Pediatric Exam and Common Medical Problems Flashcards
Types of Patient Encounters
Health Supervision Well Child Check-up(WCC)
- New or established
- Acute/Illness Care
- Follow-up Care
Health Supervision Visits
- Longitudinal Care:
- Based on “Bright Futures Guidelines” for health supervision from the AAP
WCC @ Year 0-‐1:
Newborn–3-‐5days–2-‐4wks–1mo–2mo–4mo–6mo–9mo
WCC @ Year 1-‐2:
12mo–15mo–18mo
WCC @ Year 2-‐3:
24mo–30mo
WCC @ Year 3–21:
Yearly
Health Supervision Visit: Components
- Current Concerns (CC/HPI)
- Past Medical History (PMHx)
- Growth and Development
- Screening
- Immunizations
- Nutrition/Elimination
- Sleep Patterns/ Habits
- Family History
- Social History
- Physical Exam
- Anticipatory Guidance
Basics of Development
Gross Motor, Fine Motor, Communication (Receptive/ Expressive Language), Cognitive Development, Emotional/ Social/ Behavioral.
Screening Labs and Procedures
- Newborn Metabolic Screening (PKU)
- Hearing screen – OAE testing
- Hemoglobin Screening
- Lead screening
- Dyslipidemia screening
- Tuberculosis screening
- Sexual health in adolescents
- Fluoride Varnish
Hemoglobin Screening
At 12 mo
Lead screening
At 6 months- 6 years,
Testing at 1 and 2 years
Dyslipidemia screening
All children screened for cholesterol at least once between ages 9 and 11 years, and again between ages 17 and 21 years. (from the NHLBI of the NIH) endorsed by the AAP
Tuberculosis screening
- WCC; 2-4 weeks, 6 month, 12 month, 18 month, every WCC from 2 years through 21 years old.;
- Place PPD if at risk
Sexual health in adolescents
Routine pelvic exam not needed until age 21 yrs;
Annual STI screen if sexually active,
First fraction void or vaginal swab for GC/Chlamydia,
Blood draw for RPR and HIV
Fluoride Varnish
WCC at ages; 12, 18, 24 and 30 months
UF Peds Clinic Developmental Screening
Developmental Screening & Autism Screening
Developmental Screening:
- Perform at 18 and 30 month WCC.
- (May also screen other ages as needed; 2-60 months)
Tool: ASQ - Ages & Stages Questionnaire
-Communication, Gross Motor, Fine Motor, Problem solving, Personal-social (6 questions in each category)
Autism Screening:
-Screen at 24 month WCC visits
Tool: MCHAT – Modified CHecklist for Autism in Toddlers
- (validated for screening toddlers between 16 and 30 months of age)
- [23 questions]
THE “HEADS” PSYCHOSOCIAL, INTERVIEW FOR ADOLESCENTS
Home/Health Education/Employment Activities/Associations Drugs/Diet Stress/Sexuality
GOAL OF THE PREPARTICIPATION SPORTS EXAMINATION
- Identify medical problems with risks of life-threatening complications (e.g. past concussions, exercional syncope, family history of sudden death in young individuals)
- Identify pertinent medical conditions (e.g., hypertension, asthma, diabetes, allergies, seizures)
- Identify and rehabilitate old musculoskeletal injuries
- Identify and treat conditions that could interfere with performance (e.g., exercise-induced bronchospasm)
- Remove unnecessary restrictions on participation
Sports Physical Setting
- Office Based
- Records available
- Confidentiality
- Quiet
- Follow up
- Can overwhelm a small practice
- Mass Physicals
- -Large numbers
- -Consistent exams
- -Team able to gather information
- -Cheap
Hypertrophic cardiomyopathy(HCM)
- The leading cause of sudden cardiac death in young athletes
- Physical examination and medical history catch only 3% of cases
- Family history of sudden death (Familial HCM is autosomal dominant)
- 0.2% to 0.5% of the general population
- Syncope, dyspnea, palpitations, chest pain
- ECGs detect abnormalities in ~70% of asymptomatic HCM, but cannot determine if it is specifically HCM
- Echocardiograms are used to diagnose HCM (detect 80+%)
Acute Care Visits
- Sick children do not act like well children!
- Vital signs as indicated by illness: (Weight, ? Temp, ?BP; ? O2 Sat)
- Pertinent related history (Duration, symptoms, Past Hx, Ill contacts, Travel)
- Pertinent or focused physical exam
Follow-up Visits
- Assess management and therapy of previously identified concerns: (Otitis media, Growth, Asthma)
- Vital signs as indicated per problem
- Pertinent related history to identify regression or progression of illness
- Pertinent physical exam
COMPONENTS OF THE PHYSICAL EXAM
HEENT Heart/Lungs Abdomen/GU Skin Musculoskeletal Neuro
Pearls for the Physical Exam
- -Use some developmental milestone knowledge!
- -Distraction – use toys or books
- -Let the child see and touch the exam tools you will be using (Call the otoscope a “flashlight”)
- -Demonstrate on self, parent or doll before using tools on child
- -Remember to talk to the patient and family during the exam.
Pediatric Physical Exam
- -Heart and lungs FIRST!
- -Work down then up
- -Ears and mouth LAST!
Tips for Examining the Young Child
- Use a reassuring voice throughout the examination
- Avoid asking permission to examine a body part (the answer may be “No”!); instead, give choices
- Examine the child in the parent’s lap
- If unable to console the child, allow a short break
Length, Height, Weight, Head
Length/height: After age 2, kids should grow at least 5 cm/yr
Weight: Failure to thrive is inadequate weight gain for age, Growth 2 quartiles in 6 months, Weight for height 97th percentile or 2 standard deviations above mean
Blood Pressure
Elevated blood pressure during exercise, crying, anxiety.
Most frequent “cause” of elevated BP in kids is an improperly performed exam (incorrect cuff size)
Transint HTN can be from meds (prednisone, ritalin);
sustained HTN can be from renal parenchymal or artery disease, coarctation of aorta, and primary hypertension
BP:
Normal 95th percentile
Pulse
More sensitive to effects of illness, exercise, emotion. Palpate femoral or brachial, or listen to heart
Higher in infancy.
Respiration
RR/min is between 30-‐60 in newborn
Higher in infancy, nose breathers.
Temperature
Average is 99 until age 3.
101 normal around late afternoon and after vigorous activity. Young kids can have fever up to 104.
If less than 3 mo get temp rectally, if older do it axillary
Cystic Fibrosis
d/o of mucous clearance
Pathophysiology of Cystic Fibrosis
Autosomal recessive disease (Parents will have 1 in 4 chance of another affected child).
3 base pair deletion on chromosome 7 (CFTR Gene). Abnormal Cl and Na distribution across cell membranes in the epithelium.
Problems occur most often in the lungs, digestive system and sweat glands.
Most mortality is often caused by progressive lung disease. Was initially failure to thrive.
Lungs become chronically infected with pseudomonas and staph. Inflammatory response causes plugging (atelectasis)
Diagnosis of Cystic Fibrosis
-Genetic testing if available in utero and newborn screen (IRT)
Presence of a meconium ileus is the earliest sign of CF (no stooling within 24hours after birth)
Sweat test – sweat chloride concentration greater than 60 mmol/L
Treatment of Cystic Fibrosis
- Treatment consists of high calorie, high protein and high fat diet as well as Pancreatic enzyme supplementation.
- Daily salt supplementation
- Airway clearance therapy (Chest PT—”The vest”)
Prognosis of Cystic Fibrosis
While life expectancy used to be late childhood, CF patients can be expected to live to early to mid-thirties.
Can develop DM, Infertility or liver failure
Laryngomalacia Pathophysiology
Benign congenital disorder cartilaginous support of supraglottic structures is underdeveloped
Common cause of extra thoracic airway obstruction
Laryngomalacia Diagnosis and Clinical Presentation
Persistent stridor in the first 6 weeks of life which may interfere with feeding (rare).
Diagnosed with laryngoscopy
Laryngomalacia Prognosis and Treatment
- Good prognosis with most cases resolving 2-3 years
- In severe cases, can be treated surgically (epiglottoplasy)
Pediatric GERD Pathophysiology
-A common disorders in babies: Small stomach capacity, Frequent large-volume feeding, Short esophageal length & Immature lower esophageal sphincter
Pediatric GERD Clinical Presentation
Severe cases FTT
Colic & Refusal to eat
Asthma, hiatal hernia, Sandifer Syndrome
Pediatric GERD of Prognosis and Treatment
Thickening of food (cereal or guar gum)
Hold upright and/or prop up the head of the crib
Gastric acid suppressors (ranitidine or lansoprazole)
Pyloric Stenosis Pathophysiology
Pyloric muscular hypertrophy (may be familial). Predominantly male, 4 times more often 1st born. Associated with erythromycin use in babies
Pyloric Stenosis Diagnosis and Clinical Presentation
Postprandial projectile vomiting between 2 and 4 weeks of age
-Constipation, Weight loss, Dehydration, Hungry and nurse avidly (at first), Hypochloremic alkalosis with potassium depletion.
Can be seen on sonogram or x-ray after swallowing contrast (“string sign”). May be able to palpate ‘olive-shaped’ pylorus RUQ. Visible peristaltic waves prior to vomiting.
Pyloric Stenosis Prognosis and Treatment
Correction of electrolyte imbalance (Acid-blocking agents) OR Surgical (Ramstedt or double Y pyloromoyotomy)
Constipation Pathophysiology/Diagnosis/Clinical Presentation
2 or more of the following for 2 months: Less than 3 bowel movements per week, More than 1 episode of encopresis per week, Impaction of the rectum with stool, Passage of stool so large it obstructs the toilet, Retentive posturing and fecal withholding, Pain with defecation, Retentive feces in the rectum results in encopresis
60% of children with constipation
Constipation Prognosis/Treatment
- Increase foods with fiber (bran, fruits, vegetables)
- If dietary changes are ineffective, may try stool softeners (Maltsupex, MiraLax)
- For encopresis, miralax (polyethylene glycol), mineral oil, gastro-colic reflex
- Treat for several months to allow bowel to return to normal
- If encopresis recurs, may consider psychiatric or emotional cause
- If persistent problem, consider referral to Gastroenterology for Hirshprung’s Disease.
Diarrhea Pathophysiology
Rotavirus is the most common cause of acute diarrhea in pediatric population (infants between 3 and 15 months of age)
Diarrhea Diagnosis/Clinical Presentation
Most often diagnosed on clinical grounds alone, but can be identified in stool or via electron microscopy
- Incubation of 1-3 days
- Vomiting followed by low grade fever and diarrhea within 24 hours
- Illness usually lasts 4-8 days
- Dehydration
- Metabolic acidosis due to bicarb loss in stool
Diarrhea Treatment
Replacement of fluid and electrolyte deficits (pedialyte)
Other Causes of Diarrhea
- Malnutrition
- Allergy
- Extra intestinal infections
- Antibiotic therapy
Post streptococcal Glomerulonephritis Pathophysiology:
7-14 days post group A B-hemolytic strep infection
Post streptococcal Glomerulonephritis Diagnosis/Clinical Presentation
- High titers of anitstreptococcal antibodies (ASO) or renal biopsy (if renal function deteriorates)
- Gross hematuria (tea-colored)
- Microscopic RBCs
- RBC casts
- Periorbital of facial edema
- Increased serum creatinine
- Hypertension (beta blocker)
Post streptococcal Glomerulonephritis Prognosis/Treatment
- Course generally 2-3 weeks
- Patient to be monitored - if function does decline then will need referral for treatment
- 85% children recover fully with some having hematuria over a year
Hematuria
Most times not harmful, but needs to be checked
Can resolve spontaneously
Hematuria Presentation and Diagnosis
Gross or symptomatic microscopic hematuria
Hx of trauma? (CT abd and pelvis)
S/S of UTI? (Ucx, treat)
S/S of perineal or meatus irritation? (Reassurance and supportive care)
S/S renal/ureteral stones? (Imaging-‐ renal US, abd plain film)
S/S of glomerular casts? (proteinuria, RBC casts)
• Yes – refer to pediatric nephrologists -> Check BUN/Cr,
electrolytes, CBC, C3/C4, albumin
• No? -‐ Consider UCx, U Ca/Creat ratio, test parents for hematuria, hemoglobin electrophoresis, renal US -> Check BUN/Cr, electrolytes, CBC, C3/C4, albumin
CF Presentation
- Failure to thrive (pancreatic insufficiency)
- –Despite good appetite, Reports of bulky foul-smelling stools (malabsorption).
- Recurrent respiratory infections: Increased anterior-posterior chest diameter, Clubbing of fingers.
