Health Supervision Well Child Flashcards
A 9-month-old male infant is seen for a health supervision visit. He is pulling to a stand, cruising, and taking one or two independent steps. His parents would like to encourage his gross motor development. They seek advice on the use of infant walkers.
Of the following, the MOST accurate response is that this device
A. accelerates the development of unassisted walking
B. is not recommended C. is safe with parental supervision D. should be used with a helmet
Are not recommended
Infant walker–related injuries are a significant source of child injury.
Despite parents’ perceptions that infant walkers accelerate the development of unassisted walking, they should not be used.
Adult supervision has not been shown to prevent walker-related injuries.
A 3-year-old boy is seen for a health supervision visit. His parents express concern that their son is not speaking at the same level as his 3-year-old cousin. They state that he can “understand everything,” but his language does not include combinations of more than 2 words. His parents understand approximately half of what he says. The boy enjoys running around with the other children at his preschool. He can draw lines but not circles and can stack up to 4 blocks. He needs assistance with removing his clothing. The boy is friendly, makes good eye contact, and smiles on being greeted. He looks confused when asked to hand over his jacket, but does so willingly when the jacket is pointed to and a hand held out for it. He looks to his parents for reassurance during the physical examination. The boy’s growth has been appropriate. His vital signs and physical examination findings are unremarkable. When offered a choice of stickers, he points to the one he wants and says “Thank you.”
Of the following, the BEST next management step for this boy is to
A. administer a general developmental screen
B. order a chromosomal microarray
C. perform an office-based hearing screen D. refer the boy to state early intervention services
administer a general developmental screen
differential diagnosis of a child with speech or language delay includes global developmental delay, autism spectrum disorder, and hearing impairment.
For a child with speech or language delay, a general developmental screen should be administered to determine if he/she has any additional delays in development and if a full developmental evaluation is needed.
A formal audiology evaluation is needed for a child with significant delays in language development. An office-based hearing screen is not sufficient because of the risk for false-negative results; milder cases of clinically significant hearing impairment may not be identified.
Children whose language delay resolves are at risk for language-based learning problems (eg, reading).
Children with both receptive and expressive language delays are more likely to have persistent problems in language development.
A language disorder occurs when language delay persists to school age, limits learning or communication, is severe, or has an atypical pattern.
This 3-year-old boy should have expressive language of at least 3-word sentences, receptive language to allow following of 3-step commands, and speech that is 75% understandable to strangers. He should be able to draw a circle, stack at least 6 blocks, undress, and put on some clothing items.
A mother requests early discharge of her neonate, who is 36 hours of age, so she can be home with her 2-year-old daughter and husband. Her mother is also staying at her home to help. The boy was born at 38 weeks 6 days in a normal spontaneous vaginal delivery without any complications after an uneventful pregnancy. He has been nursing well, voided four times, and passed stools three times. His temperature is 37.2°C, his heart rate is 120 beats/min, his respiratory rate is 40 breaths/min, and his oxygen saturation is 98% on room air. His physical examination findings are normal.
Of the following, the BEST next management step for this neonate’s care is to
A. discharge him at 72 hours of age
B. discharge now with follow-up within 48 hours C. obtain a complete blood cell count D. obtain a serum bilirubin level
discharge now with follow-up within 48 hours
Neonates at low risk of experiencing complications can be safely discharged 24 hours after birth.
Neonates discharged before 48 hours of age should follow up with a pediatric provider within 48 hours.
Social support, access to care, and maternal and newborn health should be considered when planning for discharge from the newborn nursery.
Normal physical examination findings, including vital signs for 12 hours before discharge
Temperature 36.5°C to 37.4°C while lying in an open crib
Respiratory rate less than 60 breaths/min without any increased work of breathing
Heart rate 100 to 190 beats/min while awake and more than 70 beats/min while asleep, with normal circulation and appropriate response to stimuli
One stool and normal urination
Two feedings with good latch and suck/swallow pattern, with one feeding observed
No excessive bleeding for 2 hours after a circumcision
Appropriate treatment plan for hyperbilirubinemia, if present; negative result on Coombs test
Reassuring sepsis work-up if risk factors are identified
Normal maternal laboratory findings, including negative results for syphilis, hepatitis B surface antigen, and human immunodeficiency virus
Receipt of intramuscular vitamin K
Neonates born to mothers with chronic medical conditions, excessive maternal bleeding, or complications from delivery, including the need for instrument assistance or cesarean delivery, should not be considered for early discharge.
As neonates transition from intrauterine to extrauterine physiology, cardiopulmonary complications can arise, usually within 12 hours of delivery. Other concerning conditions that can present in the newborn period include infection, ductal-dependent cardiac lesions, bowel obstructions, and feeding difficulties
A pediatrician receives a phone call from the state’s newborn screening program regarding a 7-day-old neonate with an elevated trypsinogen, which is concerning for a diagnosis of cystic fibrosis. The neonate was seen by the pediatrician’s partner 1 day ago and had appropriate feeding and growth parameters as well as normal vital signs and physical examination findings. The partner noted that there is no significant family history of diseases in childhood.
Of the following, the MOST appropriate next step is to
A. inform the parents of the diagnosis of cystic fibrosis
B. discuss the result at the 2-month health supervision visit
C. reassure the parents that this is likely a false-positive result
D. schedule the neonate for diagnostic testing
schedule the neonate for diagnostic testing
By design, newborn screening tests have high sensitivity and may have lower specificity; positive results must be promptly followed up with diagnostic testing.
Even with the history of a normal newborn screening test, evaluation for a condition should be considered when clinically suggested.
For a condition to be included on the newborn screening panel, the disorder must be associated with significant morbidity and/or mortality and be treatable, with evidence that early treatment improves outcomes. There must be an inexpensive and sensitive test that can be performed on a dried bloodspot sample and a definitive follow-up testing plan to differentiate true positives from false positives.
A 5-year-old boy is brought to the office by his mother who is concerned that her son has been intentionally banging his head. When he is watching videos, he may bang his head several times against the back of his chair. He may bang his head against the wall when he does not want to do something or when he is upset. At bedtime, the boy bangs his head on his pillow until he falls asleep. His mother is worried that he is having headaches or may cause himself serious injury.
Of the following, the MOST appropriate next step is
A. applied behavioral analysis therapy B. magnetic resonance imaging of the brain C. reassurance that these behaviors will resolve with time D. screening for a developmental disability
screening for a developmental disability
Head-banging is a repetitive motor behavior (stereotypy) that usually resolves by age 4 years in typically developing children. Persistence after age 5 years is associated with developmental disorders such as autism or intellectual disability.
Parents of typically developing toddlers or preschoolers who bang their heads should be instructed to redirect their child’s behavior and to avoid giving undue attention to the head-banging because they may inadvertently reinforce it.
In the context of a child with significantly impaired communication skills, self-injurious behaviors such as head-banging should prompt evaluation for painful medical conditions such as otitis media, sinusitis, or constipation, particularly when the behavior is acute.
A male neonate is delivered at 37 weeks’ gestation because of maternal preeclampsia. His mother’s history is significant for obesity and chronic hypertension. He weighs 2.2 kg at birth. At 18 hours after birth, shortly after breastfeeding and supplementing with formula, his bedside glucose level is 35 mg/dL (1.9 mmol/L). He is breathing comfortably in room air and has good perfusion.
Of the following, the MOST likely explanation for this neonate’s glucose level is
A. congenital hyperinsulinemia B. decreased glycogen stores C. maternal hyperglycemia D. physiologic hypoglycemia
decreased glycogen stores
Periods of prolonged neonatal hypoglycemia have been associated with seizures, cerebral palsy, and cognitive impairment.
Neonates with hypoglycemia because of elevated insulin levels have less glycogenolysis, fat metabolism, and formation of ketone bodies, decreasing the available alternate sources of energy.
Neonates at risk for hypoglycemia because of growth restriction, prematurity, family history of hypoglycemia, or inherited diseases of metabolism should be monitored closely.
The American Academy of Pediatrics recommends maintaining serum glucose levels at more than 45 mg/dL (2.5 mmol/L) by 4 hours after birth
A 13-year-old adolescent boy is seen for a preparticipation physical examination for summer camp. He and his mother have no concerns. He has no known medical problems and takes no medication. His father has hypertension. His paternal grandfather has type 2 diabetes and had a myocardial infarction at age 68 years. The patient has a blood pressure of 128/86 mm Hg and a heart rate of 102 beats/min. He has a weight of 80 kg (> 95th percentile), height of 162 cm (75th percentile), and body mass index of 30.5 kg/m2 (121% of the 95th percentile). He has acanthosis nigricans over the nape of his neck. His sexual maturity rating is 3 for pubic hair and genital development. The remainder of his physical examination findings are unremarkable.
Data from a fasting laboratory evaluation are shown:
Laboratory Test
Result
Glucose
96 mg/dL (5.3 mmol/L)
Hemoglobin A1c
5.7%
Aspartate aminotransferase
42 U/L (reference range, 10-40 U/L)
Alanine aminotransferase
65 U/L (reference range, 7-55 U/L)
Total cholesterol
214 mg/dL (5.54 mmol/L)
Triglycerides
130 mg/dL (1.5 mmol/L)
High-density lipoprotein
35 mg/dL (0.91 mmol/L)
Low-density lipoprotein
120 mg/dL (3.11 mmol/L)
Thyroid-stimulating hormone
6.0 mIU/L (reference range, 0.3-4.0 mIU/L)
Of the following, the BEST next treatment step for this adolescent is initiation of
A. atorvastatin B. levothyroxine C. lifestyle changes for weight loss D. metformin
lifestyle changes for weight loss
Components of metabolic syndrome, a constellation of risk factors for cardiovascular disease and type 2 diabetes, include obesity, hypertension, dyslipidemia, and glucose intolerance.
Recommended screening in children and adolescents with a BMI at the 85th percentile or higher includes glycemic indicators (fasting glucose, hemoglobin A1c, or oral glucose tolerance test), fasting lipids, and liver transaminases, as well as polycystic ovary syndrome (in females), obstructive sleep apnea, and psychiatric comorbidities.
Healthy lifestyle changes that promote weight loss constitute the primary management for obesity and metabolic syndrome.
otivational interviewing can be used to help set SMART (specific, measurable, attainable, relevant, timely) goals. The 9-5-2-1-0 principle provides a framework for counseling and goal setting:
9 hours of sleep per night
5 servings of fruits and vegetables per day
Less than 2 hours of screen time per day (television, computer, electronic devices)
1 hour of physical activity per day
0 sugary drinks (soda, juice)
A 15-year-old adolescent is seen for a health supervision visit. She is a competitive dancer who participates in ballet, tap, modern, and lyrical dance, with classes and rehearsals year round, for 12 to 18 hours each week. Over the past 2 years, she has sustained stress fractures in her foot and lower leg, which healed after an appropriate period of rest and progressive return to activity. She does not have any symptoms at present. The adolescent is otherwise healthy. Her growth has been tracking along the 50th percentile for height, weight, and body mass index without recent change. Her menses are regular. She has no dietary restrictions. Her physical examination findings are unremarkable; gait, strength, and range of motion are normal. The adolescent asks how she can minimize her risk of another injury this year.
Of the following, the test MOST likely to provide information useful in addressing this adolescent’s concern is
A. foot and lower leg radiography B. magnetic resonance imaging C. serum calcium level D. total 25-hydroxyvitamin D level
total 25-hydroxyvitamin D level
Measurement of serum total 25-hydroxy vitamin D should be considered for athletes with repeat stress fractures.
Current vitamin D level recommendations for optimal bone health in athletes are higher than the global consensus recommendations for avoidance of vitamin D deficiency and insufficiency.
Avoiding rapid increases in training volume or intensity
Adequate recovery between training sessions
Hard workouts should be followed by 36 to 48 hours of easy workouts or rest
Maintaining sufficient calorie intake to support good menstrual function and adequate estrogen levels in female athletes
Ensuring adequate vitamin D and calcium intake
Deficiency: <12 ng/mL (<30 nmol/L)
Insufficiency: 12-20 ng/mL (30–50 nmol/L)
Sufficiency: >20 ng/mL (>50 nmol/L)
Evidence demonstrates that in athletes and military populations, stress fracture rates are lower when 25-OH-D levels are greater than or equal to 30 ng/mL. Based on these findings, the current recommendation for athletes to minimize injury risk and optimize athletic performance is to maintain 25-OH-D levels between 32 and 50 ng/mL
A 15-year-old adolescent girl is seen for her annual health supervision visit. Her mother is concerned that she has not started her period and has lost some weight. The patient is a competitive gymnast and is on a club gymnastics team. She has not had any acne flares, hirsutism, headaches, changes in her vision, or galactorrhea. She reports no fever, diarrhea, joint pain, or rashes. She has never been sexually active. There is no family history of menstrual disorders, thyroid disease, or inflammatory bowel disease. She is alert and cooperative. She is afebrile and has a heart rate of 44 beats/min and a blood pressure of 92/50 mm Hg. Her weight is 47.2 kg (25th percentile), and her height is 155 cm (10th percentile). Her growth chart is shown (Item Q93). Her physical examination findings are otherwise normal except for extremities that are cool to the touch.
Of the following, the MOST likely diagnosis is
A. Addison disease B. anorexia nervosa C. Crohn disease D. hyperthyroidism
anorexia nervosa
Deviations in height from normal growth patterns can be the first sign of an underlying medical condition.
Female adolescents with weight loss who engage in intense exercise should be screened for an eating disorder.
Peak height velocity occurs at sexual maturity rating stage 2 to 3 in girls versus stage 3 to 4 in boys.
Delayed puberty is defined as absence of pubertal development at an age that is 2 to 2.5 standard deviations above the mean for the general population. The first sign of puberty in girls is breast development and in boys is testicular enlargement. Evaluation may be necessary in girls with lack of breast development by age 13 years and in boys with lack of testicular enlargement by age 14 years.
A 15-year-old adolescent girl is brought to the office by her mother for evaluation of irregular periods. She had menarche at age 12 years, and her periods were regular for the first 1.5 to 2 years. Over the past 12 months, she has had a period every 1 to 3 months. Her last menstrual period was 4 months ago. Since her health supervision visit 1 year ago, she has gained 9 kg, which she attributes to a poor diet. She has had intermittent flares of acne but no headaches, visual changes, abnormal hair growth, or nipple discharge. There is no family history of menstrual disorders. During the confidential psychosocial interview, she reports that she has never been sexually active.
She has a temperature of 37°C, a heart rate of 80 beats/min, a blood pressure of 120/80 mm Hg, and a respiratory rate of 18 breaths/min. She has a weight of 68 kg (>90th percentile), height of 164 cm (50th percentile), and body mass index of 25.7 kg/m2 (92nd percentile). She has scattered closed comedones on her forehead and cheeks and mild hair growth on her upper lip and lower abdomen. The remainder of her physical examination findings are unremarkable.
Of the following, the test(s) MOST likely to help confirm the diagnosis is (are)
A. follicle-stimulating hormone and luteinizing hormone B. free and total testosterone C. thyroid-stimulating hormone and free thyroxine D. urine human chorionic gonadotropin
free and total testosterone
Polycystic ovary syndrome is the most common cause of chronic anovulation and infertility in young women.
The diagnosis of polycystic ovary syndrome in adolescent girls is often based on evidence of hyperandrogenemia and ovulatory dysfunction.
The most sensitive test for diagnosis in women is a free and total testosterone level.
. It is the most common cause of hyperandrogenic anovulation and infertility in young women. Clinical symptoms include acne, hirsutism, obesity, and menstrual irregularities such as amenorrhea (primary and secondary), oligomenorrhea, and abnormal uterine bleeding.
The workup may include laboratory screenings for late-onset congenital adrenal hyperplasia, thyroid disease, hyperprolactinemia, an androgen-secreting tumor, and primary ovarian failure.
A 14-year-old adolescent boy with cerebral palsy and developmental delay is seen for a health supervision visit. He recently moved from another state, and his mother needs assistance in getting referrals for services such as physical and occupational therapy. She was not pleased with the special education programming provided at her son’s previous school and felt he was placed in too many classes with the general population of students, which were too advanced for him. The patient has an IQ of 65. He is able to interact socially with others and to complete most activities of daily living on his own. His mother is knowledgeable about the Individuals with Disabilities Education Act and the Americans with Disabilities Act. She asks for a letter for his new school to use in developing his individualized education program. She would like the pediatrician to specify that her son not be placed in mainstream classes.
Of the following, the MOST appropriate statement to include in the discussion with the mother is
A. all state and local school districts are required to provide free and appropriate education to children with disabilities up to age 21 years without parental input B. children with disabilities are rarely educated with children without disabilities to the maximum extent possible C. the parents have a right to provide input into the individualized education goals, related-service needs, and placement decisions D. the primary care provider would need to complete a full neurodevelopmental evaluation before requesting that a child with disabilities not be placed in any mainstream classes
the parents have a right to provide input into the individualized education goals, related-service needs, and placement decisions
Free and appropriate public education must be offered to all children with disabilities between 3 and 21 years of age.
Once a child is identified as having a disability, the school is required to evaluate the child to see how to best meet his or her educational needs. The evaluation is done at no cost to the family.
Schools must collaborate and consider the parents’ input when creating an individualized education program.
The child with a disability should be taught in the least restrictive environment alongside students without disabilities, as long as it meets the needs of the child. Schools must collaborate with parents and their CSHCN in creating an IEP. The parents’ input should be considered with regard to goals, objectives, and service needs. The FAPE rules do not require a school to place a child in a specific program or guarantee a specific program desired by the parent.
An 8-year-old boy is seen for a health supervision visit. He is in the third grade in a special education classroom. His parents report that he walked at 2 years, started putting 2 words together at 3 years, and has been receiving physical, occupational, and speech therapy for his entire life. His birth and postnatal history are significant for hypotonia and failure to thrive, and he required a gastrointestinal tube for feeding. His parents are currently concerned about his excessive eating behavior. His weight and height are at the 98th and 2nd percentile, respectively. He has almond-shaped eyes, a thin upper lip, small hands and feet, and a small penis with a hypoplastic scrotum. The remainder of his physical examination findings are normal.
Of the following, the MOST appropriate therapy for this condition is
A. glucocorticoid therapy in the first year after birth with nutrition management
B. growth hormone therapy in the first year after birth with nutrition management
C. growth hormone therapy in the first year after birth with supplementation of carnitine
D. levothyroxine therapy in the first year after birth with nutrition management
growth hormone therapy in the first year after birth with nutrition management
Prader-Willi syndrome is characterized by neonatal hypotonia with failure to thrive. This is replaced by hyperphagia and obesity in early childhood.
Early diagnosis of Prader-Willi syndrome is important; growth hormone therapy in conjunction with nutrition management should begin in the first year after birth, along with appropriate anticipatory guidance.
Treatment in the first year after birth includes GH therapy with nutrition management. Also important in the first year of life is respiratory support, early-intervention developmental services, and appropriate anticipatory guidance. The recommendation is that the clinician discuss GH therapy at the time of diagnosis. Early intervention with GH therapy has been shown to improve body composition and increase lean body mass. In addition, GH therapy initiated within the first year after birth has been shown to have a positive impact on respiratory drive, central apnea, verbal intelligence quotient, language, and cognitive skills.
A 1-month-old infant is being seen for a health supervision visit. She is growing well and developing normally. She was born at term without any complications, and her mother had appropriate prenatal care. She received erythromycin ophthalmic ointment before discharge from the newborn nursery. Her mother often notices mild clear drainage from the girl’s left eye that is easily wiped away with a warm damp cloth. The girl has not had any fevers or other systemic symptoms. The eye does not seem painful and is not injected. There is no lid swelling, tenderness, or erythema. The remainder of her examination findings are normal.
Of the following, the MOST likely underlying cause of this infant’s eye drainage is
A. allergic reaction B. bacterial infection C. lacrimal duct obstruction D. viral infection
lacrimal duct obstruction
Nasolacrimal duct stenosis is common, seen in up to 5% of infants.
Photophobia or eye irritation can be the result of glaucoma.
Injected sclera can occur because of an infection.
The symptom of eye drainage without inflammation or pain occurs because of incomplete opening of the valve of Hasner, the valve between the nasolacrimal duct and inferior nasal meatus
A healthy 16-year-old adolescent is seen for a health supervision visit. Her mother reports no concerns. Vital signs, growth parameters, and physical examination findings are normal. Her sexual maturity rating is stage IV; she underwent menarche at 12 years of age. Her mother reports that their religion prohibits receiving vaccines after menarche. Privately, the adolescent reports that she has researched vaccines on her own and asks that she receive all recommended vaccines.
Of the following, the BEST next step is to
A. administer all recommended vaccines confidentially B. contact the local ethics committee for further assistance C. further explore the mother’s decision regarding vaccination D. report the mother to child protective services for neglect
further explore the mother’s decision regarding vaccination
Open communication is critical when addressing or discussing vaccine or medical treatment refusal or hesitancy, even when the initial reason is religious.
Refusal of routine vaccination may not meet criteria for medical neglect, and dismissal of such families from a medical practice should be used as a last resort.
Most religions do not oppose it, and many actually encourage vaccination. These religions include Christianity, Judaism, Islam, Hinduism, and Buddhism. Catholicism permits vaccination using vaccines manufactured with cell lines derived from aborted human fetal cells (rubella, varicella, and hepatitis A) as long as no other alternative exists. Other groups, such as Christian Scientists, specifically prohibit vaccination.
The mother of a 5-year-old girl is concerned about her daughter’s excessive weight gain. The family spends a lot of time watching TV and playing computer games. The girl’s classmates are starting to tease her about her weight, particularly during physical education. The mother has obesity, and she is very concerned that her daughter seems to be following a similar weight trajectory. The girl’s last health supervision visit occurred 6 months ago. At that time, her body mass index was at the 80th percentile; her history and physical examination findings were otherwise unremarkable. The family has met with a dietician for guidance. The mother seeks advice on sustainable changes that will encourage her daughter to become more physically active.
Of the following, the mother can MOST likely achieve this goal by
A. encouraging her daughter to participate in a local sports program B. increasing her own level of physical activity C. requesting a referral for physical therapy for her daughter D. setting time limits on computer use at home
increasing her own level of physical activity
Parents should be counseled to serve as role models for healthy levels of physical activity.
Decreased screen time does not correlate with increased participation in healthy levels of physical activity.
Children with developmental coordination disorder benefit from early referral for physical therapy.
Provide toys that encourage physical movement
Balls in a variety of shapes and sizes
Ride-on toys without motors or batteries
Rocking toys
Boxes for climbing and building
Find opportunities to increase walking as a family
Walking-oriented family activities (eg, zoo, park, scavenger hunts)
Geocaching or other activities that combine technology with physical activity
Walking, in place of other transportation modes, when feasible
Encourage children to perform or help with physically active chores
Dog walking
Yard work
Housework
Learn a new activity as a family
Rock climbing
Bird watching
Dancing
Gardening
