An Approach to the Pediatric Patient

Michele Lossius, MD Department of Pediatrics University of Florida

Welcome to: Clinical Diagnosis PEDIATRICS

What to expect
7 Encounters
Introductory Lectures
Young Pediatric Patient

Interactive Sessions
1 Newborn

Overall
Learning, practice, and fun!

Adolescent Patient

3 Pediatric patients

Congenital Heart Disease

What is Pediatrics???
Children are not little adults!!!
Growth and development Full potential

Health

Behrman in Nelsons 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
Newborn 2-4 weeks 1 month 2 months 4 months 6 months 9 months

Year 1-2
12 months 15 months 18 months

Year 2-3
24 months 30 months

Year 3-21
YEARLY

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: 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 What

is a soft spot? is a red reflex?

Health Supervision Visit: Infant (1-12 months)

Review current parental concerns (rash, colds) Assess growth and development Discuss sleep Discuss nutrition
Weight, height, head circumference

Discuss voiding/stooling patterns Screening/Immunizations (birth, 2, 4, 6 months) Offer anticipatory guidance and parental support PHYSICAL EXAM

Breastfeeding Formula Food introduction +/- Supplements

Pearls
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 babywhat is cooing?
Cooing

What

Health Supervision Visit: Toddler (1-3 years)

Review current parental concerns (behavior, naps) Assess growth and development Discuss sleep and nap history Discuss nutrition
Food variety Snacks +/- Supplements Weight, height, head circumference (up to 36 months)

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
do I examine first? Where do I examine the patient? How do I examine the ears of a screaming toddler?
What

Health Supervision Visit: Preschool (4-5 years)

Review current parental concerns and assess Kindergarten readiness Assess growth and development Discuss sleep and nap history Discuss nutrition
Food variety Snacks +/- Supplements Weight, height, BMI

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, 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
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 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 Perfectand this course is about PRACTICE!!!

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

Enjoy Learning About PEDIATRICS!!!