Pediatric exam Flashcards
well child exams: 3 specific areas at each visit
Physical development
Cognitive development
Social & emotional development
Developmental Stages
Newborn 0-28 days Infancy 0-12 months Toddler/Early Childhood 1-4 years School-aged/Middle Childhood 5-10 years Adolescence (11-20 years) Early, middle, & late
Principles of Development
Predictable pathway
Controlled by maturing brain
Age specific milestones
Range of normal development is wide
Mature at different rates
Development & health affected by physical, social, environmental factor & disease
Ex: child abuse, chronic illness & low socioeconomic status
Alter rate & course of development
Hx & PE altered depending on developmental level of child
Approach differs from PE of adults
Understanding normal developmental progression helps you
baby terminology and apgar
Neonate/Newborn
Defined as the first 28 days of life
Infant
Includes the neonatal period up until and including 12 months of age
birth:
Provided neonatal resuscitation if needed
Vast majority neonates only require drying and bulb suction
APGAR Scoring 5 components classify newborn’s neurologic recovery from birth & immediate adaptation Score with 0, 1, or 2 points each: A: Appearance (color) P: Pulse G: Grimace (reflex irritability) A: Activity (muscle tone) R: Respiratory effort
apgar scoring
appearance: blue- 0, pink body blue ext.- 1, pink all over 2
pulse: absent: 0, 100- 2
Reflex irritability: no response- 0, grimace- 1, crying vigorously, sneeze or cough- 2
activity: flaccid- 0, some flexion of arms/ legs- 1, active movement- 2
resp effort: absent- 0, slow & irrecgular- 1, good, strong- 2
1 minute: 0-4 severe depression
5-7- some nervous system depression
8-10- normal
5 minute: 0-7 high risk for subsequent CNS & other organ system dysf.
8-10 normal
hospital evaluation of neonate
Done within 24 hours after delivery
Review maternal hx Medications, medical hx, and labwork (esp. GBS status = group B strep status) Review delivery record Gestation, mode of delivery, duration of labor, augmentation/induction, complications (vacuum/forceps, O2, etc.), APGAR, blood glucose (if done) Full head-to-toe exam including: Molding/fontanelles Red reflex Palate Genital Hip exam Primitive reflexes Count fingers and toes!
hospital: shortly after delivery
Erythromycin ointment in eyes to prevent infection
Vitamin K injection to prevent bleeding
Full bath
Estimating age by physical development
Gestational age and birth weight
Help predict medical problems and morbidity
Gestational age
- Based on neuromuscular signs & physical characteristics that change with gestational maturation
- Use of the Ballard Scoring System
ballard scoring system
To determine gestational age in weeks
Neuromuscular maturity
-1 to 5
Physical maturity
-1 to 5
Add both categories and use maturity rating scale to correlate total score
Gestational age classifications
42 wks post term
birth weight classification
ELBW
small/ large for gestational age
SGA 90th percentile
feeding after birth
Neonate feeding Every 3 hours Breastfeeding initially small volumes of colostrum milk will “come in” after 2-3 days and larger volumes will be taken in Formula 15-30 ml (0.5-1 oz)
Weight
Normal to lose up to 10% of birth weight over first week
Should be regained by 10-14 days of life
Voiding
3-4 voids in first 1-3 days is normal
by day 4-5 should see 6-8 voids per 24 hour period
babies and stooling
Initial stools are meconium
Should stool within first 24-hours of life
Dark, black, tarry
By 4-5 day stools change depending on type of feeding
Breast-yellow, seedy
Formula-sometimes green-yellow
Jaundice
Checked either with transcutaneous bilimeter or serum direct/indirect bilirubin levels within first 24 hours
Compare to nomogram; repeat levels if concerning (level or rate of rise)
Distinguish physiologic from pathologic jaundice
Physiologic usually appears on day 2-3
Must investigate jaundice that appears within the first 24 hours of life!
Also check Tbili if moderate visible jaundice
- ABO incompatibility/Rh
-Cephalohematoma
-Infection
-Hemoglobinopathies
–ex: thalassemia
-Enzyme deficiencies
–ex: G-6-PD
Hospital discharge
Vaginal delivery
2 days after birth
Caesarean section
3 days after birth
Prior to discharge given: Hepatitis B immunization Hearing screen Newborn Screening blood test Circumcision done, if desired
PCP follow-up within 24-48 hours after discharge
Weight loss/dehydration
Hyperbilirubinemia
Premature infants higher risk
Well Child Visit
Enable continued assessment of growth and development
- Intervene if needed with advice/medications/specialist referrals, etc.
- Provide immunizations against disease
- Provide parent with information/advice on multitude of subjects concerning infant
- Answer parent questions regarding care, growth and development of infant
Items discussed in HPI Feeding/eating Stooling/voiding Sleeping Development Safety Additional parental concerns
Review PMHx Medical problems Injuries Hospitalizations Surgery Meds Allergies Fmhx Social hx Family structure Pets/guns/daycare, etc.
Interval for well visits
3-4 days- growth 2 week- growth & development, newborn screen #2 1 month 2 mos 4 mos 6 mos 9 mos 12 mos-- HEMOGLOBIN
growth in infancy
Growth in this period is faster than any other age
Birth weight triples by 1 year of age
Height increases by 50 %
Review weight/length/head circumference and percentiles prior to examining patient
growth charts
Weight for age
Length for age or stature for age
Head circumference for age
Weight for length
Components Used for Assessment of Developmental Milestones
Physical
Gross Motor
Fine Motor
Language/Cognitive
Personal/Social
Examples of screening tools:
Ages and Stages
Denver Developmental Screening Test (DDST)
neurological development
progresses centrally to peripherally (grossfine motor)
Head control
Trunk control
Use of arms
Use of legs
Use of hands then fingers
Language/Cognitive development
Language
2 months-cooing
6 months-babbling
1 year-1-3 words
Cognitive
Learns cause/effect, object permanence & use of tools
By 9 months
Recognize strangers (stranger anxiety)
seek comfort from parent during exam
actively manipulates objects
Personal/ social development
Understanding of self & family matures
Social tasks
Bonding
Attachment to caregivers
Temperament
- Can vary greatly from one child to another
- That is, some have better ability to adapt to new environment/stimuli than others
Predictability in schedules
- Helps children feel secure
- Consistency in discipline is important
Examples of developmental milestones
Gross motor: using large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions.
Fine motor: using hands to be able to eat, draw, dress, play, write, and do many other things.
Language: speaking, using body language and gestures, communicating, and understanding what others say.
Cognitive: Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering.
Social: Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others.
General guidelines for exam (infant)
Up to 9 month can do entire exam on table
Infant in diaper only
Make sure baby does not roll off the table!
At 9 months and older examine on parent lap: stranger anxiety develops at this age
For this age group be flexible for exam sequence
Heart/lung first
HEENT generally last
Head circumference
Measure at each visit until 36 months of age
Observe for head shape, symmetry, tilt, lesions, hair abnormalities
Growth Chart
Plot height, weight, & head circumference at each visit
Infant-Growth Chart
Weight for age
Length for age
or stature for age
Head circumference for age
Weight for length
Gen/Resp./CV/Abd. Exams (babies)
Observation
Observe general appearance, comfort, wellbeing, activity level, grooming, temperament, body habitus, nutritional status
Respiratory
Observe breathing pattern, skin color, signs of distress & use of accessory muscles
Auscultate lung fields (ant./post.)
Cardiovascular Compare brachial & femoral pulses B/L Palpate PMI Auscultate with bell & diaphragm BP not routinely measure in child
