PD E2- School aged kids

What should be saved for last in exam of school aged kids?

Throat, ear & rectal exams

What is a good way to approach examining a body part in a school aged kid?

Give child control by asking them which part first (ex- which ear first?) & make a game out of it; avoid asking for permission

What age should kids have 1 parent in the room during exam?

Children under 11

How should physical restraints be used?

Hands over the head, stabilize the legs & avoid injury; use as last resort

What should be ruled out in children under 3 that appear ill and have a fever?

Sepsis, UTI, PNA, other infxs

If a child is lethargic, how should you take their temperature?

Rectally

What is sinus bradycardia in children under 3?

≤ 100 bpm

What is sinus bradycardia in 3-9 y/o?

≤ 60 bpm

HR ranges

What is normal RR in early childhood?

20-40 breaths/min

*tachypnea ≥ 40

What is the respiratory rate for late childhood?

15-25 breaths/min

At what age do children have respiratory rates same as adults?

≥ 15 y/o

How should you take blood pressure in school aged child?

Cuff should cover 2/3” of upper arm or leg, take BP in both arms and 1 leg if < 3-4 y/o to r/o coarctation of aorta

At what age do you start taking a standing height and weight?

≥ 2 y/o

How much should a child grow grow after age 2?

5cm per year

What are the 2 age groups that growth charts are separated into?

birth - 36 mos & 2-18 years

What is measured on growth charts?

Head circumference, length/weight, stature/weight, BMI

*measured in percentiles

Is it possible to examine the VA of a child < 3 y/o?

No

What should a 3 y/o’s VA be?

20/40

What should a 4 y/o’s VA be?

20/30

What should a 5 y/o’s VA be?

20/20

What condition is reduced vision in an otherwise healthy eye, sometimes referred to as a “lazy eye” & must be corrected by age 6 or can cause permanent reduced VA?

Amblyopia

What are the 3 positions you can check a child’s TM?

Lying down & restrained, parent holding child to chest, parent holding cild sitting on their lap & holding body w/ one arm and head w/ other

At what age should asx children have a full scale acoustic screening?

> 4 y/o

Hearing ranges

What does a pale and boggy nasal mucosa indicate?

Perennial allergic rhinitis

What does U/L nasal drainage w/ foul smelling discharge indicate?

FB

When are the sinuses visible on XR?

Maxillary → 4 y/o

Sphenoid → 6 y/o

Frontal → 6-7 y/o

Voice changes & reasons

What might posterior lymph nodes indicate?

Lice or scalp fungus

What tests are used to check for neck mobility/meningitis?

Kernig’s & brudzinksi’s

How does croup sound to auscultation?

Prolonged inspiration

How does asthma sound to auscultation?

Prolonged expiratory phase & expiratory breathing

How is the pulm exam different in school aged children children?

Fremitus is more pronounced, percussion is more resonant, & breath sounds are louder as closer to the chest wall & less fat, inspiration:expiration ratio 1:1

How do chest retractions d/t upper or lower airway obstruction appear?

Drawing in of suprasternal & surpaclavicular regions of the chest from accessory muscle use

Where is the heart’s position in children?

Higher & to the left in early childhood; visible at L 4th ICS until age 7 then at 5th

Left of MCL until age 4, MCL from 4-6, R of MCL ≥7

How does the heart sound in school aged children?

Higher pitch; S1 louder at apex & S2 at pulmonic, splitting S2 is common

How do benign murmurs sound?

Heard best supine with bell, ≤ grade 3, low pitch vibratory musical sound loudest along LSB; no signs of other disease

What murmur?

• benign; sounds produced by turbulence of blood in jugulars

• continuous, loudest in diastole, soft low pitch

• listen w bell above medial third of clavicles & R 1st & 2nd ICS

• goes away with pressure on jugular

Venous hum

What type of murmur?

• caused by inc blood flow through heart as tissues need more oxygen

• most assoc w tachycardia

• seen in anemias, increased metabolism, muscular activity, usually resolves when underlying is treated

Hematologic

How do pathologic murmurs sound?

Coarse, systolic, heard best at base (usually rheumatic valvulitis if after age 3)

Pallor, cyanosis, poor growth, SOB & squat

At what age do umbilical hernias usually resolve?

5 y/o

Where the is liver in school aged children?

Projects downward like a tongue, 1-2 cm below costal margin on respective side

Where is the spleen in children?

Feel diagonally and up from the midline

How can you check for abdominal pain in children?

Ask child to hop on one foot (+ peritoneal sign) or jump off table (rebound)

*child may refuse d/t pain

What is breast enlargement and pubic hair < 8 y/o?

Precocious puberty

How is the cremasteric reflex in children?

Strong; have child sit cross legs to decrease & help testicle descend into scrotum

How can you detect an inguinal or femoral hernia?

Ask child to lift something (not detected by coughing)

What are you checking for when asking pt to stand with feet together?

Genu varum (common from 2-9) & foot deformities

What is the best predictor of future intellect?

Language

What test consists of a child drawing a human figure that is scored to evaluate developmental, cognitive, & emotional functioning?

Goodenough-Harris draw a person or Gesell Figure’s test

What are two warning signs seen in school aged children?

1.Too well behaved, overly anxious to place, needy of attention, love & approval, fear of rejection , few friends & interests→ child may be attempting to care for/protect parent

2.Self defeating behavior, breaks rules, deliberately performs poorly → Fear of failure, low self esteem & confidence, reject parental authority / pressure

signs of abuse & DDX

How might a child with a heady injury from abuse present?

Lethargy, irritability, unexplained vomiting, apnea, coma, convulsions

How can abdominal trauma from abuse present?

Secondary to perforation, obstruction of bleeding, vomiting, pain, tender, shock, sepsis

What are warning signs of abuse?

Injuries in various stages of healing, multiplanar injuries, obvious patterns (like from a hand), assaultive locations such as trunk, upper arms, upper legs, neck, face & perineal area

Where does accidental bruising typically occur?

Knee, shin, forearm, forehead, chin, bony prominence, elbows, hips, spine

How does impetigo appear?

Superficial yellow crusted lesions with satellite lesions

How do non accidental hot water immersion burns appear?

B/L, symmetric with well demarcated lines & without splash marks