Peds History and Exam PDF

PEDIATRIC HISTORY & PHYSICAL EXAM Rachel Rogers, M.D. MountainView Pediatrics, PC HISTORY PEDIATRIC HISTORY Interviews occur in different clinical settings Hospital admission Outpatient clinic Preventive care Acute illness...

PEDIATRIC HISTORY & PHYSICAL EXAM Rachel Rogers, M.D. MountainView Pediatrics, PC HISTORY PEDIATRIC HISTORY Interviews occur in different clinical settings Hospital admission Outpatient clinic Preventive care Acute illness Follow-up Type of history should be according to setting PEDIATRIC HISTORY Frequently the history is obtained from a second party (Parent or caregiver) Reliability of caregiver observation varies As does concern over signs and sx’s (first time mom vs. mom of four) In older children, usually two sources of information (Patient and parent) > Age 4 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” okay  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) 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/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 Past history should also include - 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? 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 > 6moa Covid vaccine > 6moa LIVE VACCINES Rotavirus (2,4,6 months) oral Varicella (12-15 months, 4-5 yoa) MMR (12-15 months, 4-5 yoa) Intranasal influenza Live vaccines do have higher rate of side effects (fever, fussiness) IMMUNIZATION SCHEDULES Birth to 18 yrs immunization schedules including “catch-up” schedule https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent- age.html?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/h cp/imz/child-adolescent.html CDC offers laminated pocket card FREE https://www.cdc.gov/vaccines/schedules/hcp/imz/child- adolescent.html Choose “immunizations and vaccines” schedules and booklets DEVELOPMENTAL HISTORY School Present grade Specific problems Separation anxiety, attention/behavior, etc. Interaction with peers Behavior Enuresis, temper tantrums, thumb sucking, pica, nightmares, etc. DEVELOPMENTAL HISTORY Ages at which milestones achieved and current developmental abilities Smiling, rolling, sitting unassisted, crawling, walking, running, 1st word, stacking blocks, riding tricycle, etc. appropriate or delayed? Milestone regression? If abnormal – Family norms? Parents Siblings CHANGES TO DEVELOPMENTAL MILESTONES 2022 https://publications.aap.org/pediatrics/article/149/3/e2021052138/184748/E vidence-Informed-Milestones-for-Developmental CHANGES TO DEVELOPMENTAL MILESTONES 2022 Criteria for Developmental Milestones and Surveillance Tools Milestones included at age most (>75%) would be expected to demonstrate the milestone Eliminate “warning signs” Family friendly (plain language, easy answer) Shows progression of skills Include open-ended questions Include information for developmental promotion Include information on how to act early EARLY IDENTIFICATION 1:6 children have Developmental Delay Less than 25% with DD receive early intervention services before age 3 Infant Toddler Connection https://www.itcva.online The Arc of Virginia https://www.thearcofva- newpath.com CDC MILESTONE TRACKER Allows parent to track child’s development Sends notifications Gives tips and suggestions CDC MILESTONES DEVELOPMENTAL MILESTONES Every well child exam Birth – 10yrs Gross motor skills, fine motor skills, personal and social behavior, language 10yrs – 21yrs Physical maturation (tanner stages), psychological development American Academy of Pediatrics Bright Futures Website https://downloads.aap.org/AAP/PDF/periodicity_sch edule.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”  Pulls up to a stand Cruises Drinks from a cup without a lid 12 MONTHS 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 Understand 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 The "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? Is there eye-contact? Is there communication with siblings? Both patient and caregiver 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 long period between visits Very important if child has had serious illness, hospitalization or consultation with new diagnosis, or surgery Also, necessary if child has been in protective care PHYSICAL EXAM BUT FIRST…. GENERAL APPROACH TIPS AND TRICKS GENERAL APPROACH Gather as much data as possible by observation first 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 child dozes, auscultation chest/heart While parent removes shirt, examine shoulder/arm movement, head control If child kicks examiner, observe hip range of motion If infant crying, auscultate deep breaths between each cry GENERAL APPROACH Establish Rapport in 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 child - explain to the child’s level Caregiver, NOT examiner, should disrobe child Examine painful area last - Get general impression of overall attitude Be honest - If something is going to hurt, tell them that in a calm fashion Don’t lie, or you lose credibility! Understand developmental stages’ impact on child’s response Ex.- Stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult If patient cries, don’t take it personally  Examine doll or teddy first Be careful with inadvertently 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 exam “Which ear should I look in first?” Distraction is a valuable tool – Especially with toddler age Palpate belly for 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, 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 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 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 Measurements Height, weight, head circumference (first two years) Plot data Note relationships between measurements PHYSICAL EXAM Skin General inspection Birthmarks, Scars, etc. Be able to describe a rash Color – Pink, red, flesh colored Type of lesion - Macular, vesicular, papular, petechial, etc. Secondary characteristics – Excoriated, ulcerated, etc. Pattern/Distribution – Annular, linear, etc/ generalized, localized to dermatome, etc. PHYSICAL EXAM Head Fontanelles Size Tension - Examine when calm and in sitting position Sutures Head Size, shape, hair whorls, etc. dysmorphic features PHYSICAL EXAM Eyes General inspection Strabismus Slant of palpebral fissures Conjunctive, Sclera, cornea Lid and structures – Plugging of nasolacrimal ducts EOM Pupillary reaction Red Reflex PHYSICAL EXAM Ears Position of ears Observe from front Draw imaginary line from canthi to occiput Tympanic membranes - Use of pneumatic otoscopy In infant/toddlers, should be examined last! Hearing – Gross vs Diagnostic Assessment PHYSICAL EXAM Nose Patency Nasal septum Mucosa Color, edema, polyps Discharge Sinus tenderness PHYSICAL EXAM Mouth Lips Color, fissures Buccal Mucosa Color, vesicles, moist or dry Tongue Color, papillae, position, tremors Teeth and gums - Number, condition Smiles for life – tips for pediatric oral health exam and module for applying fluoride varnish + Free CME Palate – intact, arch Tonsils Size, color, exudate Posterior pharyngeal wall Gag Reflex PHYSICAL EXAM Neck Inspection Tracheal position Thyroid Pits, clefts, tags, cyst Palpation Thyroid Masses Cyst, Lymph Nodes (more prominent in childhood) ROM PHYSICAL EXAM Chest Inspection Rate/Pattern of breathing Normal respiratory rate changes with age Abdominal breathing is normal in infants Period breathing normal in infants (pause 12 degree curve further eval) Palpation ROM PHYSICAL EXAM Extremities Inspection Gross deformities - Ex. 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 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 Copyrights apply Copyrights apply Copyrights apply Copyrights apply Copyrights apply 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? DELAYED PUBERTY Females – No signs of breast development by age 13 In girls with initial pubertal changes, absence of menarche by 15 is also concerning Males – No signs of testicular enlargement by age 14 Halting or regression of pubertal development Short stature leads to taller adult height DELAYED PUBERTY Constitutional delay = Most common cause boys (60%) and girls (30%) 1-5% growth chart Diagnosis of exclusion More than 75% have family history of parental pubertal delay DELAYED PUBERTY Initial work-up: Serum FSH, LH, Testosterone (males) Estradiol (females), Thyroid, prolactin, Insulin-like growth factor, bone age radiography Refer: Endocrine CLINICAL PEARLS Early maturation typically means shorter adult stature Puberty occurs 2 years earlier in girls than boys Limbs accelerate before trunk, & distal limbs before proximal portions Bone growth accelerate puberty but bone mineralization lags behind. Puts teen at greater risk of fracture One half total body calcium is laid down during puberty in females