Peds History and Exam
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Questions and Answers

At what age is the Dtap vaccine first administered to a child?

  • 12 months
  • 2 months (correct)
  • 11 years
  • 4 years

    • Which vaccine is not a live vaccine?

  • Rotavirus
  • Hepatitis B (correct)
  • MMR
  • Varicella

    • Which immunization must be received every year after 6 months of age?

  • Covid vaccine
  • Hepatitis B
  • Influenza (correct)
  • Meningitis

    • What is one of the primary developmental milestones that a child typically achieves before their first birthday?

    <p>Sitting unassisted</p> Signup and view all the answers

    At what age does the first dose of the Hepatitis A vaccine typically occur?

    <p>12-15 months</p> Signup and view all the answers

    What is the suggested position for a neonate during a physical examination?

    <p>On the examining table</p> Signup and view all the answers

    Why is it important to gather data through observation before any physical examination?

    <p>To minimize the child's distress during the exam</p> Signup and view all the answers

    What should be the order of examination for infants and toddlers regarding the least distressing to most distressing?

    <p>Head, Heart, Ears, and Mouth</p> Signup and view all the answers

    How should rapport be established with the child before clinical interaction?

    <p>By spending time playing or interacting without clinical focus</p> Signup and view all the answers

    What is the recommended approach when the child is hesitant or saying 'no' to a proposed examination procedure?

    <p>Reassure them by explaining it will not hurt</p> Signup and view all the answers

    What is a significant consideration regarding developmental stages during a child's examination?

    <p>Normal developmental stages, like stranger anxiety, can affect cooperation</p> Signup and view all the answers

    What is the best practice regarding communication with caregivers during the examination?

    <p>The caregiver, not the examiner, should handle disrobing the child</p> Signup and view all the answers

    What should be examined last during a physical examination of a child?

    <p>The painful areas of the body</p> Signup and view all the answers

    What is a key aspect to observe during a pediatric physical exam regarding a child's general appearance?

    <p>Signs of acute illness through skin color and hydration status</p> Signup and view all the answers

    What does hypertension in children and adolescents mean according to the definition provided?

    <p>Blood pressure consistently above 95th percentile for age, sex, and height</p> Signup and view all the answers

    Why is it beneficial to engage a child with medical instruments like an otoscope?

    <p>To familiarize them with the instrument and reduce fear</p> Signup and view all the answers

    At what age are children expected to have developed a pincer grasp and wave goodbye?

    <p>12 months</p> Signup and view all the answers

    Which of the following developmental skills is expected of a child by 36 months?

    <p>Uses a fork</p> Signup and view all the answers

    What is the purpose of plotting the height and weight data of a pediatric patient?

    <p>To note relationships between measurements over time</p> Signup and view all the answers

    What percentage of children with developmental delays receive early intervention services before age 3?

    <p>25%</p> Signup and view all the answers

    What vital sign needs to be specifically monitored as it changes with age in pediatric patients?

    <p>Respiratory rate</p> Signup and view all the answers

    Which developmental milestone is typically achieved by a child at 24 months?

    <p>Points to 2 body parts</p> Signup and view all the answers

    Which range of blood pressure readings indicates pre-hypertension in children?

    <p>Between the 90th and 95th percentiles</p> Signup and view all the answers

    What is a key characteristic of milestones included in the developmental milestones criteria?

    <p>They should be family-friendly and use plain language.</p> Signup and view all the answers

    What does observing fine motor skills entail during a pediatric exam?

    <p>Noting the child's engagement with medical instruments</p> Signup and view all the answers

    What should be taken into account when interpreting vital signs for pediatric patients?

    <p>Variations in values based on age</p> Signup and view all the answers

    Which of the following skills is expected of a child at 60 months?

    <p>Hops on one foot</p> Signup and view all the answers

    What is the function of the CDC Milestone Tracker?

    <p>It allows parents to track child’s development.</p> Signup and view all the answers

    By what age should children typically be using hands to twist things and saying 'I' or 'me'?

    <p>30 months</p> Signup and view all the answers

    Which milestone is generally NOT expected of a child at 48 months?

    <p>Writes some letters in their name</p> Signup and view all the answers

    Which of the following correctly describes the types of lesions that may be present in a rash?

    <p>Macular, vesicular, papular, petechial</p> Signup and view all the answers

    What is a characteristic pattern that can be observed in distribution of rashes?

    <p>Annular, linear, generalized, localized to dermatome</p> Signup and view all the answers

    Which examination technique is essential for evaluating the tympanic membranes in infants?

    <p>Use of pneumatic otoscopy</p> Signup and view all the answers

    During a physical exam, which aspect of the mouth should NOT be overlooked?

    <p>Symmetry of the face</p> Signup and view all the answers

    When assessing the eyes during a physical exam, which feature is essential for evaluating the visual structure?

    <p>Palpebral fissures and strabismus</p> Signup and view all the answers

    What should be assessed regarding the neck during a physical examination?

    <p>Tracheal position and thyroid palpation</p> Signup and view all the answers

    Which of the following is NOT part of the examination of the respiratory system during a physical exam?

    <p>Palpation for lung sounds</p> Signup and view all the answers

    In an examination of the extremities, what type of issue should be primarily inspected?

    <p>Gross deformities</p> Signup and view all the answers

    Which vaccines are recommended at 11-12 years of age?

    <p>Tdap, Meningitis (A,C,Y), HPV</p> Signup and view all the answers

    What is a notable characteristic of live vaccines?

    <p>They tend to have a higher rate of side effects.</p> Signup and view all the answers

    At which age is the first dose of the Hepatitis A vaccine typically administered?

    <p>2 years old</p> Signup and view all the answers

    What must be considered when evaluating a child's developmental history?

    <p>Milestones achieved and current developmental abilities</p> Signup and view all the answers

    What should be assessed to identify developmental delays in a child?

    <p>Specific problems such as enuresis and tantrums</p> Signup and view all the answers

    What psychosocial factor does the 'HEADSS' mnemonic address that is crucial for adolescent well-being?

    <p>Home environment</p> Signup and view all the answers

    Which of the following is NOT typically considered when assessing family history in pediatric patients?

    <p>Parental employment status</p> Signup and view all the answers

    What is one of the key indicators to evaluate when assessing a child's gastrointestinal (GI) health?

    <p>Stool color and character</p> Signup and view all the answers

    Which of the following problems is associated with dietary changes in children?

    <p>Failure to gain weight</p> Signup and view all the answers

    During the assessment of a child's musculoskeletal system, which symptom would be most relevant?

    <p>Joint pains or swelling</p> Signup and view all the answers

    Which aspect of respiratory health should be monitored to assess chronic conditions in pediatric patients?

    <p>Hemoptysis (coughing up blood)</p> Signup and view all the answers

    What factor does NOT typically belong in the social history assessment of pediatric patients?

    <p>Ear infection history</p> Signup and view all the answers

    Which of the following is essential to observe when evaluating the patient's emotional well-being during parent/child interaction?

    <p>Parents’ responsiveness to child’s needs</p> Signup and view all the answers

    What is the appropriate position for a preschool-age child during a physical examination?

    <p>Lying/sitting on caregiver's lap</p> Signup and view all the answers

    Which strategy is essential when establishing rapport with a child before a clinical interaction?

    <p>Play or interact with the child at their level</p> Signup and view all the answers

    What is the recommended order of examination for pediatric patients, particularly infants and toddlers?

    <p>Examine the least distressing areas first</p> Signup and view all the answers

    Which action should be avoided when proposing an examination procedure to a child?

    <p>Ask for permission in an open-ended way</p> Signup and view all the answers

    How should the examiner handle a child's pain during a physical examination?

    <p>Inform the child calmly that it may hurt and examine last</p> Signup and view all the answers

    What is a significant factor to consider regarding developmental stages during a child's examination?

    <p>The presence of stranger anxiety affecting behavior during the assessment</p> Signup and view all the answers

    What is an appropriate way to conduct an observation-based assessment before a physical examination?

    <p>Engage the child in play while gathering data</p> Signup and view all the answers

    What is a key outcome of not being honest with the child about potential pain during the examination?

    <p>Lose credibility and trust with the child</p> Signup and view all the answers

    What is an effective strategy to make children more comfortable during an examination?

    <p>Allow children to play with the otoscope</p> Signup and view all the answers

    Which factor is essential for accurately assessing blood pressure in pediatric patients?

    <p>Considering age, sex, and height</p> Signup and view all the answers

    What observation is important for assessing a child's general appearance during a physical examination?

    <p>Signs of acute illness based on social interactions</p> Signup and view all the answers

    Which is NOT a vital sign that must be recorded during a pediatric examination?

    <p>Body weight change over time</p> Signup and view all the answers

    What is a key consideration when recognizing signs of pediatric hypertension?

    <p>Systolic and diastolic measurements exceeding the 95th percentile consistently</p> Signup and view all the answers

    What type of approach is recommended for assessing a child's developmental status during an examination?

    <p>Use standardized assessments based on specific milestones</p> Signup and view all the answers

    At what age does the grasp reflex typically disappear in infants?

    <p>2-4 months</p> Signup and view all the answers

    What is a sign of precocious puberty in females?

    <p>Breast development before 10 years</p> Signup and view all the answers

    Which of the following is NOT included in the complete newborn hip exam?

    <p>Assessment of gait</p> Signup and view all the answers

    When should the Babinski reflex typically disappear in infants?

    <p>Up to 18 months</p> Signup and view all the answers

    What may indicate a need for neuroimaging in a child suspected of precocious puberty?

    <p>Neurologic symptoms</p> Signup and view all the answers

    What is the typical height increase rate for females around Tanner stages 2 and 3?

    <p>8.3 cm/year</p> Signup and view all the answers

    In girls, menarche typically follows breast development after how many years?

    <p>2 years</p> Signup and view all the answers

    Which primitive reflex is expected to be absent in infants by the end of the first month?

    <p>Stepping (placing) reflex</p> Signup and view all the answers

    Which of the following methods can help to reduce a child's anxiety during a physical exam?

    <p>Engage them with medical instruments like an otoscope</p> Signup and view all the answers

    What indicates that a child is at risk for hypertension based on their blood pressure readings?

    <p>Blood pressure readings consistently above the 95th percentile</p> Signup and view all the answers

    How should vital signs be interpreted in pediatric patients during a physical exam?

    <p>Normal values vary according to the child's developmental stage</p> Signup and view all the answers

    Which observation is essential when assessing a child's general appearance during a physical examination?

    <p>Skin color and hydration status</p> Signup and view all the answers

    In assessing a child's physical development, what is typically evaluated during the first two years?

    <p>Height, weight, and head circumference</p> Signup and view all the answers

    Which is a key consideration in the physical examination of the skin in pediatric patients?

    <p>Observation for birthmarks or scars</p> Signup and view all the answers

    What is an effective way to assess a child's fine motor skills during a pediatric exam?

    <p>To observe their ability to manipulate an otoscope</p> Signup and view all the answers

    What is the typical developmental milestone related to the disappearance of the Moro reflex?

    <p>Absent after 4-6 months</p> Signup and view all the answers

    When observing for signs of precocious puberty in males, at what age should secondary sexual characteristics be checked?

    <p>Younger than 9 years</p> Signup and view all the answers

    Which condition is primarily identified by dietary changes in pediatric patients?

    <p>Failure to gain/maintain weight</p> Signup and view all the answers

    Which Tanner stage corresponds to breast development and is commonly noted to start around 10 years of age for females?

    <p>Stage 2</p> Signup and view all the answers

    What is the peak height velocity for girls during sexual maturity, typically seen at ages 11-12?

    <p>$8.3cm/year$</p> Signup and view all the answers

    What psychosocial aspect does the 'HEADSS' mnemonic include that is critical for assessing adolescents?

    <p>Education</p> Signup and view all the answers

    Which of the following symptoms would most likely indicate respiratory issues in children?

    <p>Chronic cough</p> Signup and view all the answers

    Which of the following is a correct indicator of delayed disappearance of the grasp reflex?

    <p>Absent by 4-6 months</p> Signup and view all the answers

    What medical evaluations might be included during the initial work-up for precocious puberty in children?

    <p>FSH, LH, testosterone, and bone age radiography</p> Signup and view all the answers

    In assessing family history, which element is crucial to determine potential genetic predispositions?

    <p>Consanguinity</p> Signup and view all the answers

    What physical examination finding might indicate tibial torsion in a child?

    <p>In-toeing</p> Signup and view all the answers

    When evaluating a child's gastrointestinal (GI) health, which symptom should receive priority attention?

    <p>Appetite changes</p> Signup and view all the answers

    Which primitive reflex is expected to be absent during the first month of life?

    <p>Stepping reflex</p> Signup and view all the answers

    What factor is least likely to influence a child's weight changes?

    <p>Sibling age</p> Signup and view all the answers

    Which symptom from the respiratory system assessment indicates the most serious concern?

    <p>Hemoptysis</p> Signup and view all the answers

    Which aspect of a child's history would be most relevant during a social assessment?

    <p>Type of dwelling</p> Signup and view all the answers

    Which statement about gathering pediatric history is most accurate?

    <p>Older children often provide information alongside a caregiver.</p> Signup and view all the answers

    What is the recommended method for establishing rapport with a child during a physical examination?

    <p>Spend time playing or interacting with children before clinical engagement</p> Signup and view all the answers

    Which aspect is crucial when conducting a well-child visit?

    <p>Chief complaints should reflect the caregiver’s perspective.</p> Signup and view all the answers

    What is the significance of the OPQRST or OLDCARTS format in collecting the history of present illness?

    <p>It organizes symptoms and their characteristics effectively.</p> Signup and view all the answers

    Why is it important to position neonates on an examining table during a physical exam?

    <p>To facilitate easier access for the examiner</p> Signup and view all the answers

    What information is NOT typically required in a child's past medical history?

    <p>Personal opinion about the patient's health.</p> Signup and view all the answers

    In what order should a physical examination be conducted for infants and toddlers?

    <p>General Observation, Ear, Heart, Mouth</p> Signup and view all the answers

    Which detail should be included when documenting a child's immunization history?

    <p>Any missed doses and reactions to prior vaccines.</p> Signup and view all the answers

    What approach should be taken when a child expresses hesitation or says 'no' to an examination procedure?

    <p>Respect their wishes while explaining the benefits of the procedure</p> Signup and view all the answers

    What is the preferred technique to begin the physical examination of a child?

    <p>Start with general observations from a distance first</p> Signup and view all the answers

    When recording the information about a child's caregiver, which of the following is most relevant?

    <p>Caregiver's relationship to the patient.</p> Signup and view all the answers

    Which of the following is a key factor to consider regarding older children and adolescents during clinical assessment?

    <p>They can provide valuable insights into their symptoms.</p> Signup and view all the answers

    What is one of the first actions to take if a child is observed to doze during an examination?

    <p>Conduct auscultation of the chest and heart quietly</p> Signup and view all the answers

    Why should the examiner avoid inadvertently asking permission for examination procedures?

    <p>Children might feel empowered to refuse crucial assessments</p> Signup and view all the answers

    What element is crucial for a comprehensive history-taking in pediatric patients?

    <p>Recognition of potential inconsistencies in caregiver observations.</p> Signup and view all the answers

    During the physical examination, why is it crucial to inform the child about procedures that may cause pain?

    <p>To prepare them mentally and reduce panic</p> Signup and view all the answers

    At what age should the first dose of the Tdap vaccine be administered?

    <p>11-12 years old</p> Signup and view all the answers

    Which of the following vaccines is administered as a live vaccine during infancy?

    <p>MMR</p> Signup and view all the answers

    What milestone is typically achieved by a child by 12 months of age?

    <p>Saying first word</p> Signup and view all the answers

    Which developmental issue may indicate a need for further evaluation in children?

    <p>Enuresis</p> Signup and view all the answers

    Which vaccines are recommended at the age of 4-5 years?

    <p>DTaP, Polio, MMR, Varicella</p> Signup and view all the answers

    What should be the position for young infants during a physical examination?

    <p>Lying or sitting on a caregiver's lap</p> Signup and view all the answers

    Which of the following is least distressing to examine first in infants and toddlers?

    <p>Chest</p> Signup and view all the answers

    How should a caregiver handle disrobing the child during an examination?

    <p>By the caregiver, not the examiner</p> Signup and view all the answers

    Why is establishing rapport with the child important during examination?

    <p>To help the child cooperate and reduce anxiety</p> Signup and view all the answers

    What should be the examiner's approach if a child expresses they do not want an examination procedure to occur?

    <p>Explain the procedure thoroughly and seek understanding</p> Signup and view all the answers

    What is a key factor that influences a child's responses during an examination?

    <p>Developmental stages, such as stranger anxiety</p> Signup and view all the answers

    When should the most painful area of examination be assessed?

    <p>Last, to minimize distress</p> Signup and view all the answers

    Which description accurately characterizes a vesicular rash?

    <p>A rash with small, fluid-filled blisters</p> Signup and view all the answers

    What secondary characteristic indicates that a rash has been scratched?

    <p>Excoriated skin</p> Signup and view all the answers

    During a physical examination, what should be evaluated first in the eye inspection?

    <p>Strabismus</p> Signup and view all the answers

    What is an important sign to look for when assessing the position of the ears?

    <p>Symmetry with the eyes</p> Signup and view all the answers

    Which characteristic of the nasal mucosa is of particular interest during a physical examination?

    <p>Edema or presence of polyps</p> Signup and view all the answers

    What should be assessed regarding the tonsils during a physical examination?

    <p>Size, color, and presence of exudate</p> Signup and view all the answers

    In evaluating a child's respiratory system, which observation is least relevant?

    <p>Palpation of the abdomen</p> Signup and view all the answers

    What should be assessed regarding a child's extremities during a physical examination?

    <p>Symmetry and gross deformities</p> Signup and view all the answers

    What age range is typically assessed using head circumference as part of a pediatric physical examination?

    <p>0 to 2 years</p> Signup and view all the answers

    What crucial aspect should be looked for when assessing a child's general appearance during a physical examination?

    <p>Hydration status and skin color</p> Signup and view all the answers

    Which factor is essential for interpreting vital signs in pediatric patients?

    <p>Knowledge of normal values varying with age</p> Signup and view all the answers

    During a physical examination, which behavioral factors are important to observe in a pediatric patient?

    <p>Social interaction and personal behavior</p> Signup and view all the answers

    Which vital sign is crucial to specifically monitor in pediatric patients due to its variability with age?

    <p>Blood pressure</p> Signup and view all the answers

    What should be a primary focus when palpating a child's abdomen during an examination?

    <p>Checking for previous meals</p> Signup and view all the answers

    Which developmental milestone is indicative of a child being able to follow one-step directions?

    <p>Stacks 2 blocks</p> Signup and view all the answers

    What percentage of children with developmental delays receive early intervention services before age 3?

    <p>Less than 25%</p> Signup and view all the answers

    Which of the following developmental milestones would you expect a 24-month-old child to achieve?

    <p>Tries to use switches, knobs, buttons</p> Signup and view all the answers

    Which tool helps parents track their child's developmental milestones over time?

    <p>CDC Milestone Tracker</p> Signup and view all the answers

    At what age should a child typically be able to say their first name and ask questions like who, what, where?

    <p>3 years</p> Signup and view all the answers

    Which developmental change occurs among children aged 6-10 years?

    <p>Increased focus on nutrition and exercise</p> Signup and view all the answers

    Which milestone is typically NOT expected of a child by 36 months?

    <p>Sings, dances</p> Signup and view all the answers

    At what age do children typically start using parallel play?

    <p>30 months</p> Signup and view all the answers

    What is one of the significant components included in the criteria for developmental milestones?

    <p>Family-friendly language and information</p> Signup and view all the answers

    What ability should a 48-month-old child have regarding ball play?

    <p>Catches a large ball</p> Signup and view all the answers

    What is one factor affecting the reliability of a caregiver's observation during pediatric history collection?

    <p>The caregiver's relationship with the child</p> Signup and view all the answers

    Which aspect of the past medical history should be included when assessing a pediatric patient?

    <p>Current medications and any complications</p> Signup and view all the answers

    Which of the following details is crucial when documenting a child's immunization history?

    <p>Any missed doses or reactions to vaccines</p> Signup and view all the answers

    In pediatric history taking, at what age is it typical to gather information from both the patient and parent?

    <p>Age 4</p> Signup and view all the answers

    What key information should be included under the 'General Information' section of a pediatric history?

    <p>Identifying data such as birth date and gender</p> Signup and view all the answers

    What information does the 'S' in the OPQRST format stand for when evaluating a child's symptoms?

    <p>Severity of symptoms</p> Signup and view all the answers

    Why is it important to assess the developmental history of a child during pediatric evaluation?

    <p>To evaluate growth patterns and possible delays</p> Signup and view all the answers

    Which of the following is a common dietary change recommended for children facing obesity?

    <p>Incorporating more whole grains</p> Signup and view all the answers

    What is a significant concern when assessing a child's gastrointestinal (GI) health?

    <p>Stool color and character</p> Signup and view all the answers

    Which area is NOT specifically examined under respiratory concerns for pediatric patients?

    <p>Visual problems</p> Signup and view all the answers

    What psychosocial factor does the 'HEADSS' mnemonic specifically address in adolescents?

    <p>Education</p> Signup and view all the answers

    What is an important component of family history to assess in pediatric patients?

    <p>Mental health disorders</p> Signup and view all the answers

    Which symptom would be most relevant when evaluating a child's musculoskeletal system?

    <p>Joint pains or swelling</p> Signup and view all the answers

    In assessing social history, which aspect is particularly important for school-aged children and adolescents?

    <p>School and peer relations</p> Signup and view all the answers

    What aspect of the parent/child interaction should be evaluated during pediatric assessments?

    <p>Parental response to the child's needs</p> Signup and view all the answers

    What constitutes hypertension in children and adolescents?

    <p>Systolic and/or diastolic blood pressure consistently &gt;95th percentile</p> Signup and view all the answers

    Which vital sign is particularly important to monitor as it varies with age?

    <p>Blood pressure</p> Signup and view all the answers

    Which behavior indicates a child may be exhibiting signs of acute illness during examination?

    <p>Abnormal cry or lethargy</p> Signup and view all the answers

    What is the purpose of using distraction techniques with toddlers during exams?

    <p>To reduce anxiety and make the process less intimidating</p> Signup and view all the answers

    What is the correct action if a child's blood pressure is between the 90th and 95th percentiles?

    <p>Implement lifestyle interventions</p> Signup and view all the answers

    How should vital signs be interpreted in relation to a child's age?

    <p>Normal values vary and should be adjusted for age</p> Signup and view all the answers

    What would you assess regarding a toddler's general appearance during a physical examination?

    <p>Behavior, body habitus, and interaction with others</p> Signup and view all the answers

    What is one of the criteria for developmental milestones according to the latest guidelines?

    <p>Milestones included at age most (&gt;75%) would be expected to demonstrate the milestone.</p> Signup and view all the answers

    Which age is associated with a child typically recognizing familiar people?

    <p>6 months</p> Signup and view all the answers

    At what age do children typically start using a pincer grasp and waving bye-bye?

    <p>12 months</p> Signup and view all the answers

    What is the percentage of children with developmental delays who receive early intervention services before age 3?

    <p>25%</p> Signup and view all the answers

    Which developmental skill is expected of a child at 36 months?

    <p>Understands 75% of language</p> Signup and view all the answers

    Which of the following developmental milestones should a child typically reach by 2 years of age?

    <p>Kicks a ball</p> Signup and view all the answers

    What is one primary function of the CDC Milestone Tracker?

    <p>To allow parents to track their child’s development</p> Signup and view all the answers

    At what age do most children transition to using basic words like 'mama' or 'dada'?

    <p>15 months</p> Signup and view all the answers

    What type of skills does developmental surveillance cover from birth to 10 years?

    <p>Physical and psychological development</p> Signup and view all the answers

    Which major developmental milestone is typically expected at 5 years of age?

    <p>Counts to 10</p> Signup and view all the answers

    At what age should the palmar and plantar grasp reflexes be absent?

    <p>2-4 months</p> Signup and view all the answers

    What developmental change is expected in females around the age of 10 years?

    <p>Breast development starts</p> Signup and view all the answers

    Which of the following is NOT a characteristic of precocious puberty in females?

    <p>Menarche after 10 years</p> Signup and view all the answers

    When is the peak height velocity typically observed in girls?

    <p>Around 11-12 years</p> Signup and view all the answers

    What should be included in the initial work-up for suspected precocious puberty?

    <p>Bone age radiography</p> Signup and view all the answers

    Which condition is characterized by in-toeing or out-toeing gait in children?

    <p>Tibial torsion</p> Signup and view all the answers

    What is the normal age range for the disappearance of the Moro (startle) reflex?

    <p>4-6 months</p> Signup and view all the answers

    What is considered the normal age range for menarche to occur in females?

    <p>9-15 years</p> Signup and view all the answers

    Study Notes

    Vaccine Schedule

    • Birth: Hepatitis B
    • 2, 4, 6 months: Dtap, Polio, Hib, PCV, Hep B, Rotavirus
    • 12- 15 months: Varicella, MMR, Dtap, Polio, Hib, PCV, Hep A
    • 2 years old: Hep A
    • 4-5 years old: Dtap, Polio, MMR, Varicella
    • 11- 12 years old: Tdap, Meningitis (A,C,Y), HPV
    • 16 years old: Meningitis (B), Booster Men (A,C,Y)
    • Influenza: Yearly for children over 6 months old
    • Covid vaccine: Available for children over 6 months old

    Live Vaccines

    • Rotavirus (2, 4, 6 months): Oral administration.
    • Varicella (12-15 months, 4-5 years old):
    • MMR (12-15 months, 4-5 years old):
    • Intranasal influenza:
    • Live vaccines carry a higher risk of side effects, like fever and fussiness.

    Immunization Schedules

    • Vaccine schedules for birth to 18 years old, including "catch-up" schedules, are available from the CDC website.
    • The CDC provides a free laminated pocket card for vaccine schedules.

    Developmental History

    • School:
      • Current grade.
      • Specific problems, such as separation anxiety, attention/behavior issues, or interaction with peers.
    • Behavior:
      • Enuresis, temper tantrums, thumb sucking, pica (eating non-food substances), nightmares, etc.
    • Developmental milestones:
      • Ages at which milestones were achieved and the child's current abilities.
      • Examples include smiling, rolling over, sitting unassisted, crawling, walking, running, saying their first word, stacking blocks, riding a tricycle.
      • Note any delays or regressions in milestones.
      • If developmental issues exist, consider family norms.

    Changes to Developmental Milestones

    • New criteria for developmental milestones and surveillance tools were introduced in 2022.
    • New features of the revised milestones include:
      • Focus on milestones demonstrated by the majority (over 75%) of children at a given age.
      • Removal of "warning signs."
      • Clear and accessible language for families.
      • Emphasis on the progression of skills.
      • Inclusion of open-ended questions.
      • Information on promoting developmental skills.
      • Tools for early intervention.

    Early Identification

    • It is estimated that 1 in 6 children have a developmental delay, and less than 25% receive early intervention services before age 3.
    • Resources for families include:
      • Infant Toddler Connection: [Insert website]
      • The Arc of Virginia: [Insert Website]

    CDC Milestone Tracker

    • The CDC's milestone tracker allows parents to track their child's development.
    • The tracker sends notifications and provides tips and suggestions.

    Developmental Milestones

    • Every well-child exam should assess development:
      • Birth to 10 years old:
        • Gross motor skills
        • Fine motor skills
        • Personal and social behavior
        • Language
      • ** 10 years to 21 years:**
        • Physical maturation (Tanner stages)
        • Psychological development

    Physical Exam

    • General Approach
      • Gather information through observation first.
      • Position patients appropriately:
        • Neonates and young infants: Examine on the table.
        • Preschoolers: Lie or sit on a caregiver's lap.
        • Adolescents: Examine without family present.
      • Stay at the child's level.
      • Order of the exam: Start with less distressing areas and work towards more sensitive areas.
        • For infants/toddlers, examine ears and mouth last.
      • Use opportunism: If the child is drowsy, auscultate the chest and heart. If the child is kicking, observe hip range of motion.
      • Establish rapport: Spend time playing or interacting with the child before the exam.
      • Include the child: Explain the exam to them using appropriate language.
      • Caregivers, not the examiner, should disrobe the child.
      • Examine painful areas last.
      • Be honest: If the exam will hurt, tell the child calmly.
      • Understand developmental stages: Consider how the child's development may affect their response.
      • Don't take it personally if the child cries.

    Physical Exam Key Tips

    • Examine a doll or teddy bear first to create a less stressful experience.
    • Offer choices when appropriate: Ask the child which ear to examine first instead of asking permission.
    • Use distraction as a valuable tool. For example, palpate the belly with the child for the "lunch" they ate earlier.

    Physical Exam Components

    • General appearance: Recognize signs of acute illness by observing skin color, hydration, respirations, mental status, cry, and social interaction.
    • Vital signs: Observe heart rate, respiratory rate, blood pressure, and temperature. Remember that normal values change with age.
    • Measurements: Measure height, weight, and head circumference (up to two years old). Plot data and observe relationships between these measurements.
    • Skin: Inspect the skin for birthmarks, scars, and rashes. Describe rashes using color (pink, red, flesh colored), type of lesion (macular, vesicular, papular, petechial), secondary characteristics (excoriated, ulcerated), and pattern/distribution (annular, linear, generalized, dermatome localized).
    • Head: Examine fontanelles for size and tension. Observe sutures, head size, shape, hair whorls, and dysmorphic features.
    • Eyes: Inspect for strabismus, palpebral fissure slant, conjunctiva, sclera, cornea, lids and structures, and check for plugged nasolacrimal ducts. Evaluate extraocular movements (EOM), pupillary reaction, and the red reflex.
    • Ears: Observe the position of the ears from the front. Draw an imaginary line from the canthi to the occiput. Examine the tympanic membranes using pneumatic otoscopy. Remember to examine infant/toddler ears last. Assess hearing through gross and diagnostic evaluation.
    • Nose: Check for patency (airflow), nasal septum (deviations), mucosa (color, edema, polyps), discharge, and sinus tenderness.
    • Mouth: Examine lips for color and fissures, buccal mucosa for color, vesicles, and moisture, and tongue for color, papillae, position, and tremors. Evaluate teeth and gums for number and condition, palate for intactness and arch formation, tonsils for size, color, and exudate, the posterior pharyngeal wall, and gag reflex.
    • Neck: Inspect for tracheal position, thyroid, pits, clefts, tags, and cysts. Palpate for thyroid and masses (cysts, lymph nodes, which are more prominent in childhood). Assess range of motion (ROM).
    • Chest: Inspect for rate and pattern of breathing. Note that normal respiratory rate changes with age, abdominal breathing is normal in infants, and periodic breathing is normal in infants. Palpate the chest and assess ROM.
    • Extremities: Inspect for gross deformities.

    Vaccine Schedule

    • Hepatitis B: Birth
    • Dtap, Polio, Hib, PCV, Hep B, Rotavirus: 2, 4, 6 months
    • Varicella, MMR, Dtap, Polio, Hib, PCV, Hep A: 12-15 months
    • Hep A: 2 years old
    • Dtap, Polio, MMR, Varicella: 4-5 years old
    • Tdap, Meningitis (A,C,Y), HPV: 11-12 years old
    • Meningitis (B), Booster Men (A,C,Y): 16 years old
    • Influenza: Yearly >6 months
    • Covid vaccine: > 6 months old

    Live Vaccines

    • Rotavirus (oral): 2, 4, 6 months
    • Varicella (12-15 months, 4-5 years old):
    • MMR (12-15 months, 4-5 years old):
    • Intranasal influenza:

    Immunization Schedules

    Developmental History

    • School: Present grade, specific problems with separation anxiety, attention, behavior, interaction with peers
    • Behavior: Enuresis; temper tantrums; thumb sucking; pica; nightmares
    • Developmental Milestones:
      • Ages at which milestones achieved (smiling, rolling, sitting, crawling, walking, running, 1st word, stacking blocks, riding tricycle, etc.)
      • Appropriate or delayed development?
      • Milestone regression?
      • If abnormal, Family norms?
    • Feeding Problems: Resolved or current
    • Weight Problems:
      • Obesity: Dietary changes, Setting and reaching goals
      • Failure to gain/maintain weight:
    • Fluoride?

    Pediatric Review of Systems

    • General: weight changes, weight at birth
    • Skin and Lymph: rashes, adenopathy, lumps, bruising, bleeding, pigmentation changes
    • HEENT: headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis, caries
    • Cardiac: cyanosis, dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations
    • Respiratory: pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB
    • GI: stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, colic, appetite
    • GU: frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema
    • Musculoskeletal: joint pains, swelling, fever, scoliosis, myalgia, weakness, injuries, gait changes
    • Pubertal: secondary sexual characteristics, menses, menstrual problems, pregnancies, sexual activity
    • Allergy: urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

    Family History

    • Siblings: Number and ages
    • Consanguinity:
    • Genetic Disorders:
    • Early Childhood Deaths:
    • All Systems: Minimum first-degree relatives
      • Cardiovascular Disease:
        • Premature or sudden cardiac death
      • Mental Health Disorders and Substance Use:

    Social History

    • Home Environment Assessment:
      • How many and WHO in home?
      • Type of dwelling: Age of home, water source, heating and cooling, Other risks (basement, stairs, pets)
      • Resources:
      • Caregivers' social habits: Tobacco, alcohol, etc.
      • Caregivers employed: Who cares for patient when away from home?
    • School and peer relations: Important in school-aged children and adolescents

    Social History ("HEADSS")

    • Home:
    • Education:
    • Activities:
    • Drugs & Drinking:
    • Sex & Sexuality:
    • Suicidality & Mental Health:

    Parent/Child Interaction

    • Parent's response to child's needs:
      • Eye contact?
      • Communication with siblings?
      • Communication with each other (parent to parent, parent to child) with sensitivity and respect?
    • Parent handling and response to the child: Developmentally appropriate?

    Interval History

    • Necessary if long period between visits.
    • Important if:
      • Child has had serious illness
      • Hospitalization
      • Consultation with new diagnosis, or surgery
      • Child in protective care

    Physical Exam - General Approach: "Tips and Tricks"

    • Gather data by observation:
      • Position of patient:
        • Neonates and young infants - On examining table
        • Preschool - Lying/sitting on caregiver's lap
        • Adolescent - Without family present
      • Stay at child's level: Do not tower over them!
      • Order of exam: Least distressing to most distressing.
        • Infants/toddlers - Ear and mouth last
      • Opportunism: While waiting for the parent to remove the child's clothing, assess shoulder/arm movement, head control.

    General Approach

    • Establish Rapport:
      • Spend time playing or interacting with children before examining them.
      • Include child - explain to the child's level.
    • Caregiver disrobes child.
    • Examine painful area last.
    • Be honest: Tell child if something is going to hurt, but be calm.
    • Understand developmental stages & impact on response.
    • If patient cries, don't take it personally.

    General Approach - Examination Strategies

    • Examine doll or teddy bear first.
    • Be careful asking permission.
      • "I'm going to look in your ears now, okay?" What happens when they say no?
      • Give choices where it doesn't affect the exam: "Which ear should I look in first?"
    • Distraction:
      • Palpate belly for what they had for lunch.
      • Use light on the otoscope to light up their finger: Ask to see if they have light up ears, nose, teeth, etc.
      • Ask them to place the ear/nose speculum on the otoscope like a hat. They become familiar with the instrument, and it is less "scary." Also good chance to observe fine motor skills.
      • Blow out light on otoscope or pretend to blow out birthday candles for deep breath.

    Physical Exam

    • General Appearance:
      • Recognize signs of acute illness (skin color, hydration status, respirations, mental status, cry, social interaction).
      • Important to look at behavior, development, body habitus, relationship to parent and examiner.

    Physical Exam - Vital Signs

    • Heart Rate:
    • Respiratory Rate:
    • Blood Pressure:
    • Temperature:
    • Remember normal values change with age. Use PALS reference card.

    Pediatric BP Measurement

    • Hypertension in children and adolescents: defined as systolic and/or diastolic blood pressure consistently > 95th percentile for age, sex, and height.
    • Pre-hypertension: Blood pressures between the 90th and 95th percentiles. Lifestyle interventions indicated.
    • THE FOURTH REPORT ON THE Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.

    Physical Exam - Measurements

    • Height:
    • Weight:
    • Head Circumference: (First two years)
    • Plot data! Note relationships between measurements.

    Physical Exam - Skin

    • General Inspection:
      • Birthmarks, scars, etc.
      • Tibial torsion - "W" sitting
      • Symmetry
      • Edema
      • Clubbing
    • Joints: Motion, stability, swelling, tenderness. Complete "newborn" hip exam up to 6 months of age.
    • Muscles:

    Physical Exam - Extremities

    • Gait: In-toeing, out-toeing, Genu varum (bow-leg), Genu valgus (knock-knee)

    Physical Exam - Neurologic Exam

    • Most accomplished through observation:
      • Cranial nerves:
      • Sensation:
      • Cerebellum:
      • Muscle tone and strength:
      • Reflexes:
        • Deep tendon reflexes (DTRs)
        • Superficial reflexes (abdominal and cremasteric)
        • Neonatal primitive reflexes - When should they disappear?

    Neurological - Primitive Reflexes

    • Grasp (palmar and plantar): Absent after 2-4 months
    • Moro (startle): Absent after 4-6 months
    • Suck: Variable disappearance around 6 months
    • Rooting: Variable disappearance
    • Stepping (placing): Absent 1st month; variable disappearance
    • DTR's: (+) Babinski normal up to 18 months, others may be brisk.

    Puberty - Normal Puberty - Females

    • Breast development: At ~ 10 years old due to increased ovarian estradiol secretion.
      • Range 8-12 years.
    • Peak height velocity: During sexual maturity rating 2 and 3 (~6 mos prior to menarche).
      • ~8.3 cm/year at ~11-12 years.
    • Menarche: Follows ~ 2.5 years after onset of breast development at 12.5 years.
      • Range: 9-15 years.
      • Thin, white discharge noted 6 months prior to menarche.

    Sexual Maturity Ratings - Tanner Stages

    • Ratings or stages used to describe and classify physical changes and correlate with pubertal events.
      • Females: Breast development and pubic hair development.
      • Males: Genital and pubic hair development.
    • Affected by body habitus and demographic factors.

    When to Suspect Disorders of Puberty? Precocious Puberty

    • Females: Secondary sexual characteristics identified younger than 8 years old.
    • Males: Secondary sexual characteristics identified younger than 9 years old.
    • Relatively tall stature leads to shorter adult height.

    Precocious Puberty

    • Initial work-up: FSH, LH, testosterone (males), estradiol (females), Thyroid function, Bone age radiography.
    • Neuroimaging: MRI brain for girls younger than 6 years old and ALL boys. Image if neurologic symptoms including headache, vision changes, or seizures.
    • Refer: Endocrine.

    Pediatric History

    • Interviews occur in different clinical settings: hospital admission, outpatient clinic (preventive care, acute illness, follow-up)
    • The type of history should be according to the setting.
    • Frequently, the history is obtained from a second party (Parent or caregiver)
    • The reliability of caregiver observation varies, as does concern over signs and symptoms.
    • In older children (usually older than 4), there should be two sources of information: patient and parent.
    • Confidentiality becomes an issue in adolescents.

    General Information

    • Date of Visit
    • Identifying data: name, birth date, gender, race, informant – relationship to patient

    Chief Complaint

    • What brings the patient in for the visit in caregiver or patient own words.
    • “Well visit” is acceptable as a chief complaint.

    History of Present Illness

    • Details about the events leading to the visit using OLDCARTS or OPQRST format
      • O - Onset of event
      • P - Provocation or Palliation
      • Q - Quality of pain or other symptom
      • R - Region or Radiation
      • S - Severity
      • T - Time (History)
    • Johnny is a ____ month/year old caucasian male who presents today accompanied by_____ (caregiver, if present) for _____ month/year well check with no concerns.

    Past Medical History

    • Current or chronic medical illness with date of onset.
    • Mention accidents, injuries or poisonings.
    • Hospitalizations: Date, reason for hospitalization, any complications.
    • Surgeries (even if minor): Date, location, provider, complications.
    • Medications: Dose, route, frequency, indication.
    • Allergies: Drugs, food, environmental.
    • List other members of the care team.

    Additional Past Medical History

    • Pregnancy/Birth/Neonatal history
      • Birth Weight
      • Gestational Age
      • Maternal complications
      • Alcohol/drug/environmental exposure
      • Problems in the newborn period
    • Immunization status
    • Development
    • Diet

    Immunization History

    • Extremely important to document
      • Missed doses?
      • Any reactions?
    • Feeding problems
      • Resolved or current.
    • Weight problems
      • Obesity: Dietary changes, setting and reaching goals.
      • Failure to gain or maintain weight.
    • Fluoride

    Pediatric Review of Systems

    • General: Weight changes, weight at birth.
    • Skin and Lymph: Rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes.
    • HEENT: Headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis, caries.
    • Cardiac: Cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations.
    • Respiratory: Pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB.
    • GI: Stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, colic, appetite.
    • GU: Frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema.
    • Musculoskeletal: Joint pains or swelling, fevers, scoliosis, myalgia or weakness, injuries, gait changes.
    • Pubertal: Secondary sexual characteristics, menses and menstrual problems, pregnancies, sexual activity.
    • Allergy: Urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions.

    Family History

    • Number and ages of siblings
    • Consanguinity
    • Known genetic disorders
    • Early childhood deaths
    • All systems - Minimum first-degree relatives
      • Cardiovascular disease
        • Premature or sudden cardiac death
    • Don’t forget mental health disorders and substance use.

    Social History

    • Assessment of the home environment
      • How many and WHO in home
      • Type of dwelling
        • Age of home, water source, heating and cooling
        • Other risks – basement (dry or damp), stairs
      • Pets
      • Resources
      • Caregivers’ social habits – Tobacco, EtOH, etc. Are caregivers employed?
      • Who cares for the patient when away from home?
    • School and peer relations are important for school-aged children and adolescents.

    Social History: HEADSS Mnemonic

    • Home: Home environment
    • Education: School life, performance, relationships with teachers and peers
    • Activities: School and non-school activities.
    • Drugs: Tobacco, alcohol, and illicit drug use
    • Sex: Sexual activity, including sexual orientation and concerns.
    • Suicidality and Mental Health: Depression, anxiety, suicidal ideation, and other mental health conditions.

    Parent/Child Interaction

    • How does the parent respond to the child’s needs?
    • Is there eye-contact?
    • Is there communication with siblings?
    • Do the caregivers communicate to each other/patient with sensitivity and respect?
    • Does the parent handle and respond to the child in a developmentally appropriate way?

    Interval History

    • Necessary if a long period between visits.
    • Very important if the child has had a serious illness, hospitalization, consultation with a new diagnosis, or surgery.
    • Also, necessary if the child has been in protective care.

    Physical Exam

    • Gather as much data as possible by observation first.

    General Approach

    • Position of patient:
      • Neonates and young infants - On examining table.
      • Up through preschool - Lying/sitting on caregivers lap.
      • Adolescent - Without family present.
      • Stay at the child’s level as much as possible – Do not tower!!
    • Order of exam: Least distressing to most distressing
      • Infants/toddlers – Ear and Mouth last.
    • Opportunism:
      • If the child dozes, auscultate the chest and heart.
      • While the parent removes the shirt, examine shoulder/arm movement and head control.
      • If the child kicks the examiner, observe hip range of motion.
      • If the infant is crying, auscultate deep breaths between each cry.

    General Approach: Establishing Rapport

    • Establish Rapport in an age-appropriate manner:
      • Spend time playing or interacting with children before interacting with them clinically, but don’t be too silly or they might not listen to your instructions later on.
      • Include the child - explain to the child’s level.
    • Caregiver, NOT examiner, should disrobe the child.
    • Examine the painful area last. This helps to get a general impression of the overall attitude.
    • Be honest - If something is going to hurt, tell them that in a calm fashion.
      • Don’t lie; you will lose credibility!
    • Understand developmental stages’ impact on the child’s response.
      • Example: Stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult.

    General Approach: Tips and Tricks

    • Examine a doll or teddy first.
    • Be careful with inadvertently asking permission:
      • “I’m going to look in your ears now, okay?”
        • What happens if they say “no”?
    • Give choices where it doesn't affect the exam.
      • “Which ear should I look in first?”
    • Distraction is a valuable tool — Especially with toddler age.
      • Palpate the belly and ask them what they had for lunch.
      • Otoscope light up finger – Ask to see if they have light up ears, nose, teeth, etc.
      • Ask them to place the ear/nose speculum on the otoscope like a hat.
        • They become familiar with the instrument; it will be less “scary”.
        • Also a good chance to observe fine motor skills.
      • Blow out the light on the otoscope or pretend to blow out birthday candles for a deep breath.

    Physical Exam : General Appearance

    • Recognize signs of acute illness by looking at: skin color, hydration status, respirations, mental status, cry, social interaction.
    • Important to look at behavior, development, body habitus, relationship to parents and examiner.

    Physical Exam : Vital Signs

    • Heart rate, respiratory rate, blood pressure, and temperature.
    • Remember normal values change with age.
      • Listed on PALS reference card – Keep in whitecoat pocket on peds rotation.

    Pediatric Blood Pressure Measurement

    • Children and adolescents – hypertension defined as systolic and/or diastolic blood pressure consistently > 95th percentile for age, sex, and height.
    • Blood pressures between the 90th and 95th percentiles are considered pre-hypertensive and are an indication for lifestyle interventions.

    Physical Exam : Measurements

    • Height, weight, head circumference (first two years).
    • Plot data.
    • Note the relationships between the measurements.

    Physical Exam : Skin

    • General inspection: Birthmarks, scars, symmetry, edema, clubbing, tibial torsion ("W" sitting).
    • Joints: Motion, stability, swelling, tenderness. (Complete "newborn" hip exam up to 6 months of age).
    • Muscles: Inspect and palpate.

    Physical Exam : Extremities

    • Gait: In-toeing, out-toeing, genu varum (bow-leg), genu valgus (knock-knee).

    Physical Exam : Neurological

    • Most accomplished through observation alone.
    • Cranial nerves
    • Sensation
    • Cerebellum
    • Muscle tone and strength
    • Reflexes: Deep tendon reflexes, superficial (abdominal and cremasteric), neonatal primitive - when should they disappear.

    Neurological : Primitive Reflexes

    • Grasp (palmar and plantar): Absent after 2-4 months.
    • Moro (startle): Absent after 4-6 months.
    • Suck: Variable disappearance around 6 months.
    • Rooting: Variable disappearance.
    • Stepping (placing): Absent 1st month; variable disappearance.
    • Deep tendon reflexes: (+) Babinski normal up to 18 months; others may be brisk.

    Puberty

    • Precocious Puberty
      • Females – Secondary sexual characteristics identified younger than 8 yo.
      • Males – Secondary sexual characteristics identified younger than 9 yo.
      • Relatively tall stature leads to shorter adult height.
    • Tanner Stages
      • Ratings used to describe and classify physical changes and correlate with pubertal events in males and females.
      • Affected by body habitus and demographic factors.

    When to Suspect Disorders of Puberty?

    • Precocious Puberty:
      • Initial work-up: FSH, LH, testosterone (males), estradiol (females), Thyroid function, Bone Age radiography
      • Neuroimaging: MRI Brain girls younger than 6 years old and ALL boys (image if neurologic symptoms including headache, vision changes or seizures)
      • Refer: Endocrine.

    Vaccination Schedule

    • Birth: Hepatitis B vaccine
    • 2, 4, 6 months: DTaP, Polio, Hib, PCV, Hep B, Rotavirus vaccines
    • 12-15 months: Varicella, MMR, DTaP, Polio, Hib, PCV, Hep A vaccines
    • 2 years old: Hep A vaccine
    • 4-5 years old: DTaP, Polio, MMR, Varicella vaccines
    • 11-12 years old: Tdap, Meningitis (A,C,Y), HPV vaccines
    • 16 years old: Meningitis (B), Booster Men (A,C,Y) vaccines
    • Influenza: yearly vaccination recommended for all individuals over 6 months of age
    • COVID-19: vaccination recommended for all individuals over 6 months of age

    Live Vaccines

    • Rotavirus (2, 4, 6 months) oral: administered orally
    • Varicella (12-15 months, 4-5 years old) and MMR (12-15 months, 4-5 years old): administered via injection
    • Intranasal influenza: administered intranasally
    • Live vaccines generally have a higher rate of side effects: such as fever and fussiness

    Developmental History

    • School: current grade, specific problems (e.g., separation anxiety, attention/behavior issues), interactions with peers
    • Behavior: enuresis, temper tantrums, thumb sucking, pica, nightmares, etc.
    • Ages at which milestones achieved: smiling, rolling, sitting unassisted, crawling, walking, running, first word, stacking blocks, riding tricycle, etc. Note whether these milestones are at an appropriate age or delayed. Determine if there has been any milestone regression.
    • Family norms: are the milestones in line with family norms?
    • Parents and Siblings: history of parents and siblings
    • Developmental Milestones (2022 changes): updated guidelines for developmental milestones and surveillance tools are available on the American Academy of Pediatrics website

    Early Identification of Developmental Delay

    • Prevalence: 1 in 6 children have developmental delay
    • Intervention: Less than 25% of children with developmental delay receive early intervention services before the age of 3
    • Resources for Early Intervention:

    CDC Milestone Tracker

    • Benefits: allows parents to track their child's development and receive notifications. Provides useful tips and suggestions based on tracked development.

    Developmental Milestones

    • Every Well-Child Exam (Birth-10 years):
      • Gross motor skills: ability to control large muscle movements (e.g., walking, jumping, throwing)
      • Fine motor skills: ability to control small muscle movements (e.g., grasping, writing, drawing)
      • Personal and social behavior: interaction with others, self-care, and social understanding
      • Language: ability to understand and communicate verbally
    • Every Well-Child Exam (10-21 years):
      • Physical maturation: Tanner stages, indicating puberty milestones
      • Psychological development: emotional and cognitive development

    General Approach to Physical Exam

    • Observation First: gather information through observation before performing the physical exam.
    • Positioning:
      • Neonates and young infants: on the examining table
      • Up to preschool: lying/sitting on caregiver's lap
      • Adolescents: examined without family present
    • Stay at Child's Level: avoid towering over children, but instead, try to be at their eye level.
    • Order of Exam: least distressing to most distressing, especially in infants and toddlers (ears and mouth last).
    • Opportunism: utilize opportunities during the exam to gather information (e.g., listen to chest/heart sounds while child dozes, observe shoulder/arm movement during shirt removal).
    • Establish Rapport:
      • Age-appropriate interaction: interact with children in a way that is appropriate to their age and developmental stage.
      • Include the child: explain procedures to them at their level of understanding.
      • Caregiver disrobing: the caregiver, not the examiner, should disrobe the child.
      • Painful areas last: always examine painful areas last in order to minimize distress.

    Tips and Tricks for Establishing Rapport

    • Honesty: be honest with the child if a procedure will hurt, but explain it calmly.
    • Developmental Stages: understand how different developmental stages may impact a child's response.
    • Use of dolls or teddy bears: let the child examine a doll or teddy bear first.
    • Avoid asking permission: asking for permisson ("I'm going to look in your ears now, okay?") can lead to challenges if the child says "no."
    • Give choices: where possible, provide choices that don't affect the exam (e.g., "Which ear should I look in first?").
    • Distraction: use distraction techniques to help the child relax (e.g., palpate the belly while asking about lunch, pretend to blow out birthday candles for a deep breath).

    Physical Exam

    General Appearance

    • Acute Illness: look for signs of acute illness (e.g., skin color, hydration status, respiration rate, mental status, cry pattern, social interaction)
    • Behavior: observe behavior, development, body habitus, and relationship with parent and examiner.

    Vital Signs

    • Heart Rate: assess heart rate, respiration rate, blood pressure, and temperature.
    • Age-Specific Values: note that normal values change with age. Refer to the PALS reference card (keep a white coat pocket on pediatric rotations).

    Measurements

    • Height, Weight, Head Circumference: measure height, weight, and head circumference (first two years).
    • Plot Data: plot data on appropriate growth charts.
    • Relationships: observe the relationships between different measurements.

    Skin

    • Inspection: examine for any birthmarks, scars, or unusual markings.
    • Rash Description: be able to precisely describe any rash, noting:
      • Color: pink, red, flesh-colored, etc.
      • Type: macular (flat), vesicular (blister-like), papular (raised), petechial (pinpoint red spots), etc.
      • Secondary Characteristics: excoriated (scratched), ulcerated, etc.
      • Pattern/Distribution: annular (ring-shaped), linear, generalized, localized to dermatome, etc.
    • Fontanelles: examine fontanelles (soft spots on the skull) for size and tension (examine while child is calm and sitting).
    • Sutures: inspect sutures (joints between skull bones).
    • Shape: Observe head size, shape, hair whorls, and any dysmorphic features.

    Eyes

    • General Inspection: examine for strabismus (misaligned eyes), palpebral fissure slant, conjunctival (eye lining) color, sclera (white part of the eye) color, corneal (transparent outer layer of the eye) condition.
    • Extraocular Movements: test eye movements in all directions.
    • Pupillary Reaction: check pupillary light reflex.
    • Red Reflex: assess the red reflex (reflection of light from the retina).

    Ears

    • Position: examine ear position from the front, drawing an imaginary line from the inner corner of the eyes to the back of the head.
    • Tympanic Membranes: utilize pneumatic otoscopy (an instrument that allows visualization of the eardrum) to examine the tympanic membranes.
    • Hearing: assess gross hearing (e.g., response to sound) and potentially refer for diagnostic hearing tests.

    Nose

    • Patency: check for nasal patency (airflow through the nose).
    • Septum: examine the nasal septum.
    • Mucosa: inspect nasal mucosa for color, edema (swelling), polyps (growths).
    • Discharge: note any nasal discharge (e.g., color, consistency).
    • Sinus Tenderness: assess sinus tenderness (by pressing on specific areas of the face).

    Mouth

    • Lips: examine lip color and for fissures (cracks).
    • Buccal Mucosa: inspect the buccal mucosa (lining of the cheeks) for color, vesicles (blisters), and moisture.
    • Tongue: look for tongue color, papillae (bumps on the surface), position, and tremors.
    • Teeth and Gums: note the number of teeth present and their condition, and examine gum health.
    • Palate: check palate integrity and arch (high or low arch).
    • Tonsils: assess tonsil size, color, and exudate
    • Posterior Pharyngeal Wall: examine the posterior pharyngeal wall.
    • Gag Reflex: test the gag reflex.

    Neck

    • Inspection: examine neck position, trachea position, thyroid gland, and for pits, clefts (grooves), tags (skin flaps), or cysts.
    • Palpation: palpate the thyroid and for any neck masses.
    • ROM: test neck range of motion.

    Chest

    • Inspection: assess the pattern and rate of breathing.
      • Normal values: remember that normal respiratory rate changes with age.
      • Abdominal breathing: observe if abdominal breathing is present (normal in infants).
      • Period breathing: note if period breathing is present (normal in infants, characterized by pauses in breathing followed by a large increase in the rate of breathing).
    • Palpation: palpate the chest.
    • ROM: test chest range of motion.

    Extremities

    • Inspection: inspect for any gross deformities (e.g., abnormalities in limb shape or alignment).

    Pediatric History & Physical Exam

    • Interviews in different clinical settings: Hospital admission, Outpatient clinic (Preventive care, Acute illness, Follow-up)
    • Type of history should vary based on setting.
    • History frequently obtained from second party (Parent or caregiver)
      • Reliability of caregiver observation varies
      • As does concern over signs and symptoms (first time mom vs. mom of four)
    • In older children, usually two sources of information (Patient and parent) - Age 4 and up
    • Confidentiality becomes an issue in adolescents.
    • General Information
      • Date of Visit
      • Identifying data: Name, Birth date, Gender, Race, Informant (Relationship to patient)
    • Chief Complaint
      • What brings patient in for visit in caregiver or patient own words
      • "Well visit" is acceptable
    • History of Present Illness
      • Events leading to visit in OPQRST or OLDCARTS format
      • O - Onset of event
      • P - Provocation or Palliation
      • Q - Quality of pain or other symptom
      • R - Region or Radiation
      • S - Severity
      • T - Time (History)
    • Past Medical History
      • Current/chronic medical illness with date of onset
        • Mention accidents, injury or poisonings
      • Hospitalizations - Date, reason for hospitalization, any complications
      • Surgeries (even if minor) - Date, location, provider, complications
      • Medications - Dose, route frequency, indication
      • Allergies - Drugs, food, environmental
      • List other members of care team
    • Past Medical History (Continued)
      • Pregnancy/Birth/Neonatal history
        • Birth Weight
        • Gestational Age
        • Maternal complications
        • Alcohol/drug/environmental exposure
        • Problems in the newborn period
      • Immunization status
      • Development
      • Diet
    • Immunization History
      • Extremely important
      • Missed doses? Any reactions? Parents and siblings.
    • Developmental Milestones
    • Early Identification
    • CDC Milestone Tracker
      • Allows parent to track child’s development
      • Sends notifications
      • Gives tips and suggestions
    • Developmental Milestones
      • Every well-child exam:
        • Birth - 10 years: Gross motor skills, fine motor skills, personal and social behavior, language
        • 10 years - 21 years: Physical maturation (Tanner stages), psychological development
    • American Academy of Pediatrics Bright Futures Website
      • https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf?_ga=2.24025970.999672650.1661705183-1667011755.1661705182
    • 2 Months
      • Holds head up when on tummy
      • Moves both arms and legs
      • Watches you as you move
      • Reacts to loud noise
      • Smiles when you talk to them
    • 4 Months
      • Holds head steady
      • Brings hand to mouth
      • Turns head towards sound
      • Uses arm to swing at toys
      • Smiles to get attention
    • 6 Months
      • Rolls from tummy to back
      • Pushes up with straight arms
      • Reaches to grab toy
      • Blow raspberries
      • Knows familiar people
    • 9 Months
      • Sits without support
      • Rake with fingers
      • Bangs two objects
      • Looks when name called
      • “Mama” and “Dada”
    • 12 Months
      • Pulls up to a stand
      • Cruises
      • Drinks from a cup without a lid
      • Pincer grasp
      • Waves bye-bye
      • Plays pat-a-cake
    • 15 Months
      • Takes a few steps on their own
      • Finger feeds
      • 1-2 words like ‘mama’ or ‘dada’
      • Follows one step directions
      • Stacks 2 blocks
      • Claps when excited
    • 18 Months
      • Walks well
      • Scribbles
      • Drinks from cup
      • Moves away but looks for reassurance
      • Puts hands out to be washed
    • 24 Months (2 Years Old)
      • Kicks a ball
      • Runs
      • Walks up stairs without support
      • Puts 2 words together
      • Tries to use switches, knobs, buttons
      • Points to 2 body parts
      • Looks at face to see reaction
    • 30 Months
      • Uses hands to twist things
      • Jumps off ground with 2 feet
      • 50 plus words
      • Says “I” “me” “we”
      • Parallel play
      • Says “look at me”
      • Follows simple commands
      • Knows one color
    • 36 Months (3 Years Old)
      • Strings items together
      • Puts on some clothes
      • Uses a fork
      • Copies a circle
      • Asks who, what, where
      • Says first name
      • Understands 75% of language
      • Notices other children and joins in play
    • 48 Months (4 Years)
      • Catches a large ball
      • Serves food and pours water with supervision
      • Unbuttons ‘some’ buttons
      • Appropriate pencil grasp
      • Names a few colors
      • Tells what comes next in story
      • Plays pretend
    • 60 Months (5 Years)
      • Counts to 10
      • Writes some letters in their name
      • Hops on one foot
      • Buttons some buttons
      • Sings, dances
      • Simple chores
    • Normal Growth and Development (Ages 6-10 Years)
      • Development/Education
      • Nutrition
      • Sleep
      • Exercise
      • Social emotional health
      • Bedwetting
    • Normal Growth and Development (Ages 11-12 Years)
      • Bright Futures Survey
      • Puberty
      • Mental Health
      • Nutrition
      • Sleep
      • Exercise
    • Normal Growth and Development (Ages 13-18)
      • Educational
      • Mental Health
      • Puberty
      • Confidentiality
      • Nutrition
      • Sleep
      • Exercise
    • Nutrition
      • Current Diet
        • Texture issues
      • Breast or bottle fed
      • When rice cereal, solid foods, etc. introduced
      • Feeding problems
        • Resolved or current
      • Weight problems
        • Obesity - Dietary changes
        • Setting and reaching goals
        • Failure to gain/maintain weight
      • Fluoride?
    • Pediatric Review of Systems
      • General - weight changes, weight at birth
      • Skin and Lymph - rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes
      • HEENT - headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis, caries
      • Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations
      • Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB
      • GI - stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, colic, appetite
      • GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema
      • Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or weakness, injuries, gait changes
      • Pubertal - secondary sexual characteristics, menses and menstrual problems, pregnancies, sexual activity
      • Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions
    • Family History
      • Number and ages of siblings
      • Consanguinity
      • Known genetic disorders
      • Early childhood deaths
      • All systems - Minimum first-degree relatives
        • Cardiovascular disease
          • *Premature or sudden cardiac death
        • Don’t forget mental health disorders and substance use
    • Social History
      • Assessment of the home environment
        • How many and WHO in home
        • Type of dwelling
          • Age of home, water source, heating and cooling
          • Other risks - basement (dry or damp), stairs
        • Pets
        • Resources
        • Caregivers’ social habits - Tobacco, EtOH, etc.
        • Are caregivers employed?
        • Who cares for patient when away from home?
      • School and peer relations important in school-aged children and adolescents.
    • Social History (Continued)
      • "HEADSS" mnemonic reminds clinicians about the psychosocial factors that influence the physical and emotional well-being of adolescents
        • Home
        • Education
        • Activities
        • Drugs and Drinking
        • Sex and Sexuality
        • Suicidality and Mental Health
    • Parent/Child Interaction
      • How does the parent respond to the child’s needs?
      • Give choices where it doesn’t affect exam
        • “Which ear should I look in first?”
      • Distraction is a valuable tool - Especially with toddler age
        • Palpate belly asking what they had for lunch
        • Otoscope light up finger - Ask to see if they have light up ears, nose, teeth, ect.
        • Ask them to place ear/nose speculum on otoscope like a hat
        • They become familiar with instrument making it less “scary”
        • Good chance to observe fine motor skills
        • Blow out light on otoscope or pretend to blow out birthday candles for deep breath
    • Physical Exam
      • General Appearance
        • Recognize signs of acute illness by looking at skin color, hydration status, respirations, mental status, cry, social interaction
        • Important to look at behavior, development, body habitus, relationship to parent and examiner
    • Physical Exam (Continued)
      • Vital signs: Heart rate, Respiratory rate, Blood pressure and temperature
      • Remember normal values change with age
        • Listed on PALS reference card - Keep in whitecoat pocket on peds rotation
    • Pediatric BP Measurement
      • Children and adolescents - hypertension defined as systolic and/or diastolic blood pressure consistently >95th percentile for age, sex, and height
      • Blood pressures between the 90th and 95th percentiles are considered pre-hypertensive and are an indication for lifestyle interventions
    • THE FOURTH REPORT ON THE Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
    • Physical Exam (Continued)
      • Measurements: Height, weight, head circumference (first two years)
        • Plot data
        • Note relationships between measurements
    • Physical Exam (Continued)
      • Skin: General inspection
        • Birthmarks, Scars, etc. tibial torsion – “W” sitting
        • Symmetry
        • Edema
        • Clubbing
      • Joints: Motion, stability, swelling, tenderness
        • Complete “newborn” hip exam up to 6 months of age
      • Muscles:
    • Physical Exam (Continued)
      • Extremities: Gait
        • In-toeing, out-toeing
        • Genu varum (bow-leg)
        • Genu valgus (knock-knee)
    • Physical Exam (Continued)
      • Neurologic Exam - Most accomplished through observation alone
        • Cranial nerves
        • Sensation
        • Cerebellum
        • Muscle Tone and Strength
        • Reflexes - DTR, Superficial (abdominal and cremasteric), Neonatal primitive - when should they disappear
    • Neurological – Primitive Reflexes
      • Grasp (palmar and plantar) - Absent after 2-4 months
      • Moro (startle) - Absent after 4-6 months
      • Suck - Variable disappearance around 6 months
      • Rooting - Variable disappearance
      • Stepping (placing) - Absent 1st month; variable disappearance
      • DTR’s – (+) Babinski normal up to 18 months, others may be brisk
    • Puberty
    • Normal Puberty - Females
      • Breast development at ~ 10 y/o as a result of increased ovarian estradiol secretion
        • Range 8-12 years.
      • Peak height velocity during sexual maturity rating 2 and 3 (6 mos prior to menarche) - ~8.3cm/year at ~11-12 years.
      • Menarche follows ~ 2.5 years after onset of breast development at 12.5 years
        • Range 9-15 years
        • Thin white discharge noted 6 mo prior menarche.
    • Sexual Maturity Ratings - Tanner Stages
      • Ratings or stages used to describe and classify physical changes and correlate with pubertal events
        • Females - Breast development and pubic hair development
        • Males - Genital and pubic hair development
      • Affected by body habitus and demographic factors
    • When to suspect disorders of puberty? Precocious Puberty
      • Females - Secondary sexual characteristics identified younger than 8 yo.
      • Males - Secondary sexual characteristics identified younger than 9 yo.
      • Relatively tall stature leads to shorter adult height.
    • Precocious Puberty
      • Initial work-up: FSH, LH, testosterone (males), estradiol (females), Thyroid function, Bone Age radiography
      • Neuroimaging: MRI Brain girls younger than 6 years old and ALL boys (image if neurologic symptoms including headache, vision changes or seizures)
      • Refer: Endocrine.
    • When to suspect disorders of puberty?
      • Females - Secondary sexual characteristics identified younger than age 8
      • Males - Secondary sexual characteristics identified younger than age 9.
      • Relatively tall stature leads to shorter adult height

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