Exam #2 pityriasis rosea

pityriasis rosea

  1. pityriasis rosea Common, benign, often asymptomatic, of unknown etiology (higher incidence in cold months)
    Rash: Herald patch (2-10 cm) oval lesion with central clearing on trunk, precedes appearance of rash by 7-14 days; erythematous macules progressing to papules (become oval); fine scale present; rash run in parallel formation creating a “Christmas tree” distribution on trunk; mild itching; duration 6-12 weeks
    Tx: generally none needed; may tx mild pruritus; sunlight exposure will hasten disappearance of lesions (caution against sunburn)
  2. Pediculosis Common in children of all socioeconomic groups
    Less common in African-American
    Spread of disease: by direct contact or indirect by contact with personal belonging (combs, headphones, bed)
    Head lice survive 1-2 days away from scalp
    Adult female louse survives by sucking human blood, deposits 6-10 eggs per day on glue-like substance about 4mm from the scalp on the hair shaft within a waterproof shell
    Nits incubate about 1 week, hatch and grow into adults over 1-2 weeks, then begin laying eggs
    Head lice live around 30 d on a host and lay up to 100 nits
    Excoriation from scratching, secondary bacterial infections, and cervical adenopathy are common
    Nits (ova) generally seen (hatched, old nits farther out from scalp); few adult lice seen
    AAP discourages “no-nit” policies due to be ineffective in controlling head lice transmission
  3. pediculosis treatment Tx: Permethrin 1% cream (OTC), leave on 10 minutes/rinse (RID/NIX), >2m, repeat 7-10days

    Malathion lotion 0.5% (Ovide)- leave on for 8 hours (flammable) , >6 years, repeat 7-9 days
    Benzyl alcohol 5% lotion (Ulesfia) >6m, repeat 7 days
    Spinosad 0.9% (Natroba), >4y, can pass into breast milk and produce CNS depression, repeat 7 days (ovicidal so not need to comb) costly $210+
    Ivermectin 0.5% lotion (Sklice), >6y, can pass through breast milk, 0.2mg/kg po, repeat in 8-10 days if see infestation still
    Isopropyl myristate rinse (Resultz), flammable, repeat 7 days)
    Repeat around one week later
    Comb out nits (tedious)
    Wash bed linens in hot water
    Bag stuffed animals x 2 weeks if cannot wash

  4. scabies Infestation: Common in children and institutionalized
    Female mites lay eggs and fecal pellets, hatch 10-30 days post contact
    Presentation: burrows “S” shaped (esp. initial infestation) – web spaces, side of foot; vesicles; papules; intense pruritus (awakens at night), can last 1-4 weeks post treatment
  5. scabies treatment Tx: Scabicide (5% permethrin drug of choice); Elimite, >2m, (apply/leave on 8-14 hours/wash off. Repeat in 7 days)
    Apply to entire body below head for 8-14 hrs, remove by bathing, (infants/toddlers tx head and neck down but avoid eyes) Do not over treat
    All household members should be tx’d at same time
    Wash lines, bag toys x 1 week
    Vacuum house
    Can be itchy and have rash up to 3 weeks post treatment
    Contagious until 24 hours after treatment
  6. tinea capitis mainly in 2-10 yr olds; erythema, scaling of scalp; patchy hair loss; boggy, tender scalp lesion (kerion with hypersensitivity rx to fungus)
  7. tinea capitis treatment Griseofulvin 10-20 mg/kg/day x 4-8 weeks. May be given as daily dose (max 1gm) or divided bid (continue until clinically gone about 4-6 weeks), > 2years. If treat more than 8 weeks needs to check CBC, renal and hepatic panel (risk neutropenia, hepatotoxicity, nephrotoxicity)
    Terbinafine oral granules, >4y, do LFTs, Cr at baseline, CBC if > 6wk treatment if immunodeficient (can cause neutropenia)
    Azole antifungals…fluconazole, itraconazole, ketoconazole
    Take with high fat foods for best absorption
    May add Selenium sulfide, 1% or 2.5% shampoo 2x/week-not on inflamed skin                          May need antibiotic if secondary infection
    Clean (in bleach solution) combs, hair tools
    Hair re-growth may be slow
  8. tinea corporis (face and body) common in warm climates; well-demarcated, circular lesion with central clearing and raised, scaly, vesicular border; pruritus common
  9. tinea corporis treatment Tx: antifungal topical usually around 2-4 wks
    Ketaconazole 2% QD x 2wk, >2y
    Lotrisone (clotrimazole/betamethasone dipropionate) BID x 4wk, >17y
    Terbinafine 1% BID x 1-4wk, >12y
    Miconazole 2%, BID x 2wk, >2y
    Clotrimazole 1%, BID x 2-4 wk
    Sports return to play after 72 hours and is covered
  10. tinea pedis common in adolescents/adults; scaly, pruritic vesicular lesions of feet
    not typical under 10 yrs old
  11. tinea pedis treatment Tx: antifungal topical- need to do longer up 6 weeks
    Ketoconazole 2% QD x 6wk, >2y
    Lotrisone (has anti-inflammatory as well) 1%, 0.05% BID x 4 wk, >17y
    Terbinafine 1% BID 1-4wk, >12y
    Miconazole 2%, BID 4wk, >2y
    Clotrimazole 1%, BID, 2-4 wk
    Rx: Econazole or Ciclopirox
    Keep feet dry, cotton socks
  12. tinea curis common in males, esp. obese; sharply demarcated, scaly, pruritic patches
    Treatment: Corporis, cruris, pedis: antifungal cream (clotrimazole 1%, miconazole 2%) bid x 2-6 weeks
    Wear cotton underwear
  13. Tinea/Pityriasis Versicolor Superficial fungal infection, a skin infection where small depigment area are seen on tan skin
    Annular, scaling, discrete maculae’s or patches- hypopigmented in dark colored people and hyperpigmented (salmon-colored to brown) in light colored people mostly on neck, shoulders, upper back, face and arms
  14. Tinea/Pityriasis versicolor treatment Selenium sulfide 2.5% lotion >2y or 1% shampoo (OTC) widespread around lesions for 30 minutes (or overnight) twice weekly x 2-4 months and then monthly x 3 months
    Adolescents can use ketoconazole 2% shampoo
    Can also use creams used for tinea corporis
    Resistant cases- PO fluconazole 200-400 mg weekly x 2-3 doses, f/u in one month
  15. atopic dermatitis 3 Phases:
    -Infantile: onset 1 – 6 months (until 2 yrs)
    -Childhood: onset 3 to 10 yrs
    -Adult: onset after 12 yrs (on-going through life)
    Probable immunologic cause (elevated IgE seen in most pts) with strong family hx
    Can see a triad of eczema, allergic rhinitis, and asthma
    s/S: abnormally dry skin; severe itching (esp. in evenings); pattern of severe pruritus and erythema leading to skin changes (dry and scaly); may be red, papular lesions or lichenification; periods or exacerbation/remission
    Diff. Dx: seborrhea, contact dermatitis, pityriasis rosea, psoriasis, fungal infections
    Tx Goals: hydration and lubrication of skin; antipruritic agents to break itch-scratch cycle; topical steroids; monitor/prevent secondary infections
  16. atopic dermatitis treatment Educate Patient/Family on breaking itch/scratch cycle:
    -Keep environment slightly cool and humid
    Daily soaks in tepid water with mild soap
    -Wear 100% cotton; avoid wool or synthetics
    Use fragrant-free laundry products
    -Emotional stress can worsen (but not cause) condition
    Refer if has severe skin eruptions or don’t respond to treatment (allergist/dermatology/immunologist)
    Tx: creams (Vanicream/Cetaphil) /emollients (Eucerin, Aveeno) /ointments (Aquaphor) (penetrate more)                                                                                                                              Face/private- OTC hydrocortisone BID (Class 7 steroid)
    Increase potency -start with 2% hydrocortisone cream/ointment, increase to triamcinolone 0.1% thin layer daily – not over moderate potency steroid
    Immunomodulators: tacrolimus 0.03% ointment (Protopic) or pimecrolimus 1% cream (Elidel) >2y apply BID, black box warning-lymphoma-causal relationship not established, recommend not long term use, S.E.- burning, itchiness, stinging 5 minutes after application lasting up to one hour- reduces after 1 week.
    Wet wrap therapy (WWT)- usual topical agent (not topical calcineurin inhibitor), then put on wet cotton underwear and dry outside layer and sleep overnight
    Good start formula-partial hydrolyzed-prevent eczema??
    Early eczema- take out eggs and see if makes difference
  17. Warts Common in children, benign, skin tumors caused by HPV (human papillomavirus)
    Incidence: 10% of school-age children
    incubation 1-6 months; usually resolve in 2 years without any treatment
    Common warts (verrucae vulgaris) – often found on hands esp. around nails
    Plantar warts – found on heel/ball of foot; cause significant pain; weight bearing areas at increased risk; may be clustered; look for black dots than can be seen with shaving of outermost horny layer of lesion
    Flat warts (verrucae planae): common on face, arms, legs; occur in clusters; are pink, light brown or yellow; resistant to treatment; resemble nevi
  18. warts treatment Tx: Most non-genital warts will eventually resolve spontaneously, if not: topical salicylic acid q HS for 6-8 weeks; liquid nitrogen with follow-up in 2-4 weeks for repeat.
    Refer – flat warts for removal (resistant and usually on face or extremities)
  19. acne Affects 30-90% of adolescents (males>females); begins 1-2 years before puberty
    Obstruction of sebaceous follicles
    Comedone open: blackhead
    Comedone closed: whitehead
    Papulopustular, cystic
  20. acne vulgaris treatment Benzoyl peroxide (BPO) 2.5 – 10% (antimicrobial) -will stain clothes/pillow cases daily or BID (not with retinoid)
    Can add antibacterial ointment such as clarithromycin 1% or erythromycin 2% separately or combines called benzaclin 1%/5% or benzamycin 3%/5%                                                              Topical retinoids (Tretinoin: Retin-A or Retin-A micro/or adapalene:Differin) start with lowest dose) 0.025% cream qhs apply on dry face
    Azelaic acid topical (Azelex) 15-20% BID
    Creams less drying, gel most drying, also can have wash, pads, lotion form
    Oral antibiotics: minocin (minocycline) 50-100mg daily up to 6 months, causes birth defects photosensitivity, need to check hepatic panel if take more than 6 months-can increase LFTs, >12y, not with milk products. Not appropriate until see papulopustular acne with some cystic acne and also on chest, shoulders, back or resistant after trying all topical meds.
    Erythromycin 250-500mg BID has been used (GI side effects)
    Hormonal: BCP: Ortho-Tri-Cyclen, Yaz/Loryna, Estrostep
    Oral Accutane (retinoid) is only prescribed by dermatology – needs close follow up labs.
    Treat emotional aspects of acne as well (can be devastating to self-esteem/self-image, frequent follow-up)
    Recommend Cetaphil or dove soap, cleanse BID
    Caused usually but stress/hormones- no soda or junk food
  21. Impetigo Bacterial skin infection of epidermis by Staph. Aureus, Strep. Pyrogenes, MRSA
    Rash: multiple 1-2mm superficial vesicles easily ruptured leaving erosions covered with moist, honey-colored crust
    Face and extremities most common sites
    Diff. Dx: tinea, herpes simplex, contact dermatitis, 2nd degree burn
  22. impetigo treatment Tx: If only few lesion- mupirocin (Bactroban) BID x7-10days; or retapamulin (Altabax) BID
    For multiple lesions –
    Cephalexin 40mg/kg/d x 10d-BID
    Augmentin 40 mg/kg/d x 10d- BID
    Dicloxacillin: 12.5-25 mg/kg/d x for 10 days-QID
    Sports participation: 72 hours of antibiotic treatment, all the lesion’s crusts have dried, and there have been no new lesions within the last 48 hours,
    **cannot cover active lesions to participate
    **everyone else contagious x 24 hours (no school)
  23. Molluscum Contagiosum viral skin infection that causes raised, pearl-like papules or nodules on the skin
    Wart-like papule; 3-12 week incubation; grows to 5 mm; waxy, umbilicated with soft, white center; spread thru scratching; commonly on axillae, trunk, face, genitals
    Cause: poxvirus
  24. Molluscum Contagiosum treatment Tx: usually spontaneously resolves after 9-12 months without any treatment. If spreading on face, near eye would refer to dermatology
  25. seborrheic dermatitis Common, chronic inflammatory disease with fine, dry, white or yellow scale on inflamed base (remissions/exacerbations)
    Infants: cradle cap
    Small children: scalp, face, and diaper area
    Older: usually scalp
    an inflammation that causes scaling and itching of the upper layers of the skin or scalp
  26. seborrheic dermatitis treatment Tx: Cradle cap – bland shampoos (i.e. Johnson’s baby shampoo) left on 5-10 minutes then rinsed; Can use selsun blue (selenium sulfide shampoo) but will burn if gets in eyes- 2x/wk
    Face or diaper area – low potency hydrocortisone lotion 1% q day no longer than 2 weeks; leave diaper area open to air as much as possible
    Adolescents: Rx: Selenium sulfide 2.5%- apply 2 x/week x 2 weeks, (OTC) T gel (salicylic acid)-3x/wk, leave on 10 minutes, rinse
  27. candidiasis Yeast-like fungus, Candida albicans, part of normal flora; becomes invasive when moisture, warmth, and breaks in skin cause overgrowth
    Rash: pruritic; diaper area – beefy red, well-demarcated, creases involved, scrotum may be involved (may be satellite pustules/papules, erosions); intertriginous areas – most often in obese pts, red moist, glistening plaque or papules & pustules
  28. candidiasis treatment TX: Diaper area- wash with plain H2O, dry well; dc all powders/creams, Nystatin cream 3-4x per day for 7-10 days;
    Intriginous areas- Nystatin or Lotrimin cream BID x 10 days
    Always treat skin a few days after rash is gone
  29. Fifth’s disease Mild viral disease with erythematous eruptions
    **caused by parvovirus B19
    Common in school-aged and adolescents
    Incubation: 4-14 days; rash and joint symptoms 2-3 weeks after infection
    **Most communicable before onset of rash
    Rash: bright, red rash to cheeks and forehead “slapped cheek”; with/without mild fever, HA, cold symptoms; rash spreads to trunk and distal extremities with lace-like appearance; rash becomes transient with heat/cold
    Exposure during first half of pregnancy – risk of fetal death
    Tx: usually none, or symptomatic
  30. Roseola Acute viral infection primarily in children < 3 years cause by herpes virus-6
    Incubation: 5-15 days (most communicable during febrile stage)
    Acute fever (3-4 days) as high as 105°F, followed by rash
    Rash- pinkish maculopapular rash starting on trunk, spreading to face and extremities; typically children are playful and no change in appetite even with high fever
    Tx: symptomatic
  31. Scarlatina (scarlet fever) Acute infectious disease usually associated with strep pharyngitis (response to bacterial exotoxin)
    Common in 6-12 yrs olds
    Incubation: 3-5 days
    Communicable: during incubation and illness (approximately 10 days) (on antibiotics > 24 hrs – OK)
    Rash- fine, pin-point, sandpaper texture, generalizes, fades after 3-4 days;
    S/S: abrupt onset of fever, pharyngitis, HA, stomach (less often); rash follows initial symptoms; circumoral pallor, strawberry tongue, general adenopathy, skin desquamation
    Tx: PCN 50 mg/kg/day- meds for strep
  32. Varicella (chicken pox) Highly contagious, pruritic, vesicular, exanthem caused by varicella-zoster virus
    Spread by airborne respiratory secretions
    Incubation: 10-21 days
    Rash- macular then to papular, then to vesicles, then crusting within 24 hrs
    Communicable: 1-2 days before rash until all vesicles have crusted (usually 5 days)
    In children, illness mild
    Adolescents/adults more severe illness with increased mortality
    S/S: Low fever, malaise, pruritis
    Tx: consider oral acyclovir for adolescents/adults; treat itching
  33. Cat scratch fever Infection causing unilateral regional adenitis usually due to scratch of a cat
    Bartonella henselae cause in most cases
    80% of cases are in < 20 year-olds
    Dx base on + criteria (3 out of 4)
    -Hx of animal (cat) contact with scratch
    -Positive cat scratch disease skin test
    -Regional adenopathy
    -Bx lymph node
    Adenopathy occurs after 7-12 days; mild malaise, HA, achiness
    Tx: antibiotics not recommended for healthy patients
  34. Influenza psoriasis triggered after flu shot
  35. Iron deficiency anemia Microcytic anemia with ↓ serum iron, ↓ ferritin, and ↑ TIBC.

    Most common; 25% age 10-15 months, greater incidence in black children

    Onset 6-24 months

    Most common cause poor dietary intake; others – rapid growth, low birth weight, (adults) blood loss usually GI

    History: irritable, fatigued, recurrent infections, PICA, decreased exercise tolerance

    Symptoms: pale, irritability, recurrent infections, PICA, decreased exercise tolerance, systolic ejection murmur(chronic), craves ice (older age children)

    Risks: lead to poor cognitive, motor development if untreated

    Possible physical findings: pallor, splenomegaly, systolic ejection murmur, dyspnea, tachypnea

    DDx: thalassemia, anemia of chronic disease, lead poisoning, infection, inflammatory disease, GI abnormalities

  36. Iron deficiency anemia testing  -CBC- see low hgb/hct, high RDW, low MCV/MCHC
    -Ferritin. If ferritin < 10ug/L specificity for iron deficiency 99%.
    -Sed rate- helps determine effectiveness of treatment
    Hgb/Hct usually screened at 9-12 months
    Normal hemoglobin 11 + 0.1 X year of age till age 10 years of age
    MCV 70 + 1 X age in years till age 10 then normal 80-100
    Mentzer index MCV/RBC > 13 favors iron deficiency, <13 favors Thalassemia
  37. Iron deficiency anemia treatment Elemental Iron 6mg/kg/d TID, if mild 3mg/kg/d daily to BID, better absorbed if given with orange juice not milk- give through straw- stains teeth
    Increase iron containing food  See in 2-4 weeks recheck CBC/retic count- should see hemoglobin increase 1g per deciliter and presence of reticulocytosis—confirms diagnosis
    Also prescribe miralax for constipation >1 year
    Check CBC/ferritin at 3 months and every 3 months until ferritin 40-50ng/ml before stopping treatment, re check 6 months after resolution.
    Refer if:
    -No improvement after treatment with iron supplement (recheck 1-4 weeks depending on severity)
    -Hgb less than 7 (immediately)
    -If suspect chronic iron def. anemia with neurocognitive or cardiac symptoms
  38. Thrombocytopenia an abnormally decreased number of platelets in the blood, impairing the clotting process
    Presentation: acute onset, nose bleeds, a lot of bruising, petechiae/purpura, especially on extremities, otherwise PE normal
    Diagnosis of exclusion (r/o infection, leukemia, aplastic anemia)
    Diagnostic testing; CBC – decreased platelets count otherwise normal, PT, aPTT normal
    Frequently recover spontaneously within few months
  39. thrombocytopenia treatment Avoid trauma – no sports/PE (intracranial hemorrhage risk esp plat < 10,000/ul)
    Refer hematology if severely low platelets or chronic – possible hospitalization, may need platelet transfusion, splenectomy, PCN prophylaxis
    no aspirin or NSAIDs
    (ordered if admitted or by hematology)
    2-3 weeks of prednisone 1-2mg/kg/d-max 60mg, if not responsive then immunoglobulin (IVIG)- 0.8-1g/kg/d for 1-2d, anti-Rh immunoglobulin, spleenectomy (if chronic-rare)- needs pneumococcal, H. Influenza type b, and meningococcal vaccines 2 weeks prior
    Worry if increase mucosal bleeding, GU or GI tract bleeding, hematemesis, or hemoptysis
  40. pyloric stenosis •Muscular hypertrophy of pylorus
    •Progress to gastric outlet obstruction
    •Regurgitation progressing to projectile nonbilious emesis
    •More common in males (4:1)
    •Presents usually between 3-6 weeks, before 12 weeks
    •Palpable, olive-sized mass (5-15mm) in RUQ-rare to find (13%)
    •Vigorous/visible gastric peristalsis from left to right
    •Poor weight gain                                                                                                                                    Frequently dehydration
    Dx- abdominal sonogram or upper GI
    Referral for surgery (pyloromyotomy
  41. Infantile colic •Rules of three: Unexplained crying/fussiness that lasts for > 3 hours/day for more than 3 weeks (onset usually 1-3 weeks of age)
    •Self-limiting and episodic
    •Overfeeding, swallowed air, diet of breast feeding mothers (spicy, caffeine, nuts, eggs, nuts, citrus, etc.), food allergies, and emotional stress can aggravate, over-stimulation and inability to self-sooth
    •Tx: Soothing music or motion, dark & quiet room, swaddle
    •Previously thought it due to immature GI tract/constipation/gas/cow’s milk allergy
    •With colic, no vomiting/diarrhea
    •Support parents-resolves by 4 months of age
  42. Intussusception Invagination of bowels proximal to ileocecal valve (one segment of intestine into another segment)- can lead to necrosis
    Unknown etiology
    Peak incidence 5 to 12 months; up to 6 years, higher in males (3:1)
    Normal up to symptoms starting: abdominal pain/distention, draw up knees, emesis, diarrhea, bloody BM with mucus, lethargy, may feel abdominal mass (sausage shaped-usually upper mid abdomen)
    Classic triad:
    1) Intermittent colicky abdominal pain (crampy)
    2) Currant jelly stools (bloody/mucousy)
    3) Emesis-bilious
    Dx: ultrasound(first choice), abdominal radiograph, barium/air contrast enema
    •Barium/air enema diagnostic and may reduce.
    If no improvement, surgery is needed
    <10% recurrence, usually within 72 hours
  43. Appendicitis Acute inflammation of appendix resulting from obstruction of the appendiceal lumen
    Significant cause of abdominal pain and most frequent problem requiring surgery in children

    Highest incidence in pre-adolescent, adolescent and young adults (15y-30y)                                    SXS: Fever, anorexia, pain, diarrhea, vomiting (can be bilious), guarding
    Pain starts as generalized periumbilical then localizes to RLQ
    McBurney’s point – rebound tenderness localized over site of appendix (line drawn from hip to umbilicus-1/3 way up from hip is the point), heel-drop jarring test (toe x 15sec, drop forcefully on heels, or lay down and dorsiflex foot quickly), positive Psoas sign (Flex thigh at hip or lay on side and extend leg back),positive obturator sign(flex knee and internally rotate), Rovsing sign (pressure deep in LLQ with sudden release elicits RLQ pain)
    Rectal exam- could clarify site of tenderness (right side) or reveal a localized appendiceal mass
    Dx: abdominal sonogram (93% sensitivity experienced sonographer), CBC, C-reactive protein (CPR), CT, radio-opaque fecalith (seen in 2/3 cases of ruptured appendix), exploratory laparotomy/laparoscopy
    Tx: Appendectomy- if perforates longer hospitalization with IV antibiotics                       Constipation                                                                                                                                                    Passage of frequent, hard, dry, stools (may have abdominal distention and palpable mass in LLQ)
    •Most common causes: changes in feeding regimen; initiation of toilet training, environmental factors; pain with stools; iron supplement (after newborn period); medication
    •Most children, no organic cause is found
    •Incidence higher in boys
    •In females UA should be done to R/O concurrent UTIs
    Functional fecal retention:
    •Infants: when weaning from breast milk to formula
    •Toddlers: during toilet training
    •Children beginning school

  44. Constipation diet management (less than 1 yr old)  Give fruit juices (such as apple or pear juice) twice a day to babies over 2 months old. Switching to soy formula may also result in looser stools. If your baby is over 4 months old, add strained foods with a high fiber content such as cereals, apricots, prunes, peaches, pears, plums, beans, peas, or spinach twice a day. Strained bananas and apples are also helpful.
  45. Constipation diet management (more than 1 yr old) •Make sure that your child eats fruits or vegetables at least 3 times a day. Some examples are prunes, figs, dates, raisins, bananas, apples, peaches, pears, apricots, beans, peas, cauliflower, broccoli, and cabbage. Warning: Avoid any foods your child can’t chew easily.
    •Increase bran. Bran is a natural stool softener because it has a high fiber content. Make sure that your child’s daily diet includes a source of bran, such as one of the “natural” cereals, unmilled bran, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Popcorn is one of the best high-fiber foods for children over 4 years old.
    •Decrease the amount of constipating foods in your child’s diet to 3 servings per day. Examples of constipating foods are cow’s milk, ice cream, cheese, and yogurt. Fiber one bars have 9 grams fiber (want it more than 3 grams for fiber)
    •Increase the amount of pure fruit juice your child drinks. (Orange juice will not help constipation as well as other juices).
    •Increased water intake
    •Older children over 2 years of age substitute skim milk for whole milk which can be constipating
  46. Constipation treatment •Osmotic stool softeners: over 1-2 years
    -Polyethylene glycol solution (MiraLax)- <17y: 0.8g/kg daily, max 17g/day: dissolve in 4-8 oz liquid (may take 1-4 days for results)- OTC
    -MOM 1 to 3 cc/kg per day in 1 or 2 doses (adolescent 30-60 cc in single dose) for more rapid results- OTC
    -Mineral oil – 1 Tbsp with evening meal for 1 week- OTC
    Stimulant laxatives:(Senokot >2y (OTC)/Lactulose 1ml/kg po daily or BID, max 60ml/day (Rx))
    Infants: 1-2 tablespoons corn syrup per day and or apple/pear juice (1 ounce per month of life up to 4 months-max 4 ounces juice per day)
    Avoid finger dilation, OTC laxatives, or suppositories, power struggles with child
  47. Encopresis  Regular, involuntary fecal incontinence that results from chronic constipation and possible fecal impaction
    Presents usually in children > 4 years and is rare before 3 years (school-aged most affected)
    Most common cause: chronic constipation
    Hx: retentive posturing, enuresis (30%), incontinent stools with dribbling or soiling, moodiness, abdominal pain, difficulty making it to toilet, irritability
  48. Encopresis management  Goals: Disimpact the bowel; restore the urge to defecate; establish regular bowel habits; and prevent reimpaction.
    Disimpaction – manual removal or saline enemas or pediatric Fleets AM and HS for no longer than 3 days
    MiraLax, 0.8g/kg/d up to 17g/day and continue stool softeners at least 1 month for daily soft mushy stool.
    Prevent reimpaction – laxative to achieve multiple, spontaneous, stools
    Bowel retraining – daily routine, quiet setting, after meals to take advantage of gastrocolic reflex
    Increase fluid and fiber intake
  49. Inguinal hernia •Contents (intestines, ovaries, or testes) come through inguinal canal and enter scrotum with boys (swelling and pain). In girls, the inguinal canal is the passageway for a ligament that holds the uterus in place.
    •Bulge in inguinal area between thigh and groin-any age may present
    •Boys more common 9:1, African American
    •Requires surgical repair with kids/teens (increase risk of strangulation)
  50. Umbilical hernia  defect in midline fascia (herniated bowel or omentum. Increases with Valsalva-BM or crying)
    Tx: < 1.5 cm monitor (usually spontaneously resolve); > 1.5 cm usually require surgery if persists past 4-5 years of age
  51. Gastroenteritis
  52. ORT (oral rehydration therapy) -Mild to moderate dehydration: 60-80 ml/kg over 1st 4 hours (i.e. Pedialyte RS)
    -Can make own solution: 6 level teaspoons of sugar, half level teaspoon of salt in one liter water or buy pedialyte
    -Estimate 4-8 oz of fluid loss/diarrhea stool
    -5-10 ml/kg for each episode of vomiting
    -If vomiting, give 2-5 ml of ORT q few minutes
  53. Cystic fibrosis Inherited autosomal recessive, a mutation of the CF gene on chromosome 7.

    Multisystem affects secretory glands of mucus and sweat; mostly affects lungs, pancreas, liver, intestines, sinuses and sex organs. More common in Caucasian/European ancestry
    S/S – poor weight gain, cough/thick secretions, salty skin (parents notice when kissing child), steatorrhea-greasy bulky stools
    Dx – Newborn screen (blood), if positive then Sweat test (> 60 mEq/L chloride on 2 specimens)
    Tx – multidisciplinary, control inflammation and infection, maximize function

 

pityriasis rosea

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