ECR2 Exam 2 Study Guide AY 24-25 PDF

ECR2 – Exam 2 Study Guide Geriatric Medicine: Be able to identify/compare/contrast dementia and delirium - Dementia: Chronic, progressive cognitive decline. Key features include memory loss, impaired executive function, and difficulty with language and reasoning. Examples: Alzheimer’...

ECR2 – Exam 2 Study Guide Geriatric Medicine: Be able to identify/compare/contrast dementia and delirium - Dementia: Chronic, progressive cognitive decline. Key features include memory loss, impaired executive function, and difficulty with language and reasoning. Examples: Alzheimer’s disease, vascular dementia. - Delirium: Acute, reversible state of confusion, often due to an underlying cause like infection or medication. Key features include fluctuating levels of consciousness and attention deficits. Identify how to test/screen for dementia - Tools: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA). Identify the frequent causes of delirium (*do not memorize all of Beer’s List) - Common triggers include infections (UTI, pneumonia), electrolyte imbalances, medications, dehydration, and surgery. Avoid memorizing Beer’s List but know medications like benzodiazepines and anticholinergics can contribute. Identify common medical concerns for the geriatric population (with focus on quality of life) Example: Incontinence, insomnia, loss of function, depression, diet, etc. - Incontinence, insomnia, mobility issues, depression, and malnutrition. Focus on improving the quality of life using therapies and assistive devices. Be comfortable with the common ways to address those unique concerns Example: physical/occupation therapy, assistive devices - Physical Therapy: Focuses on improving strength, balance, mobility, and reducing the risk of falls. - Common interventions: balance exercises, gait training, and strengthening routines. - Occupational Therapy: Helps maintain or regain independence in daily activities (e.g., dressing, cooking). - Can recommend modifications in the home to ensure safety, like grab bars or non-slip mats. - Assistive Devices: Examples include walkers, canes, hearing aids, glasses, and mobility scooters. These devices are tailored to individual needs to enhance quality of life and independence. - Medication Management: Simplifying regimens to prevent polypharmacy and reduce adverse drug reactions. - Using pill organizers or electronic reminders. - Nutrition Counseling: Addressing dietary concerns, such as malnutrition or special diets for conditions like diabetes or hypertension. Identify the risks to elderly patients “from” medicine. Example: Polypharmacy, polyprovider, etc. - Many Providers - Hard to keep track of everyone - The heart doctor, the kidney doctor, the “one for the prostate” - Hard to keep up with plans and follow-ups - Polypharmacy - We end up on a lot of medications  - If you can simplify a regimen, try it - “Relaxed goals” - How necessary is that med? - Know when to NOT start a medicine (ex. Blood thinners) - Organization for taking meds - Neglect/Abuse - No gold standard for diagnosis - Always be mindful - Consider the “home environment” - Chronic Pain - Pain control - Dependence/addiction concerns (or lack thereof) Be able to identify common psychosocial concerns of the geriatric patient. Example: Loss of independence, social isolation, etc. - Social isolation - Support systems - Loss of autonomy - Finances - End of life issues - Activity level - Nutrition/diet - Cultural/ethnic/religious sensitivity - Not always a Chemistry/Mechanical Solution Be comfortable with End-of-Life goals. When to have the discussion, Power of Attorney, etc. - Best to do early and revisit often - What are your wishes while you are still healthy enough to tell me - We can always change them - Make sure family knows so they can support PATIENT wishes - POLST form Be comfortable with common immunizations for the adult population. Example: Tdap, pneumococcal, zoster, flu Focus on “when” such things are needed (yearly?, age 50 or 65?) - Tdap (Tetanus, Diphtheria, Pertussis) - Primary Schedule: One dose of Tdap during adulthood if not received previously. - Booster: Every 10 years. - Influenza Vaccine (Flu Shot) - Annually for all adults. - High-dose or adjuvanted flu vaccines are recommended for adults aged 65 and older. - Pneumococcal Vaccines (PCV20) - Adults aged 65+ or younger adults with specific risk factors - Zoster Vaccine (Shingles) - Two doses, 2-6 months apart, starting at age 50. - Hepatitis Vaccines - Hepatitis A: Two doses, 6 months apart, for adults at risk  - Hepatitis B: Three doses over six months or a two-dose accelerated schedule for adults at risk Be comfortable with the common screening recommendations for adults. Example: colon cancer, breast cancer, lung cancer, DEXA scans. Focus on “when” such things are needed (age or specific conditions) - Colon Cancer - Adults aged 45-75 (earlier if high risk, such as family history or inflammatory bowel disease). - Every 10 years with a colonoscopy. - Breast Cancer - Women aged 40-74. - Biennial mammograms starting at age 50 - Lung Cancer - Adults aged 50-80 with a history of heavy smoking (20+ pack-years) and currently smoking or quit within the past 15 years. - Annual low-dose CT (LDCT) screening. - Osteoporosis (DEXA Scans) - Evaluate all postmenopausal women aged ≥50 years for osteoporosis risk - Men aged 70+ or earlier with risk factors. - Every 2 years if initial results indicate low bone density. - Cervical Cancer - Women aged 21-65. - Ages 21-29: Pap smear every 3 years. - Ages 30-65: Pap smear every 3 years or co-testing (Pap + HPV) every 5 years. - Prostate Cancer - Men aged 55-69 - Periodic PSA (prostate-specific antigen) testing. LGBTQI Health, Disease Prevention and Family Planning and Transgender Workshop- List and discuss the health concerns for which LGBTQI populations are at increased risk - Mental Health: Higher rates of depression, anxiety, suicidal behavior, and eating disorders due to stigma, discrimination, and minority stress. - Substance Use Disorders: Increased use of tobacco, alcohol, and drugs, often linked to coping with minority stress. - STIs and HIV: Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV and other STIs. - Cardiovascular Risk: Smoking, obesity, and disordered eating contribute to increased cardiovascular risks. - Cancer Prevention: Delayed cancer screenings among sexual minority women due to healthcare avoidance. - Violence and Trauma: Elevated rates of hate crimes, sexual assault, and intimate partner violence, particularly among transgender individuals and LGBTQIA+ people of color. Identify key clinical approaches to health promotion and screening when addressing LGBTQI health disparities - Patient-Centered Care: Treat the whole person, not just a collection of risk factors. - Screening and Prevention: - Follow CDC guidelines for STI screening (e.g., HIV, syphilis, gonorrhea, and chlamydia). - Perform cancer screenings (e.g., mammograms, cervical screenings) according to general population guidelines. - Cardiovascular health: Regularly screen for blood pressure and lipid disorders. - Culturally Competent Communication: - Use inclusive language. - Avoid assumptions about sexual orientation, gender identity, or relationship structures. Identify demographics, dynamics, and challenges of LGBT relationships ***Pay particular focus on what this group is particularly at risk for - Demographics: - Varied relationships: monogamous, non-monogamous, same-sex, opposite-sex, and polyamorous. - High prevalence of bisexual and transgender individuals navigating unique relationship dynamics. - Challenges: - Stigma: Internalized and societal stigma impacting relationship quality. - Healthcare Barriers: Limited legal protections and healthcare access, particularly for non-monogamous and transgender couples. - Discrimination: Bisexual and transgender individuals may face exclusion within LGBTQIA+ and heterosexual communities. - Risks: Higher susceptibility to mental health issues, intimate partner violence, and social isolation. Explain methods by which LGBT people can become parents - Adoption: Domestic, international, and foster care options, though legal and societal barriers remain in  some states and countries. - Alternative Insemination: Lesbian couples and single individuals using known or anonymous sperm donors. - Surrogacy: Often chosen by gay male couples; gestational surrogacy allows for biological parenthood without a genetic tie to the surrogate. - Second-Parent Adoption: Allows same-sex partners to adopt their partner’s biological or adoptive child, providing legal protections. Summarize research on children of LGBT parents - Psychological Well-Being: Outcomes for children raised by LGBTQIA+ parents are comparable to those raised by heterosexual parents. - Identity Development: No significant differences in sexual orientation or gender identity compared to peers. - Social Adjustment: Children may experience bullying but often show resilience due to open family dynamics and acceptance. - Unique Strengths: Potential for greater openness and empathy in children of LGBTQIA+ parents. List strategies for helping LGBT families thrive - Build Support Networks: Encourage participation in LGBTQIA+ community groups and family events. - Education and Advocacy: - Advocate for diversity in schools and community settings. - Help children practice responses to negative comments to build confidence. - Healthcare Guidance: - Ensure families have legal protections like medical powers of attorney and joint adoptions. - Provide access to LGBTQIA+-affirming mental health resources. Describe the guidelines for creating a safe and welcoming clinic environment for transgender and non binary people. ***Be mindful of what their concerns are and how you can allay those fears - Key Concerns: - Fear of misgendering or discrimination. - Avoidance of care due to past negative experiences. - Allaying Fears: - Use inclusive forms and language (e.g., gender-neutral pronouns). - Train staff on cultural competency. - Display symbols of LGBTQIA+ inclusivity (e.g., pride flags). - Respect Privacy: - Ensure private discussions and avoid outing patients unintentionally. Be confident in gender affirming approaches to the medical encounter with transgender and non binary people. - Affirm Identity: - Use the patient’s preferred name and pronouns. - Avoid assumptions about anatomy or identity based on appearance. - Provide Comprehensive Care:  - Discuss hormone therapy, surgical options, and reproductive health. - Screen for general health risks and ensure access to mental health services. - Address Fears: - Acknowledge historical biases in healthcare and commit to respectful, affirming care. Recognize terminology and definitions related to sex and gender. - Sex: Biological attributes (e.g., chromosomes, hormones, anatomy). - Gender: A social construct involving roles, behaviors, and identity. - Gender Identity: How an individual personally identifies (e.g., male, female, non-binary). - Gender Expression: External presentation of gender (e.g., clothing, behavior). - Sexual Orientation: Whom an individual is attracted to romantically or sexually. - Cisgender: Gender identity matches the sex assigned at birth. - Transgender: Gender identity differs from the sex assigned at birth. Newborn Assessment Recognize terminology used in discussing newborns. Be able to describe meconium, SGA, AGA, LGA, vernix, fontanelle, molding, perioral cyanosis, acrocyanosis, milia (review Bates’ or a medical dictionary if necessary) - Meconium: The first stool passed by a newborn, typically dark green and sticky. - SGA (Small for Gestational Age): Birth weight below the 10th percentile for gestational age. - AGA (Appropriate for Gestational Age): Birth weight between the 10th and 90th percentiles. - LGA (Large for Gestational Age): Birth weight above the 90th percentile. - Vernix Caseosa: A white, creamy substance covering the newborn’s skin, providing protection in utero. - Fontanelle: Soft spots on a newborn’s skull where the bones haven’t fused yet; anterior fontanelle closes by 7–19 months, and posterior by 2 months. - Molding: Shaping of the newborn’s head as it passes through the birth canal. - Perioral Cyanosis: Bluish discoloration around the mouth, often transient. - Acrocyanosis: Bluish discoloration of the hands and feet, common in newborns. - Milia: Small white or yellow cysts on the skin, caused by clogged sweat glands. Recognize concerns unique to the newborn history - Pregnancy Complications: Gestational diabetes, preeclampsia, infections, or medication exposure. - Delivery Method: Vaginal vs. cesarean. - Birth History: Resuscitation needs, APGAR scores, meconium presence. - Feeding and Voiding Patterns: Initial feeding within the first hour and regular urine output. Describe the goals and details of a newborn physical examination - Goals: - Identify anomalies or complications. - Reassure parents about their infant's health. - Details: - Observation: Assess positioning, tone, color (e.g., acrocyanosis vs. central cyanosis). - Head: Check for caput succedaneum, cephalohematoma, fontanelles. - Cardiorespiratory: Monitor rate, rhythm, and distress signs. - Abdomen: Evaluate cord vessels and for any masses. - Extremities: Inspect digits and perform hip assessments. - Neuro: Check reflexes, tone, and responsiveness. Recognize components of the newborn physical examination - Skin: Color, rashes, bruising. - Head: Shape, fontanelles, caput, or cephalohematoma. - Chest: Breathing patterns, symmetry, heart and lung sounds. - Abdomen: Cord inspection, organ palpation. - Genitourinary: Anatomy, testicular descent, or ambiguous genitalia. - Extremities: Hip dysplasia (Barlow and Ortolani tests), digits. - Neurological: Primitive reflexes. Recognize techniques and skills necessary for a newborn assessment - Perform the examination in a quiet state. - Use soothing techniques to keep the baby calm. - Begin with non-invasive observations before proceeding to more intrusive maneuvers.  - Warm hands and equipment to avoid startling the infant. Describe the Apgar and Ballard scoring system ***Fun Fact: Only children of obstetricians usually have an APGAR of 10 (a professional courtesy to describe their kids as extra healthy) ***Maintain focus on what these tests are looking for (you won’t be expected to calculate either, but know what is generally good and generally bad) - APGAR: - Evaluates Appearance, Pulse, Grimace, Activity, and Respiration. - Score of 8–10 is normal, 5–7 indicates some distress, 0–4 is critical. - Performed at 1 and 5 minutes after birth to determine need for intervention. - Ballard: - Assesses gestational age by examining neuromuscular and physical maturity. - Includes signs like the square window, popliteal angle, and scarf sign. - Greater muscle tone indicates higher gestational maturity. Describe the Ortolani test, Barlow test ***Know when and why we do these things – as with all tests “what is a positive test and what do we do about it?” - Barlow Test: Evaluates the ability to dislocate the hip with pressure; a positive test suggests instability. - Ortolani Test: Detects dislocated hips by attempting to reduce them; a positive test suggests hip dysplasia. - Follow-Up: Positive results require confirmation via ultrasound and may lead to hip immobilization or surgical correction. Describe these primitive reflexes: Moro, startle, suck, root, grasp - Moro Reflex: Startle response; arms extend and then come together. - Startle Reflex: Response to loud sounds, similar to Moro. - Sucking Reflex: Newborn instinctively sucks when the roof of the mouth is touched. - Rooting Reflex: Baby turns head toward a touch on the cheek. - Grasp Reflex: Fingers close around an object placed in the hand. Describe hyperbilirubinemia and its importance in the newborn - Definition: Elevated bilirubin levels leading to jaundice. - Causes: - Physiologic: Immature liver function. - Pathologic: Hemolysis, sepsis, or blood group incompatibility. - Risks: Severe levels can lead to kernicterus (bilirubin-induced brain damage). - Management: Monitor levels; treat with phototherapy or exchange transfusion if necessary. Recognize the importance of timing in newborn assessment - Early identification of congenital anomalies and health issues is critical. - Timing helps address immediate needs (e.g., resuscitation) and informs follow-up care. Recognize the role of the pediatrician for patient and parents, including anticipatory guidance, postpartum screening, follow up visit concerns - Patient: Monitor growth and development, provide vaccinations, and screen for complications. - Parents: - Offer anticipatory guidance (e.g., feeding, sleep). - Screen for postpartum depression. - Address concerns during follow-up visits. Apply history, findings and exam skills to common newborn presentations and clinical scenarios Pediatrics Recognize terminology used in discussing pediatric patients - NSVD: Normal spontaneous vaginal delivery. - BMI Percentiles: Used for pediatric weight classification (e.g., 95th% for overweight). - Developmental Milestones: Key physical, cognitive, and socio-emotional behaviors expected at certain ages. - Denver II Developmental Assessment: Screening tool for developmental milestones. Describe concerns regarding the approach to a pediatric patient - Approach with patience; avoid rushing, especially with anxious children. - Adapt based on developmental stage: - Infants: Perform the exam on the parent’s lap. - Older children: Engage directly and use age-appropriate language. - Perform least invasive parts first (e.g., cardiopulmonary exam before otoscopic exam). - Observe child-parent interactions to understand family dynamics. Describe components of the pediatric history, including the unique components of: birth history, nutritional assessment, sleep history, elimination history, developmental history, immunizations, family and social structure - Birth History: Delivery type, prenatal care, and complications (e.g., preterm, NICU stays). - Nutritional Assessment: Feeding method (breast or formula), introduction of solids, growth trends. - Sleep History: Sleep duration, position (supine vs. prone), and environment (co-sleeping vs. separate room). - Elimination History: Stool frequency, toilet training, and bedwetting. - Developmental History: Parent-reported milestones and observations; assess gross/fine motor, cognitive, and socio-emotional development. - Immunizations: Status per CDC guidelines. - Family and Social Structure: Household dynamics, daycare, major family changes (e.g., divorce, deaths). - Recognize the importance of the child’s birth history - Birth history provides insights into potential developmental or medical challenges, such as prematurity, prenatal substance exposure, or birth-related complications. Recognize components of the pediatric physical examination - Vital Signs: Age-specific norms for temperature, pulse, respiratory rate, and BP. - Growth Parameters: Weight, height, head circumference. - General Appearance: Assess for activity, interaction, and signs of distress. - Systems Exam: - Cardiovascular: Murmurs, cyanosis. - Pulmonary: Retractions, abnormal breath sounds. - Abdomen: Inspect for masses or hepatosplenomegaly. - Musculoskeletal: Gait, symmetry, and posture. - Neurological: Reflexes, tone, and development. Recognize the Glabellar Reflex and the Asymmetric Tonic Neck Reflex - Glabellar Reflex: Tapping between the eyes causes blinking; persistence in older children may indicate neurological concerns. - Asymmetric Tonic Neck Reflex: When the head is turned to one side, the arm on that side extends, and the opposite arm flexes; typically disappears by 4–6 months. Describe growth across the pediatric spectrum (newborn through adolescence) with regard to rate, weight, height, head circumference ***Keep the focus on general trends, you wouldn’t be asked to give specific numbers/values - Weight: - Doubles by 4–6 months, triples by 12 months. - Height: - Increases by 50% by 1 year, doubles by age 4. - Head Circumference: - Grows 12 cm in the first year, slows after age 1. - Growth trends are tracked using CDC growth charts. Describe cyanosis, retractions, Stills murmur, Venous Hum, strabismus, leukocoria, red reflex ***Know which ones are pathologic and which are benign - Cyanosis: Blue discoloration; central cyanosis is pathologic, peripheral (acrocyanosis) may be benign in newborns. - Retractions: Signs of respiratory distress; intercostal, suprasternal, or subcostal retractions indicate increased work of breathing. - Still's Murmur: Benign vibratory or musical murmur, typically early-mid systolic. - Venous Hum: Benign, continuous murmur heard under the clavicle. - Strabismus: Misalignment of the eyes; concerning if persistent after 6 months. - Leukocoria: White reflex in the pupil; pathologic, suggests retinoblastoma or cataract. - Red Reflex: Normal reddish-orange reflection from the retina; absence suggests cataract or retinoblastoma. Recognize techniques and skills necessary for a pediatric assessment including anticipatory guidance - Build trust by engaging the child in age-appropriate ways. - Use distraction techniques during exams (e.g., toys, games). - Provide anticipatory guidance tailored to age (e.g., nutrition, safety, milestones). - Include both the child and parent in discussions. Recognize the different realms and components of normal child development: physical (fine and gross motor), cognitive/language, social/emotional ***(You are not required to know the specific milestones at particular ages yet—but if you are going into Peds, it’ll be on your boards!) - Physical: - Gross Motor: Rolling, crawling, walking. - Fine Motor: Grasping, transferring objects. - Cognitive/Language:  - Babbling, recognizing names, following commands. - Social/Emotional: - Smiling, stranger anxiety, interactive play. Apply history, findings and exam skills to common pediatric presentations and clinical scenarios ***Reminder, a lot of pediatrics is working with parents, communicate with them (always a must) Adolescent Medicine Recognize terminology used in discussing adolescent medicine - Adolescence: The transitional stage from puberty to adulthood, typically starting between 11–13 years and ending by 18–20 years, involving physical, psychological, and emotional development. - Tanner Staging/Sexual Maturity Rating (SMR): Stages of physical development in males and females, categorized from I (prepubertal) to V (adult maturity). Recognize concerns unique to the adolescent history - Establish confidentiality to ensure honest communication. - Address psychosocial history using tools like HEADS (Home, Education, Activities, Diet/Drugs/Depression, Sexuality/Safety). - Understand parental, peer, and societal influences. - Recognize their developmental stage to tailor the approach. Describe physical development in puberty (including Sexual Maturity Rating/Tanner staging) - Females: - SMR I: Prepubertal. - SMR II: Breast budding, sparse pubic hair. - SMR III: Enlargement of breasts, darker pubic hair. - SMR IV: Areola and nipple form a secondary mound, pubic hair spreads. - SMR V: Mature breast and pubic hair patterns. - Males: - SMR I: Prepubertal. - SMR II: Testicular enlargement, sparse pubic hair. - SMR III: Penis elongates, darker pubic hair. - SMR IV: Further growth of penis and testes. - SMR V: Adult genitalia and pubic hair. Contrast psychological development in early, middle, and late adolescence - Early Adolescence (12–14 years): - Rapid physical growth and egocentrism. - Concrete thinking and focus on same-sex friendships. - Middle Adolescence (15–17 years): - Development of secondary sexual characteristics. - Increased independence, abstract thinking, and opposite-sex friendships. - Late Adolescence (18–21 years): - Establishment of identity and vocational goals. - Shift to individual friendships over peer groups. - Higher risk of stress-induced illness. Describe concerns unique to the adolescent patient encounter and well-being - Confidentiality: Key for open discussions. - Preventative Focus: Address high-risk behaviors, mental health, and sexual health. - Developmental Tailoring: Adjust questions and counseling based on maturity level. Distinguish confidentiality and informed consent - Confidentiality: Information shared in the medical encounter is private unless the patient is homicidal, suicidal, or abused. - Informed Consent: Patient’s voluntary agreement after being informed of risks and benefits of a procedure or treatment. Recognize causes of adolescent morbidity and mortality - Leading causes include accidents, suicide, and homicide. - Other concerns: - Risky sexual behaviors. - Substance use. - Mental health issues. Recognize and apply the components and purpose of the HEADS, CRAFFT, and FISTS screening interviews ***Know why each is used and what the acronyms stand for - HEADS: - H: Home (family dynamics). - E: Education (academic performance and goals). - A: Activities (hobbies, screen time). - D: Diet/Drugs/Depression. - S: Sexuality/Safety. - CRAFFT (substance use screening): - C: Riding in a Car with someone under the influence. - R: Using to Relax. - A: Using Alone. - F: Forgetting events under influence. - F: Family/Friends raising concerns. - T: Getting into Trouble due to substance use. - FISTS (violence screening): - F: Fighting. - I: Injuries. - S: Sexual violence. - T: Threats. - S: Self-defense. Describe SHADESS model and strength based interviewing - SHADESS:  - School: Academic performance as a marker for life. - Home: Living environment and family dynamics. - Activities: Engagement in extracurriculars. - Drugs: Substance use. - Emotions: Mental health. - Safety: Risk of violence. - Sexuality: Relationships and sexual health. - Strength-Based Interviewing: - Focus on positive behaviors and strengths. - Praise successes to build rapport. - Engage in a dialogue rather than a checklist approach. Describe challenges and goals unique to the adolescent encounter - Challenges: - Adolescents may be reluctant to disclose information. - Peer and parental pressures influence their decisions. - They may lack trust in healthcare providers. - Goals: - Build trust through nonjudgmental, open-ended questions. - Promote preventative care and address risk behaviors. - Support autonomy while encouraging parental communication. Apply history, physical and confidentiality concerns to management of common clinical scenarios Childhood Abuse and Neglect Recognize risk factors for childhood abuse and neglect - Parental Factors: - Substance use or abuse. - Mental illness or history of abuse. - Young or inexperienced parents. - Lack of education. - Absentee parents or quick relationships. - Social isolation. - Child Factors: - Behavior issues, including ADHD or colic. - Chronic medical conditions or disabilities. - Prior history of abuse. - Being an unwanted child. - Environmental Factors: - Domestic violence. - Poverty. - Lack of social support. - Large families or multiple children in the home. Recognize various types of abuse and neglect - Physical Abuse: - Inflicted injuries such as bruises, burns, fractures, or internal injuries - Pathognomonic injuries like immersion burns or metaphyseal fractures. - Sexual Abuse: - Involves children in activities they cannot consent to or understand. - Includes direct abuse (e.g., genital contact) and indirect abuse (e.g., pornography exposure). - Neglect: - Failure to provide physical, nutritional, or medical care. - "Failure to thrive" often results from nutritional neglect. - Emotional Abuse: - Difficult to measure but includes behaviors causing psychological harm. Recognize various signs and symptoms of abuse and neglect - Physical Signs: - Bruises: Unusual locations (e.g., upper arms, trunk, face) or pattern marks (e.g., handprints, belts). - Burns: Symmetrical burns, immersion injuries. - Fractures: Rib fractures, metaphyseal lesions, or skull fractures. - Internal Injuries: Abdominal trauma, liver or spleen lacerations. - Behavioral Signs: - Excessive fear or aggression. - Withdrawal or regression. - Difficulty trusting adults or forming relationships.  - Sexual Abuse Indicators: - Genital symptoms like bleeding, discharge, or pain. - Evidence of STIs or pregnancy in prepubescent children. - Neglect Indicators: - Poor growth or malnutrition ("failure to thrive"). - Unclean or inappropriate clothing. - Lack of medical care or delayed developmental milestones. Recognize health care providers’ obligations to children suspected of being abused/neglected - Mandated Reporting: - Healthcare providers are legally required to report suspected child abuse or neglect. - Report immediately to child protective services or the designated hotline (e.g., 1-800-25-ABUSE in Illinois). - Evaluation: - Conduct thorough physical exams to document injuries or signs of neglect. - Use imaging (e.g., head CT, skeletal surveys) to confirm physical injuries. - Order lab tests if nutritional neglect or metabolic issues are suspected. - Documentation: - Record detailed histories, including explanations from caregivers. - Note discrepancies between reported histories and clinical findings. - Referral and Support: - Refer the child and family for additional support services, including social workers, counseling, and foster care as needed. Joint Pain Describe the three basic dilemmas algorithm branching points: localized vs systemic, articular vs non articular, and Inflammatory vs non-inflammatory. ***Pro-Tip: This is a great way to approach any joint concern (it’s structured and each item helps to adjust your differential diagnosis. Be comfortable utilizing this approach in assessing joint pain cases). ***Joint disease and musculoskeletal maneuvers can seem nebulous at times. Below are some more focused notes to help. ***Reminder that “inflammatory markers” include ESR and CRP Recognize signs and symptoms associated with Rheumatic Diseases: Spondyloarthropathies, Rheumatoid arthritis, Chronic non-organic pain and acute/recurrent disease. Spondyloarthritis: (systemic) chronic, inflammatory arthritis with negative RF. - These diseases are generally asymmetric, oligoarticular, and affect the lower extremity. The hallmark of these diseases is enthesitis (inflammation at the site where tendons and ligaments insert into bone): as seen in sausage digits - Differentiate these four diseases: - Ankylosing spondylitis (AS)--sacroiliitis invariable, males - Reactive arthritis (ReA)--uveitis, urethritis, CB, KB, males - Enteroarthritis (EA)--association with IBD (“IBD associated”) - Psoriatic arthritis (PsA)--usually has psoriasis; “sausage digits” Rheumatoid arthritis: chronic, inflammatory arthritis of symmetric joints with positive RF. The hallmark of disease is morning stiffness (joint swelling is usually too subjective). RA has a predilection for wrist and proximal small joints of the hands, usually spares the DIP joints (to differentiate from osteoarthritis), has tendency towards bone erosion and nodule formation and spares the lumbosacral and thoracic spines. Chronic non-organic pain: chronic, systemic, non-inflammatory non articular disease The hallmark of fibromyalgia is widespread pain and fatigue with poor and/or unrefreshing sleep. There is also presence of tender points (70%) – often called trigger points. There is no underlying organic pathology detectable - Variations: - Myofascial pain syndrome (MFPS) (*localized variant) - Chronic fatigue syndrome (CFS) - Others (affective spectrum diseases, central sensitization syndromes, functional somatic syndromes...). Note that Polymyalgia Rheumatica differs from fibromyalgia in that the former is inflammatory. Acute/Recurrent disease: acute and/or recurrent inflammatory arthritis are usually monoarticular. The differential diagnosis includes: - Septic (bacterial)—infected joint will be red, warm, swollen, tender; usually has underlying joint disease to begin with (OA) or prior intervention (fracture/repair, injections) – it’s easier to infect a not normal joint; check joint fluid, culture - TB/fungal--often a more chronic process - Crystalline--multiple attacks, crystal analysis - Gout: MTP-knee-wrist; tophi; X-ray; joint sample shows crystals - CPPD (Pseudogout): knee, ankle, wrist, MCP; X-ray findings can be suggestive of CPPD ·Chronic phase: either may resemble RA (chronic polyarthritis) - Lyme: combines elements of viral, septic, spondyloarthritis Be able to apply joint pain history and physical findings to patient scenarios List the sensory, motor, and reflex distribution for the spinal nerves in the cervical and lumbar spine regions. Be comfortable with the specific tests listed below, including how the test is performed, definition of a positive test and the diagnosis suggested by a positive test: - Cervical Spine: Spurling’s maneuver - Shoulder: Hawkin’s impingement sign, Neer’s impingement sign, Jobe/empty can test Lumbar Spine: Femoral Stretch Test, Straight Leg Raise Test - Knee: McMurray’s Test, Appley’s Compression Test, Anterior Drawer Test, MCL and LCL ligament stability testing