Ambulatory Peds Flashcards
Considerations for the Tone of the Ped. Examination
Talk to the child!!
- directly to them using langugage they will understand
- can interview without om or dad starting at 10/11 & should be doing taht by 12 (consider developmental age)
Caregiver is also your pt!
- lsiten to their worries about serious disease/development issues
Tips
- sit at level of child
- under 6 months: exam on table
- older infants: sit in moms lap
- dont undress immediately, warm your hands
- do least intrusive to most and distrct with toys
Tips for Peds by age group
Toddlers
preschoolers
school aged
Toddlers
- can cry when you start: theyre scare
- stay happy, talk calmy and assured: they will sense confience and trust
- let toddler play with instrument before use
- do exam while they sit in moms lap
Preschool
- encourge them to participate in the history and the PE (where to look first)
- hand over hand technique
- be honest with what might be painful
School Aged
- let them give the history
- small talk with them
- explain things in simple terms
- be honest with painful
Key Pearls about the Comprehensive Ped. Visit
- History taking
History Taking
- prenatal history & birth hisotry
- growth and development
- social hisotry
- psychosocial hisotry: wahts a typical day like for them
- parental well being! screen for PP depression every visit birth to 12 months
Prenata and Natal History specifics
- planned/wanted pregnancy
- materal health and labs & WT gain
- length and complications of pregnancy
- medications and alcohol/drug use
Natal
- C-section v vaginal
- complications
- resusitation
- birth weight, length and head circum.
- newborn screen
The Prenatal/Neonatal Visits
Key Pearls on what to include
Screening and Health Maitnence
- newborn screening, materal screening
- immunizations
- social hisotry: living, food, environment, familily support
Newborn care
- feeding breast v bottld
- handwashing
- limit expousre in first 6-8 weeks
Safety
- carseats
- back to sleep
- water temp < 120 degrees
Neonatal Specifcs (after born)
Cord Care
- 2-3 weeks to fall off, watch infections
Skin Care
- avoid sunlight directly, no sunscreen until 6months
- avoid powder
Feeding
Breast
- 8-12feds/24 hours
- continue prenatals and no alcohol
Bottle
- 8x/24 hours via cues
- prepare and store properly
- no proping bottle
Neonatl PE from freemands lecture
Infant Visits “Well-Check”
what to include
Infant Visit
- if not gotten, get prenatal/natal history and birth hx.
- inquire about feeding: vitamin (VIT D!!), iron and floride assessments
- solid foods?
- physical growth
- developmental milestones
Observe parent/child interactions
physical exam : barlow and ortolani at every infant visit
Assessing the Social Environement for peds of all ages
biologic needs and environemental assessment
Famil Environement
- family from nuclear, extended, single parenet, same sex, etc.
- family parenting style and discipline
Mental heatlhy
- parental depression
- IPV
- substance use
PArental Employement
- poverty, homeless
- school, daycare, etc.
neighborhoor
virtaul environemtn (technologY!!!)
Developmental Assessment at Well Checks for Kids
Primary Screen
4 caterogires of developmental assessment
DEvelopment = predicatble process but the range of normal is wide!!!
- follow criteria if any screening you do turn positive
- early intervention is best= no more wait and see!
Primary Screen
- listen to mom and obstain history
- vitals
- observeation of development at visits
- using screening tools
- recognize conditions that may increase risk of delayes and refer those for help
Development Assessment of
- socail/emotional
- langugage/communication
- cognitive milestones
- movement/phsycial developement
Surveillance v Screening
developmental assessment for peds.
Surveillance
- informal, just monitoring developmental status overtime
- interpret information in terms of environement,socical and medical facors of child
- include parental concerns in youe eval. and those formal dvelopment screening
Screening
- breif assessments of fevelopmental status utalizing a standardized instrument
- done at : 9,18,24/30 months
- 18 & 24 months for ASD Screen
- the AAP/CDC, the ASQ or the PEDS screens are good
- the M-CHAT for ASD
there are secondary screening tools when the ^^ priamry tool sindicate a need to look further
- vanderbilt/connor = ADHA
- SCARED = anxiety
- depression
- ASQ-social/emotiona = depression/anxiety
Assessment: Growth and Development
somatic v maturational
Somatic
- physical grwoth via lenght, weight and head circumference
Maturational
- puberty onset
- sexual maturity rating
0-2 Years Old
- WHO standards
- weight
- length
- head circumferences : occiptal-frontal
- weight for length
2 Years +
- CDC chart
- Stature (height)
- weight
- BMI : curves can be used for Z scores and pecentiles of BMI
Assessment: General Appearance
Muclse Tone
Sick v Not Sick
Crying
Facial Features/dysmorphia
Symmetry of FAce and Body Features
parent child interation
Muscle Tone
- lack of tone = sick baby or MSK/neuro disorder “floppy baby”
Assessment: Appearance
Facial Features
Facial Features
- mouth, lipds, philturm
- nose shape
- distance between eyes
- direction of palpebral fissures
- size/shape of ears and relation to eyes
Assessment: Appearance
Crying
Crying
Shrill/High Pitch = increase ICP, newborn to narcotics mother
Hoarse = hypocalcemis, tetany, hypothyroid
continuous inspiratory/exporiatoyr stridor = obstructed upper airway, small larynx, tracheomalacia
lack of cry = happy baby or SEVERELY ILL BABY
Assessment: Vitals
Temp
HR
RR and distress
BP and reasons for getting a BP earlier than 3 or a must
Temperature
- rectal is GS for under 2
- work up fully if temp in infant < 2 is greater than 100.4
- somtimes kids get high fevers for minor illnesses, but always want to check
Heart Rate
- faster than adults
- varies with dehydration, fever and anxiety
Respirations
- faster than adults
look for respiratory distress
- flaring nose, pallor/cyanosis
- grunting, wheezing, stridor
- retractions
Blood Pressure
- should be done on all infants > 3
- values based off percentiles
Warrent Early BP monitor
- premature, VLBW
- herat disease
- renal/urologic dz.
BP necessity when
- treatment with drugs to increas BP
- conditions with inc. BP
- increased ICP
Assessment: Head
fotanels close when
early v delayed closure
Fontanels : openings that allow head to move during brith
diameter should be 2x width
- posterior : closes by 2 months
- anterior closes by 12-15 months
Early close
- craniosynstosis
- hyperparathyroid or phyerphospate
Late Close
- can be normal
- cong. hypothyroid
- megancephay
- increase ICP
- downs
- rickets
can appear sunken in with dehydration or bulding with increased ICP
helmets can help with funky heads
Craniosynostosis v nonsynostoic plagiocephaly
Craniosynostosis
- asymmertical head shape ebcause of growth restirction due to fused suture line in skull : unknown etiology
- a fused suture line = 1 or more
- Xray/CT and srugery to fix
N-P
- external mlding due to back sleeping, restructive interuterine environment, torticollis or preamture
- external molding
- a flat spot on the back fo the head due to positioning
- normal suture lines
- helmets to fix
Skin Assessment of Peds
color
lesions
rashes
abuse
Ocular Assessment in Peds.
vision assessment when
when to optho
Vision
- screening is vital!!!
- letahl conditions like retinoblastoma need to be picked up
- “windoe period” for vision to correct before perminant damange
- ages 6-8 is when they go to optho. but this is past the window to fix eye issues
- vision is essentail for dvelopment brain connections
Occular Assessment
Eye exam includes what tests
Eye exam
- vision screen
- visualacuity test: usually 3+ years
- red reflex
- external exam
- alignment and corneal light reflex
- motlitiy of EOM
- pupil exam
- fudoscopic exam 4+
Occular Assessment
History
History
- do they sit close to tv, interesting in books, fixate on objects
- eye crossing
- reddness or discahgerge
- photophobia
- family hx.? retinblastoma = screen in first degree realtives
Occular Assessment
symptoms of potential vision loss
treatment is to send to optho for all
Symptoms
- no eye contact in those > 8 weeks
- head tile/face turn
- unable to comply with age appropriate screenings
- tearing (nasolac. duct obstruction)
- photophobia
- squinting
Occular Assessment
Visual Screenings and Tests
Can they See?
- infants/toldders: get attention with toy and watch their fixation
- older kids: formal acuity test (3/4+)
Screening
- instrument bases
- autorefractors
Visual Acuity
- 0-2 monhts : blink to bright light and equal pupils
- 6-8 weeks: fixed and tracking
- 6months -2 years: fix and follow with one eye cover
- 3+ years old: can do the lea symbol
- older: can do the normal test with letters
difference in > 2 or more of the lines = referr to optho
Occular Assessment
Red Reflex Testing
Red Reflex
- view both eyes 2-3 feet away
distorted red reflex due to
- retine = retinoblastoma
- vitreous = hemorrhoage
- lens - catarcts
- cornea = scare
leukocorita: think retinoblasts
absernt refelx = ertinblastma or hemorrhgae
keep retinblastoma, viterous heomrrhage and cataracts high on suspiscion = urgern referral
Occular Assessment
External Eye Exam
inspection for…
- capillary hemiangiomas
- port wine stains = amblyopia
ptosis
- alone = refer to opthmo
- ptosis and miosis = neuroblastoma
examine for enlarged eye = pediatric glaucoma
hordeolum: acute and infalmmed
chalazion: chronic and hard ball
Occular Assessment
Alignment
newborns = can have stabismus but resolves by 2-4 months
pseudostrabismus can be due to epicantheal folds
Abnormal Aligment
- esodeviation : converge to middle (esotropia = visable in normal conditions, esophoria is not detecable when looking at both)
- exodeviation: diveerge to oute edges
Evaulate
- with cover, uncover test : for stabisus
- hirschberg testing: symmetry of corneal light reflex (look at light reflex directly in teh pupil)
Stabismus: always warrents a referral!!
- patching to fix, glasses or surgery
Occular Assessment
motility of EOM and nystagmus
Motlity of EOM can be tested the same: use toy instead of pen
- abnormal: CN palsay
Nystagmus
- referr to optho.
Occular Assessment
Pupillary and fundoscopic exam
Pupillary
- assess size, shape and symmetry
coloboma: irregular pupil shape = refer
can be due to genetic abnorms.
Fundoscopic
papilledema = increase ICP
Cherry red macula = Tay Sachs disease
diabetic retinopathy: screen 5 yeras post T1DM, can pick up undx. T2DM
ENT Exam
Hearing Exam
ENT: do last! most invasive for kids
Hearing Exam
- done in first month of life for formal testing
- parents usually have good index of suspicion
- formal hearing test should be done before neonate leaves hospital
Screen at…
- 4, 5, 6, 8, and 10 years (speech!)
- 1 x between 11 and 14
- 1 x between 15 - 17
- 1 x between 18 - 21
- anytime parent is concerned
- persistnet ear effeusions
0-2 months: clap = theyshould be startled
2-3 change in body movement reponses to sounds or famiai expression with familar sounds
3-4 turn and listen to voices
6-7 can same some thigns
screening for hearing is done in schools!
Ear Positioning for Assessment in peds
ear pits/tags : check waht
microotia
Ears
- should draw line from eyes to ears and have top 1/3 of ear above
- and 20 degrees rotated ear back
Low set ears
- trisopy 21
- trisomy 18
- treacher collins
- beckwith wideman
Ear pits and tags
- can beislated, but also associted with genetic consitions
- if you seen ear pits and tags, check for hearing loss and renal anomilies
Microotia
- graded I - Iv (most sever)
Cup/Lop Ears = normal
Nose and Throat Exam for Peds
teeth
neck masses
Nares patency
palate and uvual integrity
speech quality
dentition!! : CHIP DOES cover dental
Teeth
- frsit should be between 6-10 months
- watch for baby bottle decay of teeth
NEck Masses: referral to ENT
- thyroglossal: thyroid gland fails to fall to its position
Cystic Hydroma
2nd branchical cleft cyst : emryonic remains
Assessment: Chest Wall
gynocomastic specifics
Abnroaml breasts
nipple distance
- turners syndrome
gynecomastica
- meds induced (dig, INH, cimetidine, antidep.)
- breast tumor
- adrenal or gonsal lesions
- hypethyroid
- klinefelters
- severe renal/liver disease (estrogen cant clear)
Exam of Gynecomastia
- do a testicualr exam!!!: testicaulr CA
- can be benigin and spontaneously regress
- refer if they are prepubetal, under virilized, testicular mass, persisant longer than normal
sexual maturation stages
pectus excavatum (in) and carinatum (out)
Assessment: Pulmonary
upper airway issue: inspiratory finding
lower airway issue: expiratory finding
sounds transmit widely through chest in kids, difficult
Upper Airway
- nose and stethescope sound will be equal
- symmetric shoulds
- harsh and loud
Lower Airway
- variable sounds
- asymmetric
- louder when in lower chest/abd.
Assessment: Cardiovascualr
infant v toddler signs
Exam
Murmurs
Cardiovascular
Infants
- dx. before leaving hospital
- sweating, cyanotis with feeds = think this
- poor weight gain or weight loss
toddelrs/kids
- simiarl to adult sx.
- difficutl to keep up with peers!
Exam
- smaller scop
- palpate brachial and femoral pulses simultaneously
Murmurs
Still Murmur: musical, loudest in supine position, early systlic at LL sternal boarder
Physiologic Murmur (thingk high outflow state)
Systolic ejection murmus, heard at 2nd/3rd ICS
Venous Hum : upper right sternal boared, decreasd with neck pressure or turning to the right
Assessment: Abd & GU
ABdomen
- kids have pot belly but do good exam
- liver and spleen margins are often palpable
- kindeys easy to feel
- bend knees or hand over hand
GU
- usually on inspection is needed: always exaplin what you are doing and why it sok for doctor and mom to see
- sexual maturity rating
- palpate testicles for position
DRE onl for
- rectal bleeding
- sevre constipation
- sometime for appendicitis
- pelvic exam only for gyn compliants or abd.peliv pain
Assessment: Neruo
primitive refelx
Neurologic Exam
Obeserve
- moving hands and legs and neck spontaneously
- wualitative assessment
Examination Period
- response to stimuli
- strenght/motor test
- CN test
- Gait testing
Primitive reflexes
Palmar Grasp: 0-4 months
Rooting: 0-4
Trunk incurvation : 0-2
Ventral suspention: 0-4
moro reflex: 0-4
stepping reflex: days-2 months
Assessment: Ortho
Barlow and Ortolani
Scoliosis
Barlow
- dislocates unstable hip
- lay baby on back, hips and knees flex, hips are adducted in and downward pressure
- click = +
Ortolani
- after barlow: see if you can relocate
- thigh abducted, pressure on greater trochanters
- clunk = +
Scolisos
- checked in schools
- bend over and see from back
Screenings
Newborn and Immediate
Nameia
Lead
BP
TB
lipids
STIs
HIV
cervical
Newborn Screen
Bilirubin at 12-24 hours
CCHD
ANemai
- 12 months (routine)
- 15, 18, 24, 30 = high risk (vegan or poor eater)
- annually 3-18 if high risk
Lead (defer if low risk)
- screen if old home first
- if + screen : 12, 24 months
BP
- age 3+
- early if risk
TB
- periodicall if at risk
lipids
- once between 9-11 years
- once between 17-21 years
- if high risk - more often
STIs
- adolescne if at risk
HIV
- once 15-18
Cervical dysplasia
- starting at 21
Health Promotion
family support
healthy child
Oral Health!!! Flouride specifics
Family Support
- assess and help
Healhy Child
- early detection of developmental delays
- parent encourge tummy time and reading
Oral health
- intervene and educate early before teeth come up
- SES impacts oral health: caviteis = common
- use floridein toothpaste and regular brushing
- smear of paste for little ones, pea size for a little bigger
Flouride
- recommendations depend on municapline water supply flouride amounts
- flouride varinsih can be applied 3-6 months for those at risk
Health Promotion: Safety and Injuery Prevention
injury is most significant problem of children and teens
leadsing cause of death under 19
Traffic Safety
- car seats never in front seat
Burn Prevention
- smoke alarms
- hot water < 120
Fall prevention
- gates and crib rails
- AVOID USE OF WALKERS: THSES ARE NOT GOOD
Choking
- toliet paper tube test
- blind cords away
Drowning Prevention
- no buckets
- surpervise baths
BAck to sleep and infant CPR
Toddlets/Preschoolers
Traffic SAfety
fall prevention
Traffic Safety
- back seat care seats: weight height and age recommendations
- forward facing only once 60 pounds
- then to booster seat
- no thick caots
FAll PRevention
- stair/windo gaurds
- prevent furniture falls
Posion Prvetion: storage of meds and know number to call
Drowning
- locks and swim safety lessons age 1-3
SChool Aged Kids
Traffic Safety
Traffic SAfety
- booster seats and seat belts
- back seat until at least 13 years old
swim and spor safety
- helments and portective equiptment
Violence Prevention and Media USe
Violence Prevention
- Bullying: encourgae child to identfy where to get help and help parents
- monitor socail media
Media use
-Screening: who monitors and how is it mointored
- how much are they using, tv in bedroom?
under 18 months: no tech.
18-24 months: only high quality media with parent there
2 yeras: no more than 1 hours
no screens at meals or 1 hour beofre sleep
