An Approach to the Pediatric Patient

Michele Lossius, MDDepartment of Pediatrics

University of Florida

Welcome to:Clinical Diagnosis

PEDIATRICS

Introductory Lectures

Young Pediatric Patient

Adolescent Patient

Congenital Heart Disease

Interactive Sessions

1Newborn

3Pediatric patients

Overall

Learning, practice, and fun!

What to expect7 E n c o u n t e r s

Full potential

Growth and development

Health

What is Pediatrics???

Children are not little adults!!!

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 0-1Newborn

2-4 weeks

1 month

2 months

4 months

6 months

9 months

Year 1-212 months

15 months

18 months

Year 2-324 months

30 months

Year 3-21YEARLY

Health Supervision Visit: Componentshttp://brightfutures.aap.org/

Current Concerns (CC/HPI) Past Medical History (PMHx): birth

history, neonatal problems, medical problems/concerns, hospitalizations, surgeries

Growth and Development: plot on age appropriate growth charts

Screening: Hearing, Vision, Lead, TB, etc

Immunizations

Health Supervision Visit: Components (cont)

Nutrition Sleep Patterns/ Habits Family History: age and health of family

members, known genetic or other disorders, drug and alcohol use

Social History: household contacts, daycare, school, environmental and personal safety assessment

Physical Exam Anticipatory Guidance

Growth Charts

Sex Specific– Male vs. Female

Age-Specific– 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

Galant reflex

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

– 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.DistractionI 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

– Weight, height, head circumference (up to 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, 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 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 conversationalistsAnticipatory guidance during exam–Strangers–Inappropriate touch–Guns, seat 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– Crying and Colic

Infant Developmental Milestones:2 months

Holds head at 45 degrees on stomach

Holds rattle when placed in hand

Regards speaker 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”– “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 developmentally delayed. She explains 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 developmental milestones of a 2-year-old child

B. refer the child for a neurodevelopmental evaluation

C. refer the child for audiologic evaluation

D. refer the child for occupational therapy

E. schedule a 6-month follow-up evaluation to see if 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 Prints letters; draws

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

Copyright ©2008 American Academy of Pediatrics

Immunizations

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

Pediarix

Proquad

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 2010http://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 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

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

Practice Makes Perfect…and this course is about PRACTICE!!!

mms://129.106.144.1/archive/ms/pedi/PDPhysical.wmv

Enjoy Learning About PEDIATRICS!!!