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Flashcard 1425614966028

Tags
#cfa-level #economics #microeconomics #reading-13-demand-and-supply-analysis-introduction #study-session-4
Question
Reading 13 is organized as follows.

Section 2 explains how economists classify markets.

Section 3 covers the basic principles and concepts of demand and supply analysis of markets.

Section 4 introduces [...] of demand to changes in prices and income.
Answer
measures of sensitivity

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This reading is organized as follows. Section 2 explains how economists classify markets. Section 3 covers the basic principles and concepts of demand and supply analysis of markets. Section 4 introduces measures of sensitivity of demand to changes in prices and income. <span><body><html>

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1. INTRODUCTION
s to converge to an equilibrium price? What are the conditions that would make that equilibrium stable or unstable in response to external shocks? How do different types of auctions affect price discovery? <span>This reading is organized as follows. Section 2 explains how economists classify markets. Section 3 covers the basic principles and concepts of demand and supply analysis of markets. Section 4 introduces measures of sensitivity of demand to changes in prices and income. A summary and practice problems conclude the reading. <span><body><html>







Flashcard 1429338983692

Tags
#sister-miriam-joseph #trivium
Question
A practical, [...] study is one that seeks to regulate, to bring into conformity with a norm or standard
Answer
normative

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A practical, normative study is one that seeks to regulate, to bring into conformity with a norm or standard—for example, ethics. The norm of ethics is the good, and its purpose is to bring human conduct into

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Flashcard 1432952638732

Tags
#sister-miriam-joseph #trivium
Question
Which class is wider Genus or Species?
Answer
A genus is a wider class made up of two or more different species that have in common the same essence or nature.

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A genus is a wider class made up of two or more different species that have in common the same generic essence or nature.

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Flashcard 1432967843084

Tags
#cfa-level-1 #economics #economics-in-a-global-context #los #reading-20-international-trade-and-capital-flows
Question
If a Greek shipping company transports the wine that the United States imports from France, the United States would classify the cost of shipping [...] from Greece and the wine would be classified as an import of goods from France.
Answer
as an import of services

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If a Greek shipping company transports the wine that the United States imports from France, the United States would classify the cost of shipping as an import of services from Greece and the wine would be classified as an import of goods from France.

Original toplevel document

2.1. Basic Terminology
th from India and wine from France. Exports are goods and services that a domestic economy sells to other countries. For example, South Africa exports (sells) diamonds to the Netherlands, and China exports clothing to the European Union. So <span>how are services imported or exported? If a Greek shipping company transports the wine that the United States imports from France, the United States would classify the cost of shipping as an import of services from Greece and the wine would be classified as an import of goods from France. Similarly, when a British company provides insurance coverage to a South African diamond exporter, Britain would classify the cost of the insurance as an export of services to South Afr







Flashcard 1432997989644

Tags
#trivium #wikipedia
Question
In metaphysics, extension means stretching out (Latin: extensio) as well as later 'taking up space', and most recently, spreading one's [...]
Answer
internal mental cognition into the external world.

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In metaphysics, extension signifies both 'stretching out' (Latin: extensio) as well as later 'taking up space', and most recently, spreading one's internal mental cognition into the external world.

Original toplevel document

Extension (metaphysics) - Wikipedia
an>Extension (metaphysics) - Wikipedia Extension (metaphysics) From Wikipedia, the free encyclopedia Jump to: navigation, search In metaphysics, extension signifies both 'stretching out' (Latin: extensio) as well as later 'taking up space', and most recently, spreading one's internal mental cognition into the external world. The history of thinking about extension can be traced back at least to Archytas' spear analogy for the infinity of space. How far can one's hand or spear stretch out until it reaches







Flashcard 1438573006092

Tags
#cfa #cfa-level-1 #economics #microeconomics #reading-14-demand-and-supply-analysis-consumer-demand #section-3-utility-theory #study-session-4
Question
An indifference curve represents all the combinations of two goods such that the consumer is [...]
Answer
entirely indifferent among

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To represent our consumer’s preferences graphically, not just mathematically, we have the concept of an indifference curve , which represents all the combinations of two goods such that the consumer is entirely indifferent among them.

Original toplevel document

3. UTILITY THEORY: MODELING PREFERENCES AND TASTES
weaker measures than cardinal rankings because they do not allow the calculation and ranking of the differences between bundles. 3.3. Indifference Curves: The Graphical Portrayal of the Utility Function <span>It will be convenient for us to represent our consumer’s preferences graphically, not just mathematically. To that end, we introduce the concept of an indifference curve , which represents all the combinations of two goods such that the consumer is entirely indifferent among them. This is how we construct such a curve: Consider bundles that contain only two goods so that we can use a two-dimensional graph to represent them—as in Exhibit 1, where a particular bund







Flashcard 1471451630860

Tags
#biochem #biology #cell
Question
hot hydrothermal vents on the floor of the Pacific and Atlantic Oceans. They are located where the ocean floor is spread- ing as new portions of the Earth’s crust form by a gradual upwelling of material from the Earth’s interior (Figure 1–11). Downward-percolating seawater is heated and driven back upward as a submarine geyser, carrying with it a current of chemicals from the hot rocks below. A typical cocktail might include [4 gasses, 3 metals, 1 intermediate, 1 class of chemicals ]
Answer
H2S, H2 , CO, Mn2+ , Fe2+ , Ni2+ , CH 2 , NH4 + , and phosphorus-containing compounds.

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g of material from the Earth’s interior (Figure 1–11). Downward-percolating seawater is heated and driven back upward as a submarine geyser, carrying with it a current of chemicals from the hot rocks below. A typical cocktail might include <span>H 2 S, H 2 , C O, Mn 2+ , Fe 2+ , Ni 2+ , CH 2 , NH 4 + , and phosphorus-containing compounds. <span><body><html>

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Nutrition
#has-images #ir #peds
  1. NUTRITION
  • Infant feeding (30cc/1oz): breast (20kcal/oz, 0.67kcal/cc), AVG need (100kcal/kg/d)
  • For a 9mo, select which foods can be introduced at this age? What are the normal feeding stages for a child?
  • 0-6mo: breast milk or formula, 2-4oz (60-120ml) per feed, 8-12 feeds/day, 20-25min per feed
  • 6-8mo: solid food introduction – do not delay beyond 9 mo
    • 2 to 3 new foods/wk with few days in between (monitoring allergies)
    • Suggested order: meat/alternatives/iron enriched cereal (rice cereal is least allergenic)àpureed vegetablesàfruit
    • Breast milk/formula (6-8oz, 3-5/day) + infant cereal/biscuit/vege/fruit/meat/beans
  • 8-12 mo: finger foods and switch to homogenized (3%) milk (9-12mo); breast/formula (6-8oz, 3-4/day) + cheese/yogurt, bread/pasta, infant cereal, veg/fruit, meat/beans
    • Foods to avoid: honey (risk of botulism), added sugar/salt, juice (not nutritious, too much sugar), anything that is a choking hazard (chunks, round foods like grapes)
  • >12mo: avoid excessive milk (i.e. <16 oz/d)
  • Wt often falters before length (if length ↓, chr)
  • Feeding milestones
    • 0-4mo: root, suck, swallow
    • 6mo: holds bottle/cup
    • 8-12mo: finger feed, chew
    • 12-18mo: uses cup, spoon
    • 18-24mo: likes eating w/ hands
    • 2-5y: food jags (fixated on few foods)
    • 4-5y: knife, fork, good self-eater

      Composition of Human Milk
      • Colostrum
      o Energy value
      o Increased sodium, potassium, chloride
      o Increased protein, fat‐soluble vitamins, minerals
      o High level of antibodies
      o Facilitates passage of meconium and establishment of Lactobacillus
      bifidus flora in infant’s gut
      • Mature Milk
      o Energy value (0.67 kcal/mL)
      o Fat (mainly triglycerides)
      o Carbohydrates (mainly lactose)
      o Protein (Whey>Casein)
      o Vitamins/Minerals (except Vitamin D)
Benefits of Breastfeeding
• Infants
o Maternal‐infant bonding
o Composition – digestible macronutrients
o Protection against infections (AOM, RSV infection, diarrhea)
o Passive immunity (macrophages, lymphocytes (IgA), lactoferrin,
lysozyme)
o Decreased incidence of SIDS
o Decreased allergies/atopy
• Maternal
o Decreased postpartum bleeding & faster uterine involution
o Lactational amenorrhea and delayed resumption of ovulation
o Earlier return to pre‐pregnancy weight
o Improved bone remineralization postpartum (and decreased hip
fracture in postmenopausal period)
o Decreased cost
o Ready availability without prep time

Contraindications to Breastfeeding
• Medical Disorders
o Baby: Galactosemia
‐ Absent liver enzyme galactose‐1‐phosphate uridyltransferase
‐ Unable to metabolize galactose, lactose (glucose + galactose)
‐ Without galactose restriction, leads to liver failure and mental
retardation
• Infections
o Mom: HIV, Human lymphotrophic virus (HTLV‐1 or HTLV‐2),
herpetic lesions on breast, active untreated TB
• Medications (www.motherrisk.org)
o Chemotherapy, immunosuppressants, lithium, ergot alkaloids,
radiopharmaceuticals, bromocriptine, iodides

Supplements Required When Breastfeeding
• Vitamin D
o Supplemental dosage: 400 IU/d
o Side effects w/out supplementation: Rickets/hypocalcemic seizure
37
Markers of Successful Breastfeeding
• ≤7% weight loss i...
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Growth
#has-images #ir #peds
  1. GROWTH
    1. Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt
  • A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential?
  • DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy
  • Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca2+, Vit ADE
  • 14yo at 3rd %ile weight + 10th %ile height is not eating well. What are 3 possible causes?
  • See above
  • A full term baby presents with an eating disorder (i.e. FTT). What is your DDx?
  • ↓intake: non-organic, GERD, structural, CNS, genetic
  • ↓absorption: CF, CMPA, short gut, biliary atresia, GI
  • ↑loss: gastroenteritis
  • ↑demand: cardiac, ↑THY, infection, respiratory
  • Ineffective use: inborn error of metabolism
    1. Obesity
  • 14yo ♂ with weight of 67 kg, height 150cm.
  • Calculate BMI: 29.8 kg/m2
  • 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver
  • 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S
Newborn Growth Parameters
Weight
• At birth = 3.0‐3.5kg (avg)
• Normal to lose up to 10% of birth weight in first 4‐7 days
o BUT should return to birth weight no later than 10‐14 days
• Doubles birth weight by 4‐6 months; triples birth weight by 1 year
• Quadruples birth weight by 2 years
Head Circumference
• At birth = 35cm (avg)
o <32cm 􀃆 small head = small brain until proven otherwise
• May be inaccurate at birth due to caput succedaneum, molding
• 0‐3mths = +2cm/mth
• 3‐6mths =+1cm/mth
• 6‐12mths = +0.5cm/mth
Height
• At birth = 50cm (avg)
• Doubles height by 4 years
• Measure recumbent length until 2 years, then standing height

Normal Growth Velocity


Growth Charts
• Critical to use gender and age appropriate growth charts
• In 2010, the CPS, RCFPC and the Dieticians of Canada, recommended
the use of the 2006 WHO Growth Standards and Reference charts
• WHO Growth Standards based on longitudinal data from solely breast
fed for first six months, healthy children from diverse ethnic and
geographic backgrounds; use BMI after age 10.
• Growth charts are also available for premature infants and certain
syndromes
• Use corrected age up to 2 years for plotting premature infants

Failure to Thrive
Definition
• Weight < 3%ile (the further below the curve the more likely to be
pathologic in origin)
• Weight falls across major %ile lines
• Weight < 80% of ideal body weight*
* use appropriate growth charts for gender and certain genetic conditions
Factors Affecting Physical Growth
• Genetics
• Intrauterine factors
• "Internal time clock"
• Nutrition
• Endocrine hormones
• Chronic infections/diseases
• Psychosocial factors
Etiology
• Inadequate intake: insufficient provision of food, vomiting, oro‐motor
dysfunction
• Inadequate absorption: pancreatic insufficiency, celiac disease
• Increased utilization: chronic diseases, hyperthyroidism
• Ineffective utilization: chromosomal disorders
• Increased losses: chronic diarrhea, urinary losses
Differential Diagnosis
Nonorganic/
Psychosocial
Most common cause of FTT, often seen in conjunction with organic FTT
Specific ...
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Development
#has-images #ir #peds
  1. DEVELOPMENT [See chart]
    1. NORMAL
  • Case on child not toilet training: what is the likely reason?
  • Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic)
  • 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do?
  • MCQ: audiology testing, NOT genetic testing
  • Developmental milestones for 6mo.
  • Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts
  • Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay?
  • Normal: gets into sitting position without help, stands without support, walks while holding on, neat pincer grasp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins
  • 3 yo development milestone (circle 8): I guess the biggest lesson I took away with me from this exam is from the key features section and this question in particular: listen to what your predecessors have to say about the exam in the past exams you see in this email account! When I saw, in one of the previous peds exam, that one is required to pick things out of a list of 20 development milestones, none of which appears in Toronto Notes, I did not take the warning seriously, and I'm forced to pay for my irreverence. I randomly circled 8 things and would be lucky if I can walk away with half the marks. So the lesson is that not only should you remember the short list of developmental milestones from Toronto Notes or the Peds handbook you got from year 2 for the short answers part, but you should also remember a longer, more exhaustive list of milestones from some other source for the key features version of the development milestonesànot true in 2015
  • Normal: walks upstairs using handrail, stands on one foot, rides tricycles, stacks 10 blocks, twists lid off jars, copies a circle, combines 5 or more words in a sentence, understands 2-3 step commands, recognizes colours, shares willingly some of the time, make-believe games, plays with others, listens to music or stories for 5-10 minutes, jumping on one foot, washes and dries own hands, dresses self independently except shoe laces, knows own sex, tells detailed stories, knows primary colours, speaks with plurals
  • Pick developmental milestones from a list (I think for a 3yo and another one for a 4yo?)
  • See above
  • Developmental Milestones achieved by 15 mo? 18mo? What about 6-10 yrs? 16 wks?
See chart

Developmental Milestones
There are four main areas of developement – gross motor, fine motor, language and social. All areas should be explored when exploring a
developmental history. The milestones cited are, on average, those at the 50th percentile for age.




Developmental Problems
...
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Documentation
#ir #peds
DOCUMENTATION
Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools

Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer

Discharge Summary (Template)
Check patient’s name, medical record n...
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Peds Hx
#ir #peds
Identifying Data (ID)
• Name, age (years + months), sex, race
• Individuals accompanying the patient and their relationship to patient
• Previously healthy or any known major diagnoses
Chief Complaint (CC)/Reason for Referral (RFR)
• In patient’s or parent’s words (include duration of symptoms)
History of Present Illness (HPI)
• Open‐ended question, allow parents or child to express their concerns
• Select key symptoms and expand (OPQRSTUVW+ARC):
o Onset (“When was your child last well?”), frequency, duration,
timing (intermittent vs. constant),
o Progression of illness over time (“What happened next?”)
o Quality of symptoms (description, character)
o Relieving and aggravating factors
o Severity of symptoms (quantity, visual analog scale)
o Timing and treatments sought out thus far
o U – “How is this illness affecting U?” (school, work, activities
missed)
o V – Déjà Vu: “Has this happened to you before”, similar past
episodes and treatment, outcome, complications
o What do you think is going on or what are you worried about?
o Associated Symptoms (e.g., if CC is vomiting, ask about abdominal
pain, diarrhea, fever etc.)
o Risk Factors (e.g., if CC is cough, ask about personal and family
history of asthma, eczema, atopy, allergies, exposure to smoking)
o Complications (e.g., if CC is sickle cell crisis, ask about transfusions,
chest crises, ICU admissions, major infections etc.)
• For any infectious disease symptoms always ask: recent exposures to
sick contacts (family, daycare, school), recent travel, recent antibiotic
use, animal or pet exposure
• Current hospital management: What has happened so far since you
arrived at the hospital? Treatments received, investigations, your
understanding of the plan for admission
Past Medical History (PMHx)
• Significant past or ongoing medical problems including:
o Acute illnesses requiring ER visits, antibiotics, hospitalization
o Chronic illnesses (e.g. asthma, diabetes, congenital heart disease)
o Surgeries
o Accidents or injuries
o Community resources/services involved or referrals in place (e.g.
speech and language, occupational therapy)
o Other physicians or specialists involved in care
Prenatal/Pregnancy History (Preg)
• Mother’s age
• Obstetrical history – GTPAL
• Current pregnancy – “How was your pregnancy?” Any complications?”
o Screening: blood group, Rh, DAT, HBsAg, Rubella, Syphilis, HIV, GBS
o Genetic screening: MSS, FTS, IPS, amniocentesis, special tests
o Ultrasounds
o Complications: illnesses, infections, bleeding, gestational diabetes
(GDM), gestational hypertension (GHTN),
• Medications, vitamins, iron, smoking, drinking, drug use
Labour and Delivery or Birth History (L&D)
• Gestational age at birth, birth weight
• Labour complications: prolonged rupture of membranes, maternal
temperature, fetal tachycardia, meconium
• Spontaneous vaginal delivery (SVD), interventions required: forceps,
vacuum, caesarian section (C/S) and why
• Resuscitation: APGAR score, routine care, need for resuscitation, NICU
admission, duration
Newborn or Neonatal History (Neonatal)
• Common problems: jaundice, poor feeding, difficulty breathing,
cyanosis, seizures
Medications (MEDS)
• Current medications, purpose, start date, dose, duration, recent
changes and compliance
• Past medications taken for an extended period of time
• Over the counter (OTC), complementary and alternative products
(CAM), vitamins
Allergies
• Commonly no known drug allergies (NKDA)
• Medications, type of reaction (If anaphylactic then Medic alert, epipen)
• Environmental, seasonal, food
Immunizations
• Check if immunizations up to date (IUTD), any additional vaccines
given
• Ask to see immunization record
Developmental History
• Hav...
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Flashcard 1473235520780

Tags
#biology #cell #genetics #molecular
Question
cells
Answer
small, membrane-enclosed units filled with a concentrated aqueous solution of chemicals and endowed with the extraordinary ability to create copies of themselves by growing and then dividing in two

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Pharm
#ir #peds
ADDD EFFIL MOOPPPS

Acetaminophen:
- Blocks pain impulse
generation, inhibits
hypothalamic heatregulating
center to
produce antipyresis
-Pain, Fever
-May cause
hepatotoxicity at high
doses. Caution use in
patients with hepatic
impairment

Dimenhydrinate
(Gravol®)
-Blocks chemoreceptor
trigger zone, diminishes
vestibular stimulation
-Nausea,
Vomiting
-May cause sedation

Diphenhydramine
(Benadryl®)
-Competes with
histamine for H1
receptor sites on
effector cells in GIT,
respiratory tract, blood
vessels
-Pruritis
-May cause sedation

Dexamethasone:
- Anti‐inflammatory;
better taste, lower
volume than prednisone
-Asthma
Croup
-Immunosuppression
Weight gain
Hyperglycaemia
Hypertension

Epinephrine
Inhaled:
-Stimulates α, β1 and β2
adrenergic receptors to
relax smooth muscles of
bronchial tree
-Bronchiolitis,
Croup
-Can cause tachycardia

Iron (ferrous
fumerate,
ferrous
sulphate)
-Replaces iron
-Iron deficiency
-Can cause constipation,
black stools

Fluticasone
-Inhaled steroid, minimal
systemic absorption
-Asthma
(inhaled)
Allergic
Rhinitis
(intranasal)
-Ask patients to have a
drink or gargle after
inhaled use to clear
from back of throat.

Ibuprofen
-Reversibly inhibits COX
1 and 2 to decrease
prostaglandin
formation.
-Pain, Fever
-Can cause GI irritation.
Caution use in renal
impairment

Lorazepam
-Benzodiazepine. Binds
to GABA Rc complex and
enhances affinity of
GABA for its Rc site on
the same complex.
-Seizure
Anxiety
disorder
Severe nausea
-Anterograde amnesia,
risk of paradoxical
effects. Risk of CNS
depression and
excessive sedation.

Morphine
-Binds to opiate
receptors in the CNS to
inhibit pain pathways.
-Pain
-May cause CNS
depression

Omeprazole
-Inhibits parietal cell
H+/K+ ATP pump to
suppress basal and
stimulated acid
secretion
-GERD
-Fairly well tolerated.
Can cause headache, GI
side effects (abdominal
pain, diarrhea, nausea)

Ondansetron
-Selective 5‐HT3‐
receptor antagonist,
blocking serotonin, both
peripherally on vagal
nerve terminals and
centrally in the
chemoreceptor trigger
zone
-Post‐operative
nausea &
vomiting,
gastroenteritis,
cyclic vomiting
-Can cause QTc
prolongation. Caution
use in patients with
known QT
prolongation or in
patients on other QTc
prolonging agents.

Phenobarbital
-Long acting barbiturate
with sedative, hypnotic
and anticonvulsant
properties
-Seizures
-Can cause CNS
depression

Polyethylene
Glycol 3350
-Osmotic agent. Causes
water retention in stool
to increase stool
frequency
-Constipation
-Can cause abdominal
bloating, cramping,
nausea and diarrhea

Prednisone
-Decreases neutrophil
migration and reverses
capillary permeability
to prevent or control
inflammation
-Asthma
-Immunosuppression,
weight gain,
hyperglycemia,
hypertension

Salbutamol
-Acts on β2 receptors to
relax bronchial smooth
muscles
-Asthma
-Tachycardia,
hypokalemia,
restlessness
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Peds Px
#ir #peds

PEDIATRIC PHYSICAL EXAM

General (GEN)

• Appearance: Distressed? Sick? Toxic?

• Behaviour: Co‐operative, agitated, level of activity (sedate, listless, alert, active, playful), communication (interactive, shy, non‐verbal), interaction with caregivers and interviewer

• Development: “pulling up to stand in crib”, “running around”

• Dysmorphic features and body habitus: look at face, ears, hands, feet, genitalia, height, weight, body fat

• Colour: cyanotic, gray, mottled, pale, pink, jaundice

• Nutritional Status: malnourished, well‐nourished, overweight, obese

• Hydration Status: Mucous membranes, tears, skin turgor, fontanelle, sunken eyes, in addition to appropriateness of vital signs. Classify: mild, moderate, severe dehydration

• Circulation: Signs of poor circulation? (e.g., cool extremities; weak, rapid pulse; poor capillary refill; cyanotic, gray, or mottled colour)

• Respiratory: Work of breathing

Normal Pediatric Vital Signs

AGE HR SYSTOLIC BP RR Newborn (<1 week) 90‐160 60‐70 30‐60 Neonate (<1 month) 90‐140 75‐90 30‐60 Infant (<1 year) 100‐190 75‐120 24‐40 Toddler (1‐2years) 90‐150 75‐120 22‐34 Preschool (3‐5years) 90‐120 75‐125 18‐30 Child (6‐12 years) 60‐120 83‐120 16‐24 Adolescent (>12 years) 70‐100 90‐130 12‐18 Adult (>18 years) 60‐100 90‐130 12‐18

• Blood pressure averages vary significantly based on age and height

• A general rule for average blood pressure in children and adolescents is: o Systolic BP 50th percentile (sBP) = 90 + 2 X age o Diastolic BP (dBP) = 2/3 X sBP

Normal Temperature Ranges Syllabus: Leduc et al. Temperature measurement in paediatrcs. Canadian Paediatric Society. 2015.

ROUTE NORMAL TEMPERATURE RANGE Rectal 36.6°C to 38°C (97.9°F to 100.4°F) Ear 35.8°C to 38°C (96.4°F to 100.4°F) Oral 35.5°C to 37.5°C (95.9°F to 99.5°F) Axillary 34.7°C to 37.3°C (94.5°F to 99.1°F)

12

Temperature Measurement Techniques

AGE SUGGESTED TECHNIQUE

Birth to 2 years

1. Rectal (definitive) 2. Axillary (screening low risk children)

Over 2 years to 5 years

1. Rectal (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Older than 5 years

1. Oral (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Anthropometrics

• Weight (Wt, kg)

• Height (Ht, cm) o Supine length to 2 years, then standing height

• Head Circumference (HC, cm) o Generally do from birth to 2 years. >2 yrs, if have specific concerns

• BMI

HEENT (Triple S: size, shape, symmetry)

• Head: shape and symmetry of skull/fontanelles, dysmorphic, sutures

• Eyes: red reflex in infants, strabismus, pupillary response, fundoscopy, lids, conjunctivitis, acuity (>3 years)

• Ears: otoscope, tympanic membranes (TM x 2): clear, erythematous, bulging, effusion, retracted, ear shape, hearing

• Mouth: lips (lesions, colour), mucous membranes including gingiva, tongue, hard/soft palate

• Dentition: presence of teeth, tooth decay

• Pharynx: tonsils, erythema, exudates

• Neck: lymphadenopathy, masses, thyroid, webbing (Noonan, Turner syndrome), torticollis, nuchal rigidity

...
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Uncomplicated Pneumonia
#ir #peds

Abstract

Although immunization has decreased the incidence of bacterial pneumonia in vaccinated children, pneumonia remains common in healthy children. Symptoms of bacterial pneumonia frequently overlap those present with viral infections or reactive airway disease. Optimally, the diagnosis of bacterial pneumonia should be supported by a chest radiograph before starting antimicrobials. Factors such as age, vital signs and other measures of illness severity are critical when deciding whether to admit a patient to hospital. Because Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children, prescribing amoxicillin or ampicillin for seven to 10 days remains the mainstay of empirical therapy for nonsevere pneumonia .If improvement does not occur, consideration should be given to searching for complications (empyema or lung abscess). Routine chest radiographs at the end of therapy are not recommended unless clinically indicated.

Key Words: Antimicrobial therapy; Bacterial pneumonia; Viral pneumonia

Most physicians who care for children and youth have had experience with managing acute pneumonia. The incidence of pneumonia due to any etiology is lower in the developed areas of the world compared with less developed areas because immunization coverage rates may be lower in developing areas.[1] Pneumococcal conjugate vaccines have been shown to decrease radiologically proven pneumonia admission rates in children younger than five years of age by an average of 27%.[2][3]

The present practice point focuses on the current diagnosis and management of uncomplicated, acute, community-acquired pneumonia in healthy immunized children with no underlying pulmonary pathology aside from mild reactive airways disease. The present practice point does not apply to persistent (chronic) pneumonia syndromes (with symptoms for >2 weeks), aspiration pneumonia or recurrent pneumonias, or to pneumonia associated with chronic medical problems such as immunodeficiency, because these pneumonias may be caused by different pathogens or require more extensive investigation. The present practice point replaces a previous document published in 2011.[4]

Definition and host risk factors

Pneumonia is an acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen. Bacterial infections are usually primary but, occasionally, viral respiratory tract infections such as influenza are followed by bacterial pneumonias.[5] Uncomplicated pneumonias may be accompanied by small parapneumonic effusions. Evidence of empyema (pus in the pleural space), a lung abscess or a necrotic portion of lung parenchyma implies the development of a complicated pneumonia.

Etiology

The most common causes of pneumonia in infants and preschool children are viruses that usually, but not exclusively, circulate in winter (eg, respiratory syncytial virus, influenza, parainfluenza virus and human metapneumovirus). Viruses as a sole cause of pneumonia are less common in older children, with the exception of influenza.

Among bacteria, Streptococcus pneumoniae continues to be the most common bacterial pathogen causing pneumonia in children of all ages. Group A streptococcal pneumonia is much less common. Although Staphylococcus aureus

...
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Pneumonia: viral vs bacterial
#ir #peds
viral:
more assc sx's, high/low lymphocytes

bact:
higher T, just cough &amp; fever, really high/low WBCs (neutrophils), ESR higher
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Approach to xray
#ir #peds
1) • Identification: • Name • Date • Supine or erect

2) quality: rotation, penetration (intervertebral spaces through the heart shadow), Inspiration (when the 8-9th posterior rib is visible or 6th anterior rib)
-Hyperinflation – > 9 posterior ribs
-Poor inspiration – < 8 posterior ribs

3) white:
-soft tissue
-bones
-heart (size, shape, position)

4) black structures
-Trachea and bronchi
-Lungs – Size – Compare 3 lung fields – Hilum and vascular structure (» Size » Shape » Density)
- Stomach bell

5) Other structures
– Diaphragm
– Costrophrenic angles and pleura
– Mediastinal structures
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#ir #peds
One of the fi rst tasks as an emergency
physician is to put the patient at ease. Talk
to the child as well as the parents. For
older children, introduce yourself to them
fi rst before the parents and sit down on
the bed or chair as to not tower over them.
Try to facilitate the relationship and open
up communication by noticing something
cool about them (i.e. light-up shoes, Dora
T-shirt or fun toy).
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
unicate or cooperate with the physical exam. While each physician may vary with style points and favorite tricks, here are a few tips for the pediatric physical exam to improve your interaction and comfort level. <span>One of the fi rst tasks as an emergency physician is to put the patient at ease. Talk to the child as well as the parents. For older children, introduce yourself to them fi rst before the parents and sit down on the bed or chair as to not tower over them. Try to facilitate the relationship and open up communication by noticing something cool about them (i.e. light-up shoes, Dora T-shirt or fun toy). While doing the actual physical exam, try to use the parent’s lap as much as possible as the child is most comfortable there. To distract and calm them, consider tel




#ir #peds
While doing the actual physical exam, try
to use the parent’s lap as much as possible
as the child is most comfortable there. To
distract and calm them, consider telling
them a story throughout the exam or try
to make the physical exam a game – play
with the instruments.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
rents and sit down on the bed or chair as to not tower over them. Try to facilitate the relationship and open up communication by noticing something cool about them (i.e. light-up shoes, Dora T-shirt or fun toy). <span>While doing the actual physical exam, try to use the parent’s lap as much as possible as the child is most comfortable there. To distract and calm them, consider telling them a story throughout the exam or try to make the physical exam a game – play with the instruments. Finally, consider having something fun in your pocket such as stickers or a bubble-blowing pen to make the experience more enjoyable. In general, when evaluating any




#ir #peds
Finally, consider
having something fun in your pocket such
as stickers or a bubble-blowing pen to
make the experience more enjoyable.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
arent’s lap as much as possible as the child is most comfortable there. To distract and calm them, consider telling them a story throughout the exam or try to make the physical exam a game – play with the instruments. <span>Finally, consider having something fun in your pocket such as stickers or a bubble-blowing pen to make the experience more enjoyable. In general, when evaluating any child, observation is the best initial diagnostic tool. The degree of alertness and interaction, responsiveness to parents and r




#ir #peds
observation is the best initial diagnostic
tool. The degree of alertness and
interaction, responsiveness to parents and
respiratory status are all valuable measures
of illness that may either suggest or
eliminate concerns of toxicity.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
xam a game – play with the instruments. Finally, consider having something fun in your pocket such as stickers or a bubble-blowing pen to make the experience more enjoyable. In general, when evaluating any child, <span>observation is the best initial diagnostic tool. The degree of alertness and interaction, responsiveness to parents and respiratory status are all valuable measures of illness that may either suggest or eliminate concerns of toxicity. After observation, it is important to begin the exam with auscultation of the heart and lungs as this is usually when the child is calm, quiet and most cooperative.




#ir #peds
After observation, it is important to begin
the exam with auscultation of the heart
and lungs as this is usually when the child
is calm, quiet and most cooperative. Do
not forget that a negative lung auscultation
is not suffi cient to rule out signifi cant
pulmonary disease; the appearance of the
patient (tachypnea, respiratory distress) is
much more predictive.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
t initial diagnostic tool. The degree of alertness and interaction, responsiveness to parents and respiratory status are all valuable measures of illness that may either suggest or eliminate concerns of toxicity. <span>After observation, it is important to begin the exam with auscultation of the heart and lungs as this is usually when the child is calm, quiet and most cooperative. Do not forget that a negative lung auscultation is not suffi cient to rule out signifi cant pulmonary disease; the appearance of the patient (tachypnea, respiratory distress) is much more predictive. Finally, always save the worst for last. The last items to perform in the physical exam should always be those things that are most threatening to the child, includi




#ir #peds
The last items to perform in the physical
exam should always be those things that
are most threatening to the child, including
looking in the ears and mouth.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
e lung auscultation is not suffi cient to rule out signifi cant pulmonary disease; the appearance of the patient (tachypnea, respiratory distress) is much more predictive. Finally, always save the worst for last. <span>The last items to perform in the physical exam should always be those things that are most threatening to the child, including looking in the ears and mouth. Here are a few cases to illustrate the importance of the physical exam and emphasize other tips for evaluating those age groups that provide the most anxiety an




#ir #peds
Newborn
Case 1: A 3-week-old male presented to the
emergency department for congestion and
cough. Mom stated that the infant was not
eating as well, but had normal wet diapers.
No fever noted at home or on exam.
As mentioned above, it is important to
observe the newborn. One of the best tips
is to undress and hold the baby. Holding
allows the clinician to assess multiple
things at once, including level of alertness,
respiratory status and tone. This initial
assessment gives the clinician a good
sense of “sick or not sick.”
It is also important to have the baby
undressed to do a careful examination,
looking for rashes, bruises, hair
tourniquets, etc. During the exam, this
newborn was observed to have an apneic
episode. The patient was admitted for
an evaluation that ultimately revealed a
diagnosis of pertussis.
Infant
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
3; looking in the ears and mouth. Here are a few cases to illustrate the importance of the physical exam and emphasize other tips for evaluating those age groups that provide the most anxiety and diffi cult exam. <span>Newborn Case 1: A 3-week-old male presented to the emergency department for congestion and cough. Mom stated that the infant was not eating as well, but had normal wet diapers. No fever noted at home or on exam. As mentioned above, it is important to observe the newborn. One of the best tips is to undress and hold the baby. Holding allows the clinician to assess multiple things at once, including level of alertness, respiratory status and tone. This initial assessment gives the clinician a good sense of “sick or not sick.” It is also important to have the baby undressed to do a careful examination, looking for rashes, bruises, hair tourniquets, etc. During the exam, this newborn was observed to have an apneic episode. The patient was admitted for an evaluation that ultimately revealed a diagnosis of pertussis. Infant Case 2: A 5-month-old male presented with fever and fussiness. The patient was seen fi ve days earlier with fever and URI, diagnosed with otitis media and disch




#ir #peds
Infant
Case 2: A 5-month-old male presented
with fever and fussiness. The patient
was seen fi ve days earlier with fever and
URI, diagnosed with otitis media and
discharged home with amoxicillin. Prior to
arrival, the patient had multiple episodes
of vomiting and decreased urine output.
Initial assessment revealed an illappearing,
febrile infant. While observing
the infant and beginning the physical
exam, it is important to place your hand on
the infant’s head and assess the fontanelle.
A fontanelle is measured as full, fl at, or
depressed. Cup your palm on the back of
the baby’s head and then move forward.
The curve of your palm should touch the
fontanelle if it is normal. If the fontanelle
doesn’t touch, it is depressed; if it pushes
your hand up, it is full.
In young infants, a bulging fontanelle may
be seen with meningitis, but meningismus
is rare before one year of age. Another
possible exam fi nding in infants with
meningitis is a paradoxical response
to consoling maneuvers like cuddling.
When a caregiver “cuddles” an infant,
the meninges are stretched and irritated
making the infant more fussy. By contrast,
the same infant will calm when laid fl at.
This infant’s fontanelle was full and
tense. Throughout the exam, the patient
was irritable and diffi cult to console. The
infant was appropriately resuscitated and
underwent a full septic work-up, revealing
pneumococcal meningitis.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
king for rashes, bruises, hair tourniquets, etc. During the exam, this newborn was observed to have an apneic episode. The patient was admitted for an evaluation that ultimately revealed a diagnosis of pertussis. <span>Infant Case 2: A 5-month-old male presented with fever and fussiness. The patient was seen fi ve days earlier with fever and URI, diagnosed with otitis media and discharged home with amoxicillin. Prior to arrival, the patient had multiple episodes of vomiting and decreased urine output. Initial assessment revealed an illappearing, febrile infant. While observing the infant and beginning the physical exam, it is important to place your hand on the infant’s head and assess the fontanelle. A fontanelle is measured as full, fl at, or depressed. Cup your palm on the back of Rose House, MD EM/Pediatrics Resident Indiana University Indianapolis, IN “In general, when evaluating any child, observation is the best initial diagnostic tool.” 34 EMResident the baby’s head and then move forward. The curve of your palm should touch the fontanelle if it is normal. If the fontanelle doesn’t touch, it is depressed; if it pushes your hand up, it is full. In young infants, a bulging fontanelle may be seen with meningitis, but meningismus is rare before one year of age. Another possible exam fi nding in infants with meningitis is a paradoxical response to consoling maneuvers like cuddling. When a caregiver “cuddles” an infant, the meninges are stretched and irritated making the infant more fussy. By contrast, the same infant will calm when laid fl at. This infant’s fontanelle was full and tense. Throughout the exam, the patient was irritable and diffi cult to console. The infant was appropriately resuscitated and underwent a full septic work-up, revealing pneumococcal meningitis. Toddler Case 3: An 18-month-old male presents with complaint of seizure witnessed at home 20 minutes prior to arrival. Many pediatric patients will present to&#




#ir #peds
Toddler
Case 3: An 18-month-old male presents
with complaint of seizure witnessed at
home 20 minutes prior to arrival.
Many pediatric patients will present to
the emergency department after a seizure.
When evaluating this patient, it is crucial to
do a good neurological exam. The biggest
tip for the pediatric neurological exam is
to stop, look and listen. You will learn the
most from the child’s spontaneous activity,
including mental status, cranial nerves,
coordination, and motor status.
Assess patients based on developmental
milestones for their age group. If
age appropriate, make sure to watch
them walk. Also, watch the child sit
unsupported as truncal instability may be a
clue to vertiginous symptoms or cerebellar
pathology. Try to carry one thing that
could fake for a toy or draw a face on a
tongue depressor to help attract the child’s
attention.
Upon examination of this patient, he had
right-sided weakness which resolved
within an hour. The patient was diagnosed
with Todd’s paralysis and new-onset
seizure disorder.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
elle was full and tense. Throughout the exam, the patient was irritable and diffi cult to console. The infant was appropriately resuscitated and underwent a full septic work-up, revealing pneumococcal meningitis. <span>Toddler Case 3: An 18-month-old male presents with complaint of seizure witnessed at home 20 minutes prior to arrival. Many pediatric patients will present to the emergency department after a seizure. When evaluating this patient, it is crucial to do a good neurological exam. The biggest tip for the pediatric neurological exam is to stop, look and listen. You will learn the most from the child’s spontaneous activity, including mental status, cranial nerves, coordination, and motor status. Assess patients based on developmental milestones for their age group. If age appropriate, make sure to watch them walk. Also, watch the child sit unsupported as truncal instability may be a clue to vertiginous symptoms or cerebellar pathology. Try to carry one thing that could fake for a toy or draw a face on a tongue depressor to help attract the child’s attention. Upon examination of this patient, he had right-sided weakness which resolved within an hour. The patient was diagnosed with Todd’s paralysis and new-onset seizure disorder. Preschooler Case 4: A 3-year-old female presents with abdominal pain and fever over the past day. Patient has some vomiting and diarrhea. Emesis is nonbilious&#




#ir #peds
Preschooler
Case 4: A 3-year-old female presents
with abdominal pain and fever over the
past day. Patient has some vomiting
and diarrhea. Emesis is nonbilious
and nonbloody. Diarrhea is watery
and yellow. The patient has also had
decreased oral intake and urine output. On
exam, the patient is febrile and appears
uncomfortable.
Performing a good abdominal exam is
critical for the assessment of this patient,
but can often be challenging. Children
cannot developmentally pinpoint the
location of abdominal pain until they are at
least four years old, and perhaps not even
then. With symptoms and an exam that are
nonspecifi c, abdominal pathology can be
very diffi cult to diagnose in this age group.
Attempt to calm and distract the patient as
much as possible.
For infants, make sure to have a pacifi er
available during the abdominal exam.
Another option for the crying infant is to use
sucrose to calm them during auscultation
and palpation. Flexing the hips will also
facilitate relaxation and a better exam. For
patients that are ticklish, you can have the
child place their hand on yours and push
down as if they are doing the exam.
For children with abdominal pain, make sure
to always undress the patient and evaluate for
rashes to assure that diseases like HenochSchönlein
Purpura (HSP) are not missed.
Also, referred pain is very common, and
pneumonia or strep throat may present with
abdominal pain of any location with focal or
diffuse pain on exam.
Using the above techniques, the patient
in the case was found to have signifi cant
tenderness without rebound. Upon further
evaluation, the patient was found to have
acute appendicitis.
The above tips and tricks should allow
for a smoother encounter with the pediatric
patient. If the tactics are not working,
do your physical exam in stages. Start
quickly with the most essential, then return
frequently to perform each additional
layer. Always remember that a graceful
approach will go a long way with assessing
children. „
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
elp attract the child’s attention. Upon examination of this patient, he had right-sided weakness which resolved within an hour. The patient was diagnosed with Todd’s paralysis and new-onset seizure disorder. <span>Preschooler Case 4: A 3-year-old female presents with abdominal pain and fever over the past day. Patient has some vomiting and diarrhea. Emesis is nonbilious and nonbloody. Diarrhea is watery and yellow. The patient has also had decreased oral intake and urine output. On exam, the patient is febrile and appears uncomfortable. Performing a good abdominal exam is critical for the assessment of this patient, but can often be challenging. Children Figure 1: Additional Tips & Tricks General Always undress. Eyes If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause them to open their eyes. Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and will just anger them more. Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or noises to help assess extraocular movements. Ears If having a hard time looking in the ears, hold arms above head. If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the opposite side of the ear you want to look in. The child will often track with the light and turn their head so their ear is then right in front of you. Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against the side of the face (See Figure 2).2 Mouth/Throat Wetting the tongue depressor makes it taste better. Have the child pant like a dog when doing a throat swab as it helps prevent gagging. Heart If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart rate momentarily so that you can better ausculate for murmurs. Lungs If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask them to pretend to blow out the birthday candles. cannot developmentally pinpoint the location of abdominal pain until they are at least four years old, and perhaps not even then. With symptoms and an exam that are nonspecifi c, abdominal pathology can be very diffi cult to diagnose in this age group. Attempt to calm and distract the patient as much as possible. For infants, make sure to have a pacifi er available during the abdominal exam. Another option for the crying infant is to use sucrose to calm them during auscultation and palpation. Flexing the hips will also facilitate relaxation and a better exam. For patients that are ticklish, you can have the child place their hand on yours and push down as if they are doing the exam. For children with abdominal pain, make sure to always undress the patient and evaluate for rashes to assure that diseases like HenochSchönlein Purpura (HSP) are not missed. Also, referred pain is very common, and pneumonia or strep throat may present with abdominal pain of any location with focal or diffuse pain on exam. Using the above techniques, the patient in the case was found to have signifi cant tenderness without rebound. Upon further evaluation, the patient was found to have acute appendicitis. The above tips and tricks should allow for a smoother encounter with the pediatric patient. If the tactics are not working, do your physical exam in stages. Start quickly with the most essential, then return frequently to perform each additional layer. Always remember that a graceful approach will go a long way with assessing children. „<span><body><html>




#ir #peds
Figure 1: Additional Tips & Tricks
General
Always undress.
Eyes
If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause
them to open their eyes.
Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and
will just anger them more.
Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or
noises to help assess extraocular movements.
Ears
If having a hard time looking in the ears, hold arms above head.
If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the
opposite side of the ear you want to look in. The child will often track with the light and turn their head
so their ear is then right in front of you.
Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the
thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against
the side of the face (See Figure 2).2
Mouth/Throat
Wetting the tongue depressor makes it taste better.
Have the child pant like a dog when doing a throat swab as it helps prevent gagging.
Heart
If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart
rate momentarily so that you can better ausculate for murmurs.
Lungs
If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask
them to pretend to blow out the birthday candles.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patient
sed oral intake and urine output. On exam, the patient is febrile and appears uncomfortable. Performing a good abdominal exam is critical for the assessment of this patient, but can often be challenging. Children <span>Figure 1: Additional Tips & Tricks General Always undress. Eyes If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause them to open their eyes. Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and will just anger them more. Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or noises to help assess extraocular movements. Ears If having a hard time looking in the ears, hold arms above head. If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the opposite side of the ear you want to look in. The child will often track with the light and turn their head so their ear is then right in front of you. Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against the side of the face (See Figure 2).2 Mouth/Throat Wetting the tongue depressor makes it taste better. Have the child pant like a dog when doing a throat swab as it helps prevent gagging. Heart If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart rate momentarily so that you can better ausculate for murmurs. Lungs If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask them to pretend to blow out the birthday candles. cannot developmentally pinpoint the location of abdominal pain until they are at least four years old, and perhaps not even then. With symptoms and an exam that are&




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Informed Consent (c.f. assent): 1) appropriate info 2) decision-making capacity 3) voluntariness (←the 3 hallmarks of informed consent)
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Highlight doc Day 1
BIOETHICS : Informed Consent (c.f. assent): 1) appropriate info 2) decision-making capacity 3) voluntariness (←the 3 hallmarks of informed consent) Confidentiality Age not a factor Unless teen is Suicidal, homicidal, has thoughts of self-harm/harming others <16yo w/ hx of current/past abuse Disclosu




#ir #peds
Confidentiality
  • Age not a factor
  • Unless teen is
    • Suicidal, homicidal, has thoughts of self-harm/harming others
    • <16yo w/ hx of current/past abuse
    • Disclosure of abuse & children <16yo in home
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Highlight doc Day 1
BIOETHICS : Informed Consent (c.f. assent): 1) appropriate info 2) decision-making capacity 3) voluntariness (←the 3 hallmarks of informed consent) Confidentiality Age not a factor Unless teen is Suicidal, homicidal, has thoughts of self-harm/harming others <16yo w/ hx of current/past abuse Disclosure of abuse & children <16yo in home Capacity & consent Capable if Able to UNDERSTAND info relevant to making decision re: tx Eg I’ll lose my leg if I don’t manage my DM &#




#ir #peds
Capacity & consent
  • Capable if
    • Able to UNDERSTAND info relevant to making decision re: tx
      • Eg I’ll lose my leg if I don’t manage my DM
    • And able to APPRECIATE consequences of a decision
      • Eg of no appreciation: That’s in the future so I don’t care if I’ll lose my leg, I want to live my life now
  • Assume everyone’s capable.
    • Don’t assume incapability b/c
      • Age, Refusal/Disagreement w/ tx, Request for alt tx, Psych/neuro dx, Disability
  • Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg
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Highlight doc Day 1
Confidentiality Age not a factor Unless teen is Suicidal, homicidal, has thoughts of self-harm/harming others <16yo w/ hx of current/past abuse Disclosure of abuse & children <16yo in home <span>Capacity & consent Capable if Able to UNDERSTAND info relevant to making decision re: tx Eg I’ll lose my leg if I don’t manage my DM And able to APPRECIATE consequences of a decision Eg of no appreciation: That’s in the future so I don’t care if I’ll lose my leg, I want to live my life now Assume everyone’s capable. Don’t assume incapability b/c Age, Refusal/Disagreement w/ tx, Request for alt tx, Psych/neuro dx, Disability Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg Assent = children given info they understand & some appropriate choice in tx Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, autho




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Assent = children given info they understand & some appropriate choice in tx
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Highlight doc Day 1
/c Age, Refusal/Disagreement w/ tx, Request for alt tx, Psych/neuro dx, Disability Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg <span>Assent = children given info they understand & some appropriate choice in tx Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, authority) ETHICAL PRINCIPLES Mother doesn’t want her child to




#ir #peds
Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, authority)
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Highlight doc Day 1
ity Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg Assent = children given info they understand & some appropriate choice in tx <span>Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, authority) ETHICAL PRINCIPLES Mother doesn’t want her child to be vaccinated. Which ethical principle would you apply to give the vaccine to the child who doesn’t




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Best interests of child: looking at their interests broadly & not focusing exclusively on biomed facts; value judgment; harm-benefit balance
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Highlight doc Day 1
tand relevant info (risks, benefits) 2) appreciate consequences Disagree: 1) best interests of the child (non-maleficence, beneficence), 2) justice Agree: 1) best interests of the child (non-maleficence, beneficence), 2) family centred-care <span>Best interests of child: looking at their interests broadly & not focusing exclusively on biomed facts; value judgment; harm-benefit balance Family centered-care: triadic model of therapeutic relationship; child’s best interest trumps FCC 9yo with HIV, parents do not want child to know Dx. Give 2 reasons to supp




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Family centered-care: triadic model of therapeutic relationship; child’s best interest trumps FCC
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Highlight doc Day 1
ice Agree: 1) best interests of the child (non-maleficence, beneficence), 2) family centred-care Best interests of child: looking at their interests broadly & not focusing exclusively on biomed facts; value judgment; harm-benefit balance <span>Family centered-care: triadic model of therapeutic relationship; child’s best interest trumps FCC 9yo with HIV, parents do not want child to know Dx. Give 2 reasons to support parents, 2 reasons to support informing the child. How would this change if he was 12yo? &#13




#ir #peds
(list of 6? principles that the professor asked us to memorize for the exam)
BEST INTERESTS OF THE CHILD: survival, harms/benefits, Tx, QoL
DEVELOPING CHILD AUTONOMY
FAMILY CENTRED CARE
TRUTH TELLING/DISCLOSURE
CONFIDENTIALITY: exceptions (harm, self-harm, abuse <16y)
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Highlight doc Day 1
inician may rely upon during times of dilemma (2 marks). PRO s : better-informed clinical decision CON s : AEs (HA, back pain, hemorrhage) Strategies: 1) go along, 2) do it, 3) better understand decision/share rationale <span>BEST INTERESTS OF THE CHILD: survival, harms/benefits, Tx, QoL DEVELOPING CHILD AUTONOMY FAMILY CENTRED CARE TRUTH TELLING/DISCLOSURE CONFIDENTIALITY: exceptions (harm, self-harm, abuse <16y) Resources: hospital ethicist, CCB (if concern over best interests) 14yo ♂ comes to you with whom it took time for you to develop trusting relationship. He confide




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Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt
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Growth
GROWTH Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential? &#




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  • A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential?
  • DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy
  • Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca2+, Vit ADE
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Growth
GROWTH Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential? DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca 2+ , Vit ADE 14yo at 3 rd %ile weight + 10 th %ile height is not eating well. What are 3 possible causes? See above A full term baby presents with an eating




#ir #peds
  • A full term baby presents with an eating disorder (i.e. FTT). What is your DDx?
  • ↓intake: non-organic , GERD, structural, CNS, genetic
  • ↓absorption: CF, CMPA, short gut, biliary atresia, GI
  • ↑loss: gastroenteritis
  • ↑demand: cardiac, ↑THY, infection, respiratory
  • Ineffective use: inborn error of metabolism
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Growth
obstructive uropathy Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca 2+ , Vit ADE 14yo at 3 rd %ile weight + 10 th %ile height is not eating well. What are 3 possible causes? See above <span>A full term baby presents with an eating disorder (i.e. FTT). What is your DDx? ↓intake: non-organic , GERD, structural, CNS, genetic ↓absorption: CF, CMPA, short gut, biliary atresia, GI ↑loss: gastroenteritis ↑demand: cardiac, ↑THY, infection, respiratory Ineffective use: inborn error of metabolism Obesity 14yo ♂ with weight of 67 kg, height 150cm. Calculate BMI: 29.8 kg/m 2 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtO




#ir #peds
  • 14yo ♂ with weight of 67 kg, height 150cm.
  • Calculate BMI: 29.8 kg/m2
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Growth
ganic , GERD, structural, CNS, genetic ↓absorption: CF, CMPA, short gut, biliary atresia, GI ↑loss: gastroenteritis ↑demand: cardiac, ↑THY, infection, respiratory Ineffective use: inborn error of metabolism Obesity <span>14yo ♂ with weight of 67 kg, height 150cm. Calculate BMI: 29.8 kg/m 2 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S Newborn Growth Parameters&#




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4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S
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Growth
esia, GI ↑loss: gastroenteritis ↑demand: cardiac, ↑THY, infection, respiratory Ineffective use: inborn error of metabolism Obesity 14yo ♂ with weight of 67 kg, height 150cm. Calculate BMI: 29.8 kg/m 2 <span>4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S Newborn Growth Parameters Weight • At birth = 3.0‐3.5kg (avg) • Normal to lose up to 10% of birth weight in first 4‐7 days o BUT should return to birth weight




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Newborn Growth Parameters
Weight
• At birth = 3.0‐3.5kg (avg)
• Normal to lose up to 10% of birth weight in first 4‐7 days
o BUT should return to birth weight no later than 10‐14 days
• Doubles birth weight by 4‐6 months; triples birth weight by 1 year
• Quadruples birth weight by 2 years
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Growth
14yo ♂ with weight of 67 kg, height 150cm. Calculate BMI: 29.8 kg/m 2 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S <span>Newborn Growth Parameters Weight • At birth = 3.0‐3.5kg (avg) • Normal to lose up to 10% of birth weight in first 4‐7 days o BUT should return to birth weight no later than 10‐14 days • Doubles birth weight by 4‐6 months; triples birth weight by 1 year • Quadruples birth weight by 2 years Head Circumference • At birth = 35cm (avg) o <32cm 􀃆 small head = small brain until proven otherwise • May be inaccurate at birth due to caput succedaneum, moldin




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Head Circumference
• At birth = 35cm (avg)
o <32cm 􀃆 small head = small brain until proven otherwise
• May be inaccurate at birth due to caput succedaneum, molding
• 0‐3mths = +2cm/mth
• 3‐6mths =+1cm/mth
• 6‐12mths = +0.5cm/mth
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Growth
mal to lose up to 10% of birth weight in first 4‐7 days o BUT should return to birth weight no later than 10‐14 days • Doubles birth weight by 4‐6 months; triples birth weight by 1 year • Quadruples birth weight by 2 years <span>Head Circumference • At birth = 35cm (avg) o <32cm 􀃆 small head = small brain until proven otherwise • May be inaccurate at birth due to caput succedaneum, molding • 0‐3mths = +2cm/mth • 3‐6mths =+1cm/mth • 6‐12mths = +0.5cm/mth Height • At birth = 50cm (avg) • Doubles height by 4 years • Measure recumbent length until 2 years, then standing height Normal Growth Velocity &#13




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Height
• At birth = 50cm (avg)
• Doubles height by 4 years
• Measure recumbent length until 2 years, then standing height
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Growth
• At birth = 35cm (avg) o <32cm 􀃆 small head = small brain until proven otherwise • May be inaccurate at birth due to caput succedaneum, molding • 0‐3mths = +2cm/mth • 3‐6mths =+1cm/mth • 6‐12mths = +0.5cm/mth <span>Height • At birth = 50cm (avg) • Doubles height by 4 years • Measure recumbent length until 2 years, then standing height Normal Growth Velocity Growth Charts • Critical to use gender and age appropriate growth charts • In 2010, the CPS, RCFPC and the Dieticians of Can




#has-images #ir #peds
Normal Growth Velocity

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Growth
, molding • 0‐3mths = +2cm/mth • 3‐6mths =+1cm/mth • 6‐12mths = +0.5cm/mth Height • At birth = 50cm (avg) • Doubles height by 4 years • Measure recumbent length until 2 years, then standing height <span>Normal Growth Velocity Growth Charts • Critical to use gender and age appropriate growth charts • In 2010, the CPS, RCFPC and the Dieticians of Canada, recommended the use of t




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use BMI after age 10.
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Growth
the use of the 2006 WHO Growth Standards and Reference charts • WHO Growth Standards based on longitudinal data from solely breast fed for first six months, healthy children from diverse ethnic and geographic backgrounds; <span>use BMI after age 10. • Growth charts are also available for premature infants and certain syndromes • Use corrected age up to 2 years for plotting premature infants Failure to Thri




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Failure to Thrive
Definition
• Weight < 3%ile (the further below the curve the more likely to be
pathologic in origin)
• Weight falls across major %ile lines
• Weight < 80% of ideal body weight*
* use appropriate growth charts for gender and certain genetic conditions
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Growth
om diverse ethnic and geographic backgrounds; use BMI after age 10. • Growth charts are also available for premature infants and certain syndromes • Use corrected age up to 2 years for plotting premature infants <span>Failure to Thrive Definition • Weight < 3%ile (the further below the curve the more likely to be pathologic in origin) • Weight falls across major %ile lines • Weight < 80% of ideal body weight* * use appropriate growth charts for gender and certain genetic conditions Factors Affecting Physical Growth • Genetics • Intrauterine factors • "Internal time clock" • Nutrition • Endocrine hormones • Chronic infec




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Factors Affecting Physical Growth
• Genetics
• Intrauterine factors
• "Internal time clock"
• Nutrition
• Endocrine hormones
• Chronic infections/diseases
• Psychosocial factors
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Growth
ther below the curve the more likely to be pathologic in origin) • Weight falls across major %ile lines • Weight < 80% of ideal body weight* * use appropriate growth charts for gender and certain genetic conditions <span>Factors Affecting Physical Growth • Genetics • Intrauterine factors • "Internal time clock" • Nutrition • Endocrine hormones • Chronic infections/diseases • Psychosocial factors Etiology • Inadequate intake: insufficient provision of food, vomiting, oro‐motor dysfunction • Inadequate absorption: pancreatic insufficiency, celiac disease




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Etiology of FTT
• Inadequate intake: insufficient provision of food, vomiting, oro‐motor
dysfunction
• Inadequate absorption: pancreatic insufficiency, celiac disease
• Increased utilization: chronic diseases, hyperthyroidism
• Ineffective utilization: chromosomal disorders
• Increased losses: chronic diarrhea, urinary losses
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Growth
onditions Factors Affecting Physical Growth • Genetics • Intrauterine factors • "Internal time clock" • Nutrition • Endocrine hormones • Chronic infections/diseases • Psychosocial factors <span>Etiology • Inadequate intake: insufficient provision of food, vomiting, oro‐motor dysfunction • Inadequate absorption: pancreatic insufficiency, celiac disease • Increased utilization: chronic diseases, hyperthyroidism • Ineffective utilization: chromosomal disorders • Increased losses: chronic diarrhea, urinary losses Differential Diagnosis Nonorganic/ Psychosocial Most common cause of FTT, often seen in conjunction with organic FTT Specific Organic Diseases • Genetic: T




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Differential Diagnosis:
Nonorganic/Psychosocial
-Most common cause of FTT, often seen in conjunction with organic FTT

Specific Organic Diseases
• Genetic: Turner/Downs/Russell Silver Syndrome, FAS, TORCH
• Cardiac: Chronic cardiac failure
• Pulmonary: Recurrent or chronic infections, Cystic Fibrosis
• GI: GERD, vomiting, IBD, chronic liver disease, malabsorption
syndromes (Celiac Disease, CF, Schwachman Diamond syndrome)
• Renal: Chronic renal failure, obstructive uropathies
• Endocrine: Hyperthyroidism, hypopituitarism, DM‐1, DI
• CNS: Difficulty coordinating swallow, MR, CP, Diencephalic Syndrome
• Haematology: Chronic hematologic disorders, malignancies
• Inflammatory/Immune: SLE, immunodeficiencies
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Growth
adequate absorption: pancreatic insufficiency, celiac disease • Increased utilization: chronic diseases, hyperthyroidism • Ineffective utilization: chromosomal disorders • Increased losses: chronic diarrhea, urinary losses <span>Differential Diagnosis Nonorganic/ Psychosocial Most common cause of FTT, often seen in conjunction with organic FTT Specific Organic Diseases • Genetic: Turner/Downs/Russell Silver Syndrome, FAS, TORCH • Cardiac: Chronic cardiac failure • Pulmonary: Recurrent or chronic infections, Cystic Fibrosis • GI: GERD, vomiting, IBD, chronic liver disease, malabsorption syndromes (Celiac Disease, CF, Schwachman Diamond syndrome) • Renal: Chronic renal failure, obstructive uropathies • Endocrine: Hyperthyroidism, hypopituitarism, DM‐1, DI • CNS: Difficulty coordinating swallow, MR, CP, Diencephalic Syndrome • Haematology: Chronic hematologic disorders, malignancies • Inflammatory/Immune: SLE, immunodeficiencies Risk Factors Child Factors • Premature, low birth weight • Feeding, sleep or elimination problems • Recurrent illness • Developmental delay Pare




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Risk Factors
Child Factors
• Premature, low birth weight
• Feeding, sleep or elimination problems
• Recurrent illness
• Developmental delay
Parental Factors
• Parents abused or neglected as children
• Unwanted, unplanned pregnancy
• Marital problems, single parent
• Drugs/alcohol
• Young inexperienced parents
• Unwell/stressed parent
• Poor follow‐up, uncooperative parents
• Misconceptions of eating habits and nutrition
Child and Parental Factors
• Difficulty feeding, refusal to feed
• Colic, sleep problems
• Behavioural issues
• Parent not able to recognize child’s needs and respond to child’s cues
Environmental Factors
• Low SES, unemployment
• Lack of support, social isolation
• Lack of access to consistent medical care
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Growth
perthyroidism, hypopituitarism, DM‐1, DI • CNS: Difficulty coordinating swallow, MR, CP, Diencephalic Syndrome • Haematology: Chronic hematologic disorders, malignancies • Inflammatory/Immune: SLE, immunodeficiencies <span>Risk Factors Child Factors • Premature, low birth weight • Feeding, sleep or elimination problems • Recurrent illness • Developmental delay Parental Factors • Parents abused or neglected as children • Unwanted, unplanned pregnancy • Marital problems, single parent • Drugs/alcohol • Young inexperienced parents • Unwell/stressed parent • Poor follow‐up, uncooperative parents • Misconceptions of eating habits and nutrition Child and Parental Factors • Difficulty feeding, refusal to feed • Colic, sleep problems • Behavioural issues • Parent not able to recognize child’s needs and respond to child’s cues Environmental Factors • Low SES, unemployment • Lack of support, social isolation • Lack of access to consistent medical care History • Duration of problem, detailed dietary and feeding history, appetite, behavior before and after feeds, BM history, vomiting • Pregnancy, birth, birth




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FTT History
• Duration of problem, detailed dietary and feeding history, appetite,
behavior before and after feeds, BM history, vomiting
• Pregnancy, birth, birth weight, postpartum history, developmental
history, growth patterns
• Family patterns of growth including parental heights and age of
puberty
• Current illnesses, symptoms, past medical history
• Family relationships, detailed social history
• Assess child’s temperament, child‐parent interaction, feeding
behaviour, parental psychosocial issues
Physical Exam
• Ht/Wt/HC‐ plot on growth chart; compare to prior values
• HR, RR, BP
• Complete general physical examination
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Growth
issues • Parent not able to recognize child’s needs and respond to child’s cues Environmental Factors • Low SES, unemployment • Lack of support, social isolation • Lack of access to consistent medical care <span>History • Duration of problem, detailed dietary and feeding history, appetite, behavior before and after feeds, BM history, vomiting • Pregnancy, birth, birth weight, postpartum history, developmental history, growth patterns • Family patterns of growth including parental heights and age of puberty • Current illnesses, symptoms, past medical history • Family relationships, detailed social history • Assess child’s temperament, child‐parent interaction, feeding behaviour, parental psychosocial issues Physical Exam • Ht/Wt/HC‐ plot on growth chart; compare to prior values • HR, RR, BP • Complete general physical examination Investigations/Imaging • Use your history and physical exam to guide your choice of investigations • Consider investigations to look for etiology and investiga




#ir #peds
FTT Investigations/Imaging
• Use your history and physical exam to guide your choice of
investigations
• Consider investigations to look for etiology and investigations to assess
for other deficiencies
• CBC, lytes, urea, creatinine, TSH, T4, U/A, celiac screen, vitamin A,D,E,
ferritin, calcium
• Consider karyotype, microarray, bone age (AP x‐ray of L hand and
wrist) if also short stature
Management
• Treat underlying cause
• Provide education about age‐appropriate foods, mealtime scheduling
and behaviour
• Caloric fortification of food
• May need referral to dietitian, social work
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Growth
rament, child‐parent interaction, feeding behaviour, parental psychosocial issues Physical Exam • Ht/Wt/HC‐ plot on growth chart; compare to prior values • HR, RR, BP • Complete general physical examination <span>Investigations/Imaging • Use your history and physical exam to guide your choice of investigations • Consider investigations to look for etiology and investigations to assess for other deficiencies • CBC, lytes, urea, creatinine, TSH, T4, U/A, celiac screen, vitamin A,D,E, ferritin, calcium • Consider karyotype, microarray, bone age (AP x‐ray of L hand and wrist) if also short stature Management • Treat underlying cause • Provide education about age‐appropriate foods, mealtime scheduling and behaviour • Caloric fortification of food • May need referral to dietitian, social work Overweight and Obesity Introduction • Growth monitoring should be performed at primary care visits for children and youth ages 17 and younger • BMI = mass




#ir #peds
  • Case on child not toilet training: what is the likely reason?
  • Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic)
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Development
DEVELOPMENT [See chart] NORMAL Case on child not toilet training: what is the likely reason? Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic) 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do? MCQ: audiology testing, NOT genet




#ir #peds
  • 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do?
  • MCQ: audiology testing, NOT genetic testing
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Development
ee chart] NORMAL Case on child not toilet training: what is the likely reason? Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic) <span>5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do? MCQ: audiology testing, NOT genetic testing Developmental milestones for 6mo. Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, g




#ir #peds
  • Developmental milestones for 6mo.
  • Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts
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Development
ogic, communication, psychologic) 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do? MCQ: audiology testing, NOT genetic testing <span>Developmental milestones for 6mo. Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay? Normal: gets into sitti




#ir #peds
  • Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay?
  • Normal: gets into sitting position without help, stands without support, walks while holding on, neat pincer grasp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins
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Development
ting Developmental milestones for 6mo. Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts <span>Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay? Normal: gets into sitting position without help, stands without support, walks while holding on, neat pincer grasp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins 3 yo development milestone (circle 8): I guess the biggest lesson I took away with me from this exam is from the key features section and this question in particular: list




#ir #peds
  • 3 yo development milestone (circle 8):
  • Normal: walks upstairs using handrail, stands on one foot, rides tricycles, stacks 10 blocks, twists lid off jars, copies a circle, combines 5 or more words in a sentence, understands 2-3 step commands, recognizes colours, shares willingly some of the time, make-believe games, plays with others, listens to music or stories for 5-10 minutes, jumping on one foot, washes and dries own hands, dresses self independently except shoe laces, knows own sex, tells detailed stories, knows primary colours, speaks with plurals
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Development
sp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins <span>3 yo development milestone (circle 8): I guess the biggest lesson I took away with me from this exam is from the key features section and this question in particular: listen to what your predecessors have to say about the exam in the past exams you see in this email account! When I saw, in one of the previous peds exam, that one is required to pick things out of a list of 20 development milestones, none of which appears in Toronto Notes, I did not take the warning seriously, and I'm forced to pay for my irreverence. I randomly circled 8 things and would be lucky if I can walk away with half the marks. So the lesson is that not only should you remember the short list of developmental milestones from Toronto Notes or the Peds handbook you got from year 2 for the short answers part, but you should also remember a longer, more exhaustive list of milestones from some other source for the key features version of the development milestonesànot true in 2015 Normal: walks upstairs using handrail, stands on one foot, rides tricycles, stacks 10 blocks, twists lid off jars, copies a circle, combines 5 or more words in a sentence, understands 2-3 step commands, recognizes colours, shares willingly some of the time, make-believe games, plays with others, listens to music or stories for 5-10 minutes, jumping on one foot, washes and dries own hands, dresses self independently except shoe laces, knows own sex, tells detailed stories, knows primary colours, speaks with plurals Pick developmental milestones from a list (I think for a 3yo and another one for a 4yo?) See above Developmental Milestones achieved by 15 mo? 18m




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There are four main areas of developement – gross motor, fine motor, language and social.
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Development
milestones from a list (I think for a 3yo and another one for a 4yo?) See above Developmental Milestones achieved by 15 mo? 18mo? What about 6-10 yrs? 16 wks? See chart Developmental Milestones <span>There are four main areas of developement – gross motor, fine motor, language and social. All areas should be explored when exploring a developmental history. The milestones cited are, on average, those at the 50th percentile for age. Develo




#has-images #ir #peds
The milestones cited are, on average, those at the 50th percentile for age.


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Development
out 6-10 yrs? 16 wks? See chart Developmental Milestones There are four main areas of developement – gross motor, fine motor, language and social. All areas should be explored when exploring a developmental history. <span>The milestones cited are, on average, those at the 50th percentile for age. Developmental Problems Differential Diagnosis • Motor o Problems with CNS (e.g., Cerebral palsy) o Problems with PNS (e.g., Muscul




Flashcard 1473379962124

Tags
#ancient-history #history #roman-empire #rome #wiki
Question
What political event was correlated with Rome's expansion in the 6th Century BC?
Answer
the founding of the republic

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Rome had begun expanding shortly after the founding of the republic in the 6th century BC

Original toplevel document

Roman Empire - Wikipedia
gelink] [emptylink] The Augustus of Prima Porta (early 1st century AD) [imagelink] [emptylink] Bust of Tiberius Julius Sauromates II (d. 210 AD), ruler of the Bosporan Kingdom in Roman Crimea, one of Rome's client states <span>Rome had begun expanding shortly after the founding of the republic in the 6th century BC, though it did not expand outside the Italian Peninsula until the 3rd century BC. Then, it was an "empire" long before it had an emperor. [10] [11] [12] [13] The Roman Republ







Flashcard 1473382321420

Tags
#ancient-history #history #roman-empire #rome #wiki
Question
In what century did Rome begin expanding after the formation of the republic?
Answer
6th century BC

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Rome had begun expanding shortly after the founding of the republic in the 6th century BC

Original toplevel document

Roman Empire - Wikipedia
gelink] [emptylink] The Augustus of Prima Porta (early 1st century AD) [imagelink] [emptylink] Bust of Tiberius Julius Sauromates II (d. 210 AD), ruler of the Bosporan Kingdom in Roman Crimea, one of Rome's client states <span>Rome had begun expanding shortly after the founding of the republic in the 6th century BC, though it did not expand outside the Italian Peninsula until the 3rd century BC. Then, it was an "empire" long before it had an emperor. [10] [11] [12] [13] The Roman Republ







Flashcard 1473384680716

Tags
#ancient-history #history #roman-empire #rome #wiki
Question
What did Rome start doing shortly after the founding of the Republic in the 6th Century BC?
Answer
Rome began expanding

statusnot learnedmeasured difficulty37% [default]last interval [days]               
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Rome had begun expanding shortly after the founding of the republic in the 6th century BC

Original toplevel document

Roman Empire - Wikipedia
gelink] [emptylink] The Augustus of Prima Porta (early 1st century AD) [imagelink] [emptylink] Bust of Tiberius Julius Sauromates II (d. 210 AD), ruler of the Bosporan Kingdom in Roman Crimea, one of Rome's client states <span>Rome had begun expanding shortly after the founding of the republic in the 6th century BC, though it did not expand outside the Italian Peninsula until the 3rd century BC. Then, it was an "empire" long before it had an emperor. [10] [11] [12] [13] The Roman Republ







CLIPP 8 - neonatal jaundice
#ir #peds

8. 6-day-old with jaundice - Meghan

February 1, 2017 1:39:29 PM EST

Knowledge

Jaundice

Jaundice is the physical finding associated with hyperbilirubinemia and may result from both unconjugated and conjugated forms of bilirubin.

Unconjugated hyperbilirubinemia can have serious consequences.

Kernicterus

Definition

Kernicterus is the pathological term used to describe staining of the basal ganglia and cranial nerve nuclei by bilirubin. Kernicterus also describes the clinical condition that results from the toxic effects of high levels of unconjugated bilirubin.

Sequelae

Severely affected newborn infants may:

lose the suck reflex become lethargic develop hyperirritability and seizures, and ultimately die

Infants who survive may develop:

opisthotonus (abnormal posturing that involves rigidity and severe arching of the back, with the head thrown backward) rigidity oculomotor paralysis tremors

Cho Sooyoung - sooyoung.cho@mail.utoronto.ca 1/22

hearing loss, and ataxia

Screening and Treatment

In the past, kernicterus among full-term newborn infants primarily resulted from the hemolysis and subsequent unconjugated hyperbilirubinemia that was caused by Rh incompatibility (erythroblastosis fetalis). These infants typically were severely anemic, in shock and acidotic, and had total bilirubin levels well above 25 mg/dL (428 μmol/L). Screening for Rh incompatibility and the use of anti-Rh immunoglobulin (RhoGAM®) have markedly reduced Rh-induced hemolysis and the incidence of kernicterus. In addition, treatment of unconjugated hyperbilirubinemia with phototherapy has had an important impact on management of hyperbilirubinemia.

See the associated reference ranges in conventional and SI units. (http://www.med- u.org/virtual_patient_cases/labreferences)

Newborn Bilirubin Physiology

Most (~75%) of the bilirubin produced in the healthy newborn comes from physiological breakdown of red blood cells.

Pathway

The hemoglobin released from the red cells is converted to unconjugated bilirubin that is insoluble in aqueous solutions and binds to albumin in the blood stream. In the liver the bilirubin is extracted by the hepatocytes where it binds to cytosolic proteins and is then conjugated with glucuronide by uridine diphosphate glucuronyl transferase (UDPGT, also known as glucuronosyl transferase). The conjugated bilirubin is water-soluble and is excreted into the bile and then into the intestine.

In adults, most of the bile is metabolized by the intestinal flora to urobilin and excreted in the stool. The newborn infant, however, lacks the gastrointestinal flora to metabolize bile, which allows the β-glucuronidase present in the meconium to hydrolyze the conjugated bilirubin back to its unconjugated form.

The unconjugated bilirubin is then reabsorbed into the blood stream where it binds to albumin. Newborns absorb significant quantities of bilirubin through this process, known as enterohepatic circulation.

Etiologies of Jaundice

2/22

Physiologic Jaundice

This is defined as a total bilirubin level ≤ 15 mg/dL (≤ 257 μmol/L) in full-term infants who are otherwise healthy and have no other demonstrable cause for elevated bilirubin.

Almost all newborn infants have hyperbilirubinemia, but it is benign and self- limited.

Physiologic jaundice i

...
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#ir #peds
developmental problems Differential Diagnosis
• Motor
o Problems with CNS (e.g., Cerebral palsy)
o Problems with PNS (e.g., Muscular dystrophy)
o Metabolic conditions (e.g., Hypothyroidism)
o Genetic syndromes (e.g., Down Syndrome)
• Language
o Structural/functional abnormalities of oromotor anatomy
o Hearing impairment
o Pure language disorders
o Pervasive developmental disorders (e.g., Autism Spectrum
Disorder)
• Cognitive
o Global developmental delay due to:
- Genetic conditions (e.g., Fragile X)
- Deprived environment
- Prenatal/perinatal events leading to brain anoxia/ischemia
(rare)
- Prenatal exposures (e.g., Fetal Alcohol Spectrum Disorders)
• Emotional/Social
o Pervasive developmental disorders (e.g., Autism Spectrum
Disorder)
o Deprived environment
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Development
e motor, language and social. All areas should be explored when exploring a developmental history. The milestones cited are, on average, those at the 50th percentile for age. Developmental Problems <span>Differential Diagnosis • Motor o Problems with CNS (e.g., Cerebral palsy) o Problems with PNS (e.g., Muscular dystrophy) o Metabolic conditions (e.g., Hypothyroidism) o Genetic syndromes (e.g., Down Syndrome) • Language o Structural/functional abnormalities of oromotor anatomy o Hearing impairment o Pure language disorders o Pervasive developmental disorders (e.g., Autism Spectrum Disorder) • Cognitive o Global developmental delay due to: - Genetic conditions (e.g., Fragile X) - Deprived environment - Prenatal/perinatal events leading to brain anoxia/ischemia (rare) - Prenatal exposures (e.g., Fetal Alcohol Spectrum Disorders) • Emotional/Social o Pervasive developmental disorders (e.g., Autism Spectrum Disorder) o Deprived environment Management • Motor o Educate parents about poor correlation between motor delays and intelligence o Refer to Physiotherapy and Occupational therapy o




#ir #peds
developmental problem Management
• Motor
o Educate parents about poor correlation between motor delays and
intelligence
o Refer to Physiotherapy and Occupational therapy
o Educate parents on developmental targets and techniques for
helping achieve specific milestones
- e.g. adequate ‘Tummy Time’ to facilitate development of head
control, rolling over, etc.
• Language
o Audiology assessment
o Referral to local early intervention services
o Speech and language (SLP) evaluation
o Enroll child in nursery school
o Educate parents regarding language facilitation techniques
- make noises or sing and repeat sounds the child says
- ask questions/make comments that lead to a response
- label objects and emphasize action words
- read to the child
- use simple, slow language
• Cognitive
o Thorough history:
- Pregnancy (obstetrical history, exposures, complications)
- Birth (gestational age, complications, delivery, resuscitation)
- Family History (parents, siblings, consanguinity)
- Social History (identify deprived environments)
o Physical exam including head growth, dysmorphic features,
neurologic exam
o Hearing/vision assessment
o Other tests as indicated: karyotype, blood lead levels, metabolic
screen, TSH, CT/MRI
o Find appropriate schooling/community living
o Help family find support groups, funding, respite
• Emotional/Social
o Early intervention with early intervention therapists
o Provide opportunities for increased contact with other children e.g.,
play groups, structured daycare
o Refer to specific therapeutic groups
o If applicable, remove child from deprived environment with help of
children’s aid society
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Development
brain anoxia/ischemia (rare) - Prenatal exposures (e.g., Fetal Alcohol Spectrum Disorders) • Emotional/Social o Pervasive developmental disorders (e.g., Autism Spectrum Disorder) o Deprived environment <span>Management • Motor o Educate parents about poor correlation between motor delays and intelligence o Refer to Physiotherapy and Occupational therapy o Educate parents on developmental targets and techniques for helping achieve specific milestones - e.g. adequate ‘Tummy Time’ to facilitate development of head control, rolling over, etc. • Language o Audiology assessment o Referral to local early intervention services o Speech and language (SLP) evaluation o Enroll child in nursery school o Educate parents regarding language facilitation techniques - make noises or sing and repeat sounds the child says - ask questions/make comments that lead to a response - label objects and emphasize action words - read to the child - use simple, slow language • Cognitive o Thorough history: - Pregnancy (obstetrical history, exposures, complications) - Birth (gestational age, complications, delivery, resuscitation) - Family History (parents, siblings, consanguinity) - Social History (identify deprived environments) o Physical exam including head growth, dysmorphic features, neurologic exam o Hearing/vision assessment o Other tests as indicated: karyotype, blood lead levels, metabolic screen, TSH, CT/MRI o Find appropriate schooling/community living o Help family find support groups, funding, respite • Emotional/Social o Early intervention with early intervention therapists o Provide opportunities for increased contact with other children e.g., play groups, structured daycare o Refer to specific therapeutic groups o If applicable, remove child from deprived environment with help of children’s aid society Developmental Surveillance Rourke Baby Record Available in the Syllabus and through the CPS website at: www.cps.ca/english/statements/CP/Rourke/RBROntario.pdf&




#ir #peds
Enhanced 18Month
WellBaby
Visit
Syllabus: Canadian Task Force on Preventative Health Care. Recommendations on
screening for developmental delay. CMAJ. 2016; 188(8):579.
• Important time to review child’s developmental domains and
achievement of milestones
• Visit should incorporate use of Rourke Baby Record, screening for
parental morbidities (mental health, physical illness), promotion of
literacy activities (reading, singing), and information about resources
• Standard developmental screening tools (eg: Nipissing) no longer
recommended for children whose parents or clinicians have no
concerns regarding delay
• Screening still appropriate in children presenting with
signs/symptoms, or parental concerns of delay.
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Development
: o Growth and nutrition o Nutrition o Development milestones – to aid developmental surveillance, not a screen. Set after time of normal milestone acquisition. o Anticipatory guidance o Physical examination <span>Enhanced 18Month WellBaby Visit Syllabus: Canadian Task Force on Preventative Health Care. Recommendations on screening for developmental delay. CMAJ. 2016; 188(8):579. • Important time to review child’s developmental domains and achievement of milestones • Visit should incorporate use of Rourke Baby Record, screening for parental morbidities (mental health, physical illness), promotion of literacy activities (reading, singing), and information about resources • Standard developmental screening tools (eg: Nipissing) no longer recommended for children whose parents or clinicians have no concerns regarding delay • Screening still appropriate in children presenting with signs/symptoms, or parental concerns of delay. Greig Health Record Available in the Syllabus and through the CPS website at: www.cps.ca/english/statements/CP/PreventiveCare.htm • Evidenced based health prom




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Attention Deficit/Hyperactivity Disorder
Syllabus: Floet et al. Attention Deficit/Hyperactivity Disorder. Pediatrics in Review.
2010;31(2):56.
American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the
Diagnosis, Evaluation and Treatment of Attention‐Deficit/Hyperactivty Disorder in
Children and Adolescents. Pediatrics. 2011;128(5):1007.
Introduction
• ADHD is a neurobehavioral disorder defined by symptoms of
inattention, hyperactivity, and impulsivity.
• There is a two‐ to three‐fold higher prevalence in boys than girls with
girls being more likely to be diagnosed with the inattentive‐type ADHD
• Can profoundly effect academic performance, social interactions and
well being
DSM5
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity‐impulsivity
that interferes with functioning or development, as characterized by
(1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social
and academic/occupational activities:
a. Often fails to give close attention to details or makes careless
mistakes in schoolwork, at work, or during other activities (e.g.,
overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious
distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks
but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and
belongings in order; messy, disorganized work; has poor time
management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (e.g., schoolwork or homework;
for older adolescents, preparing reports, completing forms,
reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older
adolescents, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running
errands; for older adolescents, returning calls, paying bills,
keeping appointments).
j. Hyperactivity and impulsivity: Six (or more) of the following
symptoms have persisted for at least 6 months to a degree that
is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is
expected (e.g., leaves his or her place in the classroom, in the
office or other workplace, or in other situations that require
remaining in place).
c. Often runs about or climbs in situations where it is
inappropriate. (Note: In adolescents, may be limited to feeling
restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often "on the go," acting as if "driven by a motor" (e.g., is
unable to be or uncomfortable being still for extended time, as
in restaurants, meetings; may be experienced by others as being
restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before...
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Development
BMI o Psychosocial history and development o Nutrition o Education o Behaviour and family issues o Injury prevention and safety o Physical examination o Guidelines and resources (eg: vaccinations) <span>Attention Deficit/Hyperactivity Disorder Syllabus: Floet et al. Attention Deficit/Hyperactivity Disorder. Pediatrics in Review. 2010;31(2):56. American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention‐Deficit/Hyperactivty Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007. Introduction • ADHD is a neurobehavioral disorder defined by symptoms of inattention, hyperactivity, and impulsivity. • There is a two‐ to three‐fold higher prevalence in boys than girls with girls being more likely to be diagnosed with the inattentive‐type ADHD • Can profoundly effect academic performance, social interactions and well being DSM5 Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder A. A persistent pattern of inattention and/or hyperactivity‐impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents, returning calls, paying bills, keeping appointments). j. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents, may intrude into or take over what others are doing). B. Several inattentive or hyperactive‐impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive‐impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). Types • Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity‐impulsivity) are met for the past 6 months. • Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity‐impulsivity) is not met for the past 6 months. • Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity‐impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. Risk Factors • Genetic factors: heritability is approximately 75% • Nongenetic factors: perinatal stress and low birth weight, traumatic brain injury, maternal smoking during pregnancy, severe early deprivation Physical Exam A physical examination is important in ruling out underlying medical or developmental problems such as the following: • emotional or behavioral (eg. anxiety, depression, oppositional defiant and conduct disorders) • developmental (eg. learning and language disorders or other neurodevelopmental disorders) • physical conditions (eg. tics, sleep apnea) Examination should include observation of the child and the parent and their relationship. Investigations • Laboratory and imaging studies are not routinely recommended. However, consideration of hearing and vision tests, thyroid function studies, blood lead levels, genetic karyotyping and brain imaging studies if indicated by past medical history or physical examination • In most cases, laboratory investigations will not be necessary • Consider a psycho‐educational evaluation including both cognitive and academic testing to assess for learning problems Management Syllabus: Belanger et al. Cardiac risk assessment before the use of stimulant medications in children and youth. Paediatrics and Child Health. 2009;14(9):579. Feldman et al. Extended‐release medications for children and adolescents with attention‐deficit hyperactivity disorder. Paediatrics and Child Health. 2009;14(9):593. Bernard‐Bonnin A‐C et al. The use of alternative therapies in treating children with attention deficit hyperactivity disorder. Paediatrics and Child Health. 2002;7(10):710zXXZas Paediatrics and Child Health. 2009;14(9):593.F. • Approach to treatment is multidisciplinary • Psychoeducation and support for patient and family • In cases of ADHD without co‐morbidity, behavioural therapies have not been shown to be helpful for the core symptoms of ADHD • School aged children (6‐18 yrs): o First line is stimulant medication(s) o Second line is non‐stimulant medications o Third line is behavior management: positive reinforcement, time out, response cost, token economy • Pre‐school aged children (4‐5 yrs): o First line is behavior management: positive reinforcement, time out, response cost, and token economy o Second line is stimulant medication(s) • Dietary interventions such as the elimination of sugar have NOT proven to have an observable effect. Other dietary interventions (i.e., elimination of food additives or addition of dietary supplements) require evidence‐based research • Follow‐up and long‐term management are required as ADHD does not resolve with age Medications • Stimulants (methylphenidate, dextroamphetamine) are considered first line because they are highly efficacious in reducing symptoms • Extended release stimulant medications are associated with decreased use of street drugs among adolescents with ADHD, decrease in rate of injuries, STI’s and unwanted pregnancies • Immediate‐release medications such as Ritalin should be avoided as they are much easier to divert, crushed Ritalin may be snorted or made into an injectible form, mixed with narcotics and taken as a ‘speed‐ball’ • Medications should be used 365 days per year in adolescents • Careful titration of medication to optimize effects, minimize side effects and enhance compliance is essential. Autism Spectrum Disorder Syllabus: Johnson C et al. Identification and Evaluation of Chidlren with Autism Spectrum Disorders. Pediatrics. 2007;120(5):1183. Har




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Autism Spectrum Disorder
Syllabus: Johnson C et al. Identification and Evaluation of Chidlren with Autism
Spectrum Disorders. Pediatrics. 2007;120(5):1183.
Harrington et al. The Clinician’s Guide to Autism. Pediatrics in Review.
2014;35(2):62.
Simms et al. Autism, Language Disorder, and Social (Pragmatic) Communication
Disorder: DSM‐V and Diferential Diagnosis. Pediatrics in Review. 2015;36(8):355.
Introduction
• The essential features of autism spectrum disorder are persistent
impairment in reciprocal social communication and social interaction,
and restricted, repetitive patterns of behavior, interests, or activities.
• These symptoms are present from early childhood and limit or impair
everyday functioning
• Social skills deficits can be noticed in infancy with aversion to cuddling
and lack of acknowledgement of the caregiver
• Also can involve language delays/deficits, motor signs (e.g.,
stereotypies, toe walking), sensory deficits (e.g., intolerance to sound)
• Cognitive abilities vary; typically difficulties with reasoning/planning,
greater abilities in rote memory
DSM5
Criteria for Autism Spectrum Disorder
A. Persistent deficits in social communication and social interaction
across multiple contexts, as manifested by the following, currently or
by history (examples are illustrative, not exhaustive; see text):
1. Deficits in social‐emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back‐and‐forth
conversation; to reduced sharing of interests, emotions, or affect; to
failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and
body language or deficits in understanding and use of gestures; to a
total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties adjusting
behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in
peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as
manifested by at least two of the following, currently or by history
(examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or
speech (e.g., simple motor stereotypies, lining up toys or flipping
objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior (e.g., extreme
distress at small changes, difficulties with transitions, rigid thinking
patterns, greeting rituals, need to take same route or eat same food
every day).
3. Highly restricted, fixated interests that are abnormal in intensity or
focus (e.g., strong attachment to or preoccupation with unusual
objects, excessively circumscribed or perseverative interests).
4. Hyper‐ or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).
C. Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited
capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) o...
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th narcotics and taken as a ‘speed‐ball’ • Medications should be used 365 days per year in adolescents • Careful titration of medication to optimize effects, minimize side effects and enhance compliance is essential. <span>Autism Spectrum Disorder Syllabus: Johnson C et al. Identification and Evaluation of Chidlren with Autism Spectrum Disorders. Pediatrics. 2007;120(5):1183. Harrington et al. The Clinician’s Guide to Autism. Pediatrics in Review. 2014;35(2):62. Simms et al. Autism, Language Disorder, and Social (Pragmatic) Communication Disorder: DSM‐V and Diferential Diagnosis. Pediatrics in Review. 2015;36(8):355. Introduction • The essential features of autism spectrum disorder are persistent impairment in reciprocal social communication and social interaction, and restricted, repetitive patterns of behavior, interests, or activities. • These symptoms are present from early childhood and limit or impair everyday functioning • Social skills deficits can be noticed in infancy with aversion to cuddling and lack of acknowledgement of the caregiver • Also can involve language delays/deficits, motor signs (e.g., stereotypies, toe walking), sensory deficits (e.g., intolerance to sound) • Cognitive abilities vary; typically difficulties with reasoning/planning, greater abilities in rote memory DSM5 Criteria for Autism Spectrum Disorder A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Deficits in social‐emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back‐and‐forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper‐ or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently cooccur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. Risk Factors • Male (4x risk) • Having another child with autism • Advanced parental age • Genetic/cytogenetic/syndromic conditions o Down Syndrome, Tuberous sclerosis, untreated PKU, Fragile X, Angelman, Cornelia de Lange syndrome • Early bilateral mesial temporal lobe lesions due to herpes simplex or anoxic/ischemic damage • Very low birth weight, especially with retinopathy of prematurity • No association between MMR vaccination and autism o Studies that showed causation were fraudulent Screening • Developmental surveillance is encouraged at all well baby/child visits • Developmental screening at 18 month visit • Targeted (secondary) screening is recommended in high risk children (risk factors, parental concerns, teacher observations, missed milestones etc) and requires use of specific screening tools (e.g. CHAT) • Determination that a child is at high risk of ASD should result in immediate referral to an experienced diagnostician or an interdisciplinary assessment team INADEQUATE LANGUAGE FEATURES SUGGESTING AUTISM At any age • Regression of language or communicative gestures • Lack of reliable orienting to speech, turning to name • Concern about language comprehension • Persistent mutism unpredictably interrupted by rare isolated clear words or sentences In toddlers • No pointing by 1 year; dragging by the hand • No words by 12‐14 months • Less than a dozen words by 18 months • No 2‐word phrases by 2 years or sentences by 3 years • Very delayed or absent head shaking or nodding to signify no/yes In preschoolers and older children • Failure to answer questions or responding beside the point • Inability to use language conversationally, “talking to talk” rather than to communicate (request, show, etc) • Frequent, persistent verbatim repetition (echolalia) • Persistent pronoun inversion (you/me confusion), referring to self by name • Verbatim repetition of overlearned expressions (delayed echolalia, formulaic speech) rather than self‐generated expressions • Inability to recount an event or tell a coherent story • Perseveration on a favorite topic • Overuse of pedantic words or expressions • High‐pitched, sing‐song, or uninflected robotic speech Investigations • Formal audiological assessment o Consider blood tests: genetic (karyotype, Fragile X, 22q deletion, microarray), metabolic, lead levels and neurologic tests: MRI, EEG Diagnosis • In accordance with DSM‐V Criteria • Interdisciplinary approach is ideal • Assessment of cognitive and developmental levels is required • Can be diagnosed as early as 18 months by experienced professionals • Should be made on the basis of a thorough developmental history and structured behavioural observation and clinical judgment. • The use of at least one standardized, norm‐referenced parent report measure and at least one standardized, norm‐referenced behavioral observation measure is recommended. Management • Early, multi‐disciplinary intervention is beneficial • Structured learning • Speech and language assessment and therapy • Occupational therapy ‐ sensory integration • Behaviour management support • Medications for self‐injurious and aggressive behaviours o SSRIs, psychotropic drugs (e.g., Risperidone), anticonvulsants • Social skills training • Vocational counseling Note: Elimination diets and vitamins have no proven efficacy Learning Disorders Syllabus: Rimrodt et al. Learning Disabilities and School Failure. Pediatrics in Review. 2011;32(8):315. Byrd R. School Failure: Assessment,




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Learning Disorders
Syllabus: Rimrodt et al. Learning Disabilities and School Failure. Pediatrics in
Review. 2011;32(8):315.
Byrd R. School Failure: Assessment, Intervention, and Prevention in Primary Care
Pediatrics. Pediatrics in Review. 2005;26(7):233.
• Represent a disability based on a descrepency between a person’s
intellectual ability and actual academic performance
• Further specificed into the particular area of academic function
affected:
o Mathematics disorder
o Reading disorder
o Disorder of reading expression
• Any child who has school problems and is suspected of having a
learning disability should be referred for a comprehensive
psychoeducational evaluation
• Accomodations can be made at school through the Identification,
Placement, and Review Committee (IPRC). The IPRC will:
o decide whether or not a student should be identified as exceptional
o identify the areas of a student’s exceptionality
o decide an appropriate placement for a student
o review identification and placement at least once per school year
• An IEP (Individual Education Plan) is developed (in consultation with
parents and the student) for each student who has been identified as
exceptional by the IPRC process. An IEP is a written plan that describes
the strengths and needs of the student, services established to meet
that student’s needs, and how these should be delivered
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‐injurious and aggressive behaviours o SSRIs, psychotropic drugs (e.g., Risperidone), anticonvulsants • Social skills training • Vocational counseling Note: Elimination diets and vitamins have no proven efficacy <span>Learning Disorders Syllabus: Rimrodt et al. Learning Disabilities and School Failure. Pediatrics in Review. 2011;32(8):315. Byrd R. School Failure: Assessment, Intervention, and Prevention in Primary Care Pediatrics. Pediatrics in Review. 2005;26(7):233. • Represent a disability based on a descrepency between a person’s intellectual ability and actual academic performance • Further specificed into the particular area of academic function affected: o Mathematics disorder o Reading disorder o Disorder of reading expression • Any child who has school problems and is suspected of having a learning disability should be referred for a comprehensive psychoeducational evaluation • Accomodations can be made at school through the Identification, Placement, and Review Committee (IPRC). The IPRC will: o decide whether or not a student should be identified as exceptional o identify the areas of a student’s exceptionality o decide an appropriate placement for a student o review identification and placement at least once per school year • An IEP (Individual Education Plan) is developed (in consultation with parents and the student) for each student who has been identified as exceptional by the IPRC process. An IEP is a written plan that describes the strengths and needs of the student, services established to meet that student’s needs, and how these should be delivered Bullying Syllabus: Lamb et al. Approach to Bullying and Victimization. Canadian Family Physician. 2009;55(4):356. Introduction • Defined as the use of pow




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Bullying
Syllabus: Lamb et al. Approach to Bullying and Victimization. Canadian Family
Physician. 2009;55(4):356.
Introduction
• Defined as the use of power or aggression to cause distress or control
of another
• Can be direct (face‐to‐face) or indirect (gossip, exclusion)
• Negative actions can include:
o Physical actions (punching, kicking, biting)
o Verbal actions (threats, name calling, insults)
o Social exclusion (spreading rumours, gossiping, excluding)
• Actions are repeated and the intensity or duration establishes
dominance

History
• When a physician identifies a possible bullying situation, the following
questions can help determine what type of help may be appropriate
o Who do you bully/who bullys you?
o What do you do to others/what do others do to you? (e.g. gossiping,
insults, hitting, etc.)
o When and how often do you bully/are you bullied?
o Where do you bully/where are you bullied?
o Why do you bully others/why do you think you are bullied?
o How do you think the kids feel when you bully them or how do you
feel when you are bullied?
Management
• Comprehensive strategies that encompass the school, family and
community are most likely to be effective
o establish a social school environment that promotes safety
o provide access to health and mental health services
o integrate school, family and community prevention efforts
o provide training to enable school staff to promote safety and
prevent violence effectively
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been identified as exceptional by the IPRC process. An IEP is a written plan that describes the strengths and needs of the student, services established to meet that student’s needs, and how these should be delivered <span>Bullying Syllabus: Lamb et al. Approach to Bullying and Victimization. Canadian Family Physician. 2009;55(4):356. Introduction • Defined as the use of power or aggression to cause distress or control of another • Can be direct (face‐to‐face) or indirect (gossip, exclusion) • Negative actions can include: o Physical actions (punching, kicking, biting) o Verbal actions (threats, name calling, insults) o Social exclusion (spreading rumours, gossiping, excluding) • Actions are repeated and the intensity or duration establishes dominance History • When a physician identifies a possible bullying situation, the following questions can help determine what type of help may be appropriate o Who do you bully/who bullys you? o What do you do to others/what do others do to you? (e.g. gossiping, insults, hitting, etc.) o When and how often do you bully/are you bullied? o Where do you bully/where are you bullied? o Why do you bully others/why do you think you are bullied? o How do you think the kids feel when you bully them or how do you feel when you are bullied? Management • Comprehensive strategies that encompass the school, family and community are most likely to be effective o establish a social school environment that promotes safety o provide access to health and mental health services o integrate school, family and community prevention efforts o provide training to enable school staff to promote safety and prevent violence effectively Toilet Training Syllabus: Clifford et al. Toilet Learning: Anticipatory Guidance with a child‐oriented approach. Paediatrics and Child Health. 2000;5(6):333. F




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Toilet Training
Syllabus: Clifford et al. Toilet Learning: Anticipatory Guidance with a child‐oriented
approach. Paediatrics and Child Health. 2000;5(6):333.
Feldman. Managing primary nocturnal enuresis. Paediatr Child Health. 2005;
10(10):611.
Bayne et al. Nocturnal enuresis: An approach to assessment and treatment. Peditrics
in review. Pediatrics in Review. 2014; 35(8):327.
Austin et al. Dysfunctional Voiding. Pediatrics in Review. 2000;21(10):336.
Har et al. Encoperesis. Pediatrics in Review. 2010;31(9):368.
Signs of a child’s toilet learning readiness
• Can understand and follow simple instruction
• Diaper is consistently dry for 2 to 3 hours at a time or after naps
• Bowel movements are somewhat regular and predictable
• Seems uncomfortable with soiled diapers and wants to be changed
• Recognizes and tells or shows need to urinate or stool
• Can walk to bathroom and pull pants up and down
• Is stable on potty (good trunk support)
• Interested and motivated to learn how to use the potty
• Shows interest in 'big kid' underwear
- Child does not need to show all of the signs, but at least a few should be
present to indicate the child is ready for toilet training
- Average age for a child to be toilet trained is between 2 to 3 years old
- Advise parents to expect accidents during initial training
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fety o provide access to health and mental health services o integrate school, family and community prevention efforts o provide training to enable school staff to promote safety and prevent violence effectively <span>Toilet Training Syllabus: Clifford et al. Toilet Learning: Anticipatory Guidance with a child‐oriented approach. Paediatrics and Child Health. 2000;5(6):333. Feldman. Managing primary nocturnal enuresis. Paediatr Child Health. 2005; 10(10):611. Bayne et al. Nocturnal enuresis: An approach to assessment and treatment. Peditrics in review. Pediatrics in Review. 2014; 35(8):327. Austin et al. Dysfunctional Voiding. Pediatrics in Review. 2000;21(10):336. Har et al. Encoperesis. Pediatrics in Review. 2010;31(9):368. Signs of a child’s toilet learning readiness • Can understand and follow simple instruction • Diaper is consistently dry for 2 to 3 hours at a time or after naps • Bowel movements are somewhat regular and predictable • Seems uncomfortable with soiled diapers and wants to be changed • Recognizes and tells or shows need to urinate or stool • Can walk to bathroom and pull pants up and down • Is stable on potty (good trunk support) • Interested and motivated to learn how to use the potty • Shows interest in 'big kid' underwear - Child does not need to show all of the signs, but at least a few should be present to indicate the child is ready for toilet training - Average age for a child to be toilet trained is between 2 to 3 years old - Advise parents to expect accidents during initial training Sleep Requirements Newborns • Should sleep on back in crib with flat surface, no pillows or soft items • In parents’ room for first 6 months Older b




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Sleep Requirements

Newborns
• Should sleep on back in crib with flat surface, no pillows or soft items
• In parents’ room for first 6 months
Older babies
• Maintain regular daytime and bedtime schedule
• Start consistent bedtime routine
• Avoid putting baby to bed with a bottle

Sleep Problems
Night terrors
• Parasomnia that occurs in first third of night
• High to extreme autonomic agitation
• High arousal threshold, agitated if awakened
• No daytime sleepiness or recall of event
Nightmares
• Occur in last third of night during REM sleep
• Mild to high autonomic arousal/agitation
• Low arousal threshold, agitated after event
• Can have daytime sleepiness and frequent, vivid recall of event
• Very common
BEARS Screening Tool for Pediatric Sleep Disorders

Sleep associations
• Infant or toddler child has learned to fall asleep only under certain
conditions or has specific sleep associations that require parental
intervention, such as being rocked or fed, which are usually readily
available at bedtime
• During the night, when the infant or toddler awakens, they are not able
to get back to sleep ("self‐soothe") unless those same conditions are
available
90
o The infant then "signals" the caregiver by crying or coming into the
parents' bedroom if the child is no longer in a crib until the
necessary associations are provided
o Ferber method advocates that at bedtime child is put in bed while
they are drowsy, but still awake, to help them learn how to fall
asleep on their own (self‐soothe)
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least a few should be present to indicate the child is ready for toilet training - Average age for a child to be toilet trained is between 2 to 3 years old - Advise parents to expect accidents during initial training <span>Sleep Requirements Newborns • Should sleep on back in crib with flat surface, no pillows or soft items • In parents’ room for first 6 months Older babies • Maintain regular daytime and bedtime schedule • Start consistent bedtime routine • Avoid putting baby to bed with a bottle Sleep Problems Night terrors • Parasomnia that occurs in first third of night • High to extreme autonomic agitation • High arousal threshold, agitated if awakened • No daytime sleepiness or recall of event Nightmares • Occur in last third of night during REM sleep • Mild to high autonomic arousal/agitation • Low arousal threshold, agitated after event • Can have daytime sleepiness and frequent, vivid recall of event • Very common BEARS Screening Tool for Pediatric Sleep Disorders Sleep associations • Infant or toddler child has learned to fall asleep only under certain conditions or has specific sleep associations that require parental intervention, such as being rocked or fed, which are usually readily available at bedtime • During the night, when the infant or toddler awakens, they are not able to get back to sleep ("self‐soothe") unless those same conditions are available 90 o The infant then "signals" the caregiver by crying or coming into the parents' bedroom if the child is no longer in a crib until the necessary associations are provided o Ferber method advocates that at bedtime child is put in bed while they are drowsy, but still awake, to help them learn how to fall asleep on their own (self‐soothe) Colic Syllabus: Cohen et al. Colic. Pediatrics in Review. 2012;33(7):332. • Infantile colic is defined as o paroxysms of irritability, fussiness or crying that




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Colic
Syllabus: Cohen et al. Colic. Pediatrics in Review. 2012;33(7):332.
• Infantile colic is defined as
o paroxysms of irritability, fussiness or crying that start and stop
without obvious cause;
o episodes lasting 3 h or more per day and occurring at least three
days per week for at least three weeks; and
o no failure to thrive
• Peaks at 6 weeks of age and typically ends by 3‐4 months
• Crying is most frequent in the late afternoon or evening
• Holding or rocking and offering a pacifier might help
• There is no evidence that medicines really help with colic
• There is no or insufficient evidence to support dietary changes
including probiotics, lactose free diet, soy formulas
• If there is a concern about cow’s milk protein allergy, a time limited
(two week) trial of hypoallergenic formula or elimination of cow’s milk
from the maternal diet can be undertaken
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ntil the necessary associations are provided o Ferber method advocates that at bedtime child is put in bed while they are drowsy, but still awake, to help them learn how to fall asleep on their own (self‐soothe) <span>Colic Syllabus: Cohen et al. Colic. Pediatrics in Review. 2012;33(7):332. • Infantile colic is defined as o paroxysms of irritability, fussiness or crying that start and stop without obvious cause; o episodes lasting 3 h or more per day and occurring at least three days per week for at least three weeks; and o no failure to thrive • Peaks at 6 weeks of age and typically ends by 3‐4 months • Crying is most frequent in the late afternoon or evening • Holding or rocking and offering a pacifier might help • There is no evidence that medicines really help with colic • There is no or insufficient evidence to support dietary changes including probiotics, lactose free diet, soy formulas • If there is a concern about cow’s milk protein allergy, a time limited (two week) trial of hypoallergenic formula or elimination of cow’s milk from the maternal diet can be undertaken Gotta Find Strong Coffee Soon •Gross Motor •Fine Motor •Speech/ Language •Cognitive •Social Emotional, Behaviour •(Adaptive Skills) A




developmental milestones categories mnemonic
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Gotta Find Strong Coffee Soon
•Gross Motor
•Fine Motor
•Speech/ Language
•Cognitive
•Social Emotional, Behaviour
•(Adaptive Skills)
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actose free diet, soy formulas • If there is a concern about cow’s milk protein allergy, a time limited (two week) trial of hypoallergenic formula or elimination of cow’s milk from the maternal diet can be undertaken <span>Gotta Find Strong Coffee Soon •Gross Motor •Fine Motor •Speech/ Language •Cognitive •Social Emotional, Behaviour •(Adaptive Skills) Approach to Developmental History -History of presenting illness -Perinatal history (TORCH inf's) -Past medical history -Hearing, vision, sleep, feeding&#




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Approach to Developmental History
-History of presenting illness
-Perinatal history (TORCH inf's)
-Past medical history
-Hearing, vision, sleep, feeding
-Developmental history (-start asking from several age groups lower than current age; observe child)
-Family history (developmental delay, learning disabilities
metabolic/genetic conditions
consanguinity)
-Social history (typical day, language spoken at home, other children at home, daycare/preschool, child maltx/CAS, income, etc)

physical exam
•Weight, height and head circumference at 50th percentile (want to know if macro/microcephaly, any dysmoprhic ft's
make sure to undress & look at skin)
•Low, posteriorly rotated ears but no other dysmorphic features or unusual birth marks
•Normal general and neurologic examinations


GLOBAL DEVELOPMENTAL DELAY
Significant delay (at least two standard deviations below the mean with standardized tests) in at least two developmental domains from the following:
Gross or fine motor
Speech/ language
Cognition
Social/ personal
Activities of Daily Living
-Child must be less than 5 years old

Causes of GDD/ID
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f cow’s milk from the maternal diet can be undertaken Gotta Find Strong Coffee Soon •Gross Motor •Fine Motor •Speech/ Language •Cognitive •Social Emotional, Behaviour •(Adaptive Skills) <span>Approach to Developmental History -History of presenting illness -Perinatal history (TORCH inf's) -Past medical history -Hearing, vision, sleep, feeding -Developmental history (-start asking from several age groups lower than current age; observe child) -Family history (developmental delay, learning disabilities metabolic/genetic conditions consanguinity) -Social history (typical day, language spoken at home, other children at home, daycare/preschool, child maltx/CAS, income, etc) physical exam •Weight, height and head circumference at 50th percentile (want to know if macro/microcephaly, any dysmoprhic ft's make sure to undress & look at skin) •Low, posteriorly rotated ears but no other dysmorphic features or unusual birth marks •Normal general and neurologic examinations GLOBAL DEVELOPMENTAL DELAY Significant delay (at least two standard deviations below the mean with standardized tests) in at least two developmental domains from the following: Gross or fine motor Speech/ language Cognition Social/ personal Activities of Daily Living -Child must be less than 5 years old Causes of GDD/ID . Pediatric milestones in development 1 year: - single words 2 years: - 2 word sentences -understands 2 step commands 3 years:




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Pediatric milestones in development
1 year:
-single words
2 years:
-2 word sentences
-understands 2 step commands
3 years:
-3 word combos
-repeats 3 digits
-rides tricycle
4 years:
-draws square
-counts 4objects

Stairs mnemonic. Two at two. One at four.
Two feet on each step at two years. One foot per step at four years.
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lopmental domains from the following: Gross or fine motor Speech/ language Cognition Social/ personal Activities of Daily Living -Child must be less than 5 years old Causes of GDD/ID . <span>Pediatric milestones in development 1 year: - single words 2 years: - 2 word sentences -understands 2 step commands 3 years: - 3 word combos -repeats 3 digits -rides tri cycle 4 years: -draws square -counts 4 objects Stairs mnemonic. Two at two. One at four. Two feet on each step at two years. One foot per step at four years. Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there (remember “sit at six”). Just with th




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Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there (remember “sit at six”). Just with these two milestones you can pretty much fill in everything else. Remember that everything is from head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neck control). You roll at 4 months (at level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull to stand (crawl, pull to stand at 9 months) which makes sense as being between sitting and walking.
In Review:
2 months: lift head 45 degrees
4 months: roll over (front to back first, then back to front, easier if you can push off with hands)
6 months: sit (halfway to goal, halfway through year, “sit at six”)
9 months: crawl, stand (halfway between sitting and goal)
12 months: walk (the goal)

15 months – 5 years: Memorize these milestones in a story as they are harder to associate with particular months like the first year. Using this progression story may help you.
15 months: walks well
18 months: throws objects
24 months/2 years: up and down stairs (one foot at a time); run
3 years: Tricycle (3 wheels, 3 years), jump in place
4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 when on 1 foot), hop
5 years: skip (5 looks like an “S”kips)
Story: a child on the 1st floor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2) CLIMBS up the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off the stairs and 5) SKIPS away
3. Once you’ve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize the archetype babies for each age group. These little stories incorporate all the other milestones into a single image which is much easier than trying to memorize many unrelated facts. There are some ways to conceptually link milestones across categories, but they are not frequent enough to be useful for fast recall and the salient milestones and timing which is what happens on tests and during morning report.

Here are all the babies with milestones listed:
2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smile
Parent’s Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline

4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (these are vowel sounds), and laughs
Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that he will cram into his mouth

6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiar faces
Street-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks he recognizes

9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxiety
Watch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says “mama” to get attention of parents.

12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekaboo
Playful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to play patacake and peekaboo before waving bye bye.

15 months: walks well, imitates, controlled release of blocks (can stack 2)
Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower

18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of body
Sir Charming Baby: needs to get note to Rapunzel so scribbles note on pape...
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Development
-repeats 3 digits -rides tri cycle 4 years: -draws square -counts 4 objects Stairs mnemonic. Two at two. One at four. Two feet on each step at two years. One foot per step at four years. <span>Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there (remember “sit at six”). Just with these two milestones you can pretty much fill in everything else. Remember that everything is from head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neck control). You roll at 4 months (at level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull to stand (crawl, pull to stand at 9 months) which makes sense as being between sitting and walking. In Review: 2 months: lift head 45 degrees 4 months: roll over (front to back first, then back to front, easier if you can push off with hands) 6 months: sit (halfway to goal, halfway through year, “sit at six”) 9 months: crawl, stand (halfway between sitting and goal) 12 months: walk (the goal) 15 months – 5 years: Memorize these milestones in a story as they are harder to associate with particular months like the first year. Using this progression story may help you. 15 months: walks well 18 months: throws objects 24 months/2 years: up and down stairs (one foot at a time); run 3 years: Tricycle (3 wheels, 3 years), jump in place 4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 when on 1 foot), hop 5 years: skip (5 looks like an “S”kips) Story: a child on the 1st floor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2) CLIMBS up the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off the stairs and 5) SKIPS away 3. Once you’ve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize the archetype babies for each age group. These little stories incorporate all the other milestones into a single image which is much easier than trying to memorize many unrelated facts. There are some ways to conceptually link milestones across categories, but they are not frequent enough to be useful for fast recall and the salient milestones and timing which is what happens on tests and during morning report. Here are all the babies with milestones listed: 2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smile Parent’s Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline 4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (these are vowel sounds), and laughs Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that he will cram into his mouth 6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiar faces Street-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks he recognizes 9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxiety Watch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says “mama” to get attention of parents. 12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekaboo Playful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to play patacake and peekaboo before waving bye bye. 15 months: walks well, imitates, controlled release of blocks (can stack 2) Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower 18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of body Sir Charming Baby: needs to get note to Rapunzel so scribbles note on paper to throw into high 4 block tower, catapult has cup on end, shoves note in with spoon, and throws note at tower, hitting Rapunzel in the face 2 years: Run, stairs (1 foot at a time), 20-50 words, 2 step command, parallel play Bad Twins: mom gives two commands to twin boys to run to the stairs, then walk up the 25 stairs. Each walks up the 25 stairs not helping the other. 3 years: Jump, Tricycle, dresses self (shirt, pants, shoes), full name, “you, me, I” James Bond Baby: springs into action … jumps into 3-piece suit, stands in front of mirror and says full name, jumps on tricycle. “You.Me. I,” is his pickup line. 4 years: Stairs (alternating feet), hop, undresses, 1 foot (4 seconds), 4 word phrases (complete sentences), cooperative play Bedtime Story Baby: really wants story time, so runs up stairs, hops on one foot to undress, so she and mom can read a story together. A Wrinkle in Time. 5 years: Skip, Tie shoes, Difference between reality/fantasy Oz Baby: ties ruby shoes, skips down Yellow Brick Road back to Kansas Developmental assessment Primitive reflexes Mnemonic: MPRAG M Moro P Placing reflex R Rooting A Aton




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Developmental assessment
Primitive reflexes
Mnemonic: MPRAG
M Moro
P Placing reflex
R Rooting
A Atonic neck reflex
G Grasp reflex
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Development
n one foot to undress, so she and mom can read a story together. A Wrinkle in Time. 5 years: Skip, Tie shoes, Difference between reality/fantasy Oz Baby: ties ruby shoes, skips down Yellow Brick Road back to Kansas <span>Developmental assessment Primitive reflexes Mnemonic: MPRAG M Moro P Placing reflex R Rooting A Atonic neck reflex G Grasp reflex Head circumference with age · Remember 3, 9, and multiples of 5: Newborn 35 cm 3 mos 40 cm 9 mos 45 cm 3 yrs 50 cm 9 yrs 5




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Head circumference with age
· Remember 3, 9, and multiples of 5:
Newborn 35 cm
3 mos 40 cm
9 mos 45 cm
3 yrs 50 cm
9 yrs 55cm
Head Circumference
336:633
Infants increase their head circumference by 12 centimeters during the first year
of life as they start with an average of 35 centimeters and end up with an average
of 47 centimeters.
To remember the rates of increase at various months of the first year, we can use
the above mnemonic;

*It means that during the first three months infants will gain six centimeters
increase in OFC (occipitofrontal circumference) which means 2 centimeters per
month.

*The next three months the rate is three centimeters in three months which means
1 cm per month.

*The next six months the rate is three centimeters in six months which means 0.5
cm per month.
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Development
13; Developmental assessment Primitive reflexes Mnemonic: MPRAG M Moro P Placing reflex R Rooting A Atonic neck reflex G Grasp reflex <span>Head circumference with age · Remember 3, 9, and multiples of 5: Newborn 35 cm 3 mos 40 cm 9 mos 45 cm 3 yrs 50 cm 9 yrs 55 cm Head Circumference 336:633 Infants increase their head circumference by 12 centimeters during the first year of life as they start with an average of 35 centimeters and end up with an average of 47 centimeters. To remember the rates of increase at various months of the first year, we can use the above mnemonic; * It means that during the first three months infants will gain six centimeters increase in OFC (occipitofrontal circumference) which means 2 centimeters per month. * The next three months the rate is three centimeters in three months which means 1 cm per month. * The next six months the rate is three centimeters in six months which means 0.5 cm per month. Length and height values and acceleration Although there are a number of formulas that facilitate the estimation o




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Length and height values and acceleration
Although there are a number of formulas that facilitate the estimation of the expected
length or height at a given age but this mnemonic is incredibly easy to remember. Just
remember
multiples of the number 5
Birth
1 Year
4 Years
8 Years
12 Years
50 cm
75 cm
100 cm
125 cm
150 cm
25cm/yr*
10 cm/yr*
5cm/yr*
5cm/yr*
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Development
hs the rate is three centimeters in three months which means 1 cm per month. * The next six months the rate is three centimeters in six months which means 0.5 cm per month. <span>Length and height values and acceleration Although there are a number of formulas that facilitate the estimation of the expected length or height at a given age but this mnemonic is incredibly easy to remember. Just remember multiples of the number 5 Birth 1 Year 4 Years 8 Years 12 Years 50 cm 75 cm 100 cm 125 cm 150 cm 25cm/yr* 10 cm/yr* 5cm/yr* 5cm/yr* Weights of children with age Newborn 3 kg 6 mos 6 kg (2x birth wt at 6 mos) 1 y




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Weights of children with age
Newborn 3 kg
6 mos 6 kg (2x birth wt at 6 mos)
1 yr 10 kg (3x birth wt at 1 yr)
3 yrs 15 kg (odd yrs, add 5 kg until 11 yrs)
5 yrs 20 kg
7 yrs 25 kg
9 yrs 30 kg
11 yrs 35 kg (add 10 kg thereafter)
13 yrs 45 kg
15 yrs 55 kg
17 yrs 65kg

124 124 rule.
1day birth wt (this is the easy one)
2week regain birth wt
4month 2x birth wt
12month 3x birth wt
24month 4x birth wt
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Development
25cm/yr* 10 cm/yr* 5cm/yr* 5cm/yr* <span>Weights of children with age Newborn 3 kg 6 mos 6 kg (2x birth wt at 6 mos) 1 yr 10 kg (3x birth wt at 1 yr) 3 yrs 15 kg (odd yrs, add 5 kg until 11 yrs) 5 yrs 20 kg 7 yrs 25 kg 9 yrs 30 kg 11 yrs 35 kg (add 10 kg thereafter) 13 yrs 45 kg 15 yrs 55 kg 17 yrs 65 kg 124 124 rule. 1day birth wt (this is the easy one) 2week regain birth wt 4month 2x birth wt 12month 3x birth wt 24month 4x birth wt <span><body><html>




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Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools
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Documentation
DOCUMENTATION Admission Note (Template) Paediatric History and Physical Examination (as previous), and: INVESTIGATIONS • Blood work: CBC, electrolytes, glucose, renal function, liver function • Microbiology: blood, urine, CSF, nasal, stool cultures • Imaging: x‐ray, ultrasounds, CT, MRI • Pathology: if relevant IMPRESSION/ASSESSMENT (IMP) This is a (year old) (sex) [who is previously healthy] or [with a history of XYZ] presenting with (brief summary of pertinent positive/ negative symptoms on history, signs on physical examination and relevant investigations) with a most likely diagnosis of _____________. DIFFERENTIAL DIAGNOSIS (DDX) May chose to use broad categories by system or process when considering specific diagnoses (i.e., use of VITAMINS ACD acronym) Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/ Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social, Allergic, Congenital, Degenerative, Endocrine MANAGEMENT PLAN/ADMISSION ORDERS (PLAN) • Admit: Admit to (your service) under (your consultant today). • Diagnosis: This is what you suspect they have. (e.g., Asthma) • Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going for surgery or procedures), Breast feed ad lib, Formula, Tube feeds (NG‐tube, G‐tube, GJ‐tube) • Activity: AAT (Activity as Tolerated), bedrest • Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS q4h (if particularly sick patient requiring more frequent vitals), Special parameters (e.g., Neurological vitals) • Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights • Investigations o Bloodwork (Hematology, Biochemistry) o Microbiology o Imaging o Consults • Drugs o Past: Medication Reconciliation – all regular medications (may not need all; e.g., no need for previous PO antibiotics if starting IV) o Present: what does patient need now o Future: anticipate what patient may need; e.g., fever, nausea, pain, stools Progress Note (Template) (Service) Progress Note Date, Time ID Age, sex with a history of (non‐active/chronic issues) admitted with (list active/acut




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Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer
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Documentation
egular medications (may not need all; e.g., no need for previous PO antibiotics if starting IV) o Present: what does patient need now o Future: anticipate what patient may need; e.g., fever, nausea, pain, stools <span>Progress Note (Template) (Service) Progress Note Date, Time ID Age, sex with a history of (non‐active/chronic issues) admitted with (list active/acute issues for why the patient is admitted). Could also include a list of recent events that occurred since the most recent note. SUBJECTIVE • How was patient overnight, how they feel that day, any new concerns from the patient/parent • What has changed since the previous note? Does the patient have any new symptoms? Any pain? How is the patient coping with the active symptoms, progression, better/worse. • Ask the parents and patient’s nurse: behaviour, activity, sleep, appetite, in and outs. OBJECTIVE Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid balance General: what the patient is doing, appearance, behaviour, cognition, cooperation, disposition P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it is common for hospitalized patients to develop problems in these regions. INVESTIGATIONS New lab results, imaging or diagnostic tests/ interventions and relevant results still pending MEDS Reviewed daily regarding changes such as new/held/discontinued/ restarted (e.g. Ampicillin day 2/10) IMPRESSION/ASSESSMENT (IMP) Summarize what the new findings mean, what progress is being made. Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/ consult? Differential diagnosis if anything has been ruled in/out? PLAN (P) 1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day course required, await urine C&S) 2. Issue (2) 􀃆 plan 3. Issue (3) 􀃆 plan 4. Disposition – plans for home, transfer Discharge Summary (Template) Check patient’s name, medical record number, date of birth, date of admission, date of discharge, most responsible physician (MRP), ref




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Discharge Summary (Template)
Check patient’s name, medical record number, date of birth, date of
admission, date of discharge, most responsible physician (MRP), referring
physician name.
FINAL DISCHARGE DIAGNOSIS
• Often only one diagnosis is responsible for admission (i.e. vasoocclusive
crisis, asthma exacerbation, bronchiolitis or Kawasaki
Disease)
• However sometimes there are associated diagnoses (i.e. Gastroenteritis
with dehydration and renal failure, osteomyelitis with bacteremia)
OTHER DIAGNOSIS (nonactive
or those affecting hospital stay)
Other diagnoses requiring treatment during hospitalization or underlying
medical diagnoses existing prior to admission
HISTORY OF PRESENTING ILLNESS
(Name) is a (year old) (sex) [who is previously healthy] or [with a past
medical history of XYZ] who presented with (X) day history of (summary
of pertinent positive and negative symptoms on history and other
relevant/contributing elements of birth history, development, past
investigations/treatment, immunizations as appropriate). Significant
signs on initial physical examination included__________. In the ER,
management included _______________.
COURSE IN HOSPITAL
(Name) was admitted to (name of service and ward)… [and describe
briefly the events and progression of illness while in hospital including
results and management. If the child has multiple medical issues, this
section can be done by system (cardiovascular, respiratory, fluids and
nutrition, ID, CNS, etc). List significant/complex investigations (with
results) under a separate heading.
At discharge, describe current symptoms, physical examination and
pending results.
DISCHARGE MEDICATIONS
Drug name, dose, route, dosing interval frequency, and duration
DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP
All discharge summaries must include at least 3 essential elements
1. Discharge treatment plan including duration
2. Follow‐up with primary care physician in… (specify a reasonable time
frame)
3. Seek medical attention if…
May include other referrals and follow‐up appointments as necessary,
pending investigations and other community resources
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Documentation
t? PLAN (P) 1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day course required, await urine C&S) 2. Issue (2) 􀃆 plan 3. Issue (3) 􀃆 plan 4. Disposition – plans for home, transfer <span>Discharge Summary (Template) Check patient’s name, medical record number, date of birth, date of admission, date of discharge, most responsible physician (MRP), referring physician name. FINAL DISCHARGE DIAGNOSIS • Often only one diagnosis is responsible for admission (i.e. vasoocclusive crisis, asthma exacerbation, bronchiolitis or Kawasaki Disease) • However sometimes there are associated diagnoses (i.e. Gastroenteritis with dehydration and renal failure, osteomyelitis with bacteremia) OTHER DIAGNOSIS (nonactive or those affecting hospital stay) Other diagnoses requiring treatment during hospitalization or underlying medical diagnoses existing prior to admission HISTORY OF PRESENTING ILLNESS (Name) is a (year old) (sex) [who is previously healthy] or [with a past medical history of XYZ] who presented with (X) day history of (summary of pertinent positive and negative symptoms on history and other relevant/contributing elements of birth history, development, past investigations/treatment, immunizations as appropriate). Significant signs on initial physical examination included__________. In the ER, management included _______________. COURSE IN HOSPITAL (Name) was admitted to (name of service and ward)… [and describe briefly the events and progression of illness while in hospital including results and management. If the child has multiple medical issues, this section can be done by system (cardiovascular, respiratory, fluids and nutrition, ID, CNS, etc). List significant/complex investigations (with results) under a separate heading. At discharge, describe current symptoms, physical examination and pending results. DISCHARGE MEDICATIONS Drug name, dose, route, dosing interval frequency, and duration DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP All discharge summaries must include at least 3 essential elements 1. Discharge treatment plan including duration 2. Follow‐up with primary care physician in… (specify a reasonable time frame) 3. Seek medical attention if… May include other referrals and follow‐up appointments as necessary, pending investigations and other community resources Handover At Sick Kids, IPASS is the format used for handover. • Illness severity o Stable / Watcher / Unstable • Patient Summary o Summary state




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Handover
At Sick Kids, IPASS
is the format used for handover.
• Illness severity
o Stable / Watcher / Unstable
• Patient Summary
o Summary statement
o Events leading up to admission
o Hospital course
o On‐going assessment
o Plan
• Action Items
o To‐do list
o Timeline and ownership
• Situational awareness and contingency planning
o Know what’s going on
o Plan for what might happen
• Synthesis by receiver
o Receiver summarizes what was heard
o Asks questions
o Restates key actions/to do items
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Documentation
rimary care physician in… (specify a reasonable time frame) 3. Seek medical attention if… May include other referrals and follow‐up appointments as necessary, pending investigations and other community resources <span>Handover At Sick Kids, IPASS is the format used for handover. • Illness severity o Stable / Watcher / Unstable • Patient Summary o Summary statement o Events leading up to admission o Hospital course o On‐going assessment o Plan • Action Items o To‐do list o Timeline and ownership • Situational awareness and contingency planning o Know what’s going on o Plan for what might happen • Synthesis by receiver o Receiver summarizes what was heard o Asks questions o Restates key actions/to do items<span><body><html>




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Irritability may be the only way that a young child can express pain or discomfort from any source,
including:
Meningeal irritation
Headache from intracranial irritation
Simple exhaustion
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CLIPP 11 - Kawasaki
11. 5-year-old with fever and adenopathy - Jason January 27, 2017 2:09:56 PM EST Knowledge Irritability in a Child Irritability may be the only way that a young child can express pain or discomfort from any source, including: Meningeal irritation Headache from intracranial irritation Simple exhaustion Pediatric Vital Signs As a child gets older, the normal ranges for vital signs change, making it important to look at ageappropriate reference values. The normal hea




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Pediatric Vital Signs
As a child gets older, the normal ranges for vital signs change, making it important to look at ageappropriate
reference values.
The normal heart rate for a 5-year-old is 80 to 100 beats per minute
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CLIPP 11 - Kawasaki
Irritability in a Child Irritability may be the only way that a young child can express pain or discomfort from any source, including: Meningeal irritation Headache from intracranial irritation Simple exhaustion <span>Pediatric Vital Signs As a child gets older, the normal ranges for vital signs change, making it important to look at ageappropriate reference values. The normal heart rate for a 5-year-old is 80 to 100 beats per minute. Rashes Associated with Fever (Part 1) Children get many different kinds of rashes-many, though not all, related to infections. Below are descriptions and photos of rashe




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Rashes Associated with Fever (Part 1)
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Cho Sooyoung - sooyoung.cho@mail.utoronto.ca 1/15
Enterovirus
Usually erythematous and maculopapular, and may involve the palms and
soles. Infrequently, it can be petechial.
In hand-foot-and-mouth disease (caused by Coxsackie virus), presents as a
vesicular rash on the hands and feet and with ulcers in the mouth.
Usually seen in late summer and early fall.
While the fever associated with enteroviruses may be high, it usually lasts only
a few days.
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CLIPP 11 - Kawasaki
; Pediatric Vital Signs As a child gets older, the normal ranges for vital signs change, making it important to look at ageappropriate reference values. The normal heart rate for a 5-year-old is 80 to 100 beats per minute. <span>Rashes Associated with Fever (Part 1) Children get many different kinds of rashes-many, though not all, related to infections. Below are descriptions and photos of rashes associated with fever. Cho Sooyoung - sooyoung.cho@mail.utoronto.ca 1/15 Enterovirus Usually erythematous and maculopapular, and may involve the palms and soles. Infrequently, it can be petechial. In hand-foot-and-mouth disease (caused by Coxsackie virus), presents as a vesicular rash on the hands and feet and with ulcers in the mouth. Usually seen in late summer and early fall. While the fever associated with enteroviruses may be high, it usually lasts only a few days. Erythema infectiosum Also called fifth disease, this is caused by parvovirus B19. There is frequently an associated low-grade fever (37.8-38.3 degrees C, or 100




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Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Erythema
infectiosum
Also called fifth disease, this is caused by parvovirus B19.
There is frequently an associated low-grade fever (37.8-38.3 degrees C, or
100-101 degrees F), with a rash appearing seven to ten days later.
The characteristic rash starts as facial erythema-the "slapped cheek"
appearance. This can spread to the trunk and have an erythematous macular
appearance. Central clearing of the rash appears, giving a lacy appearance.
The rash often lasts longest on the extremities, where it has a lacy, reticular
appearance.
People with fifth disease can also develop pain and swelling in their joints
(polyarthropathy syndrome).
Individuals with underlying immune deficiencies who are exposed to this virus
are at risk for developing aplastic anemia.
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CLIPP 11 - Kawasaki
presents as a vesicular rash on the hands and feet and with ulcers in the mouth. Usually seen in late summer and early fall. While the fever associated with enteroviruses may be high, it usually lasts only a few days. <span>Erythema infectiosum Also called fifth disease, this is caused by parvovirus B19. There is frequently an associated low-grade fever (37.8-38.3 degrees C, or 100-101 degrees F), with a rash appearing seven to ten days later. The characteristic rash starts as facial erythema-the "slapped cheek" appearance. This can spread to the trunk and have an erythematous macular appearance. Central clearing of the rash appears, giving a lacy appearance. The rash often lasts longest on the extremities, where it has a lacy, reticular appearance. People with fifth disease can also develop pain and swelling in their joints (polyarthropathy syndrome). Individuals with underlying immune deficiencies who are exposed to this virus are at risk for developing aplastic anemia. Measles After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and along




#ir #peds
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Measles
After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and
conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and
along the hairline.
The rash spreads downward, reaching the feet in two or three days.
The initial rash appears on the buccal mucosa as red lesions with bluish white
spots in the center (known as Koplik spots). These have frequently
disappeared by the time the patient presents to medical attention.
Immunization is very effective in preventing this infection.
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CLIPP 11 - Kawasaki
le with fifth disease can also develop pain and swelling in their joints (polyarthropathy syndrome). Individuals with underlying immune deficiencies who are exposed to this virus are at risk for developing aplastic anemia. <span>Measles After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and along the hairline. The rash spreads downward, reaching the feet in two or three days. The initial rash appears on the buccal mucosa as red lesions with bluish white spots in the center (known as Koplik spots). These have frequently disappeared by the time the patient presents to medical attention. Immunization is very effective in preventing this infection. All photos in this case showing disease manifestations are courtesy of Gary Williams, MD, and the University of Wisconsin teaching file. Hyperlink "hands "




#ir #peds
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Meningococcemia
Caused by the bacteria Neisseria meningitidis, onset is abrupt and
accompanied by fever, chills, malaise, and prostration.
The initial rash may be urticarial, maculopapular, or petechial (marked
by small, purplish, hemorrhagic spots).
In fulminant cases, it can become purpuric, marked by large
hemorrhages into the skin.
Immunization is effective in preventing this infection.
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CLIPP 11 - Kawasaki
erial is not included in this Summary, please open Case to review. Hyperlink " Measles " This Multimedia material is not included in this Summary, please open Case to review. Rashes Associated with Fever (Part 2) <span>Meningococcemia Caused by the bacteria Neisseria meningitidis, onset is abrupt and accompanied by fever, chills, malaise, and prostration. The initial rash may be urticarial, maculopapular, or petechial (marked by small, purplish, hemorrhagic spots). In fulminant cases, it can become purpuric, marked by large hemorrhages into the skin. Immunization is effective in preventing this infection. Roseola This macular or maculopapular rash, also called exanthem subitum, starts on the trunk and spreads to the arms and neck. There is usually less involvement of




#ir #peds
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Roseola
This macular or maculopapular rash, also called exanthem subitum,
starts on the trunk and spreads to the arms and neck.
There is usually less involvement of the face and legs.
The rash is preceded by three or four days of high fevers, which end
as the rash appears.
Usually seen in children less than two years old.
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CLIPP 11 - Kawasaki
aculopapular, or petechial (marked by small, purplish, hemorrhagic spots). In fulminant cases, it can become purpuric, marked by large hemorrhages into the skin. Immunization is effective in preventing this infection. <span>Roseola This macular or maculopapular rash, also called exanthem subitum, starts on the trunk and spreads to the arms and neck. There is usually less involvement of the face and legs. The rash is preceded by three or four days of high fevers, which end as the rash appears. Usually seen in children less than two years old. 3/15 Scarlet fever This rash, caused by infection with group A Streptococcus, consists of very fine papules, often described as feeling like sandpaper. It is er




#ir #peds
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Scarlet fever
This rash, caused by infection with group A Streptococcus, consists of
very fine papules, often described as feeling like sandpaper.
It is erythematous, but blanches.
The rash starts in the groin, axillae, and neck, but rapidly spreads.
The fever can be high, and the disease is usually self-limited, lasting
less than 10 days.
It is important to treat with antibiotics to prevent non-suppurative
complications of strep, including rheumatic fever.
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CLIPP 11 - Kawasaki
s and neck. There is usually less involvement of the face and legs. The rash is preceded by three or four days of high fevers, which end as the rash appears. Usually seen in children less than two years old. 3/15 <span>Scarlet fever This rash, caused by infection with group A Streptococcus, consists of very fine papules, often described as feeling like sandpaper. It is erythematous, but blanches. The rash starts in the groin, axillae, and neck, but rapidly spreads. The fever can be high, and the disease is usually self-limited, lasting less than 10 days. It is important to treat with antibiotics to prevent non-suppurative complications of strep, including rheumatic fever. Varicella The rash, also known as chicken pox, starts on the trunk and spreads to the extremities and head. Each lesion progresses from an erythematous macule to pap




#ir #peds
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Varicella
The rash, also known as chicken pox, starts on the trunk and spreads
to the extremities and head.
Each lesion progresses from an erythematous macule to papule
to vesicle to pustule, and then crusts over.
Lesions at various stages of development are seen in the same area of
the body.
There is usually a mild fever.
The disease is self-limited, lasting about a week.
Immunization is effective in preventing this infection.
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CLIPP 11 - Kawasaki
reads. The fever can be high, and the disease is usually self-limited, lasting less than 10 days. It is important to treat with antibiotics to prevent non-suppurative complications of strep, including rheumatic fever. <span>Varicella The rash, also known as chicken pox, starts on the trunk and spreads to the extremities and head. Each lesion progresses from an erythematous macule to papule to vesicle to pustule, and then crusts over. Lesions at various stages of development are seen in the same area of the body. There is usually a mild fever. The disease is self-limited, lasting about a week. Immunization is effective in preventing this infection. Hyperlink " Meningococcemia " This Multimedia material is not included in this Summary, please open Case to review. Hyperlink " Roseola " This Mu




Flashcard 1473443663116

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#python #sicp
Question
How should float values be treated? Are they real numbers?
Answer
float values should be treated as approximations to real values.

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xactly, without any approximation or limits on their size. On the other hand, float objects can represent a wide range of fractional numbers, but not all numbers can be represented exactly, and there are minimum and maximum values. Therefore, <span>float values should be treated as approximations to real values.<span><body><html>

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2.1 Introduction
ming languages: a "floating point" representation. While the details of how numbers are represented is not a topic for this text, some high-level differences between int and float objects are important to know. In particular, <span>int objects represent integers exactly, without any approximation or limits on their size. On the other hand, float objects can represent a wide range of fractional numbers, but not all numbers can be represented exactly, and there are minimum and maximum values. Therefore, float values should be treated as approximations to real values. These approximations have only a finite amount of precision. Combining float values can lead to approximation errors; both of the following expressions would evaluate to 7 if not fo







Flashcard 1473446022412

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Question
What is the underlying idea of data abstraction?
Answer
the underlying idea of data abstraction is to identify a basic set of operations in terms of which all manipulations of values of some kind will be expressed, and then to use only those operations in manipulating the data.

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In general, the underlying idea of data abstraction is to identify a basic set of operations in terms of which all manipulations of values of some kind will be expressed, and then to use only those operations in manipulating the data. By restricting the use of operations in this way, it is much easier to change the representation of abstract data without changing the behavior of a program.

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2.2 Data Abstraction
efore continuing with more examples of compound data and data abstraction, let us consider some of the issues raised by the rational number example. We defined operations in terms of a constructor rational and selectors numer and denom . <span>In general, the underlying idea of data abstraction is to identify a basic set of operations in terms of which all manipulations of values of some kind will be expressed, and then to use only those operations in manipulating the data. By restricting the use of operations in this way, it is much easier to change the representation of abstract data without changing the behavior of a program. For rational numbers, different parts of the program manipulate rational numbers using different operations, as described in this table. Parts of the program that... Treat rationals







Flashcard 1473448381708

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Question
Why are data abstraction operations limited to those operations in terms of which all manipuations of values will be expressed?
Answer
By restricting the use of operations in this way, it is much easier to change the representation of abstract data without changing the behavior of a program.

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n>In general, the underlying idea of data abstraction is to identify a basic set of operations in terms of which all manipulations of values of some kind will be expressed, and then to use only those operations in manipulating the data. By restricting the use of operations in this way, it is much easier to change the representation of abstract data without changing the behavior of a program.<span><body><html>

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2.2 Data Abstraction
efore continuing with more examples of compound data and data abstraction, let us consider some of the issues raised by the rational number example. We defined operations in terms of a constructor rational and selectors numer and denom . <span>In general, the underlying idea of data abstraction is to identify a basic set of operations in terms of which all manipulations of values of some kind will be expressed, and then to use only those operations in manipulating the data. By restricting the use of operations in this way, it is much easier to change the representation of abstract data without changing the behavior of a program. For rational numbers, different parts of the program manipulate rational numbers using different operations, as described in this table. Parts of the program that... Treat rationals







Flashcard 1473450741004

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Question

We follow the same recursive analysis of the problem as we did while counting: partitioning n using integers up to m involves either

  1. [...]
  2. partitioning n using integers up to m-1 .

For base cases, we find that 0 has an empty partition, while partitioning a negative integer or using parts smaller than 1 is impossible.

Answer
partitioning n-m using integers up to m , or

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We follow the same recursive analysis of the problem as we did while counting: partitioning n using integers up to m involves either partitioning n-m using integers up to m , or partitioning n using integers up to m-1 . For base cases, we find that 0 has an empty partition, while partitioning a negative integer or using parts smaller than 1 is impossible.</sp

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2.3 Sequences







Flashcard 1473455459596

Tags
#python #sicp
Question
How is the "character" type implemented in python?
Answer
Python does not have a separate character type; any text is a string, and strings that represent single characters have a length of 1.

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Python does not have a separate character type; any text is a string, and strings that represent single characters have a length of 1.

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Flashcard 1473457818892

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Question
The tree is a [...]
Answer
fundamental data abstraction that imposes regularity on how hierarchical values are structured and manipulated.

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The tree is a fundamental data abstraction that imposes regularity on how hierarchical values are structured and manipulated.

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Flashcard 1473460178188

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Question
A tree with no branches is called a [...]
Answer
leaf

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A tree with no branches is called a leaf

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2.3 Sequences







Flashcard 1473462537484

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Question
Any tree contained within a tree is called a [...] of that tree (such as a branch of a branch)
Answer
sub-tree

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Any tree contained within a tree is called a sub-tree of that tree (such as a branch of a branch)

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Flashcard 1473464896780

Tags
#matlab #programming
Question
Once the context of a problem is familiarized what comes next?
Answer
Step 2 Problem statement. Develop a detailed statement of the mathematical problem to be solved with a computer program

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Step 2 Problem statement. Develop a detailed statement of the mathematical problem to be solved with a computer program.

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Flashcard 1473467256076

Tags
#matlab #programming
Question
What comes after determining the inputs and outputs of the program?
Answer
Step 4 Algorithm. Write the pesudo-code in a top-down process

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Step 4 Algorithm. Design the step-by-step procedure in a top-down process that decomposes the overall problem into subordinate problems. The subtasks to solve the latter are refined by designing an itemized list of steps to be programmed. This list o f tasks is the structure plan and is written in pseudo- code (i.e., a combination of English, mathematics, and anticipated MATLAB commands). The goal is a plan that is understandable and easily translated into a computer language.

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Flashcard 1473469615372

Tags
#python #sicp
Question
A binary tree is either [...]
Answer
a leaf or a sequence of at most two binary trees.

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A binary tree is either a leaf or a sequence of at most two binary trees.

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Flashcard 1473471974668

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#python #sicp
Question
A list is depicted as [...].
Answer
adjacent boxes that contain the elements of the list

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A list is depicted as adjacent boxes that contain the elements of the list. Primitive values such as numbers, strings, boolean values, and None appear within an element box. Composite values, such as function values and other lists, are indicated by an arrow.<

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2.3 Sequences







Flashcard 1473479052556

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#python #sicp
Question
A linked list is a [...]
Answer
pair containing the first element of the sequence and the rest of the sequence

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A linked list is a pair containing the first element of the sequence (in this case 1) and the rest of the sequence (in this case a representation of 2, 3, 4). The second element is also a linked list. The rest of the inner-most linked list containing only 4 is 'empty' , a value that represents an em

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2.3 Sequences







Flashcard 1473481411852

Tags
#bayes #programming #r #statistics
Question
1. A probability value must be [...]
Answer
nonnegative (i.e., zero or positive).

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1. A probability value must be nonnegative (i.e., zero or positive).

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Flashcard 1473483771148

Tags
#bayes #programming #r #statistics
Question
3. For any two mutually exclusive events, the probability that one or the other occurs is [...]
Answer
the sum of their individual probabilities.

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3. For any two mutually exclusive events, the probability that one or the other occurs is the sum of their individual probabilities.

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Flashcard 1473488489740

Question
How should programs use data in accordance with data abstraction princples?
Answer
They should use data in such a way as to make as few assumptions about the data as possible

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The basic idea of data abstraction is to structure programs so that they operate on abstract data. That is, our programs should use data in such a way as to make as few assumptions about the data as possible

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2.2 Data Abstraction
we can make an abstraction that separates the way the function is used from the details of how the function is implemented. Analogously, data abstraction isolates how a compound data value is used from the details of how it is constructed. <span>The basic idea of data abstraction is to structure programs so that they operate on abstract data. That is, our programs should use data in such a way as to make as few assumptions about the data as possible. At the same time, a concrete data representation is defined as an independent part of the program. These two parts of a program, the part that operates on abstract data and the part that defines a concrete representation, are connected by a small set of functions that implement abs







Flashcard 1473490849036

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Question
Some examples of aggregation functions:
Answer
The built-in functions sum , min , and max are all examples of aggregation functions.

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The built-in functions sum , min , and max are all examples of aggregation functions.

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Flashcard 1473493994764

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Question
The root value of a sub-tree of a tree is called a [...] in that tree.
Answer
node (or node value)

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The root value of a sub-tree of a tree is called a node (or node value) in that tree.

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Flashcard 1473496354060

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#matlab #programming
Question
What comes after transforming the algorithm pseudocode into computer langage?
Answer
Step 6 Evaluation. Test all of the options and conduct a validation study of the program.

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Step 6 Evaluation. Test all of the options and conduct a validation study of the program. For example, compare results with other programs that do similar tasks, compare with experimental data if appropriate, and compare

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Flashcard 1473498713356

Tags
#bayes #programming #r #statistics
Question
2. The sum of the probabilities across all events in the entire sample space must be [...] (i.e., one of the events in the space must happen, otherwise the space does not exhaust all possibilities).
Answer
1.0

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2. The sum of the probabilities across all events in the entire sample space must be 1.0 (i.e., one of the events in the space must happen, otherwise the space does not exhaust all possibilities).

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Flashcard 1473503431948

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Question

Native data types have the following properties:

  1. [...]
  2. There are built-in functions and operators to manipulate values of native types.

Answer
There are expressions that evaluate to values of native types, called literals.

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The values we have used so far are instances of a small number of native data types that are built into the Python language. Native data types have the following properties: There are expressions that evaluate to values of native types, called literals. There are built-in functions and operators to manipulate values of native types. The int class is the native data type used to represent integers. Integer literals (sequences of adjac

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2.1 Introduction
instances of the int class. These two values can be treated similarly. For example, they can both be negated or added to another integer. The built-in type function allows us to inspect the class of any value. >>> type(2) <span>The values we have used so far are instances of a small number of native data types that are built into the Python language. Native data types have the following properties: There are expressions that evaluate to values of native types, called literals. There are built-in functions and operators to manipulate values of native types. The int class is the native data type used to represent integers. Integer literals (sequences of adjacent numerals) evaluate to int values, and mathematical operators manipulate these values. >>> 12 + 3000000000000000000000000 3000000000000000000000012 Python includes three native numeric types: integers ( int ), real numbers ( float ), and complex numbers ( c







Flashcard 1473505791244

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Question

Native data types have the following properties:

  1. There are expressions that evaluate to values of native types, called literals.
  2. [...]

Answer
There are built-in functions and operators to manipulate values of native types.

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have used so far are instances of a small number of native data types that are built into the Python language. Native data types have the following properties: There are expressions that evaluate to values of native types, called literals. <span>There are built-in functions and operators to manipulate values of native types. The int class is the native data type used to represent integers. Integer literals (sequences of adjacent numerals) evaluate to int values, and mathematical operators manipulate these

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2.1 Introduction
instances of the int class. These two values can be treated similarly. For example, they can both be negated or added to another integer. The built-in type function allows us to inspect the class of any value. >>> type(2) <span>The values we have used so far are instances of a small number of native data types that are built into the Python language. Native data types have the following properties: There are expressions that evaluate to values of native types, called literals. There are built-in functions and operators to manipulate values of native types. The int class is the native data type used to represent integers. Integer literals (sequences of adjacent numerals) evaluate to int values, and mathematical operators manipulate these values. >>> 12 + 3000000000000000000000000 3000000000000000000000012 Python includes three native numeric types: integers ( int ), real numbers ( float ), and complex numbers ( c







Flashcard 1473507364108

Question
In general, we can express abstract data using a collection of [3 things].
Answer
collection of selectors and constructors, together with some behavior conditions

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In general, we can express abstract data using a collection of selectors and constructors, together with some behavior conditions. As long as the behavior conditions are met (such as the division property above), the selectors and constructors constitute a valid representation of a kind of data. The implementation

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2.2 Data Abstraction
enom . In addition, the appropriate relationship must hold among the constructor and selectors. That is, if we construct a rational number x from integers n and d , then it should be the case that numer(x)/denom(x) is equal to n/d . <span>In general, we can express abstract data using a collection of selectors and constructors, together with some behavior conditions. As long as the behavior conditions are met (such as the division property above), the selectors and constructors constitute a valid representation of a kind of data. The implementation details below an abstraction barrier may change, but if the behavior does not, then the data abstraction remains valid, and any program written using this data abstraction will remain correct. This point of view can be applied broadly, including to the pair values that we used to implement rational numbers. We never actually said much about what a pair was, only that the la







Flashcard 1473512082700

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Question

Sequences contain smaller sequences within them. A [...] of a sequence is any contiguous span of the original sequence, designated by a pair of integers.

Answer
slice

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Sequences contain smaller sequences within them. A slice of a sequence is any contiguous span of the original sequence, designated by a pair of integers. As with the range constructor, the first integer indicates the starting index of the sli

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Flashcard 1473516801292

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Question
For lists the add function in the operator module (and the + operator) yields a list that is the [...]
Answer
concatenation of the added arguments

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the add function in the operator module (and the + operator) yields a list that is the concatenation of the added arguments

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2.3 Sequences
he built-in len function returns the length of a sequence. Below, digits is a list with four elements. The element at index 3 is 8. >>> digits = [1, 8, 2, 8] >>> len(digits) 4 >>> digits[3] 8 Additionally, <span>lists can be added together and multiplied by integers. For sequences, addition and multiplication do not add or multiply elements, but instead combine and replicate the sequences themselves. That is, the add function in the operator module (and the + operator) yields a list that is the concatenation of the added arguments. The mul function in operator (and the * operator) can take a list and an integer k to return the list that consists of k repetitions of the original list. >>> [2, 7] + digits * 2 [2, 7, 1, 8, 2, 8, 1, 8, 2, 8] Any values can be included in a list, including another list. Element selection can be applied multiple times in or







Flashcard 1473519160588

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The mul function in operator (and the * operator) can take a list and an integer k to return [...]
Answer
the list that consists of k repetitions of the original list.

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The mul function in operator (and the * operator) can take a list and an integer k to return the list that consists of k repetitions of the original list.

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2.3 Sequences
he built-in len function returns the length of a sequence. Below, digits is a list with four elements. The element at index 3 is 8. >>> digits = [1, 8, 2, 8] >>> len(digits) 4 >>> digits[3] 8 Additionally, <span>lists can be added together and multiplied by integers. For sequences, addition and multiplication do not add or multiply elements, but instead combine and replicate the sequences themselves. That is, the add function in the operator module (and the + operator) yields a list that is the concatenation of the added arguments. The mul function in operator (and the * operator) can take a list and an integer k to return the list that consists of k repetitions of the original list. >>> [2, 7] + digits * 2 [2, 7, 1, 8, 2, 8, 1, 8, 2, 8] Any values can be included in a list, including another list. Element selection can be applied multiple times in or







Flashcard 1473523879180

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A tree has a [2 things]
Answer
root value and a sequence of branches.

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A tree has a root value and a sequence of branches.

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2.3 Sequences







Flashcard 1473526238476

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#matlab #programming
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What is the first consideration in building a matlab program?
Answer
Step 1 Problem analysis. The context of the proposed investigation must be es- tablished to provide the proper motivation for the d esign of a computer program. The designer must fully recognize the need and must develop an understanding of the nature of the problem to be solved.

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Step 1 Problem analysis. The context of the proposed investigation must be es- tablished to provide the proper motivation for the d esign of a computer program. The designer must fully recognize the need and must develop an understanding of the nature of the problem to be solved.

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Flashcard 1473528597772

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Once the problem is mathematically well defined, what comes next?
Answer
Step 3 Processing scheme. Define the inputs required and the outputs to be pro- duced by the p rogram.

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Step 3 Processing scheme. Define the inputs required and the outputs to be pro- duced by the p rogram.

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Flashcard 1473530957068

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Once pseudocode is written for the algorithm what comes next?
Answer
Step 5 Program algorithm. Translate or convert the algorithm into a computer language (e.g., MATLAB) and debug the syntax errors until the tool executes successfully.

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Step 5 Program algorithm. Translate or convert the algorithm into a computer language (e.g., MATLAB) and debug the syntax errors until the tool executes successfully.

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Flashcard 1473533316364

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Once the validation step of the algorithm is complete what comes next?
Answer
Step 7 Application. Solve the problems the program was designed to solve. If the program is well designed and useful, it can be saved in your working directory (i.e., in your user-developed toolbox) for future use

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Step 7 Application. Solve the problems the program was designed to solve. If the program is well designed and useful, it can be saved in your working directory (i.e., in your user-developed toolbox) for future use

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Flashcard 1473535675660

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Question
Linked lists have recursive structure: the rest of a linked list is a [...or...]
Answer
linked list or 'empty'

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Linked lists have recursive structure: the rest of a linked list is a linked list or 'empty'

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The general technique of isolating the parts of a program that deal with how data are represented from the parts that deal with how data are manipulated is a powerful design methodology called [...]
Answer
data abstraction.

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The general technique of isolating the parts of a program that deal with how data are represented from the parts that deal with how data are manipulated is a powerful design methodology called data abstraction.

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2.2 Data Abstraction
ta enables us to increase the modularity of our programs. If we can manipulate geographic positions as whole values, then we can shield parts of our program that compute using positions from the details of how those positions are represented. <span>The general technique of isolating the parts of a program that deal with how data are represented from the parts that deal with how data are manipulated is a powerful design methodology called data abstraction. Data abstraction makes programs much easier to design, maintain, and modify. Data abstraction is similar in character to functional abstraction. When we create a functional abstraction, the details of how a function is implemented can be suppressed, and the p







Flashcard 1473540394252

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Question
What is the procedure for evulating a list comprehension? (4 steps)
Answer
To evaluate a list comprehension,
  1. Python evaluates the <sequence expression> , which must return an iterable value.
  2. Then, for each element in order, the element value is bound to <name> ,
  3. the filter expression is evaluated, and if it yields a true value, the map expression is evaluated.
  4. The values of the map expression are collected into a list.

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Flashcard 1473542753548

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Partition trees. Trees can also be used to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents [...]. In a non-leaf partition tree:

  • the left (index 0) branch contains all ways of partitioning n using at least one m ,
  • the right (index 1) branch contains partitions using parts up to m-1 , and
  • the root value is m .
Answer
the choices taken during computation

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Partition trees. Trees can also be used to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree: the left (index 0) branch contains all ways of partitioning n using at least one m , the right (index 1) branch contains partitions using parts up to m-

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2.3 Sequences







Flashcard 1473545112844

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Question

Partition trees. Trees can also be used to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree:

  • the left (index 0) branch contains [...]
  • the right (index 1) branch contains partitions using parts up to m-1 , and
  • the root value is m .
Answer
all ways of partitioning n using at least one m ,

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to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree: the left (index 0) branch contains <span>all ways of partitioning n using at least one m , the right (index 1) branch contains partitions using parts up to m-1 , and the root value is m .<span><body><html>

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2.3 Sequences







Flashcard 1473547472140

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Question

Partition trees. Trees can also be used to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree:

  • the left (index 0) branch contains all ways of partitioning n using at least one m ,
  • the right (index 1) branch contains [...] , and
  • the root value is m .
Answer
partitions using parts up to m-1

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ize m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree: the left (index 0) branch contains all ways of partitioning n using at least one m , the right (index 1) branch contains <span>partitions using parts up to m-1 , and the root value is m .<span><body><html>

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2.3 Sequences







Flashcard 1473549831436

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Question

Partition trees. Trees can also be used to represent the partitions of an integer. A partition tree for n using parts up to size m is a binary (two branch) tree that represents the choices taken during computation. In a non-leaf partition tree:

  • the left (index 0) branch contains all ways of partitioning n using at least one m ,
  • the right (index 1) branch contains partitions using parts up to m-1 , and
  • the root value is [...] .
Answer
m

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hoices taken during computation. In a non-leaf partition tree: the left (index 0) branch contains all ways of partitioning n using at least one m , the right (index 1) branch contains partitions using parts up to m-1 , and the root value is <span>m .<span><body><html>

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2.3 Sequences