An Approach to the Pediatric Patient
Michele Lossius, MD Department of Pediatrics University of Florida
Welcome to: Clinical Diagnosis
What to expect 7 Encounters Introductory Lectures
Interactive Sessions
Young Y oung Pediatric Pediatric Patient Patient
1 Newborn
Adolescent Patient Patient
Congenital Heart Disease
3 Pediatric patients
Overall
Learning, practice, and fun!
What is Pediatrics??? Children are not little adults!!!
Health
Growth and development
Full potential
Behrman in Nelson’s Textbook of Pediatrics
A General Approach to the Pediatric Patient
Age Based: – Newborn/Infant – Early Childhood – Middle Childhood – Adolescent
Must relate to the child and the parents/caretaker Anticipatory Guidance
Types of Patient Encounters
Health Supervision Acute Care
Follow-up Care
Initial/New Patient
Prenatal Interview
Health Supervision Visits Longitudinal Care: Year 0-1
Year 1-2
Year 2-3
Year 3-21
Newborn
12 months
24 months
YEARLY YEARL Y
2-4 weeks
15 months
30 months
1 month
18 months
2 months 4 months 6 months 9 months
Health Supervision Visit: Components http://brightfutures.aap.org/
Current Concerns (CC/HPI) Past Medical History (PMHx): birth history, neonatal problems, medical problems/concerns, hospitalizations, surgeries Growth and Development: Development : plot on age appropriate growth charts Screening:: Hearing, Vision, Lead, TB, etc Screening
Immunizations
Health Supervision Visit: Components (cont)
Nutrition Sleep Patterns/ Habits Family History: History: age and health of family members, known genetic or other disorders, drug and alcohol use Social History: History: household contacts, daycare, school, environmental and personal safety assessment Physical Exam Anticipatory Guidance Guidance
Growth Charts
Sex Specific – Male vs. Female
Age-Specific Age-Speci fic – Birth → 36 months – 2 → 20 years – Disease specific
Graphs for: – – – – –
Weight Length Head Circumference Weight : height ratio BMI = Wt (kg)/ Ht (m)2
Growth Chart: Female 0-36 months
Health Supervision Visit: Newborn (0-1 month) Review pregnancy and neonatal history Discuss other concerns (eg. jaundice, spitting up) Assess growth and development
– Weight, height, head circumference
Screening and Immunizations PHYSICAL EXAM Offer anticipatory guidance and parental support – Nutrition/Feeding – Sleep – Safety
PEARLS What do I examine first? I think I heard a murmur????? Reflexes: Moro reflex
Gala Ga lant nt re refl flex ex
What is a soft spot?
What is a red reflex?
Health Supervision Visit: Infant (1-12 months) Review current parental concerns (rash, colds) Assess growth and development development
– Weight, height, head circumference
Discuss sleep Discuss nutrition – – – –
Breastfeeding Formula Food introduction +/- Supplements
Discuss voiding/stooling patterns Screening/Immunizations (birth, 2, 4, 6 months) Offer anticipatory guidance and parental support PHYSICAL EXAM
Pearls What do I examine first? Do I have to use the exam table? Remember to talk to the patient and family during the exam. Distraction I have never seen a baby…what is cooing?
Cooing
Health Supervision Visit: Toddler (1-3 years) Review current parental concerns (behavior, naps) Assess growth and development development
– Weight, height, head circumference (up to 36 36 months)
Discuss sleep and nap history Discuss nutrition – Food variety – Snacks – +/- Supplements
Discuss voiding/stooling patterns and toilet readiness Behavior and discipline Screening/Immunizations (12, (12, 15, 18 months) Offer anticipatory guidance and parental support PHYSICAL EXAM
Pearls What do I examine first? Where do I examine the patient? How do I examine the ears of a screaming toddler?
Health Supervision Visit: Preschool (4-5 years)
Review current parental concerns and assess “Kindergarten readiness” Assess growth growth and development – Weight, height, BMI
Discuss sleep and nap history Discuss nutrition – Food variety – Snacks – +/- Supplements
Discuss toileting practices Behavior, discipline, separation anxiety Immunizations (4 year old boosters) Offer anticipatory guidance and parental support PHYSICAL EXAM
Pearls Now we have conversationalists Anticipatory guidance during exam
–Strangers –Inappropriate touch –Guns, seat belts, belts, helmets
Basics of Development
Gross Motor Milestones Fine Motor Milestones Receptive Language Expressive Language Behavioral Development
Infant Developmental Milestones: Birth 1 month
Moves extremities equally Hands fisted Responds to sound Cries
Discuss:
– General Temperament Temperament – Crying and Colic
Infant Developmental Milestones: 2 months Holds head at 45 degrees on stomach Holds rattle when placed in hand Regards speaker and Vocalizes “ooo” and social smile
Infant Developmental Milestones: 4 months
Bears weight on legs; rolls over Grasps hands together Looks toward voice Squeals/laughs
Infant Developmental Milestones: 6 months
Pulls to sit with no head lag; sits unassisted Transfers object hand to hand Turns to voice Imitates sounds; babbles
Infant Developmental Milestones: 9 months
Crawls; pulls to standing Thumb-finger grasp Understand “no” Non-specific babbling – “dada” – “dada” – “mama” – “mama”
Infant Developmental Milestones: 12 months
Stands alone, cruises, may walk Fine Pincer grasp Follows command with gesture Specific Words (2-3)
Infant Developmental Milestones: 15 months
Walks well, stoops & recovers Drinks from cup Follows simple commands 3-5 words
Infant Developmental Milestones: 18 months
Beginning to run, climb Uses spoon; Scribbles Points to body parts 10-25 words
Infant Developmental Milestones: 2 years
Jumps, throws and kicks ball Removes clothing Two step commands 2 word sentences
The mother of a 2-year-old girl is very concerned that her daughter is developmental devel opmentally ly delayed. delayed. She explains explains that that the girl speaks in two- to three-word phrases. She can feed herself with a spoon, but is unable to button her clothing. She can follow simple two-step commands and can climb stairs. However, she is not yet toilet trained. Findings on physical examination are unremarkable. Of the following, you are MOST likely to: A. discuss the normal normal developmental developmental milestones of a 2-year-old 2-year-old child B. refer the the child child for a neurodevel neurodevelopme opmental ntal evaluat evaluation ion C. ref refer er the the child child for for audiol audiologi ogicc eva evalua luatio tion n D. refer the the child child for occupa occupation tional al therapy therapy E. schedule a 6-month 6-month follow-up evaluation evaluation to see if the the child has reached the milestones
Infant Developmental Milestones: 3 years
Balances on one foot; Jumps broad Copies a circle Knows age and gender Speech 75% intelligible
Infant Developmental Milestones: 4 years
Dresses without help Copies +; draws person < 4 pts Counts to 4 Tells a story
Infant Developmental Milestones: 5 years ASSESS SCHOOL READINESS!!! Skips Prin ints ts let lette ters rs;; dr draw awss Pr person 6 parts Counts to at least 10 Plays competitive sports
Infant Developmental Milestones: 6-11 years
School progress Teacher concerns: – Cognitive – Behavioral
Activities and sports Social interactions Chores, TV, video games
Immunizations
Pediarix
Proquad
DTaP Hepatitis B Polio Haemophilus influenza type B (Hib) Pneumococcal vaccine Measles, Mumps, Rubella (MMR) Varicella Meningococcal (MPSV4) Influenza (yearly) Human Papilloma Virus Hepatitis A Rotavirus Tdap
Immunizations: Age 0-6
Immunizations: Age 7-18
Environmental and Personal Safety Assessment
Car seats and seat belts Bicycle helmets Firearms in home Tobacco smoke exposure Lead exposure Tuberculosis exposure Poison Control Home safety Pool safety Oral Health
Healthy People 2010 http://www.cdc.gov/nchs/healthy_people.htm
Physical Activity Overweight and Obesity Tobacco use Substance abuse Responsible sexual behavior Mental Health Injury Prevention Environmental quality Immunizations Access to care
Acute Care Visits Sick children do not act like well children! Vital signs as indicated by illness:
– +/- O2 sat – weight
Pertinent related history Follow-up on prior problems Pertinent physical exam
Follow-up Visits
Assess management and and therapy of previously identified concerns: – Otitis media – Speech Delay – Asthma
Vital signs as indicated per problem Pertinent related history to identify progression of illness
Pertinent physical exam
New Patient Visits
Complete medical history – – – – – –
Medical conditions Hospitalizations Surgeries Immunizations Allergies Growth and development development
Complete physical exam Get a feel for the patient and family Schedule a return visit if problems are complicated or numerous
Prenatal Interview
Familiarize parents with office Establish rapport with parents Explain routine visit schedule Ease parents’ anxieties Discuss normal and abnormal newborn activities and when/how to contact pediatrician Discuss feeding plans
The Physical Exam Newborn Toddler Preschool Age Child Adolescent
mms://129.106.144.1/archive mms://129.10 6.144.1/archive/ms/pedi/P /ms/pedi/PDPhysical.wmv DPhysical.wmv
