NP630

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

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

Slide Method--room for error
Liquid--more expensive, blood doesn't alter
--ThinPrep better
--SurePrep

Bethesda Class. System since 1991
1. State. on specimen adequacy--endo cervical cells?
2. Categ.--interpretation results
negative (or benign)
epithelial cell abnormalities

Pap is only screening for CA not infection

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

PAP interpretation:
*reactive cell changes--inflammation, radiation, IUD
*glandular cells s/p hysterectomy
*atrophy--often see inflammation

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

HPV>100 types: low, medium & high-risk
*low-risk--type 6 & 11condylomata (warts)
*high-risk
--type 16 most common cause of squamous ca
--type 18 most common viral type in adenocarcinoma

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

**ASC-US=Atypical Squamous cells of undetermined significance:
--repeat in 6 months, if ASC-US or higher, colposcopy is indicated

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

**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

Amnio for fetal hemolytic dx
**done by spectrophtometric analysis
**done when indirect Coombs test is + and AAT indicate poss. of severe hemolytic disease

Risks of amnio:
*reduced after 20 weeks
*perforation of placenta or pl. vessels
*menorrhage
*abortion
*infection
*PTL or PROM
*fetal trauma
*Rhogam indicated for RH- moms

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

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

NST: side-lying position
--FHR baseline X 3 min
--monitoring for min. of 20 minutes

FHT accels 15 BPM over baseline X 15 sec for 3 episodes of shaking fetus thru mom's belly

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

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

Before 36 wks use:
*BPD
*abd circumference
*femur length

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

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)

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

Preeclampsia is gestation HTN with proteinuria (>300mg/24hr or > or= to 1+)

mainly primigravidas & adolescents & >35 y/o

complicate~12-22% of pgs

Gest. HTN= increase SBP of at least 30 mm
--increase of DBP of at least 15 mm or DBP of 90 or above
--MAP>90
--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

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

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

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

HELLP caused by ?apresoline & aldomet?

**LDH >600=HELLP
**SGOT > or = 40 = HELLP

Placenta Previs: painless bleeding, fundal height > 28 cm, FHT WNL, fetus transverse or breech, not engaged, uterus soft

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

Vasa previa: cord vessel traversing fetal membranes before inserting into the placenta.

PROM:
**leaking or gush
**+nitrazine paper (alkaline 7) (can be false+ if bloody)
**+fern test
**fluid visualized in vagina
**Amnisure

Chorioamnionitis is inflammation chorion, amnio & amniotic sac
**maternal fever & tachy
*fetus tachy
*uterine tenderness
*warm vaginal walls
*elevated WBC
*foul smelling, purulent amniotic fluid

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

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

Maternal BP of 140/90 or greater before 20 wks is chronic HTN

BPP measures fetal tone, gross body movements, fetal breathing frequency, reactive HR, amniotic fluid volume

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

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

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

Toddler toliet training--begin at 18-24 months.

Sleep--11 hours/night by 2 years old

MV safety--rear seat only

Cardiac murmurs (toddler)
>50% infants
>80% ages 3-4
innocent/pathologic 10:1

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

Preschooler neuro development--3 year old
**alternates feet going upstairs
**jumps from bottom step
**rides trike using pedals
**holds crayon w/fingers
**pincer grasp

Neurodevelopment, 4 year old
**walks down stairs alternating feet
**does broad jump
**throws ball overhand
**hops on one foot

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

Tinea cruris.
--rare in peds a puberty
--does not affect scrotum or penis
--may appear as vesicles

Diagnostic studies for tinea:
--KOH scraping
--Wood's lamp exam

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 cure:
4 weeks for capitis
1-2 weeks for corporis
1-2 weeks for cruris

Complications of tinea:
capitis--permanent alopecia or scarring
corporis & cruris--bacterial secondary infection
pedis--frequent recurrences

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.
Females>males

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

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

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

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

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!!

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

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

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

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

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

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

Roseola

Significant increase in fetal morbidity & mortality during pg

Immunoglobulin recommended for exposed pg women

SCARLET FEVER (Scarletina)--sore throat, fever, & "sandpaper rash", group A Beta-hemolytic strep pyrogenes
**6-12 years most common
**males=females
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)

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!!

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

BOARD QUESTION!!

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

Varicella vaccine must be frozen with special freezer
**can't refreeze!!

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)

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

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

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

School-aged VS:
--HR 60-100/min
--RR 18-30
--BP 90/60 to 108/60

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

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

Overweight=BMI> or = 95th percentile for age & gender

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

Both should be referred for dietary & health assessment

School-aged neurodevelopment:
*concrete operational stage
*differentiate right from left hand
*handedness is developed by age 6

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

Puberty begins in boys 11-14, in girls 10-13

Schoolage children should get 10 hours/sleep per night

Congenital calcaneovalgus foot
--very common neonatal deformity
--banana shaped sole
--dorsiflexes easily--long heel cord
--deviates laterally

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

Excessive femoral anteversion
*entire leg turns in
*both patella and foot are facing medially

Talipes equinovarus (clubfoot)
**inability to dorsiflex foot
**heel varus (bowed)
**sole kidney-bean shaped
**tight heel cord

Flexible flatfeet
**when bearing weight--no arch
** when not weight-bearing, arch is present

Internal tibial torsion:
**entire foot points inward
**patella points straight ahead

Developmental dysplasia of hip
**partial or complete subluxation/dislocation of femoral head from pelvic acetabulum (congenital hip dislocation)
**occurs postnatally not congenitally

Incidence of hip dysplasia:
--1/60 to 1/1000
--females>males
--30-50% develop in breech positions
--20% positive family hx

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)

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)

Menopause: HRT--if no uterus--don't need progestin
Benefits of HRT:
*decreases meno symptoms
*protects against RA
*protects against dementia

Absolute contraindications for HRT:
*breast ca
*estrogen dependent neoplasm
*undiagnosed abn. genital bleeding
*thromboembolic dx
*recent MI
*pregnance
*unopposed estrogen for women w/uterus

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

Menopause--HRT/WHI women's health initiative:
estrogen/progestin:
--stopped study r/t increase in breast ca
--increase risk for CHD, Stroke & PE

Lowered risk for colon ca and hip fx

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.

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

Bone mineral density testing
**all women at age 65
--T-score on DEXA of 1-2.5=osteopenia
--T-score>2.5=osteoporosis

femoral neck score better than spine score

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

IUD teaching: early warning signs---PAINS
Pain
Abdominal pain or pain w/intercourse
Infection
Not feeling well
String missing--shorter or longer