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  • Vice Chair for Clinical Operations and Financial Affairs
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Concern about the potential for congenital understanding of how to treatment diarrhea effective flexeril 15mg implement appropriate environmental malformation because of medication use occurs primarily during changes symptoms zenkers diverticulum discount 15 mg flexeril otc, appropriate methods of medication administration treatment endometriosis flexeril 15mg with visa, the? However treatment qt prolongation generic flexeril 15 mg fast delivery, in general, their sedative and im Although it is recognized that education is important for rhinitis, paired performance characteristics make them less desirable the best delivery method, frequency, and educational setting have choices than second-generation antihistamines. One-on-one allergy treatment educational safety data during pregnancy on the second-generation antihista sessions about rhinitis treatment may not be any more effective mines are comparable to those of the? Although diphenhy Oral decongestants should be avoided, if possible, during the dramine is frequently used during pregnancy and has good overall? The immunotherapy doses that the patient re evidence of risk in later trimesters. These changes can result in dryness of the mu There are no animal reproduction studies and no adequate studies in human beings. Intranasal corticosteroids may be safely used for treatment from the use of the drug in pregnant women may be acceptable of allergic rhinitis in the elderly because they do not cause any 618 despite its potential risks. X Studies in animals or human beings demonstrate fetal abnormalities, or adverse reaction reports indicate evidence of fetal risk. The risk Athletes [Summary Statement 107] of use in a pregnant woman clearly outweighs any possible Athletes with rhinitis can have their performance affected by bene? Endurance athletes, such as long distance runners or triathletes, may experience rebound nasal congestion after the initial vasoconstriction that naturally occurs risks of such malformations have been reported to be increased 619 with exercise. Prescription of medication for the competitive by combining a decongestant with acetaminophen or salicy 180 athlete should be based on 2 important principles : (1) no 600,601 lates. The safety of intranasal decongestants during preg medication given to the athlete should be on any list of doping nancy has not been studied. This drug could be considered if there has been a favorable pre Consultation with an allergist/immunologist [Summary State pregnancy response. Consultation with an allergist/immunologist Category C rating, gestational risk has not been con? The patient has complications of rhinitis, such as otitis me not increase the risk of major malformations, preterm delivery, dia, sinusitis, and/or nasal polyposis. The patient has required systemic corticosteroids for the 11,602,607-609 suring, but beclomethasone, budesonide (Pregnancy treatment of rhinitis. Treatment with medications for rhinitis is ineffective or pro started during pregnancy, intranasal budesonide, which is duces adverse events. The patient has required multiple and/or costly medications and/or associated ocular symptoms. Examination of the nose should focus on the appearance of tent with complications, such as sinusitis or otitis media, or the nasal mucus membranes, the patency of the nasal passage comorbid conditions, such as asthma; (12) family history of ways, unilaterality or bilaterality of? Nonetheless, the Oral decongestants, such as pseudoephedrine or phenyleph history and physical examination alone is often suggestive of rine, help reduce symptoms of nasal congestion in both allergic either allergic rhinitis or nonallergic rhinitis. Seasonal exacerbations are also suggestive of appetite, irritability, and palpitations. Patients with allergic rhinitis tend to develop the after taking an oral decongestant is very rarely noted in normo onset of symptoms earlier in life, typically before the age of 20 tensive patients and only occasionally in patients with controlled years, than those with nonallergic rhinitis. However, based on interindividual variation in postnasal drainage is less likely to be a result of allergic response, hypertensive patients should be monitored. Patients with vasomotor rhinitis may have symptoms Topical decongestants are appropriate to use on a short-term triggered by strong odors such as perfume or tobacco smoke. A basis for nasal congestion associated with acute bacterial or viral history of isolated rhinorrhea associated with eating is sugges infections, exacerbations of allergic rhinitis, and eustachian tube tive of gustatory rhinitis. Intermittent use of topical decongestants may be of topical decongestant sprays may have rhinitis medicamen considered, but ef? With regular daily use, some patients may problem, such as a nasal polyp, foreign body, septal deformity, or rarely a tumor. Hyposmia or anosmia are often associated develop rhinitis medicamentosa in 3 days, whereas others may not with nasal polyposis but may also occur in other forms of have evidence of rebound congestion after 4 to 6 weeks of use. Given this variability, it would be prudent to instruct patients of Many typical allergic? However, the physical examination can help identify nasal and nasal congestion, the 4 major symptoms of allergic rhinitis. They are particularly useful for treatment of more severe allergic rhinitis and may be useful in some forms of nonallergic rhinitis. Intranasal corticosteroids when given in recommended doses are Box 3: Therapeutic trial for allergic rhinitis not generally associated with clinically signi? Although local side effects are minimal, if the patient is Initial treatment of nonsevere rhinitis may include single-agent carefully instructed in the use of this class of drugs, nasal irritation or combination pharmacologic therapy and avoidance measures. Patients should be instructed to direct Oral antihistamines are generally effective in reducing rhinor sprays away from the nasal septum. The nasal septum should be rhea, sneezing, and itching associated with allergic rhinitis but periodically examined to assure that there are no mucosal have little objective effect on nasal congestion. Although nasal septal perforations are rarely caused reduce symptoms of allergic conjunctivitis, which are often by intranasal corticosteroids, mucosal erosions may suggest an associated with allergic rhinitis. Although antihis intranasal corticosteroids should be used at the lowest effective tamines can be used on an intermittent basis, such as for episodic dose. Intranasal corticosteroids may be considered for initial allergic rhinitis, it has been shown that continuous treatment for treatment without a previous trial of antihistamines and/or oral 331 seasonal or perennial allergic rhinitis is more effective, primar decongestants, and they should always be considered before ily because of unavoidable, ongoing allergen exposure. First-gen initiating treatment with systemic corticosteroids for the treatment eration antihistamines have signi? However, single administration of parenteral mines, which are associated with less risk or no risk for these corticosteroids is discouraged, and recurrent administration of side effects, are generally preferred over? In the management of a decrease in comfort and well being, sleep disturbance, an severe seasonal allergic rhinitis, patients should be advised to osmia, or ageusia. Treatment with medications for rhinitis is ineffective or pro buildings, whenever possible, with windows and doors closed. The patient has required multiple and/or costly medications costeroids and intranasal antihistamines may relieve both con over a prolonged period. Intranasal anticholinergics are useful in nonallergic rhinitis with Consultation with an allergist/immunologist may be indicated predominant rhinorrhea (eg, gustatory rhinitis). Avoiding aggravating irritants may be Box 7: Consultation with an allergist/immunologist helpful, particularly in patients suspected to have vasomotor An assessment of rhinitis by a rhinitis specialist requires a rhinitis. For patients with rhinitis medicamentosa, discontinuation detailed history and appropriate physical examination. The of nasal decongestant sprays and treatment with either intranasal history should include all of the components outlined in Box or systemic corticosteroids may be necessary. The physical examination should assess the suspected of infectious rhinitis should be treated with supportive upper airway (nose, oropharynx) and lungs. In addition, measures to relieve ostiomeatal obstruction and judicious use of rhinoscopy or examination by rigid or? Immediate hypersensitivity skin In assessing response to therapy, a variety of parameters should tests or in vitro tests for speci? These include nasal symptoms (eg, congestion, itching, and Nasal cytology may be of value. Management may include good response to treatment should be referred to an allergist/ education regarding environmental avoidance and medication immunologist. If the initial treatment of rhinitis is successful, there is still a Box 8: Does patient have an allergic basis for need for patient follow-up to assure that there is continued control rhinitis? The patient has complications of rhinitis, such as otitis ance measures and/or allergen immunotherapy. The patient has a comorbid condition, such as asthma and prick/puncture tests is approximately 70% to 75%. The number of skin tests and the allergens selected for skin treatment of rhinitis. For example, a patient with adenoidal hypertrophy, and hypertrophy of the nasal turbinates. Nasal vary and include (1) avoidance of aggravating irritants that may smears and? Effective management of allergic rhinitis may require combi nations of medications, aggressive avoidance measures, manage Box 11: Cooperative follow-up ment of coexisting conditions, and/or allergen immunotherapy.

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Cesarean newborns also experience major alterations in gut colonization medications prednisone purchase flexeril 15mg free shipping, which could also contribute treatment spinal stenosis discount flexeril 15 mg with visa. The pre and in-labor physiologic preparations of physiologic birth medications for bipolar cheap 15 mg flexeril free shipping, as detailed in 2 25 medications to know for nclex buy flexeril with paypal. Early Separation and the Mother For the mother, early separation removes the opportunity to release her own oxytocin through interac tions with her newborn, which may give physiologic protection against postpartum hemorrhage. Postpartum oxytocin peaks also occur in the maternal brain, according to animal studies. Early Separation and the Newborn For the baby, lack of skin-to-skin contact, and the associated oxytocin elevations, may increase, or fail to decrease, stress and stress hormone levels, with possible detrimental effects to newborn stress systems. Early Separation and Breastfeeding Early separation has well-established, detrimental effects on breastfeeding initiation, possibly via oxyto cin and/or prolactin disruptions. The detrimental impacts of early separation, with delayed initiation of breastfeeding, on overall breastfeed ing success are well established. The detrimental impacts of early separation of healthy mothers and newborns could have long-term consequences by disrupting the early development of offspring at tachment and attachment systems. Trans-generational programming effects are possible via epigenetic mechanisms, according to animal models. Conversely, early separation, with loss of hormonal support for maternal adaptations and attachment, may be es pecially detrimental in this group. Maternal well-being may also be impacted by early separation, according to animal studies, with anxiety and depression-like effects among separated moth ers. Separating the mother from her newborn, or delaying reunion after birth, may have detrimental impacts on maternal physiology and well-being. Animal studies show anxiety and depression-like behavior in mothers who have been separated from their newborns for several hours per day. In women, a longer period before first contact after birth has been correlated with poorer mood in hos pital and at eight months, compared with those who had earlier contact with their newborns. Oxytocin also reduces stress by centrally activating the parasympathetic nervous system, which promotes calm, connec tion, healing, and growth; and by reducing activity in the sympathetic nervous system, which reduces fear, stress, and stress hormones, and increases sociability. Oxytocin has a short half-life, but its effects can be prolonged because it modulates other brain-hormone systems (neuromodulation). The hour or so after physiologic birth is a sensitive period, when skin-to-skin maternal-newborn interac tions foster peak oxytocin activity. Synthetic oxytocin administered in labor is not thought to cross into the maternal brain in biologically significant amounts, and so may lack calming and analgesic effects. With prelabor cesarean section, mothers and babies miss their complete prelabor physiologic oxytocin preparations; and with any cesarean section, the full oxytocin processes, including the maternal late labor oxytocin surge and postpartum oxytocin peaks, may be reduced or absent. Impacts on breastfeed ing, maternal adaptations, and postpartum hemorrhage have been found. Scheduled cesarean carried out after the physiologic onset of labor may have fewer adverse oxytocin impacts than prelabor cesar ean section. Postpartum separation of healthy mothers and newborns may have detrimental short-and longer-term impacts on the oxytocin system, including:? In addition, a growing body of research suggests important roles in health and well-being, including mental health. Beta-endorphins are not as well researched as some other hormone systems, especially in relation to possible impacts of maternity care interventions. However, epidural analgesia and opioid analgesic drugs may especially impact the physiologic functioning of beta-endorphins, with uncertain effects into the future. However, as with oxytocin, there is a growing awareness of the importance of these and other endogenous opioid substances in many biological processes, including reproduction, immune function, social interactions, and psychological well-being. Beta-endorphins (?endogenous morphines) have properties in common with opioid (opiate-related) drugs, including pain relief and reward system activation. Beta-Endorphins Effects Beta endorphins act primarily in the central nervous system, where they inhibit nerve function, producing analgesia, among other effects. Release of beta-endorphins in the central nervous system is part of the medium-term stress response, designed to restore homeostasis. This response in volves other hormones such as cortisol and, in some situations, prolactin. Hormone responses to appropri ate, healthy ?eustress, such as the stress of labor and birth, are generally beneficial. However, excessive stress, with elevated or prolonged stress hormone levels, can have maladaptive or even harmful effects. The balance between healthy and harmful stress and stress hormone levels varies across individuals. Too-low levels of adaptive hormones in response to stress and pain may also be detrimental by giving in sufficient assistance. Other effects of beta-endorphins include activating brain reward centers that motivate and reward essential behaviors such as eating, mating, birthing, lactating, caring for infants, and adult social behaviors. Beta-endorphins are also involved with the immune, respiratory, and gastrointestinal systems, and implicated in conditions that include anxiety, addiction, obesity, depression, and autism. Very high levels of opioids, for example high doses of morphine,720 disrupt maternal behaviors in animals, which may reflect high satiety and low motivation. This has important survival value, both for animals living in the wild, and for humans alive today. Beta-endorphins are involved in functioning of the immune, respiratory, and gastrointestinal systems (with inhibiting effects similar to those of opioid drugs); and dysfunctions have been implicated in arthritis, epilepsy, binge-eating, and alcoholism. The major endorphin, beta-endorphin (1-31), acts by binding with the mu opioid receptor. Oxytocin and prolactin promote release of beta-endorphins, and in turn beta endorphins promote prolactin. Beta-endorphins inhibit oxytocin release in the lead-up to labor, possibly restraining labor onset. Mu and other opioid receptors have also been found in the myometrium of women in late pregnancy, where mu activation has relaxant effects596 (4. These include methodological problems with measurements and a wide variation in individual baseline levels that may reflect differing sensitivity and receptor systems. Because levels measured in the blood have generally correlated with physiologic effects, it has been presumed that this reflects central effects, but, as with oxytocin, this is not certain. However, excessive stress and pain may elevate central beta-endorphins above physiologic levels, inhibiting oxytocin release and slowing labor, as seen in animal studies. Levels are positively correlated with contraction strength, labor progress, self-reported pain, and rupture of membranes. This keeps the labor experience within eustress levels without disruption to labor processes. In another study of unmedicated multiparous women, ?A considerable increase in beta-endorphin was found without severe stress or pain. The higher rates of physiologic birth, reduced need for interventions, and good maternal-newborn outcomes that are associated with environments and mater nity care providers that support maternal emotional well-being (4. Fetal Beta-Endorphins in Labor and Birth Beta-endorphins, released with labor hypoxia, may give fetal neuroprotection, as found in animal studies. Levels have been found to be sev eral times higher in newborns who experienced excessive labor hypoxia. This exposure during breastfeeding may motivate and reward mother and baby in relation to breastfeeding. Excessive opioid activity can reduce maternal motivation and behavior,94 possibly by signaling satiety403 (4. Beta-Endorphins and Maternal Adaptations and Attachment Beta-endorphins facilitate maternal adaptations and may promote mother-infant contact and attachment by priming maternal reward centers at birth. The co-release of oxytocin with beta-endorphins with breast feeding and maternal-infant contact may maintain maternal ?addiction, with benefits to infant survival. Priming of these maternal reward circuits may ensure that the new mother will continue to be motivated to give the devoted care neces sary for offspring survival among all mammals. Among new mothers two to four weeks after birth, researchers found that those who had given birth vaginally had greater activation of brain reward centers in response to hearing their baby cry, compared with moth ers who had experienced prelabor cesarean section.

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When it is time to treatment question flexeril 15mg otc progress to medications 1040 generic flexeril 15mg on line an untethered bolus medicine qd buy discount flexeril 15 mg, the clinician could initially use small portions of items that will dissolve in the oral cavity medicine grace potter lyrics purchase flexeril with a visa. Mechanoreceptors in the periodontal ligament are prima rily responsible for the tactile function of teeth (Jacobs et al. These receptors are important for coordinating jaw muscles during biting and chewing. In order to activate receptors in the jaw musculature items with a thickness of 5mm or more are required. For this reason, a bulky but secured item such as the gauze-covered chewing gum may be advantageous in providing tactile input. Better stereognostic abili ties are indicated in individuals who are able to detect small differences in weight interdentally (between the teeth). Untethered boluses will eventually be required for successful reintroduction of chewing. Small portions of the straw could initially be placed into the mouth, moving towards progressively longer lengths of straw. The clinician could also position paste or puree into the buccal cavities and ask the patient to use their tongue to retrieve and then expectorate the bolus. Failing the use of the tongue for this manoeuvre, the clinician could teach the patient to use their? Control of a liquid bolus within the oral cavity Control of a liquid bolus within the oral cavity is a natural progression. Once a cohesive bolus can be safely controlled then a more volatile and less cohesive bolus such as liquid can be attempted. The clinician can increase the amount of time the individual holds the liquid bolus in the mouth before expectorating it. With good control the patient may be asked to move the bolus around the mouth without swallowing it (Logemann, 1998). In individuals with reduced intra-oral sensation, therapy may progress from larger and heavier boluses to smaller and lighter boluses that mimic saliva. Swallow initiation and bolus propulsion Swallow initiation and bolus propulsion require the bolus to be maintained in the oral cavity until the bolus is suf? Movements relat ing to tongue control, stabilization and posture are critical at this point following successful oral containment. Exercises in the previous paragraphs will assist in pre paring the oral musculature for containment so that the bolus is well controlled prior to the swallow. At this point, however, the best activity for swallow initiation and bolus propulsion is using these actions with a bolus. A heavy cohesive bolus may be suggested as a starting point progressing to more challenging materials such as less cohesive boluses (liquids). Note that this task also requires good lip seal, buccal tone and tongue movement (see notes above). The diameter and length of the straw can also be manipulated to make the task easier or more dif-? Length of the straw allows the clinician to manipulate the duration that the individual is sucking through the straw. The clinician can then progress to sips that are brought up the straw and then released back into the cup. Then small sips, large sips and multiple sips, can be introduced again varying viscosity as required. See notes below in improving respiratory capacity and swallow-respiratory coordination. The air pressure provides a resistance which the muscles of the soft palate must overcome to elevate the soft palate and draw the pharyngeal walls in to achieve velopharyngeal closure. The idea is that the mus cles must overcome the resistance to function and that this practice using resistance will build up muscle strength. Kuehn (1997) explains that to build biceps strength an individual will lift weights; but rather than attaching a weight to the soft palate, a column of air is injected that the muscles need to work against. The authors postulated that the effort from increased velopharyngeal effort had a? Clearance of residue from the oral cavity Clearance of residue from the oral cavity after the primary swallow occurs com monly and subconsciously throughout mealtimes. Therapy activities described above relating to using the tongue to clean palatal, buccal and dental surfaces are suggested. The clinician could place paste, thickened liquids, cold ice chips or small amounts of lemon sorbet into the buccal cavity for retrieval and expectoration. Once successful at expectoration, the individual could retrieve and then swallow the items. Three daily exercises include: maximum dura tion of sustained phonation, maximum fundamental frequency range and maximum functional speech loudness drills. Individuals are encouraged to use a louder voice while speaking and are encouraged to ?feel and think loud (Sharkawi et al. It was also noted that there was improved oral tongue and tongue base activity during the oral and pharyngeal phases of swallowing in addition to increased vocal intensity. Nasal regurgitation is only occasionally seen in individuals with dysphagia, with the dif? Treatment strategies for improvement of soft palate function and enhancing movement of the superior pharyngeal constrictors has been discussed above. Effective hyolaryngeal excursion Effective hyolaryngeal excursion is required to manually protect the airway dur ing swallowing. The mechanism for this process has been described earlier in this text (see Chapters 1 and 4). Exercises that have been proposed to improve hyola ryngeal excursion in the dysphagia literature include: the Mendelsohn manoeuvre; head lift manoeuvre and falsetto exercises. This function allows the bolus to travel into the oesopha gus and minimize residue in the pyriform sinuses post swallow. The evidence base for the technique is derived from a small number of studies, some of which have measured the effectiveness of the technique with healthy individuals (Kahrilas et al. The technique is true to the principles of exercise physiology where the target is improvement in range of movement, not force, however. The technique where the individual is required to hold the larynx up at the height of the swallow (described previously in Chapter 11) requires some strength be cause the larynx is held by the muscles against the resistance of gravity. The authors demonstrated that measurable changes in laryngeal excursion were associated with functional improve ment in feeding status. In addition, some of the patients who participated in the study revealed that they had learned the skilled movement so well (indeed had become expert in it), they that were no longer aware that they were using the technique. The Mendelsohn manoeuvre does, however, require excellent cognitive skills and considerable muscular control. It will provide the clinician with a challenge in teach ing the execution of the technique to suitable candidates. Note also that Huckabee and Pelletier (1999) suggested that the Mendelsohn manoeuvre should be used only as an exercise technique rather than employed during mealtimes. Given that the technique upsets the temporal duration of the normal swallow, they suggest that in dividuals may be more prone to aspiration. As such the individual may indeed aspirate as they learn, much as the child falls over many times before they stand and walk. To err on the side of caution, the clinician could teach the mechanics of the technique then employ it with saliva swallows. The sustained head lifts are then followed by 30 consecutive head lifts from the supine position also. For both the sustained and repeated head lifts subjects are instructed to raise the head high and forward enough to see their toes without rais ing their shoulders from the bed or? As described above, however, it does not follow a pattern of gradually increasing level of dif? To be true to the principles of exercise physiology, future efforts should be aimed at determining a step-wise programme (fewer repetitions initially, increas ing to more repetitions and more practice cycles). The concept of fatigue should be incorporated into the task by progressively making the task harder in order to cause muscle hypertrophy.

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The treatment for the child in question 5 includes (A) dietary intervention (B) enema (C) osmotic laxatives (D) behavioral intervention (E) all of the above 7 treatment multiple sclerosis flexeril 15mg fast delivery. The length of time this child will need to symptoms 24 buy flexeril 15 mg lowest price be treated is (A) 1 week (B) 2 weeks (C) 3 weeks (D) more than 6 months (E) once laxative therapy is initiated medications rapid atrial fibrillation order flexeril 15mg online, it is lifelong 8 treatment 5th finger fracture buy flexeril overnight delivery. The chance of successfully weaning all laxatives after a year is (A) 10% (B) 30-50% (C) 50-75% (D) 75-90% (E) more than 90% 9. If the child in the vignette had rectal prolapse with his constipation, the next step would be (A) a sweat test (B) a rectal biopsy (C) to treat the constipation (D) to do a detailed calorie count (E) nothing 10. Had the weight and height of the child in the vignette been less than the 5th percentile for age and there was rectal prolapse, your next step would be (A) a sweat test (B) a rectal biopsy (C) to treat the constipation (D) to do a detailed calorie count (E) nothing 11. Had the child in the vignette been treated for urinary incontinence by a urologist and his constipation began after his treatment (A) the constipation and urinary incontinence are secondary to a spinal tumor (B) urinary incontinence is usually treated with anticholinergics and the constipation is secondary to the drug (C) the constipation was previously undiagnosed and the urinary incontinence is secondary to the constipation (D) B or C (E) none of the above 12. Had the child in the vignette had painless bright red blood per rectum, the likely diagnosis would be (A) juvenile polyp (B) fissure (C) hemorrhoid (D) Meckel diverticulum (E) colon cancer 13. If this child was 6 weeks old, breast-fed, and stooled once every 5 days, the management would include (A) reassurance (B) mineral oil (C) malt soup extract (a diastatic barley malt extract) (D) rectal stimulation (E) stop breastfeeding 14. In an infant with Hirschsprung disease, the findings on physical examination include (A) empty rectum (B) rectal impaction (C) abdominal distention (D) A and C (E) B and C 17. The findings with Hirschsprung disease on barium enema would be (A) a transition zone between the dilated aganglionic section and the normal colon (B) a transition zone between the contracted aganglionic section and the dilated colon (C) a transition zone between the rectum and the dilated colon (D) a transition zone between the descending and transverse colon (E) there are no consistent findings on barium enema and rectal biopsy is the diagnostic test of choice 18. A patient with functional constipation and encopresis described in this vignette is going to have loose rectal tone and stool within the vault. A 6 yearold presenting with Hirschsprung disease would have an ultrashort segment of Hirschsprung involvement. Other neurologic symptoms and signs such as urinary incontinence and loss of reflexes can be associated. The vignette and the rectal examination findings are consistent with functional constipation. It is important to remember also to look closely for constipation when a child presents with urinary incontinence. Drugs associated with constipation include analgesics, antacids, anticholinergic, bismuth, iron, cholestyramine, and antipsychotics. Although hemorrhoids are associated with constipation in adults, they are very unusual in children. A Meckel diverticulum can cause a significant bleed, but usually the blood is not bright red. In breast-fed babies there can be stools ranging from several times a day to once every several days. As long as the stool is of normal consistency and easily passed, several days between stools is normal. Poor feeding secondary to abdominal pain or reflux is usually associated with an irritable baby. With this latter diagnosis, the baby presents with explosive diarrhea, fever, and shock. They are not malodorous, there is no blood or mucus, and they are not bulky or oily. Mom frequently sees food particles such as corn, carrots, and raisins in the stool. The first studies you would order include (A) stool for fat, reducing substances, and pH (B) a stool culture and assay for fecal leukocytes (C) stool examination for ova and parasites (D) all of the above (E) none of the above 2. The treatment for chronic nonspecific diarrhea includes (A) reassurance and limiting dietary excess (B) clear liquids when the number of stools is more than 5 per day (C) diphenoxylate/atropine when the number of stools is more than 5 per day (D) A and B (E) B and C 5. Treatment for celiac disease includes (A) gluten-free diet (B) evaluation for hypothyroidism (C) evaluation for anemia (D) all of the above (E) none of the above 8. In a child with a history of growth failure associated with rectal prolapse and chronic diarrhea, which of the following tests would likely be abnormal? If the child had stools that ?burned, the likely malabsorption would be (A) carbohydrate (B) fats (C) proteins (D) vitamins and minerals (E) bicarbonate 13. The antibiotic that most often leads to C difficile infection in pediatric patients is (A) amoxicillin (B) clindamycin (C) erythromycin (D) cefdinir (E) all of the above cause an equal incidence of C difficile 15. If the child was 6 week old with 5 loose watery stools with blood daily, the most likely diagnosis is (A) infectious colitis (B) protein intolerance (C) lactose intolerance (D) congenital C1-losing diarrhea (E) fat malabsorption 16. A microbiology lab calls you with a report of a positive C difficile toxin result on a 10-day-old patient of yours. The screening laboratory tests listed are examinations of the stool looking for malabsorption and intestinal infection; these diagnoses would not be suspected in this patient from the history or physical examination. Children can have increased diarrhea if they are put on a clear liquid diet frequently. Caution should be used in interpretation because 2-5% of celiac patients are IgA deficient and have a false-negative test result. These patients also have a high incidence of associated hypothyroidism and iron deficiency anemia. Without other signs or symptoms, imaging studies, endoscopy, and allergy testing are not indicated. In chronic cases, it is important to ensure there is adequate pancreatic enzyme replacement. In small bowel bacterial overgrowth, the peak of expired hydrogen will be early because the bacteria are in the small bowel, not the colon. In carbohydrate malabsorption there will be a later peak when the unabsorbed sugar reaches the colon. Without signs of obstruction or perforation, radiographic studies are not indicated. Although there is an increasing incidence of community-acquired C difficile, most cases in children are associated with recent antibiotic exposure. Well water exposure would raise the concern for parasitic infection, and exposure to other sick children would likely indicate a viral gastroenteritis. Lactose intolerance would likely lead to increased gas and bloating with loose, watery, and acidic stools. Lactose intolerance presents with increased gas and bloating with loose watery, nonbloody stools and is rare in this age group. On examination, you note thick, yellow-white foulsmelling discharge in the ear canal with underlying erythema. The examination also reveals tenderness when you gently tug on the pinna of the left ear and some small (<1 cm), tender, mobile anterior cervical and preauricular lymph nodes on the left side. Of the following, which is the least likely pathogen that has caused this problem? What is the most important test to perform on clear fluid associated with otorrhea? A 3-year-old boy is brought to the emergency department by his mother because of ear pain that started the day before and is progressing in intensity. He has not been ill in the last 2 weeks but was at a birthday party 3 days earlier, where his mother is ?sure he caught something from one of the other kids. On further otoscopy, you find what you believe to be a small disk-shaped battery, presumably from a toy. Her mother says that she ?failed her hearing screen performed at her school 3 months ago and was instructed to get further hearing testing. She reminds you that her daughter has had multiple ear infections in the last year. What is the most common infectious cause of sensorineural hearing loss in the United States? Which of the following does not indicate a need for hearing screening if newborn hearing screening was performed? The differential diagnosis for ear discharge also must include foreign body in the external auditory canal, chronic suppurative otitis, and acquired cholesteatoma. Tuberculous otitis media should also be considered but is unlikely a process of 2 days. The last is rare and presents with a more insidious ear discharge that is white and fluffy, sometimes with small black spores visible along the ear canal. Oral antibiotics are reserved for those with chronic otitis externa, concomitant otitis media, or a patient with an underlying immunodeficiency. Acidifying solutions such as acetic or boric acid lower the pH, thereby making the environment less favorable to the causative organisms. Topical steroids may decrease the associated inflammation and pruritus with otitis externa but are not necessary for a mild to moderate otitis externa.

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