Ambulatory Peds

Question 1

Considerations for the Tone of the Ped. Examination

Answer 1

Talk to the child!!
- directly to them using langugage they will understand
- can interview without om or dad starting at 10/11 & should be doing taht by 12 (consider developmental age)

Caregiver is also your pt!
- lsiten to their worries about serious disease/development issues

Tips
- sit at level of child
- under 6 months: exam on table
- older infants: sit in moms lap
- dont undress immediately, warm your hands
- do least intrusive to most and distrct with toys

Question 2

Tips for Peds by age group

Toddlers
preschoolers
school aged

Answer 2

Toddlers
- can cry when you start: theyre scare
- stay happy, talk calmy and assured: they will sense confience and trust
- let toddler play with instrument before use
- do exam while they sit in moms lap

Preschool
- encourge them to participate in the history and the PE (where to look first)
- hand over hand technique
- be honest with what might be painful

School Aged
- let them give the history
- small talk with them
- explain things in simple terms
- be honest with painful

Question 3

Key Pearls about the Comprehensive Ped. Visit
- History taking

Answer 3

History Taking
- prenatal history & birth hisotry
- growth and development
- social hisotry
- psychosocial hisotry: wahts a typical day like for them
- parental well being! screen for PP depression every visit birth to 12 months

Prenata and Natal History specifics
- planned/wanted pregnancy
- materal health and labs & WT gain
- length and complications of pregnancy
- medications and alcohol/drug use

Natal
- C-section v vaginal
- complications
- resusitation
- birth weight, length and head circum.
- newborn screen

Question 4

The Prenatal/Neonatal Visits

Key Pearls on what to include

Answer 4

Screening and Health Maitnence
- newborn screening, materal screening
- immunizations
- social hisotry: living, food, environment, familily support

Newborn care
- feeding breast v bottld
- handwashing
- limit expousre in first 6-8 weeks

Safety
- carseats
- back to sleep
- water temp < 120 degrees

Neonatal Specifcs (after born)

Cord Care
- 2-3 weeks to fall off, watch infections

Skin Care
- avoid sunlight directly, no sunscreen until 6months
- avoid powder

Feeding

Breast
- 8-12feds/24 hours
- continue prenatals and no alcohol

Bottle
- 8x/24 hours via cues
- prepare and store properly
- no proping bottle

Neonatl PE from freemands lecture

Question 5

Infant Visits “Well-Check”

what to include

Answer 5

Infant Visit
- if not gotten, get prenatal/natal history and birth hx.
- inquire about feeding: vitamin (VIT D!!), iron and floride assessments
- solid foods?
- physical growth
- developmental milestones

Observe parent/child interactions

physical exam : barlow and ortolani at every infant visit

Question 6

Assessing the Social Environement for peds of all ages

Answer 6

biologic needs and environemental assessment

Famil Environement
- family from nuclear, extended, single parenet, same sex, etc.
- family parenting style and discipline

Mental heatlhy
- parental depression
- IPV
- substance use

PArental Employement
- poverty, homeless
- school, daycare, etc.

neighborhoor

virtaul environemtn (technologY!!!)

Question 7

Developmental Assessment at Well Checks for Kids
Primary Screen

4 caterogires of developmental assessment

Answer 7

DEvelopment = predicatble process but the range of normal is wide!!!
- follow criteria if any screening you do turn positive
- early intervention is best= no more wait and see!

Primary Screen
- listen to mom and obstain history
- vitals
- observeation of development at visits
- using screening tools
- recognize conditions that may increase risk of delayes and refer those for help

Development Assessment of
- socail/emotional
- langugage/communication
- cognitive milestones
- movement/phsycial developement

Question 8

Surveillance v Screening
developmental assessment for peds.

Answer 8

Surveillance
- informal, just monitoring developmental status overtime
- interpret information in terms of environement,socical and medical facors of child
- include parental concerns in youe eval. and those formal dvelopment screening

Screening
- breif assessments of fevelopmental status utalizing a standardized instrument
- done at : 9,18,24/30 months
- 18 & 24 months for ASD Screen
- the AAP/CDC, the ASQ or the PEDS screens are good
- the M-CHAT for ASD

there are secondary screening tools when the ^^ priamry tool sindicate a need to look further
- vanderbilt/connor = ADHA
- SCARED = anxiety
- depression
- ASQ-social/emotiona = depression/anxiety

Question 9

Assessment: Growth and Development
somatic v maturational

Answer 9

Somatic
- physical grwoth via lenght, weight and head circumference

Maturational
- puberty onset
- sexual maturity rating

0-2 Years Old
- WHO standards
- weight
- length
- head circumferences : occiptal-frontal
- weight for length

2 Years +
- CDC chart
- Stature (height)
- weight
- BMI : curves can be used for Z scores and pecentiles of BMI

Question 10

Assessment: General Appearance

Muclse Tone

Answer 10

Sick v Not Sick

Crying

Facial Features/dysmorphia

Symmetry of FAce and Body Features

parent child interation

Muscle Tone
- lack of tone = sick baby or MSK/neuro disorder “floppy baby”

Question 11

Assessment: Appearance
Facial Features

Answer 11

Facial Features
- mouth, lipds, philturm
- nose shape
- distance between eyes
- direction of palpebral fissures
- size/shape of ears and relation to eyes

Question 12

Assessment: Appearance
Crying

Answer 12

Crying

Shrill/High Pitch = increase ICP, newborn to narcotics mother

Hoarse = hypocalcemis, tetany, hypothyroid

continuous inspiratory/exporiatoyr stridor = obstructed upper airway, small larynx, tracheomalacia

lack of cry = happy baby or SEVERELY ILL BABY

Question 13

Assessment: Vitals
Temp
HR
RR and distress
BP and reasons for getting a BP earlier than 3 or a must

Answer 13

Temperature
- rectal is GS for under 2
- work up fully if temp in infant < 2 is greater than 100.4
- somtimes kids get high fevers for minor illnesses, but always want to check

Heart Rate
- faster than adults
- varies with dehydration, fever and anxiety

Respirations
- faster than adults

look for respiratory distress
- flaring nose, pallor/cyanosis
- grunting, wheezing, stridor
- retractions

Blood Pressure
- should be done on all infants > 3
- values based off percentiles

Warrent Early BP monitor
- premature, VLBW
- herat disease
- renal/urologic dz.

BP necessity when
- treatment with drugs to increas BP
- conditions with inc. BP
- increased ICP

Question 14

Assessment: Head
fotanels close when
early v delayed closure

Answer 14

Fontanels : openings that allow head to move during brith
diameter should be 2x width
- posterior : closes by 2 months
- anterior closes by 12-15 months

Early close
- craniosynstosis
- hyperparathyroid or phyerphospate

Late Close
- can be normal
- cong. hypothyroid
- megancephay
- increase ICP
- downs
- rickets

can appear sunken in with dehydration or bulding with increased ICP

helmets can help with funky heads

Question 15

Craniosynostosis v nonsynostoic plagiocephaly

Answer 15

Craniosynostosis
- asymmertical head shape ebcause of growth restirction due to fused suture line in skull : unknown etiology
- a fused suture line = 1 or more
- Xray/CT and srugery to fix

N-P
- external mlding due to back sleeping, restructive interuterine environment, torticollis or preamture
- external molding
- a flat spot on the back fo the head due to positioning
- normal suture lines
- helmets to fix

Question 16

Skin Assessment of Peds

Answer 16

color
lesions
rashes
abuse

Question 17

Ocular Assessment in Peds.

vision assessment when
when to optho

Answer 17

Vision
- screening is vital!!!
- letahl conditions like retinoblastoma need to be picked up
- “windoe period” for vision to correct before perminant damange
- ages 6-8 is when they go to optho. but this is past the window to fix eye issues
- vision is essentail for dvelopment brain connections

Question 18

Occular Assessment
Eye exam includes what tests

Answer 18

Eye exam
- vision screen
- visualacuity test: usually 3+ years
- red reflex
- external exam
- alignment and corneal light reflex
- motlitiy of EOM
- pupil exam
- fudoscopic exam 4+

Question 19

Occular Assessment
History

Answer 19

History
- do they sit close to tv, interesting in books, fixate on objects
- eye crossing
- reddness or discahgerge
- photophobia
- family hx.? retinblastoma = screen in first degree realtives

Question 20

Occular Assessment
symptoms of potential vision loss

Answer 20

treatment is to send to optho for all

Symptoms
- no eye contact in those > 8 weeks
- head tile/face turn
- unable to comply with age appropriate screenings
- tearing (nasolac. duct obstruction)
- photophobia
- squinting

Question 21

Occular Assessment
Visual Screenings and Tests

Answer 21

Can they See?
- infants/toldders: get attention with toy and watch their fixation
- older kids: formal acuity test (3/4+)

Screening
- instrument bases
- autorefractors

Visual Acuity
- 0-2 monhts : blink to bright light and equal pupils
- 6-8 weeks: fixed and tracking
- 6months -2 years: fix and follow with one eye cover
- 3+ years old: can do the lea symbol
- older: can do the normal test with letters

difference in > 2 or more of the lines = referr to optho

Question 22

Occular Assessment

Red Reflex Testing

Answer 22

Red Reflex
- view both eyes 2-3 feet away

distorted red reflex due to
- retine = retinoblastoma
- vitreous = hemorrhoage
- lens - catarcts
- cornea = scare

leukocorita: think retinoblasts
absernt refelx = ertinblastma or hemorrhgae

keep retinblastoma, viterous heomrrhage and cataracts high on suspiscion = urgern referral

Question 23

Occular Assessment
External Eye Exam

Answer 23

inspection for…
- capillary hemiangiomas
- port wine stains = amblyopia

ptosis
- alone = refer to opthmo
- ptosis and miosis = neuroblastoma

examine for enlarged eye = pediatric glaucoma

hordeolum: acute and infalmmed
chalazion: chronic and hard ball

Question 24

Occular Assessment
Alignment

Answer 24

newborns = can have stabismus but resolves by 2-4 months

pseudostrabismus can be due to epicantheal folds

Abnormal Aligment
- esodeviation : converge to middle (esotropia = visable in normal conditions, esophoria is not detecable when looking at both)
- exodeviation: diveerge to oute edges

Evaulate
- with cover, uncover test : for stabisus
- hirschberg testing: symmetry of corneal light reflex (look at light reflex directly in teh pupil)

Stabismus: always warrents a referral!!
- patching to fix, glasses or surgery

Question 25

Occular Assessment
motility of EOM and nystagmus

Answer 25

Motlity of EOM can be tested the same: use toy instead of pen
- abnormal: CN palsay

Nystagmus
- referr to optho.

Question 26

Occular Assessment
Pupillary and fundoscopic exam

Answer 26

Pupillary
- assess size, shape and symmetry

coloboma: irregular pupil shape = refer
can be due to genetic abnorms.

Fundoscopic
papilledema = increase ICP
Cherry red macula = Tay Sachs disease
diabetic retinopathy: screen 5 yeras post T1DM, can pick up undx. T2DM

Question 27

ENT Exam

Hearing Exam

Answer 27

ENT: do last! most invasive for kids

Hearing Exam
- done in first month of life for formal testing
- parents usually have good index of suspicion
- formal hearing test should be done before neonate leaves hospital

Screen at…
- 4, 5, 6, 8, and 10 years (speech!)
- 1 x between 11 and 14
- 1 x between 15 - 17
- 1 x between 18 - 21
- anytime parent is concerned
- persistnet ear effeusions

0-2 months: clap = theyshould be startled
2-3 change in body movement reponses to sounds or famiai expression with familar sounds
3-4 turn and listen to voices
6-7 can same some thigns

screening for hearing is done in schools!

Question 28

Ear Positioning for Assessment in peds

ear pits/tags : check waht

microotia

Answer 28

Ears
- should draw line from eyes to ears and have top 1/3 of ear above
- and 20 degrees rotated ear back

Low set ears
- trisopy 21
- trisomy 18
- treacher collins
- beckwith wideman

Ear pits and tags
- can beislated, but also associted with genetic consitions
- if you seen ear pits and tags, check for hearing loss and renal anomilies

Microotia
- graded I - Iv (most sever)

Cup/Lop Ears = normal

Question 29

Nose and Throat Exam for Peds

teeth
neck masses

Answer 29

Nares patency
palate and uvual integrity
speech quality
dentition!! : CHIP DOES cover dental

Teeth
- frsit should be between 6-10 months
- watch for baby bottle decay of teeth

NEck Masses: referral to ENT
- thyroglossal: thyroid gland fails to fall to its position

Cystic Hydroma

2nd branchical cleft cyst : emryonic remains

Question 30

Assessment: Chest Wall
gynocomastic specifics

Answer 30

Abnroaml breasts
nipple distance
- turners syndrome

gynecomastica
- meds induced (dig, INH, cimetidine, antidep.)
- breast tumor
- adrenal or gonsal lesions
- hypethyroid
- klinefelters
- severe renal/liver disease (estrogen cant clear)

Exam of Gynecomastia
- do a testicualr exam!!!: testicaulr CA
- can be benigin and spontaneously regress
- refer if they are prepubetal, under virilized, testicular mass, persisant longer than normal

sexual maturation stages

pectus excavatum (in) and carinatum (out)

Question 31

Assessment: Pulmonary

Answer 31

upper airway issue: inspiratory finding
lower airway issue: expiratory finding

sounds transmit widely through chest in kids, difficult

Upper Airway
- nose and stethescope sound will be equal
- symmetric shoulds
- harsh and loud

Lower Airway
- variable sounds
- asymmetric
- louder when in lower chest/abd.

Question 32

Assessment: Cardiovascualr
infant v toddler signs

Exam

Murmurs

Answer 32

Cardiovascular

Infants
- dx. before leaving hospital
- sweating, cyanotis with feeds = think this
- poor weight gain or weight loss

toddelrs/kids
- simiarl to adult sx.
- difficutl to keep up with peers!

Exam
- smaller scop
- palpate brachial and femoral pulses simultaneously

Murmurs
Still Murmur: musical, loudest in supine position, early systlic at LL sternal boarder

Physiologic Murmur (thingk high outflow state)
Systolic ejection murmus, heard at 2nd/3rd ICS

Venous Hum : upper right sternal boared, decreasd with neck pressure or turning to the right

Question 33

Assessment: Abd & GU

Answer 33

ABdomen
- kids have pot belly but do good exam
- liver and spleen margins are often palpable
- kindeys easy to feel
- bend knees or hand over hand

GU
- usually on inspection is needed: always exaplin what you are doing and why it sok for doctor and mom to see
- sexual maturity rating
- palpate testicles for position

DRE onl for
- rectal bleeding
- sevre constipation
- sometime for appendicitis
- pelvic exam only for gyn compliants or abd.peliv pain

Question 34

Assessment: Neruo

primitive refelx

Answer 34

Neurologic Exam

Obeserve
- moving hands and legs and neck spontaneously
- wualitative assessment

Examination Period
- response to stimuli
- strenght/motor test
- CN test
- Gait testing

Primitive reflexes

Palmar Grasp: 0-4 months
Rooting: 0-4
Trunk incurvation : 0-2
Ventral suspention: 0-4
moro reflex: 0-4
stepping reflex: days-2 months

Question 35

Assessment: Ortho

Barlow and Ortolani

Scoliosis

Answer 35

Barlow
- dislocates unstable hip
- lay baby on back, hips and knees flex, hips are adducted in and downward pressure
- click = +

Ortolani
- after barlow: see if you can relocate
- thigh abducted, pressure on greater trochanters
- clunk = +

Scolisos
- checked in schools
- bend over and see from back

Question 36

Screenings

Newborn and Immediate
Nameia
Lead
BP
TB
lipids
STIs
HIV
cervical

Answer 36

Newborn Screen
Bilirubin at 12-24 hours
CCHD

ANemai
- 12 months (routine)
- 15, 18, 24, 30 = high risk (vegan or poor eater)
- annually 3-18 if high risk

Lead (defer if low risk)
- screen if old home first
- if + screen : 12, 24 months

BP
- age 3+
- early if risk

TB
- periodicall if at risk

lipids
- once between 9-11 years
- once between 17-21 years
- if high risk - more often

STIs
- adolescne if at risk

HIV
- once 15-18

Cervical dysplasia
- starting at 21

Question 37

Health Promotion
family support
healthy child
Oral Health!!! Flouride specifics

Answer 37

Family Support
- assess and help

Healhy Child
- early detection of developmental delays
- parent encourge tummy time and reading

Oral health
- intervene and educate early before teeth come up
- SES impacts oral health: caviteis = common
- use floridein toothpaste and regular brushing
- smear of paste for little ones, pea size for a little bigger

Flouride
- recommendations depend on municapline water supply flouride amounts
- flouride varinsih can be applied 3-6 months for those at risk

Question 38

Health Promotion: Safety and Injuery Prevention

Answer 38

injury is most significant problem of children and teens
leadsing cause of death under 19

Traffic Safety
- car seats never in front seat

Burn Prevention
- smoke alarms
- hot water < 120

Fall prevention
- gates and crib rails
- AVOID USE OF WALKERS: THSES ARE NOT GOOD

Choking
- toliet paper tube test
- blind cords away

Drowning Prevention
- no buckets
- surpervise baths

BAck to sleep and infant CPR

Question 39

Toddlets/Preschoolers
Traffic SAfety
fall prevention

Answer 39

Traffic Safety

• back seat care seats: weight height and age recommendations
• forward facing only once 60 pounds
• then to booster seat
• no thick caots

FAll PRevention
- stair/windo gaurds
- prevent furniture falls

Posion Prvetion: storage of meds and know number to call

Drowning
- locks and swim safety lessons age 1-3

Question 40

SChool Aged Kids

Traffic Safety

Answer 40

Traffic SAfety
- booster seats and seat belts
- back seat until at least 13 years old

swim and spor safety
- helments and portective equiptment

Question 41

Violence Prevention and Media USe

Answer 41

Violence Prevention
- Bullying: encourgae child to identfy where to get help and help parents
- monitor socail media

Media use
-Screening: who monitors and how is it mointored
- how much are they using, tv in bedroom?

under 18 months: no tech.
18-24 months: only high quality media with parent there
2 yeras: no more than 1 hours
no screens at meals or 1 hour beofre sleep