Week 2 - Pediatric assessment Flashcards
Newborn assessment
i. Eye screening – ocular
prophylaxis
vii. Hearing
ii. Rh status
iii. STDs
iv. Sickle cell anemia
v. Hypothyroidism
vi. Phenylketonuria
viii. Heart defects
ix. bilirubin
APGAR Score
0 is poor, 2 is good
- Activity (limp, some flexion, well flexed)
- Pulse (none, <100, >100)
- Grimace (no response, some motion, cry)
- Appearance (skin color – blue/pale, body pink extremities blue/ completely pink)
- Respiration ( absent, weak cry/hypoventilation, good strong cry)
Newborn physical assessment
i. Vital signs
ii. Skin – lanugo, vernix, dry cracked skin
iii. Head – modelling in vaginal delivery over suture lines
1. Fontanelles, anterior 2-3cm, posterior 1cm
iv. Face – symmetric, evaluate for dysmorphic features
v. Eyes – symmetry, size and angle of palpebral fissures, uncoordinated eye movements are common, conjuntivae may be red due to prophylaxis, check red reflex bilaterally
vi. Ears – patency of EAC, universcal screening for hearing loss
vii. Nose – patency check by closing one nostril at a time
viii. Mouth – size, symmetry of lips, movement
ix. Neck – full range of motion
x. Thorax – shape and symmetry, supernumerary and inverted nipples are common
xi. Lungs – coughing after birth, rales or crackles
xii. Heart – perfusion, point of maximal impulse, 100-190 BPM, murmurs common, BP
xiii. Abdomen – slightly protuberant and soft, fine bowel sounds, palpate liver, kidneys, spleen, first stool 24-48 hours old
xiv. Genitalia – male – testes not in sack but retrievable, check for hydrocele, femail – white discharge
xv. Anus/rectum – patency
xvi. Back/hip – curvature of feet and legs, check clavicles for fracture, check for lesions, dimples or hair along the spine, ortolani and barlow manuevers to check hips
xvii. Neuro – observe tone, movement and symmetry of extremities, elicit reflexes – suck, rooting, swallow, palmar, moro, ankle,
Newborn digestive system and nutrition
i. GI tract not fully functioning until 3 months old
ii. Digestion controlled by hydrochloric acid and renin
iii. Pancreatic amylase (for carbohydrate metabolism) deficient until 4-6 monhts old
iv. Trypsin – catabolizes proteins into polypeptides and amino acids
v. Stomach enarges to accommodate intake of food
vi. At 1 year old – tolerate 3 meals plus 2-3 snacks and milk/formula
vii. Change in stools from frequent to 1-2 a day by 1 year old
Well-Child Visit - 1-3 months old
- Sleep – 15-16 hours per night
- Structured feeding and nap times
- Safe sleep
- Tummy time
- Bright books, easy grab toys, frequent face to face time
- Consistent feedings
a. Check ability to feed, weight gain, caloric intake - Talk and or/sing every day
- Social interaction with parents, how babies react to their environment and parent’s emotional state
- Stimulating environment for cognitive development – board books, rattles, mirrors
Well-Child Visit - 4-5 months old
- Sleep – can differentiate between day and night, sleep 10-11 hours straight, 2-3 naps per day
a. Move to crib, bedtime routine - Strength and motor coordination
a. Childproof home due to increased infant mobility
b. Floor time - Nutrition
a. Ready for solid foods when good head control, sit upright alone, diminished toungue thrust reflex
b. Start peanuts 4-11 months
c. Start with infant cereal - Communication/language
a. Talk/sing throughout the day
b. Infants babble
c. Daily reading - Social/emotional growth
a. Sucking on fingers and toes
b. Reorient unwanted behavior – short attention span - Cognitive and emotional stimulation
a. More attention and play activities
b. Explore outdoors, neighborhood shops, libraries
Well-Child Visit - 6-8 months old
- Sleep
a. Sleep routine – infant in crib when tired but awake
b. Let infants who wake up put themselves back to sleep - Strength and motor coordination
a. Floor time – scoot, crawl, stand
b. Toys for enrichment
c. Childproofing
d. Active supervision - Nutrition
a. Start solids at 6 months (if not done earlier)
b. Encourage self feeding
c. Eat with family once per day - Communication/language
a. Talk with facial expressions, hand gestures
b. Read daily - Social/emotional growth
a. Favority toy or security blanket
b. Express anxiety, pleasure, discomfort, hunger, being tired - Cognitive/environmental
a. Cause and effect toys
b. Peek-a-boo
Well-Child Visit - 9-12 months old
- Sleep
a. Daily routine
b. Bed with comfort item - Strength/motor
a. Cause and effect
b. Childproofing (meds and guns)
c. Do not leave alone in the tub - Nutrition
a. Pureed, finger foods, self-feeding,
b. Wean from bottle/pacifier by 12 month - Communication
a. Gestures, pointing, vocalization, animal sounds, naming body parts or describe foods, colors etc. - Social/emotional
a. Discipline by encouraging positive behavior rather than punishment
b. Stranger anxiety - Cognitive and Environmental Stimulation
a. Play – wheels on the bus, stacking toys, board books, spoons and cups for dexterity
Anticipatory guidance - Language development
Communication/language
a. Reinforce speech and language (remember non verbal like touch)
b. Daily opportunity to practice languge skills (do not put pressure on the child to perform)
c. Receptive language first, then expressive – may not understand connotation
i. Explain which words appropriate in which settings
Anticipatory guidance - social and emotional growth
a. Actively engage with children and give guidance on appropriate behavior
b. Creative toys, nature play, allow exploration, allow choices
c. Idenfity and name feelings
d. Teach to manage anger and resolve conflicts
e. Limit screen time
f. Clear and consistent expectation
g. Differentiate discipline from punishment
h. Parents show affection
i. Needs to provide child with feeling of safety
Anticipatory guidance - cognitive and environmental stimulation- toddler
a. Provide repeated explanations to toddler
b. Don’t’ put own meaning on toddler’s question
Mental health in children
- Cognitive delays may be difficult to recognize without standardized screening
Healthy nutrition
- 5 nutritious meals and 2 nutritious snacks daily
- Eating routine with 1 meal together per day
- Monitor food choices and advise on best ones
- Importance of water and healthy food
- Encourage participation in meal planning
- Discuss nutritious choises for quick meals, school lunches, eating out
- Model healthy behavior and healthy self care behaviors
Physical activity recommendation
60 active minutes per day
Oral health
- Brushing 2x day and flossing
- Dentist 2x a year
- Dental home
- Proper hygience for orthodontic appliances
- Mouth guard during contact sports
Healthy sexual development & sexuality
- Confidential environment for info exchange
- Guidance toward healthy sexual behaviors
- Support parents and patients to provide healthy sexual behavior guidance –
a. Abstinence
b. Limiting sexual partners
c. Safe sex practices - Education on condoms, STI and HIV prevention
- Education about appropriate birth control
- Questions to explore gender identity, orientation, sexual partners, history of STIs or unintended pregnancy
- Finding out of the individual has exchanged sex for money or drugs
- Assessing sexual maturity progression
- HIV and STI screening
- Hep B and HPV vaccines
Counselling and support services
- Food resources
- Temporary shelter
- Counselling and mental health services
- Foster care
- Medical and social work services
- Juvenile protective services
- Drug rehabilitation programs
- Alternative school/vocational education programs
- Sports, fitness activities
- Support programs big brothers big sister
Screening for abuse
i. Have a low threshold for considering abuse with broken bones and injuries
ii. Story does not match injuries
iii. Fall from low heights
Gender identity development
Ask open questions, “kids your age ask about…”
Down’s Syndrome
a. Down syndrome is usually caused by an error in cell division called “nondisjunction.” Nondisjunction results in an embryo with three copies of chromosome 21 instead of the usual two.
Features of Down Syndrome
i. A flattened face, especially the bridge of the nose.
ii. Almond-shaped eyes that slant up.
iii. A short neck.
iv. Small ears.
v. A tongue that tends to stick out of the mouth.
vi. Tiny white spots on the iris (colored part) of the eye.
vii. Small hands and feet.
viii. A single line across the palm of the hand (palmar crease)
Neuro/developmental problems in Down Syndrome
i. Intellectual/cognitive disability/developmental delays
ii. Hearing loss
iii. Hypotonia (infant)
Role of the PCP for Down Syndrome children
Monitor for:
- hypothyroidism
- heart defects
- OSA
- eye exams
- neurological deficits
- growth
When should genetic testing be done in children?
i. Has a positive history for inherited disorder for
ii. dysmorphic features on physical exam consistent with known syndrome
iii. Known inborn errors of metabolism
iv. Noted developmental/growth and/or structural abnormalities
What services do genetic specialists provide?
i. Ordering the correct tests
ii. Understanding inheritance patterns and recurrence risk
iii. Genetic testing
iv. Nuances of congenital and inerited disorders
v. Evolution of clinical manifestations across the lifespan
Characteristics of Fetal Alcohol Syndrome Disorder
i. Poor pre/postnatal growth
ii. Hypotonia/poor coordination
iii. Cardiac defects
iv. Narrow eyes
v. microphthalmia,
vi. large epicanthal folds
vii. microcephaly
viii. small upper jaw
ix. smooth groove in upper lip,
x. thin upper lip
Delayed development in three or more areas: cognitive, speech, motor, psychosocial
Gender identity
A person’s internal sense of being a man/male, woman/female, both, neither, or another gender.
Gender expression
The way a person acts, dresses, speaks, and behaves (i.e., feminine, masculine, androgynous).
Gender dysphoria
Distress experienced by some individuals whose gender identity does not correspond with their assigned sex at birth
Hypothyroidism in children
- newborns are screened
- Hashimoto’s (autoimmune) is most common cause
- PE may be normal for newborns, older children may have delayed growth, weight gain, goiter, delayed deep tendon reflexes
- Managed with levothyroxine
Adrenal insufficiency
Deficiency of hormones produced by the adrenal cortex; deficits of cortisol and aldosterone are perhaps the most detrimental to body function
Primary adrenal insufficiency
inability to produce cortisol secondary to an enzyme defect in the adrenal steroid pathway
Secondary adrenal insufficiency
Result of ACTH deficiency
Clinical findings in adrenal insufficiency
- Poor appetite
- Failure to thrive
- Weight loss
- Weakness
- Vomiting
- Lethargy
- Dehydration
PE findings in patients with adrenal insufficiency
- Dehydration
- Hypotension
- Excessive pigmentation of skin and mucous membranes
Treatment for adrenal insufficiency
Hormone management by an endocrinologist
Tanner stage 1 - female
Preadolescent - no growth of pubic hair
No breast budding
Tanner stage 2- female
Initial, scarcely pigmented straight hair, especially along the medial border of the labia
Breast budding
Tanner stage 3- female
Sparse, dark, visibly pigmented curly hair on the labia
Enlargement of areola and breast tissue
Tanner stage 4- female
Hair coarse, curly and abundant but less than an adult
Separation of areola and nipple from breast - onset of menarche
Tanner stage 5- female
Lateral spreading of adult hair to medial surface of thighs
Fully developed breast, single breast contour with nipple protrusion
Tanner stage 6- female
Further extension of hair laterally, upward or dispersed (only happens in 10% of women)
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HEADSS assessment
i. Home environment
ii. Education/employment
iii. Activities
iv. Drugs
v. Sexuality/suicide/depression
vi. Safety
Tanner state 1 male
No genital growth
Tanner stage 2 male
Enlargement of testis and increased scrotal pigmentation
Tanner stage 3 male
Enlargement of penis and testicles
Tanner stage 4 male
Enlongation of penis and enlargement of testis. Development of axillae and facial hair
Tanner stage 5 male
Adult size. Increase in facial and body hair. Increase muscle mass.
