24 Months to 18 Years + PPPE (Pre-Participation Physical Exam)

Age 24 Month 30 Months 3 Year 4-5 Years 6-10 Years 11-18 Years PPPE
Measure- Wt HC Wt HC Wt BMI% Wt BMI% Wt BMI% Wt BMI% Wt BP BMI%
ments Length BMI% Length BMI% Ht BP Ht BP Ht BP Ht BP Ht PR Vision
Develop- •Walks up and •Points to 6 body •Jumps in place •Hops, Skips Tan- FEMALES MALES Key Visit Issues
ment: down stairs parts ner
•Pedals tricycle •Dresses self Breast Age (Y) Testes Age(Y) •History: Have Pt/Parent fill out
Normal •Throws/kicks ball •Uses 3-4 word Stage
•Copies square then W AA medical history side of PPPE while
•Pulls off clothes phrases •Copies circle none
triangle I < 2cm waiting for MD
•2 word sentences •Knows correct •3-4 word sen- •Knows colors II Breast bud
10+-1.8
8.9+1.9 >2.5cm 11.8(9.8-14.2) •Review med hx info with Pt/Parent
action for tences diameter
•50% speech animal/human •Tells stories <areola
•Nutrition/supplements
•Shares III Breast 11.3+1.4 10.9 + 1.4 >3 cm 13.0(11.7-14.6)
understandable to (man talks, bird •100% speech diameter > •Ergogenic/Performance Enhancing
12.9 + 1.2 12.16+1.2
stranger flies) •75% speech understandable to areola 14.3(12.6- 15.8) Substances
IV Mounding >4 cm
understandable to stranger of areola
12.9(10.4 –15.3)
•Recent illness (esp. Mono)
•Jumps in place
stranger Adult 15.1 (12.9- 17)
•Throws ball v 14.5(11.3-17.8) 5 cm •Current Medications
overhand Pubic Age (Y) Pubic Hair Age(Y) NOTE: DICTATE ALL SCREENING
•Copies vertical Hair W AA QUESTIONS NORMAL ON PPPE
line I none none FORM EXCEPT AS NOTED… then list
II Sl. 8.8 + 2.0 Sl. Pigmented abnormal
•Puts on clothes 10.5 + 1.7
12.2(10.7-13.8)
Pigmented. base of phallus
with help mons, labia or scrotus
•Brushes teeth III Dark,
11.5 + 1.4 10.4+ 1.4 Dark, coarse. 13.9(12.0-15.7)
with help coarse on Base of phallus
mons
Adult, on Adult, 14.8 (12.9 - 16.4)
IV 12.6(10.4-14.8)
mons only suprapublic Red Flags
v Adult to mid •Cardio/Respiratory Hx
Adult to
mid thigh 14.6(12.4-16.8) thigh 15.1 (13.8 - 16.8) •Syncope/family HX early death
•Neuro: seizure, concussion
Develop- •Few self help •Cannot draw a Preco- If signs of puberty White <7.8 years African If signs of puberty < 9 •Hx of injury that limited activity
•Does not have 6 •Does not years
ment: words verbally skills person with 3 body cious American <6 8 •Absence of paired organ
communicate parts •History of heat illness
Red •Unable to com- Delay- No signs of puberty >12.5 years or no menses by No signs of puberty >
needs •Cannot give first •Acute illness
Flags municate needs ed 16 or 4 years after puberty started 14 years
and last name
8
Screen- •Fe deficiency •Anemia 1 •PPD3 •CV •Hearing / Vision •Hearing / Vision 8 •Hearing / Vision 8 •Vision
screen or Rx •PPD 3 •Hgb 7
ing •Lead 2 Health4 •P.E.D.S. •PPD3 •HEADSS / GAPS: Dictate WNL except
•Lead 2 •CV Health 4
•PPD 3 •Vision •CV Health4 •Glucose6 as noted •NOTE: Do all well adolescent care
•PPD 3 •PEDS prompts for general screening
•CV Health4 •D.V. •Enuresis •PHQ Depression screen
•CV Health4
•ASQ •Constipation •Constipation •Sleep Habits
•MCHAT •D.V. •Sleep Habits •Sleep Habits •CV Health4/ Glucose 6
•PEDS •D.V.
•D.V. •Yearly Chlamydia (all)/GC (female)
•D.V. •Dietary intake form screen if sexually active, offer HIV
•Dietary intake form
•Hct/Hgb 7 and •PPD3

Immuni- •Influenza •Influenza •Influenza •DtaP#5 •Influenza •HepA status •Influenza

zations •Catch up •Catch up •Catch up •IPV#4•MMR #2 •Varicella #2 •Varicella #2 •Catch Up
including PCV-13, including PCV- including PCV-13, •Influenza •Influenza •HPV FOR ALL
Hep A 13, Hep A Hep A •Varicella#2 •Meningococcal vaccine
•Catch up including •Tdap
PCV-13, Hep A
Counsel- •Read 2yr parent •Support •Read 3yr parent •Booster seat till 8 •Booster seat until 8 yrs or 80 Ibs •Safer sex
ing handout independence, handout yrs or 80 Ibs.
offer choices •Limit TV •Drinking and driving, seat belt use
•Toilet training •Car Seats •Falls- Play
•Set clear rules equipment •Encourage reading •Gun safety
•Tantrums/ •Burns
& limits •Assign chores •Acne
Discipline •Firearm hazards •Bike safety
•Encourage
• Falls – play •Falls • Pedestrian Safety •Firearm hazards •Future goals
healthy meals/
equipment, exercise •Pedestrian Safety •Water/pool Safety •Seat belt use •Family activities
tricycles, helmets,
pedestrian safety •Supervise safe •Never follow •Firearm hazards •Bike Safety •Regular physical exercise Exam Key Areas:
play & sharing strangers
• Water/pool safety •Discuss anger •Pedestrian Safety •18 yo: open discussion re transition of •Vision
• Burns •ROR, give book •ROR, give book resolving conflicts care
w/out violence •Sport Safety •Cardiac-Listen in Standing and
• Firearm hazards Supine Positions
•Limit TV •Family activities
• Car seats •Hx of prior injury and current functional
•ROR, give book •Regular physical exercise
•Socialization with status
other children •Vision
•Limit TV •Splenomegaly
•ROR, give book •Skin
•Marfanoid Syndrome

Dental •Sippy-cup pitfalls •Dental Varnish* •Dental Varnish* •Dental home •Brushing 2x daily10 •Dental •Brushing 2x daily10 Anticipatory Guidance/Dental:
•Adult brush/BID 10 •Dental referral •Dental referral •Adult brush/BID10 home •Dental home •Usual adolescent general guidelines
•Dental Varnish* •Adult •Adult brush/BID10 •Mouth guards for sports •Performance enhancing substances
•Refer if high risk brush/BID10 •Sleep habits
•Mouth Guard
Nutrition •Choose menu, •Healthy snacks •Healthy snacks •Family meals •Family meals •Healthy food choices/family meals •Nutrition Supplements
/Supple- don't let child dic- •Choose menu •Family meals •Soda status •Balanced diet •Body image •Hydration Tips
ments tate it •Juice/soda •Juice/soda status •Vitamin D intake •Avoid excess fat, salt, sugar, •Folic Acid(0.4 mg/d) for all females
•Juice/soda status status juices/soda •Calcium 1300 mg/day and Vit. D

1
Anemia - Test Hct/Hgb in all patients with Medicaid at 12 months. Other patients assess for risk factors: premature
infants, low birth weight infants, given cow's milk before 12 months, drink more than 24 oz. of milk a day. If Hct<33 or
Hgb<11, start 5mg/kg iron and recheck in one month. AAP(2007) recommends screening all infants at 12 mo.
2
Lead-Test all Medicaid patients at 12 and 24 months. Other patients screened based on risk factors: living in house built
before 1950, living in a house built before 1978 that has been recently renovated, sibling or playmate with lead poisoning.
3
PPD- Screen patient exposed to person with TB, immigration from endemic countries; use of illicit drugs or cocaine;
exposure to person that is homeless, institutionalized in prison or nursing home, migrant farm worker, HIV infected,
visiting in endemic area > 1 mo. Perform test every 2-3 years. Retest immigrants in 6-12 months.
4
CV Health – We recommend CONSIDERING, Age 10 or older, if bmi 85%-95% and risk factors (below) fasting
cholesterol x 1, if BMI >95%ile, fasting cholesterol and fasting glucose or A1C, AST/ALT. Repeat q2 years as needed.
AAP Recs, 2008: Screen children: > 2 yr w/positive family hx of dyslipidemia or premature (<55 yo male, <65 yo female)
CVD; Whose family hx unknown; With CVD risk factors: overweight/obese(BMI > 85%); hypertension (BP> 95%);
cigarette smoking; D.M. (screening test= fasting lipid panel)
6
Glucose – See above. Obtain fasting glucose every 2 years if overweight with BMI >85%ile plus 2 of the following: Recommended dietary fluoride supplement schedule
Family hx of Type II DM. African-American, American-Indian, Hispanic, Asian, acanthosis nigricans, hypertension,
PCOS, dyslipidemia. Age Fluoride concentration in community drinking water
7
Hct/Hgb in Menstruating Females - Perform one baseline screening. Do yearly screen for moderate heavy menses,
chronic weight loss, nutritional deficit (vegetarian), or strenuous athletic activity. <0.3 ppm 0.3 – 0.6 ppm >0.6 ppm
8
Hearing / Vision- • Hearing: >20dB at 1000-4000Hz is abnormal. Repeat 1 month, and then refer.
• Vision: >20/40 or two line difference between eyes is abnormal. Refer. 6 mos – 3 years 0.25 mg/day none None
9
Fluoride - Supplement, if at risk for caries and if water fluoride deficient, or exclusively breastfed; be aware of over-
fluoridation if age < 8 yrs. 3-6 years 0.50 mg/day 0.25 mg/day None
10
Brushing < 3 years; If at risk for caries fluorinated TP (Amount of toothpaste = smear or 1/2 chocolate chip)
*Dental Varnish - Apply on all patients with Medicaid/Health Choice every 2 months from tooth eruption to 41 months. 6-16 years 1 mg/day 0/5 mg/day none

Risk for Caries

Medicaid, CHIP, uninsured
History of caries in sibs./parents
<2 years: bottle to bed(not H20)
>2 years: High Sugar Diet

11
Thin prep cytology at age 21 unless previous abnormal or severe immunosuppression

©2005 UNC Department of Pediatrics • Revised July 2010

Originally created by Frini Shah 2002