Pediatric exam Flashcards

Question

Examples of developmental milestones

Answer 1

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.

Answer 2

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

Answer 3

Weight for age Length for age or stature for age Head circumference for age Weight for length

Answer 4

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 ```

Answer 5

``` Lungs Chest symmetry Respiratory distress Nasal flaring, retractions, accessory muscle use CV Benign murmurs (PDA first 2-3 days life, Still’s murmur, pulmonary flow murmur) Brachial/femoral pulses GI Liver tip palpable 1-2 cm below costal margin No spleen palpable Can feel kidneys Anal fissures ```

Answer 6

``` Genitourinary Males Visual inspection of genitalia Gently retract foreskin BUT DO NOT FORCE RETRACTION to visualize urethral meatus Confirm B/L descended testicles Presence of hydroceles Palpate for inguinal or femoral hernias ``` Females Visual inspection of external genitalia Palpate for inguinal or femoral hernias Anal/Rectum Observe for position, fissures, fistulas Neurologic Exam Grossly assess cranial nerves (pg 813 Bates) Assess strength & muscle tone Attempt to elicit deep tendon reflexes Assess primitive reflexes in young infants

Answer 7

``` GU Female labial adhesions Male Urethral opening Circumcision Neurologic Primitive reflexes ```

Answer 8

palmar grasp B-4 mos Moro startle reflex B-4 mos rooting B- 3-4 mos parachute 4-6m & does not disappear plantar grasp B-9 m asymmetric tonic neck- B-4 m positive support- B/ 2m- 6m trunk incurvation (Galant's) B-3 m placing/ stepping B(best after day 4) to variable to disappear Landau (suspend prone-->head lifts up & spine will straigthen) B-6 m

Answer 9

Inspect - Symmetry of extremities/length - Obvious deformities Digits—syndactyly, polydactyly ``` Palpate - Spine—scoliosis, spina bifida occulta - Feet—curvature/rotation deformities (in utero) Metatarsus varus clubfoot ```

Answer 10

Hip examination Use Barlow & Ortolani maneuvers to test for signs of dislocation Can indicate developmental hip dysplasia (DHD) If Barlow and/or Ortolani test positive, need imaging to diagnose DHD Tests are effective until around 3 months after this time hip capsule begins to tighten Less reliable after this time Look for other signs--Galeazzi

Answer 11

tests for presence of posteriorly dislocated hip | rotate out

Answer 12

tests for ability to sublux or dislocate intact but unstable hip

Answer 13

``` Head Shape Scalp-wounds, hair pattern, lesions Sutures Fontanelles Eyes Note position & spacing of eyes, palpebral fissures, color, sclera, conjunctiva, eyelids, pupil size, & discharge Red reflex Visual tracking/Extraocular movements ``` ``` Nose Use speculum to assess mucosa/turbinates Avoid septum Ear Observe position (if low set ?genetic abn.), pits or tags Otoscopic exam Mouth Observe philitrum, vermillion border Inspect tongue, gingiva, teeth, buccal mucosa, palate, & oropharynx using tongue blade as needed ```

Answer 14

- Ant font—closes between 4-26 months - Post font—closes by 2 months - Nose-obligate nose breather first 2 months, only ethmoid sinuses present at birth - Teeth—6-26 months 1 tooth per month, usu. Central & lateral incisors first, molar last

Answer 15

Head-anterior/posterior fontanelles Anterior fontanelle Larger and closer later (18m-2yr) Posterior fontanelle Smaller and closes early (1-2 months of age) Both should be flat and soft in consistency Red reflex Reflection of light on retina, generally red in color Should be symmetrical reflection with light held 18 in away Abnormal could equal cataracts, glaucoma, retinoblastoma or other abnormalities of eye Oral Palate, teeth, mucus-cysts (Epstein pearls), tongue abn. (tongue-tied), tonsils Cervical lymph nodes Enlargement, size, shape, mobility Ears Pits/tags TM using insufflator if possible ear infection

Answer 16

``` Neck Observe for masses, pits & clefts Palpate masses Thyromegaly Lymph nodes Clavicle ROM Torticollis ``` Skin Observe skin during each part of the exam looking at face, arms, legs, buttocks, & torso for rashes, moles, skin discoloration (ie. bruises, Mongolian spots, hemangiomas, etc.) Look for sacral dimples, pits, hair tufts Describe any lesions in dermatologic terms in your note

Answer 17

``` Newborn benign rashes Mongolian spots Nevi Hemangiomas Sacral dimple/hair tufts ```

Answer 18

Healthy habits/behaviors Injury prevention, nutrition, oral health Parent-infant interaction Promoting development Family relationship Time for self Community interaction resources Parent usually receptive to suggestions about health promotion

Answer 19

Physical/Motor Rate of growth slows after infancy to approx. half After 2 yrs., gain 2-3 kg & 5 cm per year Gross motor-walk, jump, hop, skip Fine motor-draw lines, make circles Cognitive/Language Sensorimotor learning-touching/looking Simple problem solvingengaging in imitative play 2-3 words to sentences; by 4 yrs. 100% understandable to all Social/Emotional Imitates activities to imaginative play Drive for independence Temper tantrums common

Answer 20

Undress down to diaper Examine on parent lap Use toys/games to distract younger child Allow toddler to touch equipment Use the instrument on parent or toy first Examiner must be flexible on sequence of exam Begin with portions requiring a calm Save less tolerated portions for later Examine area of complaint at the end ``` Head circumference (1-3 yr. olds) 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 Calculate BMI Developmental milestone Confirm that child has met appropriate milestones

Answer 21

Physical/Motor Growth is steady but slow Strength & coordination improve Cognitive/Language Concrete operational-limited logic & more complex learning Self-efficacy Social/Emotional Progressively more independent Development of self esteem-family & environment contribute greatly Evolving self identity

Answer 22

School issues Performance, bullying, special ed, behavioral issues? Does your child have a place to do homework? Start talking about body changes of puberty/age appropriate Remember that health and development is heavily influenced by physical, social, environmental factors and disease (child abuse, chronic illness, socioeconomic status) Some common problems may include: asthma sxs, joint pain, speech development

Answer 23

Dressed in clothes/gowned Examine on table Describe what you are doing step-by-step (4-10 yr. olds) Respect the child’s modesty (usu. 4-10 yr. olds) Examiner must be flexible on sequence of exam Growth Chart Plot height and weight at each visit Calculate BMI

Answer 24

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.) Percuss lung fields ``` Cardiovascular Compare radial & femoral pulses B/L Palpate PMI Auscultate with bell & diaphragm Measure BP in right arm in children >3 yrs. ```

Answer 25

Still’s murmur Grade II/VI, musical, vibratory midsystolic Venous hum Soft, continuous, louder in diastole Carotid bruit Midsystolic, usu. louder on left, eliminated by carotid compression

Answer 26

Abdominal Observe shape, contour, & presence of hernias Auscultate bowel sounds in all 4 quadrants Percuss Palpate & note size of liver & spleen ``` Genitourinary Males Visual inspection of genitalia Gently retract foreskin to visualize urethral meatus Confirm B/L descended testicles Palpate for inguinal or femoral hernias ``` ``` Females Visual inspection of external genitalia Palpate for inguinal or femoral hernias Anal/Rectum Observe for position, fissures, fistulas Look for sacral dimples, pits, hair tufts ``` Lymph node Inguinal chain

Answer 27

Neurologic Exam Grossly assess cranial nerves (Bates pg. 856) Attempt to elicit deep tendon reflexes ``` MSK Observe standing and walking barefoot Assess strength & muscle tone Bowlegged/knocked-kneed Galeazzi test/sign ``` Back Observe for scoliosis, spinal defects, Mongolian spots, dimples & hair tufts Skin Observe skin during each part of the exam looking at face, arms, legs, buttocks, & torso for rashes, moles, skin discoloration Describe any lesions in dermatologic terms in your note

Answer 28

- normal-inc lumbar concavity and dec thoracic convexity and often protuberant abdomen - look at soles of shoes for wear pattern (indirectly assessing gait) - increased bowlegged—genu varum (disappears by 18 months) then knocked-kneed—genu valgum usually maximal by 3-4 yrs and corrects by 9-10 years. - intoeing—may increase up to 4 years then disappear by 10 years age

Answer 29

Head Shape Scalp-wounds, hair pattern, lesions Lymph Nodes Palpate occipital, pre/post auricular, ant. cervical, submandibular, submental, supraclavicular, axillary Neck Palpate thyroid, assess for enlargement and/or masses ``` Eyes Note position & spacing of eyes, palpebral fissures, color, sclera, conjunctiva, eyelids, pupil size, & discharge Red reflex Visual tracking/Extraocular movements Cover/uncover test (9 mo-3 yr olds) Formally assess visual acuity starting at 3 yrs. Nose Use speculum to assess mucosa/turbinates ``` Mouth Inspect teeth, tonsils, & oropharynx using tongue blade as needed Ears (may place exam earlier in PE in older child) Observe appearance and placement Palpate pinnae, tragus, mastoid Otoscopic exam in parent’s lap (on table in older child-generally tolerated by 4-5 yrs of age) Pneumatic otoscopy if suspect otitis media

Answer 30

Permanent teeth begin age 6 Peak of tonsillar growth between 8-16 years age----classified +1to +4 Ears—hearing test—usually begin at ages 3-4

Answer 31

Healthy habits & behaviors Injury & illness prevention Nutrition and oral health Parent-Child interaction Reading, fun time, TV – limiting screen time Family relationships Activities, babysitters Community Interaction Childcare, resources ``` Injury & illness prevention Booster seats Until 8 years and 4’9” Back seat and belted until 13 Bikes and skateboards Swimming, sunscreen Guns Smoke exposure Computer use/screen time (less than 2 hours per day for kids over 2 yrs) Home emergency plan Friends Poison control 1-800-222-1222 ``` Parenting/discipline: Good role models in the home; foster confidence with praise; clear and enforceable limits

Answer 32

Physical Puberty begins F (8-13 yrs.) M(9-13.5 yrs.) Cognitive Concrete operational Social Focus is on present Identity-’Am I normal?’; peers increasing importance Independence-ambivalence Concrete operational -The child is now mature enough to use logical thought or operations (i.e. rules) but can only apply logic to physical objects.

Answer 33

Physical Females feel more comfortable; males awkward Cognitive Transitional (concrete to formal operational thinking); many ideas Develop insight, reflect on feeling/thought of others Social Identity-‘Who am I?’; much introspection Independence-limit testing; experimental behaviors; dating

Answer 34

Physical Adult appearance Cognitive Formal operational Social Identity-role with respect to others, sexuality, future Independence-separation from family; toward real independence *Adolescent behavior related to developmental stage and not necessarily to chronological age or physical maturity

Answer 35

Patient should be gowned Examine on table Respect adolescent’s need for privacy & modesty Give pt. option of asking parent to leave room during PE Always have chaperone for breast & GU exam Describe what you are doing step-by-step Position patient & drape Use correct terminology for locations Ask patient to point to areas of pain & examine that area last Growth Chart Plot height & weight at every visit Calculate BMI

Answer 36

Underweight | or = 95thpercentile

Answer 37

Vital signs BP with appropriate sized cuff ``` Observation Observe patient’s general appearance Comfort, wellbeing, activity level, grooming, temperament, body habitus, nutritional status Head Shape, hair pattern, lesions ``` ``` Eyes Note position & spacing of eyes, palpebral fissure, color, sclera, conjunctiva, eyelids, pupil size, discharge Red reflex Fundoscopic exam Visual tracking/extraocular movements Formal visual acuity assessment ```

Answer 38

Nose Use spectulum to assess mucosa/turbinates Avoid septum Mouth Inspect teeth, tonsils, oropharynx Ears Observe appearance & placement Palpate pinnae, tragus, mastoid Otoscopic exam Lymph Nodes Palpate occipital, pre/post auricular, ant. cervical, submandibular, submental, supraclavicular, axillary Respiratory Note breathing pattern, skin color, signs of distress, use of accessory muscles Percuss Auscultate Cardiovascular Measure BP in both arms Compare radial & dorsalis pedis pulses B/L Palpate PMI Auscultate with diaphragm & bell with pt. lying at 30 degrees Abdominal Observe shape, contour, presence of hernias Auscultate bowel sounds in 4 quadrants Percuss abdomen Palpate abdomen, note size of liver/spleen

Answer 39

``` MSK Assess gait Strength & muscle tone Observe for scoliosis, spinal defects, or lesions Neurologic Elicit deep tendon reflexes Assess cranial nerves II-XII Sensory exam ``` Observe skin during each part of the exam looking at face, arms, legs, buttocks, & torso for rashes, moles, skin discoloration Describe any lesions in dermatologic terms in your note

Answer 40

Have chaperone present for exam Visualize external genitalia to confirm Tanner staging Male: Examine standing, observe & gently retract foreskin to visualize urethral meatus Palpate testicles for masses Palpate for inguinal/femoral hernias Females: Visual inspection of external genitalia Palpate for inguinal/femoral hernias *pelvic/breast exams-not performed until patient reaches 21 yrs. or 3 yrs. after onset of sexual activity

Answer 41

Adrenarche Activation of adrenal medulla for production of adrenal androgens Occurs before the onset of puberty Gonadarche Earliest gonadal changes of puberty-GnRH released Boys-LH stimulates testosterone production and FSH stimulates sperm maturation Girls-FSH stimulates estrogen & follicle formation and LH stimulates corpus luteum after ovulation Thelarche Beginning of breast development at puberty Pubarche Beginning of pubic hair Menarche Occurrence of first menstrual bleeding (menstruation)

Answer 42

Tanner stages or sexual maturity ratings (SMR) By Marshall and Tanner Systematized description of development of secondary sexual characteristics Girls-breast & pubic hair changes Boys-genital & pubic hair changes Five categories Stage 1-prepuberty Stage 5-adult development

Answer 43

2- elevation breast/ nipple as small mound (breast buds) Tanner 3- further enlargement of breast/ areola, no separation of contour Tanner 4- projection areola/ nipple to form secondary mount Tanner 5- mature stage, projection of nipple only

Answer 44

1- preadolescen- no pubic hair except for fine body hair (vellus hair) similar to that on abdomen 2- sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along labia 3- darker, coarser, curlier hair, spreading sparsely over the pubic symphysis 4- coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thights 5- hair adult in quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen

Answer 45

Order of changes: - Breast buds - Pubic hair - Growth spurt peaks (age 12) - Menarche (T4) Complete in 1.5-8 yrs. (avg. 4 yrs)

Answer 46

Tanner 1-preadolescent-no pubic hair (fine body hair only); penis/testes same size as childhood Tanner 2-Pubic hair-sparse slightly pigmented, straight. Penis-slight or no enlargement. Testes/scrotum-larger, slightly reddened Tanner 3-Pubic hair-darker, coarser, curlier, sparsely over pubic sym; Penis-larger in length. Testes/scrotum-further enlargement Tanner 4-Pubic hair-Coarse/curly greater than stg 3 but not as great as adult; not on thighs. Penis-further enlargement length/breadth w/ dev. of glans. Testes/scrotum-further enlarged, scrotal skin darkened Tanner 5-Pubic hair-adult quantity & quality, spread to medial thighs. Penis-adult size &shape. Testes/scrotum-adult size & shape.

Answer 47

Sequence of changes: - Testicular growth first - Pubic hair - Penile enlargement - Growth spurt peaks (age 14) Complete in 2-5 yrs. (avg. 3 yrs)

Answer 48

Anticipatory guidance Teen Promote healthy habits & behaviors Injury & illness prevention, nutrition, oral health Sexuality Confidentiality, safer sex, sexual behaviors Substance abuse Prevention strategies, parent-teen interaction Social Achievement Activities, school, future Community Interaction Resources, involvement Guidance for parents Positive interactions, support, safety, limit setting, modeling behaviors