H&P Across Populations

What are the areas of assessment for a pediatric exam?

- physical development

- cognitive development

- social and emotional development

What are the stages of development?

- newborn (0-28 days of age)

- infancy (1-12 months)

- early childhood (1-5 years)

- middle childhood (6-11 years)

- adolescence (12-18 years) -> early, middle, late

What vitals should you obtain at every visit?

height & weight

When should you measure head circumference?

birth to 36 months

When should you start measuring blood pressure?

age 2

How does the pulse change throughout development?

higher in infancy; slows down with aging

How does the respiratory rate change throughout development?

higher in infancy; slows down with aging

How should you measure temperature at

rectal temperature

How should you measure temperature at >/=2 mo of age?

tympanic temperature

What is considered a fever?

100.4

Apgar Score

evaluates the newborn's neurologic recovery from delivery and cardiopulmonary adaptation to extrauterine life

What domains does the Apgar score assess?

- heart rate

- respiratory effort

- muscle tone

- reflex irritability

- color

When do you evaluate the Apgar score?

1- and 5-minute evaluations post-birth

Describe the Apgar scoring for heart rate.

0 = absent

1 =

Describe the Apgar scoring for respiratory effort.

0 = absent

1 = slow and irregular

2 = good; strong

Describe the Apgar scoring for muscle tone.

0 = flaccid

1 = some flexion of the arms and legs

2 = active movement

Describe the Apgar scoring for reflex irritability.

0 = no response

1 = grimace

2 = cry vigorously, sneeze, or cough

Describe the Apgar scoring for color.

0 = blue, pale

1 = pink body, blue extremities

2 = pink all over

Describe the 1-minute Apgar scoring.

0-4 = severe depression, requiring immediate resuscitation

5-7 = some nervous system depression

8-10 = normal

Describe the 5-minute Apgar scoring.

0-7 = high risk for subsequent CNS and other organ system dysfunction

8-10 = normal

What vitals should you consider during the newborn assessment?

- fever (all ages) >/= 100.4

- risk for hypothermia

What should you note on the heart/lung exam of a newborn?

- respiratory effort

- murmurs

- equal UE and LE pulses

What should you note on the genital exam of a newborn?

breast buds may be present

What should you note on the abdomen exam of a newborn?

inspect - umbilical cord remnant is gone by 2 weeks of age

What should you note on the genitalia exam of a newborn?

inspect for congenital anomaly

What should you note on the MSK exam of a newborn?

- clavicle exam

- hip exam

What should you note on the skin exam of a newborn?

Vernix caseosa = present at birth

Lanugo = shed within the first few weeks of life

JAUNDICE

What stage of development has the most rapid rate of growth?

infancy

How do birth weight and height change during the first year of life?

Birth weight triples & height increases by 50%

When should a newborn be back to birth weight?

after 2 weeks

What is the sequence of examination for an infant assessment?

- perform non-disturbing maneuvers early

- perform potentially distressing maneuvers near the end (ears, mouth, abdomen)

Describe the Developmental Milestones.

- CDC revised developmental milestone checklist

- adjusted benchmarks to reflex behaviors and skills that 75% of children that age typically exhibit

- goal to identify issues earlier

- eliminate "warning signs"

- increase literacy for all patients

What are the 4 main components of the Developmental Milestones?

- social/emotional milestones

- language/communication milestones

- cognitive milestones (learning, thinking, problem solving)

- movement/physical development milestones

What are red flags considering developmental miestones?

no progression or backwards progression

When does the anterior fontanelle close?

between 4 and 26 months of age

When does the posterior fontanelle close?

by 2 months of age

What should you check during the eye exam of the infant?

presence of red reflex

What should you check during the ear exam of the infant?

acoustic blink reflex

How do infants breathe during the first 2 months of life?

nasal breathing

What sinus is present at birth?

ethmoid sinuses

What should you check during the mouth/pharynx exam of the infant?

- thrust

- palpate gums and teeth

When should teeth develop?

6 to 26 months of age, 1 tooth per month

Which teeth erupt first, and which erupt last?

central and lateral incisors erupt first, molars last

Describe the thorax in infants.

More rounded in infants than in older children and adults.

What should you inspect for when considering the heart in infants?

cyanosis

What should you consider during the male genitalia exam of an infant?

- inspect for congenital anomaly

- palpate for descent of testes into scrotal sac

What should you consider during the female genitalia exam of an infant?

inspect for congenital anomaly

What should you inspect during the abdomen exam of an infant?

umbilical cord remnant is gone by 2 weeks of age

What should you consider during the MSK exam of an infant?

- palpate the clavicle, hips

- Bowlegged growth to age 18 mo is normal

- Nursemaid's elbow

What should you consider during the neuro exam of an infant?

- reflexes

- motor function/muscle tone

What does Barlow test for?

ability to subluxate or dislocate an intact but unstable hip-laxity/clunk

How do you perform Barlow?

flex the hips and knees, adduct the leg and posteriorly direct pressure

What does Ortolani test for?

presence of dislocated hip-audible clunk

How do you perform Ortolani?

flex hip and knees at 90 degrees and abduct hip and push thigh anteriorly

Neck exam in early childhood

palpate for lymph nodes; adenopathy is common

Eye exam in early childhood

cover and uncover test for position and alignment of eyes

Ear exam in early childhood

visualization of TM is the greatest challenge

Nose/sinus exam in early childhood

maxillary sinuses are present by age 4

Heart exam in early childhood

brachial pulses still easier to feel than radial

Abdomen exam in early childhood

- protuberant abdomen still normal

- liver span 1-2 cm below costal margin is still normal

- spleen edge 1-2 cm below costal margin is normal

Male genitalia exam in early childhood

testes undescended in scrotal sac by age 1 is abnormal and need to refer

MSK exam in early childhood

- knock-knees (bow from 18 mo to knocked from age 4-10)

- acute limp

- inspect spine for scoliosis in any child who can stand

Ear exam in middle childhood

acoustic screening test

Nose exam in middle childhood

- sphenoid sinus present by 8 yo

- frontal sinuses present by 6-7 yo

Mouth/throat exam in middle childhood

- dental caries

- tonsils peak growth between 8-16 yo

Genitalia exam in middle childhood

- breast development is typically the first sign of puberty in females

- tanner stage

What are the stages of adolescence?

early, middle, and late

When does puberty end during adolescence?

ends around 14 yo for females and 16 yo for males

How does cognitive development change throughout adolescence?

move from operational thinking to logical reasoning, considering future implications

How does social and emotional development change throughout adolescence?

family to peer influence

- struggle for identity, independence and intimacy

- can see stress, high risk behaviors, and health issues

How should you approach an adolescent exam?

make the exam comfortable and confidential; express interest in them rather than their problems

- start conversations with specific questions to get the conversation going

- ask them if they have any questions

How does the cardiovascular system change during pregnancy?

- plasma volume increases

- cardiac output increases

How does the MSK system change during pregnancy?

- weight gain

- relaxin hormone

- lumbar lordosis, ligament laxity

How does the pelvis change during pregnancy?

- uterus = rises out of the pelvis

- vagina = vaginal secretions are thick, white, and more profuse

- cervix = Chadwick's sign, Mucus plug

What should be performed at the initial prenatal care visit?

- confirmation of the pregnancy

- health status of the mother

- counsel for a healthy pregnancy

- intimate partner violence screening

What should be performed at the subsequent prenatal care visit?

- continued assessment of health status of the mother

- assess fetus

- intimate partner violence screening (once per trimester)

What past obstetrical history should you obtain during the prenatal exam?

past pregnancies

- prenatal or labor complications

- birth weights

- hx of miscarriages or fetal demise

What past medical history should you obtain during the prenatal exam?

review for any systemic diseases

What family history should you obtain during the prenatal exam?

family hx of congenital diseases (sickle cell, cystic fibrosis)

Naegele's Rule (expected date of delivery)

first date of the LMP, add one week, subtract three months, and add one year

How can you verify expected dates of delivery?

- doptone (positive at 10-12 weeks)

- fetoscope (heard at 18 weeks)

- fetal movement (quickening) 18-24 weeks

- ultrasound

General exam of a pregnant woman

emotional state & nutritional status

Vitals signs of a pregnant woman

baseline blood pressure

Gestational HTN

BP becomes elevated >140/>90 after 20 weeks gestation

Preeclampsia

elevated BP >140/>90 after 20 weeks gestation with protein in the urine

How much weight will a low-BMI (>19.8) woman gain during pregnancy?

28-40 lbs

How much weight will a normal-BMI (19.9-26) woman gain during pregnancy?

25-35 lbs

How much weight will a high-BMI (26.1-29) woman gain during pregnancy?

15-25 lbs

How much weight will an obese-BMI (>29) woman gain during pregnancy?

Head exam of a pregnant woman

cholasma

Eye exam of a pregnant woman

anemia and pallor of the conjunctiva

Nose exam of a pregnant woman

congestion and edema

Mouth exam of a pregnant woman

periodontal disease

Thorax and lung exam of a pregnant woman

SOB

Heart exam of a pregnant woman

venous hums

Breast exam of a pregnant woman

- coloration

- prominent veins

When can an examiner feel fetal movement?

24 weeks

How do you measure fundal height?

measure pubis symphysis to the top of the fundus

When should the fundal height in centimeters approximate the number of weeks of gestation?

20-32 weeks

When should you auscultate the fetal heart rate?

10 weeks