivery, cyanotic, symptoms resolve in 12-24 hours
treatment transient tachypnea self limiting, supportive nutrition and/or oxygen
meconium aspiration airway obstruction and respiratory distress in a post term meconium stained infant
xray findings in a meconium aspiration baby diffuse "ropey" densities, patchy areas of atelactasis and emphysema from air trapping, hyperinflation, pneumothorax and pneumomediastinum, small PE
Innocent heart murmurs soft, systolic, asx, heard at the left sternal border
venous hum (type of innocent murmur) blood flow from head to heart- disappears with turning or head, when supine
stills murmur (type of innocent murmur) vibratory or musical that decreases with intensity when standing
VSD ventricular septum doesn't close
ASD hole in atrial septum
presentation of VSD holosystolic murmur @ LSB, acyanotic, prominent apical pulse, signs of heart failure
presentation of ASD fixed and widely split S2, soft ejection systolic murmur at ULSB, acyanotic
PDA failure of ductus arteriosus to close by 1 month after expected due date
presentation of PDA continuous "machinery" systolic murmur at L2nd ICS, increased pulse pressure, acyanotic
EKG on PDA normal! diagnosis with an echo and close!
Tetralogy of fellot 4 cardinal features large VSD, overriding aorta, right ventricle outflow tract obstruction, right ventricle hypertrophy
Tetralogy of fellot presentation loud murmur at ULSB, *cyanotic* hypercyanotic spells, squatting with exertion
chest xray shows a "boot shaped" heart...dx tetralogy of fellot
Coarctation of aorta presentation decreased femoral pulses, continuous murmur between scapulas
chest xray on coarctation rib notching
patients with coarctation of the aorta often have what other heart defect bicuspid aortic valve
mom has hypothyroidism what is baby at risk for hypothyroid
mom has hyperthyroidism what is baby at risk for transient thyrotoxicosis
mom has hypertension what is baby at risk for IUGR
mom has myathenia gravis what is baby at risk for transient myasthenia
mom has systemic lupus what is baby at risk for congenital heart block, rash, anemia, thrombocytopenia, neutropenia, cardiomyopathy, stillbirth
mom takes anti-epileptics what could happen to baby midface hypoplasia, CNS, limb, and cardiac malformation
mom takes accutane while prego what could happen to baby miscarriage, abnormal face
mom takes tetracycline while prego what could happen to baby enamel hypoplasia of teeth
mom takes lithium while prego what could happen to baby congenital heart disease
mom takes DES while prego what could happen to baby adenocarcinoma of cervix,
mom takes iodine, PTU while prego what could happen to baby hypothyroidism
mom takes cytotoxic agents while prego what could happen to baby congenital malformations
mom takes thalidomide while prego what could happen to baby phocomelia (limb shortening)
mom smokes while prego what could happen to baby SGA infant
mom drinks while prego what could happen to baby fetal alcohol syndrome
mom uses cocaine while prego what could happen to baby placental abruption
mom takes opiates, heroin, or methodone while prego what could happen to baby drug withdrawal in 1st 2 weeks of life, seizures, jitteriness, sneezing, poor feeding, vomiting, diarrhea
what does fetal alcohol syndrome look small head, flat midface, low nasal bridge, small eye openings, short nose, thin upper lip
baby has copious purulence with severe swelling of eyelids on day 2 of life N. gonorrhea
baby has scant eye discharge with mild swelling on day 14 of life C. trachomatis
Normal infant findings: acrocyanosis blue cast when exposed to cold
Normal infant findings: harlequin color change transient cyanosis of one half of body or one limb
Normal infant findings: cutis marmorata lattice-like, bluish mottled appearance
Normal infant findings: milia pinhead smooth while papules without erythema on nose, chin, forehead, usually within 1st few weeks,
Normal infant findings: vernic thick grease like protection
Normal infant findings: lanugo fine downy hair
Nevus simplex telangectasias is dermis usually bilateral fade by 1 year
"stork bite" back of head, neck
"angel kisses" upper eyelids, forehead, upper lip
"port wine stain" nevus flammeus reddish, purple on face or extremities, usually unilateral, capillary malformation that does NOT fade
capillary "strawberry" hemangiomas grow then involute after infancy
dermal melanosis dark digmentation over buttock, lower lumbar region fade by 2 years
melanocytic nevi could be at risk for melanoma
erythema toxicum erythematous "blotchy" macules with central pinpoint vessicles over entire body lasts for 1 week
Miliaria rubra due to sweat gland obstruction, scattered vesicles on erythematous base- lasts a few weeks
caput seccedeum edema, crosses suture lines and resolves in 1-2 days
cephalohematoma subperiosteal bleed, does not cross suture line, resolves in 3 weeks
anterior fontanelle 4-6 cm, closes by 4-26 months
posterior fontanelle 1-2 cm, closes by 2 months (enlarges in congenital hypothyroidism
leukocoria cataract, retinoblastoma, chorioretinitis, retinal detachment
natal teeth present at birth and must be removed to prevent aspiration
epstein pearls whitish-yellow cysts that form on the gums and roof of mouth
bohns nodules odontogenic lamina cysts with keratin
umbilical granuloma pink granulation tissue (use silver nitrate on it)
meconium is passed by 12 hours
male genitalia hernia processus vaginalis, which precedes the testis descent into the scrotum does not obliterate, presents as lump in scrotum or groin
hydrocele thinly patent processus vaginalis, nontender scrotal swelling transilluminate
labial adhesion paper thin, perineal soreness or urinary irritation use estrogen scream
galeazzi sign uneven knee levels
barlow test dislocate an unstable hip
ortolani test reduces recently dislocated hip
developmental dysplasia of the hip treatment neonates: double or triple diapers 1-6mo pavlik harness
erb-duchenne palsy (upper trunk c5-c7), waiters tip position- forearm pronates, wrist flexed
klumpke (lower trunk c7-t1) elbow flexed, hand up, like claw
physiological jaundice is always.... unconjugated
conjugated hyperbilirubinemia is... pathological
jaundice appears within first 24 hours of life hemolytic disorder or infection (always means a problem)
kernicterus neurological syndrome from deposition of unconjugated bili in brain cells (rare in FT babies)
treatment for physiologic jaundice hydration, phototherapy
critical values of blood glucose 1-3 hours <35mg/dl 3-24 hrs <40 mg/dl >24 hrs <45mg/dl
large for gestational age can be from maternal obesity, maternal diabetes
problems with large for gestational age birth asphyxia, shoulder dystocia, hypoglycemia, polycythemia
congenital infections that are transmitted toxoplasmosis, other (parvovirus), rubella, CMV, herpes, hepatitis, HIV, syphilis
neonatal menigitis caused by GBS, E.coli, listeria
neonatal conjunctivitis chlamydia, gonorrhea
neonatal pneumonia GBS, Ecoli, listeria, *s. aureus* *chlamydia*
blueberry muffin baby congenital rubella syndrome
vaccine at birth hep B
vaccine at 2 months Hep B, Dtap, Hib, IPV, PCV13, Rotavirus
vaccine at 4 months Dtap, Hib, IPV, PCV13, rotavirus
vaccine at 6 months Hep B, Dtap, Hib, IPV, PCV13, rotavirus
vaccine at 12 months Hib, PCV13, varicella, MMR, Hep A
vaccine at 15 months Dtap
vaccine at 18 months Hep A
Created by: duanea00