Well Vist: Late Childhood and Adolescence (CMPP)

Vitals for 6-12y

HR = 60-95

RR = 14-22

BP = 100-120/60-75

How does older child well visit change

Give children a gown

Talk to child prior to examining

Examine “private area” towards the end, giving them time to get comfortable

Explain what you are doing & why

Older Child HEENT Exam

Vision = Snellen chart to check

Hearing = Auditory screening,

Foreign Body

Mouth/Pharynx )

Adult teeth replace deciduous teeth

Cobblestoning in the Older Child oropharynx is a sign of

Post Nasal Drip / Allergic Rhinits

When should ear tubes fall out / be removed by ENT

6-12 y

Neck Older Child Exam

Trachea Midline

Palpate thyroid gland

Thyroglossal duct cyst

OSA

Asthma

Average Onset of Thyroglossal duct cyst

6y

Thyroglossal duct cyst

Most common congenital cyst of neck

Painless, Moves with swallowing

tx of Thyroglossal duct cyst

Follow with ENT,

Surgery to excise vs. Infection risk

Presentation of Peds OSA

Snores,

mouth breathing,

sweating,

restless sleep

dx of OSA

Sleep Study

Causes of Peds OSA

GERD,

llergies,

Hypotonia,

Adenotonsillar hypertrophy

tx of Peds OSA

Possible referral to ENT for removal adenoids and tonsils

Asthma Action Plan

A set plan of medications that the peds patient can follow depending on severity of asthma and asthma attacks

What can be used to assess for incoming asthma attack

Peak flow meter

A peak flow reading of 50-80% indicates that the patient

Will have moderate asthma attack

A peak flow reading of < 50% indicates that the patient

Hospitalization asthma attack

Asthma

Reversible obstructive disease of the lower airways

Risk Factors for Asthma

Allergen Exposure

Urban

Air Pollution

Tobacco Smoke

Recurrent Viral Infections

Obese

Maternal Asthma

Triggers for Asthma

Pets

Execrise

Pollen

Fumes

Cold

Dust

Smoke

Anger

Stress

Odor

dx of Asthma

Clincical

History of atopic disease or FHx of asthma is suggestive

Clinical response to bronchodilator therapy=support diagnosis

Classes of Asthma

Mild Intermittent

Mild Presistent

Moderate Persistent

Severe Persistent

Criteria of Mild Intermittent Asthma (Step 1)

< 2 days per week of daytime

< 2 night per month

FEV = 80

Criteria of Mild Presistent Asthma (Step 2)

> 2 days per week but < 1 daily of daytime

> 2 night per month

FEV = 80

Criteria of Moderate Persistent Asthma (Step 3)

Daily daytime

> 1 night per week

FEV1 = 60-80

Criteria of Severe Persistent Asthma (Step 4)

Continual daytime

Frequent nighttime

FEV1 < 60

Step Approach Asthma Treatment

Step1: SABA PRN

Step 2: Low Dose ICS

Step 3: Low Dose ICS + LABA or Medium Dose ICS

Step 4: Medium Dose ICS + :ABA

Step 5: High Dose ICS +LABA

Step 6: High Dose ICS + LABA + PO Steroid

Signs of Asthma Attack

Chest constriction,

Expiratory Wheezing,

Dyspnea,

Nonproductive Cough

, Prolonged Expiration,

Use of Accessory Respiratory Muscles,

Tachycardia & Tachypnea.

Pulsus Paradoxus (Drop in SBP when inspire)

Status Asthmatics

Acute Exacerbation that is UNRESPONSIVE to Bronchodilators & Corticosteroids.

Silent Chest

Absence of breath sounds

Sign of Status Asthmatics

tx Status Asthmatics

O2

Inhaled Beta Agonist

PO Steroids

Male Puberty Changes

Testicular growth & thinning scrotum 1st sign (Age11-12)

Pigmentation changes of scrotum then penile growth

Axillary hair occurs in the middle of puberty

Growth past 18 years (Up to 21)

Female Puberty Changes

Breast bud formation = 1st sign – Age 10-11

Pubic hair growth follows breast bud development

Mean age of menarche is 12.75 years

Grow until 2 years post menarche

Tanner Stages

Stage 1 = Prepuberty (Small Testicule + No hair)

Stage 2 = Enlargement of Scrotum and Testes + Breast Buds + Fine Hair on Mons

Stage 3= Enlargment of penis + Breat Tissue Growth + Coarse Hair

Stage 4 = Increase size of penis and skin darkens + Secondary Breast Mound + Hair Spreads

Stage 5 = Adult Genitla

CVA Tenderness is a sign of

Pyelonephritis

When does scoliosis screening begin

Older Child

Scoliosis Screen

Forward bend.

Lateral curvature in spine greater than 10 degrees

Send for scoliosis x-ray series with suspicion

Neuro Older Child Exam

Compare themselves to others

Use rules (Tattle): Point of view, opinion, & perception

Understand alternate point-of-view

Starting to understand time & space

Cognitively grow: Expressive/receptive language, sequencing, long-term memory, cause/effect

Concrete (factual) vs. abstract thinking (ideas)

Moral development – Become conscientious

Uncomfortable with self image, Try to fit in.

Sexual curiosity

Anticipatory Guidance of Older Child

Peer pressure

Friends / Bullying

Responsibilities (Chores)

Family environment

Exercise 1 hour per day

Limit electronics

Drug/Alcohol/Smoking

Seatbelt / Helmet

Dental care & Balanced diet

Vitals for Adolescents

HR = 55-85

RR = 12-18

BP = 110-135/65-85

How does adolescence exam change

Take general history with family

Talk directly to the patient

Gain trust

Have parent step out, continue detailed & personal history

Perform exam with a 3rd party present for private parts

How do we screen teen depression

PHQ9

Cognitive Development in Early Adolescence

Concrete thought

Self-conscious about appearance

Need for privacy

Seeks peer affiliation

Curious about anatomy

Cognitive Development in Mid Adolescence

Acne, odor

Menarche

Stereotype, peer pressure

Abstract thought

Questions sexual orientation

Tests ability to attract others

Cognitive Development in Late Adolescence

Idealism

Thinks independently

More stable body image

Forming steady relationships

Career choices

HEADSS

Discussions that should be had with adolescence in the room alone

• Home

• Education

• Activities

• Drugs

• Sexuality

• Suicide/Depression

Tests to Consider for Adolescence

Drugs = Urine Screen

Sexual Active = GC/Chlamydia Urine / Culture for UTI (Female) / Pregnancy

Precocious Puberty = TSH, FSH, LH, Testoseron

Obesity or DM = CBC, CMP, TSH, Lipids, A1C, Vit D

Anticipatory Guidance for Adolescence

Exercise

Balanced diet

Calcium intake/milk

Vitamins/supplements

Dental care

Seatbelts / helmet

Danger seeking

Pregnancy prevention

STIs

Drugs/ETOH/Vape

Gun safety

Future goals

Stressors