Integrated Pediatric Exam Study Guide

Neonate/Newborn

Birth to 1 month (28 days)

Infant

1 month to 1 year

Early childhood

1-4 years

Middle childhood

5-10 years

Adolescent

11-18 years

Well-Child Checks

Performed at:

Newborn

Month 1, 2, 4, 6, 9, 12, 15, 18, 24, 30

Year 3, 4, 5, 6, 8, 10, 11-21

Growth

Refers to the physical changes in a child's size, height, weight, face, shoe size, length of arms and legs, body shape

Height/length

Weight

Head circumference (through 24 months)

What three things do we measure at each Well child check?

Obesity

BMI >95th percentile for age is considered what?

At risk for overweight

BMI between 85-95th percentiles is considered what?

Underweight status

BMI <5th percentile for age is considered what?

Percentile

Measured in statistics indicating the value below which a given percentage of observations in a group of oberservations fall

80% of children for that age are taller than that child

If a child is in the 20th percentile for height, what does this mean?

10-15%

What is the approximate amount of weight loss to occur to baby after birth?

2 weeks

When should the baby regain birth weight by?

4-6 months

When should the baby weigh double the birth weight by?

12 months

When should the baby weigh triple the birth weight by?

24 months

When should the baby weigh quadruple the birth weight by?

2.5 kg/year

How much should the child gain between 24 months and puberty each year?

Increases 50%

Birth length should do what by 12 months?

Doubles

Birth length should do what by 36-48 months?

Breastfeeding benefits

Infants: Decreases incidence of infections, SIDS, diabetes, asthma, IBD, higher IQ, cheaper, easily absorbed, likely normal weight as adult

Mothers: Decreased incidence of breast/other cancers, osteoporosis, endometriosis, anemia, postpartum depression, promotes postpartum weight loss, delayed return to fertility

Vitamin D Supplementation

What should be given to infants that exclusively breastfeed?

15-30 g/day

How much should a breastfed baby gain per day during the first 6 months?

Development

Refers to increases and changes in physical, emotional, social, and intellectual skills

Denver Developemental Screening Test

Standardized and valuable tool used to assess children for problems who appear normal as well as to monitor children who are at higher risk

Fields of development

Gross Motor

Fine Motor

Cognitive/Language

Social/Emotional

Gross Motor Skills

Use of large muscles in arms, legs, feet, and torso

Muscles are used to sit, stand, walk, run, change positions, and balance

Fine Motor Skills

Use of small muscles in fingers, wrists, toes, lips, and tongue

Muscles are used to pick up or hold objects such as holding a spoon to eat or crayon to draw

Cognitive/Language Development

Gaining skills needed to understand and use a language

Includes spoken words as well as body language and gestures

Social/Emotional Development

Skills such as self-awareness, forming relationships with primary caregivers, interacting with other people, responding to feelings and learning self-control

Smiling, responding to affection

Good head control

Begins to roll

What gross motor skills should a 4 month old display?

Startles

What speech/language development should a 1 month old display?

Babbles

What speech/language development should a 4 month old display?

Sits

What gross motor skills should a 6 month old display?

Crawls

What gross motor skills should a 9 month old display?

Says Mama, Dada

What speech/language development should a 9 month old display?

Walks independently

What gross motor skills should a 12 month old display?

Waves bye-bye

What social development should a 12 month old display?

Stacks 2 blocks

What fine motor skills should a 15 month old display?

Throws a ball overhead

What gross motor skills should a 24 month old display?

Stack a tower of blocks

What fine motor skills should a 24 month old display?

Two-word phrases

What speech/language development should a 24 month old display?

Toilet trained

What social development should a 3 year old display?

Live vaccines

Measles, Mumps, Rubella (MMR)

Rotavirus

Varicella

Never!!! Pick up where we left off regardless of time interval

Do we restart a vaccine series if they miss a shot?

Live Virus Vaccine rules

Give on same day OR at least 4 weeks apart

PPD- give on same day as MMR or >4 weeks after MMR

Vaccinate according to chronological age

How do we vaccinate preemies?

No live vaccines!!!

What type of vaccines do we have to avoid in immunodeficient children?

Common adverse reactions to vaccines

All of the following are what?

Redness, soreness, swelling, pain, crankiness, decreased appetite, fever, malaise

Moro/Startle response

"Startle Reflex" which occurs after the abrupt extension of the infant's neck which causes the arms to flail outward then curl inward, disappears at 2-4 months

Placing Repsonse

Infant is held upright and the top of the foot is brushed against table, infant will place foot on top of table

Disappears at 6 weeks of age

Rooting reflex

Infant's cheek is stroked causing the infant to turn towards you, aids in breastfeeding

Disappears after 3-4 months

Sucking Reflex

When object is placed in infant's mouth, infant begins to suck

Reflex disappears after 4 months

Trunk Incurvation

Infant placed in ventral suspension, the examiner strokes infant from shoulder to hip on one side, causes infant to laterally curve to that side

Palmar Grasp

Occurs when finger of examiner is placed at the base of the infant's middle, ring, and little finger

Causes infant to grasp the finger, disappears around 4 months

Tonic Neck Reflex

"Fencer position" when the head of the infant is turned toward one side, the arm and leg on that side extend and the opposite arm and leg flex

1 month old

When does a baby look at parents faces?

2 months old

When does a baby begin to smile and recognize their parents?

4 months old

When does a baby begin to smile, laugh, and double their birth weight?

6 months old

When does a baby begin to sit unassisted or with minimal support? Can also begin solid foods at this point

9 months old

When does a baby begin to pull themselves up to stand?

12 months old

When does a baby say 1-2 words plus momma/dada, walks alone or with support, and can change to whole milk?

Hgb looking for anemia

Lead

What labs do we need to check at 12 months old?

3-6 words

How many words should a 15 month old say?

18 months old

When should a baby be able to use a spoon and cup & when do we do the MCHAT for Autism screening?

Autism

Persistent deficits in social communication and social interaction across multiple contexts

Restricted, repetitive patterns of behavior, interests or activities

Symptoms often present at 18 months, screen again at 24-30 month visit

24 months old

At what age should a child say 20 words, 2-word phrases, and can move to forward facing carseat?

Lead

MCHAT

What labs/screening should we perform at 24 month olds?

Toilet training

The following indicates a child is ready for what:

Dry at least two hours at a time during the day

Recognizes bowel movements before they happen

3 years old

When should a child know their age, name and sex?

Nightmares

Frightening dreams that occur during REM sleep, followed by awakening

Can often describe frightening images, recall the dream, talk about it during the day

Difficulty falling back asleep

Night terrors

Commonly occur within 2 hours after falling asleep

Screaming, thrashing around, rapid breathing

Associated with sleepwalking

Incoherent and unresponsive to comforting

No memory of event next day

4 years old

When is a child expected to sing a song and know their first and last name?

Lipids

What labs do we perform in 9-11 year olds?

Depression screening (PHQ9)

What screening do we do in 11-18 year olds?

ADHD

Associated with triad of symptoms: Impulsivity, inattention, and hyperactivity

Girls: Higher prevalence of the inattentive

Boys: Higher prevalence of the hyperactive

Atrial Septal Defect Etiology

Hole in atrial septum which is the opening between right and left atrium causing oxygenated blood to be shunted from the left atrium to the right atrium (left to right shunt, acyanotic heart defect)

Causes: Ostium secundum most common, ostium primum (mitral regurgitation), sinus venous, coronary sinus

Second most common cause of Congenital Heart Diseases

Common in fetal alcohol syndrome, more common in females

Atrial Septal Defect Signs and Symptoms

Mostly asymptomatic until >30, some symptoms include recurrent respiratory infections, failure to thrive, exertional dyspnea, fatigue, palpitations, atrial arrhythmias, syncope, stroke (paradoxical embolism)

Atrial Septal Defect Physical Exam

Systolic ejection crescendo-decrescendo flow murmur in pulmonic (left upper sternal border)

Widely split fixed S2 that does not vary with respirations

Atrial Septal Defect Diagnostics

Chest X-Ray: Cardiomegaly

ECG: Incomplete RBB

Echocardiogram: Gold Standard

Atrial Septal Defect Treatment

Spontaneous closure likely in first year if small

Surgical correction if symptomatic

Patent Ductus Arteriosus Etiology

Non-cyanotic congenital heart defect that occurs when the ductus arteriosus, a connecting vessel between the aorta and the pulmonary artery, fails to close after birth

Causes: Premature birth, perinatal distress, hypoxia delays closure, Rubella infection in first trimester

Left to right shunt occurs resulting in less blow flow out into fetus body and excessive flow through pulmonary circulation

Strong association between PDA and infants with respiratory distress syndrome

Patent Ductus Arteriosus Signs and Symptoms

Respiratory distress/apnea, failure to thrive, poor feeding, tachycardia, tire easily, weight loss, pulmonary congestion

Patent Ductus Arteriosus Physical Exam

Machine-sounding murmur

Left-ventricle overload: Prominent LV impulse, enlarged heart

Systemic circulation: Bounding pulses, widened pulse pressure

Patent Ductus Arteriosus Diagnostics

Echocardiogram: Gold Standard

Chest X-Ray: Cardiomegaly, edema

Patent Ductus Arteriosus Treatment

To close PDA: Indomethacin

To keep PDA open: Prostaglandin E1

Surgery for those who fail to respond to medication

Coarctation of the Aorta Etiology

Narrowing of the descending aorta that results in left ventricular pressure overload

o Occurs more commonly in males, link with Turner's Syndrome

Coarctation of the Aorta Signs and Symptoms

Secondary HTN, bilateral claudication, dyspnea on exertion, syncope, failure to thrive, shock

Coarctation of Aorta Physical Exam

Delayed/diminished femoral pulses: Because descending aorta narrowed so blood flow to lower extremities impaired

Strong upper extremity pulses

Multiple cardiac abnormalities present, murmurs

Coarctation of the Aorta Diagnostics

EKG: May show left ventricular hypertrophy

Chest X-Ray: "Rib Notching" due to large volume of blood going through collateral intercostal arteries

Echocardiogram: Typically confirms diagnosis

Coarctation of the Aorta Treatment

Prostaglandin E1 Infusion

Beta Blocker for HTN

Surgical Correction: Balloon angioplasty

Tetralogy of Fallot Etiology

Congenital heart malformation where the ventricular septum has deviated to the right resulting in 4 main features that include ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy

Most common cyanotic congenital heart defect, strong association with Down Syndrome

Features of Tetralogy of fallot

Ventricular Septal Defect: Shift of ventricular septum to the right causes a gap between right ventricle and left ventricle

Pulmonic Stenosis: New placement of septum blocks pulmonic valve causing it to narrow

Right Ventricular Hypertrophy: Narrowing of pulmonic valve causes right ventricle to work harder to pump blood through stenotic valve

Overriding Aorta: Aorta is receiving blood directly from both left ventricle and right ventricle and is displaced over the VSD

Ventricular septal defect TOF

Shift of ventricular septum to the right causes a gap between right ventricle and left ventricle

Pulmonic Stenosis TOF

New placement of septum blocks pulmonic valve causing it to narrow

Right Ventricular Hypertrophy TOF

Narrowing of pulmonic valve causes right ventricle to work harder to pump blood through stenotic valve

Overriding Aorta TOF

Aorta is receiving blood directly from both left ventricle and right ventricle and is displaced over the VSD

Tetralogy of Fallot Signs and Symptoms

May be asymptomatic but may have dyspnea, poor weight gain, cyanosis, tet spells (hypoxemic spells when crying or feeding, or running/playing and squatting to recover in older children)

Tetralogy of Fallot Physical Exam

Pulmonic Stenosis: Harsh, systolic ejection murmur in upper left sternal border