Pediatric health assessment - use this one!

Review of Systems (book)

1. Do you have any questions or concerns about any of the following? Height or weight Blood pressure Headaches and migraines Eyes or vision Hearing, ears or earaches Nose Frequent colds Mouth and teeth (frequency of tooth brushing, flossing) Neck and back Chest pain Coughing and wheezing Breasts Heart Stomach Nausea and vomiting Diarrhea and constipation Skin (rash, acne, sore, use of sunscreen) Muscle or joint pain Frequent or painful urination Sexual organs or genitals Menstruation or periods Sexual activity Future plans or job Physical or sexual abuse Masturbation Cancer or dying Other (explain):

The Child Health History (book)

80% of diagnoses are made on the basis of the history. The physical examination only provides a partial view of the situation as it is at the moment. It is often a cloudy picture because the body frequently responds similarly to different assaults. It is the history of the problem— its onset, duration, progress, associated symptoms, meaning, and effects on daily living—that brings the health care provider to an understanding in sufficient depth to choose appropriate management. begins with subjective data (the history), moves to objective data (the physical examination, laboratory, and test data), then lists the problems by domain (identified through the subjective and objective data), and outlines plans of care, problem by problem. I Preliminary Patient Identification Information Date: Name: Birth date: Record no.: Corrected age for preterm infant younger than 2 years: Caregiver's name: Address: Phone: Informant, relationship to patient, reliability as historian: Referral source: Languages spoken: II Database: Subjective Information—Child and Family A Chief Complaints (CC)—Child or Family 1. Concern #1: History of present illness (HPI): 2. Concern #2: HPI: B Disease History Database—Child 1. Past medical history a. Prenatal: b. Perinatal—birth weight, length, head circumference, delivery, and postpartum course: c. Past disease profile: d. Current health problems (put in table below): Diagnosis Date Provider Current Status 1. 2. 3. e. Operations and hospitalizations: f. Injuries: g. Allergies—food, environmental, medications: h. Growth: i. Immunizations: j. Medications: 2. Review of systems General: Skin: Head: EENT: Respiratory: Cardiovascular: GU: GI: Musculoskeletal: Neurologic: Endocrine: Hematologic: Dental: 3. Family history of diseases Mother, father (age, health): Mother's pregnancy history: Familial diseases: Pedigree for single disease genetics history, if appropriate to explaingenetic transmission in family or health of various family members: 4. Environmental history Air quality, tobacco smoke: Water quality: Exposures to soils with toxins, pesticides, or heavy metals: Food-borne exposures: Noise exposure: C Functional Health Problems Database—Child 1. Health maintenance and health perceptions Primary care provider—last visit: Dentist—last visit: Knowledge and skills for caregiving and self-care: Safety measures: Car: Smoke alarms: Occupational and pesticides and poisons: Guns locked: Sports equipment: Home and health management and resource issues: 2. Nutrition Diet—breakfast, lunch, dinner: Supplements—snacks, vitamins, other: Feeding strategies and patterns: Restrictions—calories, other: 3. Activities Amount and type of activities: Play: Limitations and equipment: 4. Sleep Number of hours—night, naps: Disturbances: 5. Elimination Urinary: Bowel: 6. Role relationships Family patterns: Parenting patterns: Peers and social support: Communication—verbal, nonverbal: 7. Coping and temperament and discipline Substance use and abuse—alcohol, drugs, tobacco: Indicators of depression, anxiety, mental health disorders: 8. Cognitive and perceptual problems Cognitive disturbances and school performance: Hearing deficit: Vision deficit: Kinesthetic disturbance: Attention deficits and hyperactivity: 9. Self-perception and self-concept Role identity: Self-concept and self-esteem, body image: 10. Sexual and menstrual patterns 11. Values, beliefs, and religious patterns D Developmental Issues Database —Past Milestones and Current Skills of Child 1. Motor development: Gross motor development: Fine motor development: 2. Language development: 3. Cognitive development: 4. Social development: 5. Development test scores: E Family Contextual Information 1. Family structure and roles People living in the home: Type of family—two-parent, single-parent, divorced, family, etc: 2. Family functioning—primary caregiver Family care issues (time, energy, needs of other family members, emotional stresses): 3. Family social network: Agencies involved with family: Support systems: 4. Family environment and resources: Home environment description, daycare: School and employment: III Database: Objective Information A Physical Examination Age: Sex: Height: Weight: HC: BP: TPR: BMI: 1. General appearance: 2. Skin: 3. Head: 4. Eyes: 5. Ears: 6. Nose: 7. Mouth: 8. Neck: 9. Chest and breasts: 10. Lungs: 11. Heart: 12. Abdomen: 13. Genitalia: 14. Anus and rectum: 15. Musculoskeletal: 16. Neurologic Motor—tone, strength: Reflexes: Primitive reflexes: Cranial nerves: Responsiveness: Extraneous movements: Gait and position: Cerebellar, including coordination, balance, nystagmus: Sensory function: B Screening and Laboratory Data 1. Hct and Hgb: 2. Hearing: 3. Vision: 4. TB: 5. Metabolic and newborn screens: 6. Other: C Data from Other Disciplines Physical therapy, occupational therapy, speech therapy, audiology, social work, psychology, medical specialties, home health, education: IV Problem List (Use classification of diagnoses list) Include all CCs and problems identified during the assessment. Categorize diagnoses by the following: 1. Diseases: 2. Functional health problems: 3. Developmental problems: 4. Family problems: V Plan For each problem, describe plans, including diagnostic, therapeutic, and educational activities: A. Disease Problems B. Functional Health Problems C. Developmental Problems D. Family Problems VI Disposition and Return Appointments and Purpose Adolescents: I Database—Contextual and Family Information A With Whom Do You Live? B In the Past Year Have There Been Any Changes in Your Immediate Family, Such As Marriage, separation, divorce Serious illness or injury Loss of job Move or change of address Change of school Births, deaths Other (explain): C. What Languages are Spoken in Your Home?

Functional Health Database - Adolescents (book)

A Health Maintenance and Health Perception 1. Do you usually wear a helmet for inline skating, bicycle, skateboard, motorcycle, or all-terrain vehicle use? 2. Do you usually wear a seat belt when riding in a car, truck, or van? 3. In the past year, have you been in a car when the driver has been drinking or using drugs? 4. Do you use electric tools or heavy equipment at work or home? 5. Do you have questions or concerns about preventing accidents or injuries? B Nutrition 1. Do you eat from the four food groups almost every day? 2. Do you have any diet, food, or appetite concerns? 3. Are you eating in secret? 4. Are you satisfied with your eating patterns? 5. Do you prefer a change in your current weight? 6. Have you tried to lose weight or control weight by vomiting, taking diet pills or laxatives, or starving yourself? 7. Do you have concerns about your weight? C Activities 1. Do you watch television or play video games more than 2 hours per day? 2. Are you involved with exercises that make you sweat and breathe hard at least three times per week? 3. What do you do after school? 4. Do you have physical problems that limit your exercise? 5. Do you have questions or concerns about exercise or physical activity? D Sleep 1. Do you have trouble sleeping? 2. Do you have trouble with tiredness? E Elimination Habits 1. Do you sometimes wet the bed? F Role Relationships 1. Do you have at least one friend you really like and feel you can talk to? 2. Do your parents or guardian usually listen to you and take your feelings seriously? 3. Do you and your parents or guardian do things together on a regular basis, such as eating meals, attending religious activities, performing chores or errands, playing sports, or watching television? 4. Is there a lot of tension or conflict in your home? 5. Do you have questions or concerns about family or friends? G Coping, Temperament, and Discipline 1. Alcohol In the past year, did you or friends get drunk or very high on alcoholic beverages? Have you ever consumed alcohol and then done any of the following: driven a vehicle, gone swimming or boating, gotten in a fight, used tools or equipment, done something you later regretted? Have you been criticized or gotten in trouble because of drinking? Do you have any questions or concerns about alcohol? 2. Drugs Do you or your friends ever use marijuana or street drugs? Do you ever use nonprescription drugs or drugs prescribed for someone else to get to sleep, stay awake, calm down, get high, or enhance your sports performance? Have you ever used steroids without a physician telling you to do so? Do you have any questions or concerns about drugs or drug use? 3. Tobacco Do you or your friends ever smoke cigarettes or use smokeless tobacco? Does anyone you live with smoke cigarettes or use smokeless tobacco? Do you have any questions or concerns about cigarettes or other tobacco products? 4. Emotions Have you had fun during the past 2 weeks? In general are you happy with the way things are going for you these days? During the past few weeks, have you often felt sad or down with nothing to look forward to? Have you ever seriously thought about killing yourself, made a plan to kill yourself, or actually tried to kill yourself? Do you think counseling would help you or someone in your family? Do you have any questions or concerns about physical, sexual, or emotional abuse? 5. Weapons and violence Do you or does anyone you live with have a gun, rifle, shotgun, or other firearm in your home? In the past year, have you ever carried a gun, knife, razor blade, club, or other weapon? Have you been in a physical fight during the past 3 months? Are guns or violence a problem in your neighborhood? Have you ever witnessed a violent act? When you are angry, do you ever get violent? Do you have any questions or concerns about violence or your safety? Has anyone threatened to harm you in the last year? H Cognitive and Perceptual Problems 1. In general do you like school? Why? 2. Are your grades this year better or worse than the year before? What are your usual grades? 3. Have you ever had to repeat a grade in school? 4. Do you cut classes or skip school? 5. How many days of school have you missed this year? 6. Have you ever been suspended or dropped out of school? 7. Do you have any questions or concerns about school or your learning? I SelfPerception and SelfConcept 1. Do you have any concerns about the size or shape of your body or your physical appearance? 2. What do you like about yourself? 3. What do you do best? 4. If you could, what would you change about your life or yourself? J Sexual and Menstrual 1. Do you date? 2. Do you or your friends have sexual intercourse or oral or anal sex? 3. Do you think you might be gay, lesbian, or bisexual? 4. Have you ever been told that you have a sexually transmitted disease, such as gonorrhea, genital herpes, chlamydia, trichomonas, syphilis, hepatitis, genital warts, AIDS, or HIV infection? 5. Do you have any questions or concerns about sex or relationships? 6. Are you worried about getting pregnant (girls) or do you worry about getting someone pregnant (boys)? 7. Have you ever been forced to do something sexual that you did not want to do? 8. Do you practice abstinence? 9. Do you use a birth control method? If so, which one(s)? 10. Do you want information or supplies to prevent pregnancy or sexually transmitted diseases, including HIV? K Values and Beliefs and Religious Orientation 1. Are you involved with any religious groups or activities on a regular basis? 2. Do you have any strong ethical, moral, or religious beliefs?

The Physical Examination (book)

Height, weight, head circumference, BMI, and vital signs Screening tests for hearing and vision, laboratory data and data from other disciplines General appearance: Ill or well, distressed, alert, cooperative, body build; reaction to parents; characteristic position, movements, nutrition, developmental appearance as contrasted with the stated age Skin: Color—pigmentation, cyanosis, jaundice, carotenemia, erythema, pallor; vascular—visible veins, arteries; eruptions, petechiae, ecchymosis, hives, rashes; lesions; texture, scaling, striae, scars; sweat, edema, turgor; subcutaneous tissue; distribution and color of hair; nail appearance Lymph nodes: Occipital, postauricular, preauricular, cervical, parotid, submaxillary, sublingual, axillary, epitrochlear, inguinal; size, mobility, tenderness, heat Head: Position, shape, sutures, fontanelles; size—circumference, microcephaly, macrocephaly, hydrocephaly; facial paralysis, twitching Eyes: Vision, visual fields, cover test; blinking; position— exophthalmos, enophthalmos, hypertelorism, hypotelorism; movements —strabismus, extraocular movements, nystagmus; ptosis—eyelids, sclera, conjunctivae; lesions—styes, chalazion; corneas—corneal reflex; discharge; pupils—accommodation, iris; retina—red reflex, fundus Ears: Anomalies; position; discharge; tenderness; canals; tympanic membranes—redness, light reflex, landmarks, bulging or retraction, perforation, mobility; mastoid; hearing; vestibular function Nose: Shape; alae nasi, flaring; mucosa, secretions, bleeding, airway; septum; polyps, tumors Mouth: Odor; teeth—number, edges, occlusion, caries, formation, color; gums—discoloration, bleeding; buccal mucosa; tongue—coating, protrusion, color, tremor, lesions; palate—cleft, arch; tonsils—size, color, exudate; pharynx—appearance, color, lesions Neck: Size; anomalies-webbing, edema, nodes, masses; sternocleidomastoid; trachea; thyroid; vessels; motion—head drop, tilting, nodding, range of motion Chest: Shape—circumference, symmetry, Harrison groove; movement—flaring, expansion, abdominal or thoracic breathing, intercostal retractions Breasts: Tanner stage of development, symmetry, redness, heat, tenderness, lumps; gynecomastia Lungs: Respiration—type, rate, dyspnea; exercise tolerance; cough, hemoptysis, sputum; palpation—masses, tenderness, fremitus; percussion—dullness, hyperresonance, diaphragm location; auscultation —breath sounds, crackles (rales), rubs, rhonchi, wheezes, vocal resonance Cardiovascular and heart: Blood pressure and pulse rate; inspection—vascularity, bulging, impulse; distress, cyanosis, edema, clubbing, pulsations, venous distention; palpation—femoral pulses, point of maximal impulse, thrill; auscultation—first and second heart sounds, rhythm, split, third heart sound, gallop, friction rub, venous hum, murmurs Abdomen: Inspection—shape, distention, transillumination; umbilicus, diastasis rectus, veins; peristaltic, gastric waves; auscultation —bowel sounds, bruits; palpation—superficial or deep tenderness, rebound; spleen, liver, masses, kidneys, bladder, uterus; percussion— masses, fluid, flatus Genitalia: Discharge, foreign body; male and female—Tanner staging; female—tags; labia, adhesions, vagina, clítoris; vaginal, bimanual examination for teenage girls male—penis—hypospadias, epispadias, phimosis, meatus; scrotum, testes, hydrocele, hernia; cremasteric reflex Anus and rectum: Buttocks, fistula, fissure, prolapse, polyps, hemorrhoids, rashes; rectal—rectum, fistula, megacolon, masses, prostate, tenderness; sensation Musculoskeletal: Anomalies, length, clubbing, pain, tenderness, temperature, swelling, shape, symmetry; gait—stance, balance, limp; foot position; spine—tufts of hair, dimples, masses, spina bifida, tenderness, mobility, scoliosis; posture—lordosis, kyphosis; joints—heat, tenderness, mobility, swelling, effusion; muscles—development, pain, tone, spasm, paralysis, rigidity, contractures, atrophy Nervous system: General impression, abilities, responsiveness, position, spontaneous movements, play activity; development— consistent with age or current level; state of consciousness, irritability, seizure activity; gait, stance, limp, ataxia; coordination, Romberg sign; tremors, twitching, choreiform movements, athetosis, spasticity, paralysis, flaccidity; reflexes—superficial, deep tendon, clonus, Chvostek sign; primitive reflexes for infants and children with neurologic impairments—Moro, tonic neck, Babinski, grasp, suck; thumb position; sensation—hyperesthesia, paresthesia, temperature, touch; stereognosis; cranial nerves I to XII; hearing and vision Laboratory and Radiographic Data Record hearing, vision, hematocrit or other blood tests, lead, urinalysis, newborn screening tests, and tuberculosis screening. Developmental and Psychological Test Scores Summarize social work, nutrition, physical therapy, occupational therapy, medical specialist, speech pathology, education, and other reports. Problem List: "Rule out" should not be listed as a diagnosis (it may be considered part of a plan).

What Should You Do With an Abnormal Puberty Result? (bright futures)

Precocious Puberty General Observations growth carefully plotted. Pathology more likely in those children showing clear acceleration of linear growth. If only abnormal finding is appearance of pubic hair (often accompanied by axillary hair and odor), the diagnosis is likely premature adrenarche, a benign normal variant due to an early increase in adrenal androgen secretion. occurs more often in girls but is not infrequent in boys. risk of pathology is low, and extensive hormone testing and x-ray evaluation are not needed, unless rapid progression of pubic hair and/or growth acceleration. • Labs are of limited use in typical cases in which there is early appearance of pubic hair. Dehydroepiandorsterone sulfate (DHEA-S), 17-hydroxyprogesterone, testosterone, and bone age should be considered in higher-risk cases. Luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol are of no value if there is no breast development. Breast Development Isolated breast development with normal growth starting before age 3 is most likely due to premature thelarche, another benign normal variant. monitored if there is no progression or referred to a specialist if there is rapid growth or significant increase in breast diameter over time. Breast development starting between the ages of 3 and 7 should generally be referred if it has persisted for at least 6 months. In girls ages 7 to 8, early breast development is most often found in normal girls who start to mature at the early end of the normal range. girls whose breast enlargement progresses rapidly (Tanner 3 when first seen or rapidly increases to Tanner 3) are at higher risk of pathology. Useful labs for high-risk cases: LH, FSH, estradiol, and bone age Nearly 20% of girls who start puberty before age 6 have abnormal brain magnetic resonance imaging findings (eg, a hypothalamic hamartoma [nonmalignant] or a glioma or astrocytoma), compared with about 2% of girls starting puberty between the ages of 6 and 8. The risk is much higher if there are new neurologic findings, such as visual abnormalities, severe and frequent headaches, or new onset of seizures. Genital Development Boys who have an increase in testicular and penile size before age 9 need to be referred for evaluation. Boys with a significant increase in penis size but not testicular enlargement may have congenital adrenal hyperplasia or a virilizing adrenal or testicular tumor. Boys with pubic hair only most likely have premature adrenarche; they should also be referred, though with less urgency. • Useful labs if there is both testicular and penile growth: LH, FSH, testosterone, and bone age • Useful labs if there is increased penile growth but prepubertal testes: testosterone, 17-hydroxyprogesterone, DHEA-S, and bone age Delayed Puberty Girls who have not started having breast enlargement by age 13 and boys who have not started having penile and testicular enlargement by age 14 are, by definition, delayed and need to be evaluated and appropriately managed. • Useful labs: LH, FSH (will be elevated in gonadal failure), testosterone (in boys), estradiol (in girls), and bone age may need to be evaluated for growth hormone and possibly other pituitary hormone deficiencies, as well as other chronic diseases (eg, gastrointestinal, renal, cardiac, pulmonary).

Video: Assessment of Older Child

begin the examination with the child sitting on the parent's lap, moving the child to the exam table for the components that require him to lie down. Let the parent undress the child. try to be at the child's eye level. Engage the parents - calming the child or assisting. assess temperament and bonding. Engage children in age appropriate conversation, using a playful, reassuring voice. Make a game out of the examination. Let the child see and touch the tools you will use during the examination. Avoid asking the child's permission to examine a body part. complete the examination expeditiously. Or give the child a short break. perform non-distressing maneuvers early, and potentially distressing maneuvers near the end. general survey: Behavioral problems, such as poor parent-child interactions, sibling rivalry, inappropriate parental discipline, and an overall intense temperament. look for signs of developmental delay in areas such as cognitive abilities, language, social and emotional tasks, as well as gross and fine motor skills. developmental assessment - key part of the neurological exam. Observe for signs of social or environmental problems, including parental difficulties such as stress or depression, and risk for abuse or neglect. Measure standing height (or stature).accurate, wallmounted stadiometer. Have the child stand with the heels back and the head against the wall or the back of the stadiometer. If using a wall with a marked ruler, make sure to place a board or other flat surface across the top of the child's head at a right angle to the ruler. Please note that stand-up weight scales with height attachments are relatively inaccurate. Weigh children in their underpants or gown on a stand-up scale. Use the same scales across successive visits to optimize comparability. head circumference is measured until the child reaches 24 months. may be helpful if you suspect a genetic or central nervous system disorder. assess Body Mass Index for age. early detection of obesity in children older than two years old. give parents their child's BMI results, together with information about the impact of healthy eating and physical activity. Vital Signs measure the blood pressure in children older than two years. blood pressure cuff - wide enough to cover two-thirds of the upper arm or leg. Obtain pulse rate. Measure the heart rate over a 60-second interval. The respiratory rate ranges from 20 to 40 per minute during early childhood and 15 to 25 during late childhood, reaching adult levels around age 15. You can observe for 60 seconds as the child sits quietly with shirt removed. In children, auditory canal temperature recordings are preferred over other methods because they can be obtained quickly with essentially no discomfort. Body temperature in children is less constant than in adults. The Skin inspecting and palpating the fingernails, looking especially for any clubbing or cyanosis. inspect the skin of the child's face and upper torso, noting color, pigmentation, texture, hair distribution and thickness, and any lesions. Common skin conditions in preschool children include birthmarks, nevi, and scars. Head and Face observe the shape of the head, its symmetry and the presence of abnormal facies, which may not become apparent until later in childhood. Some of the diagnostic facies include: Down syndrome, fetal alcohol syndrome, perennial allergic rhinitis, and hyperthyroidism. The Eyes Inspect each cornea, iris, and lens. Check the color of the conjunctiva and sclera. test visual acuity in each eye and to determine whether the gaze is conjugate and symmetric. Visual acuity may be difficult to measure in children younger than approximately 3 years of age who cannot identify pictures on an eye chart. For children older than 3 years, however, formal visual acuity testing is both feasible and preferred. The examiner may assess visual acuity in broad terms by having the child read letters, numbers, or symbols, or by using an "E" chart, in which the child is asked to point out which direction the letter "E" is facing. To test for conjugate gaze or to look for strabismus, —the corneal light reflex test—consists of simply observing the reflection of a light from the child's corneas. If you shine a light in front of the child's face and stand about 2 to 3 feet away, the reflections should be symmetrical and visible, very slightly nasal to the center of each pupil. The cover-uncover test may assume the form of a game. Have the child look at your smiling face. Cover one of the child's eyes. Then move your covering hand to the child's other eye and see if the first eye moves. Movement of the eye just uncovered may indicate an abnormality. When testing the visual fields in young children, test one eye at a time. Hold the child's head in the midline while bringing an object such as a toy into the field of vision from behind the child. Ears and Nose leave it for the end. child lying down and restrained by the parent, or in younger children, sitting on the parent's lap, with the child's legs restrained by the parent's legs. To view the tympanic membrane in young children, the auricle must be pulled upward, outward and backward to afford the best observation with the otoscope. hold the child's head with one hand and with that same hand, pull on the auricle. With the other hand, position the otoscope with the handle pointing downward. A pneumatic otoscope allows you to assess the mobility of the tympanic membrane as you increase or decrease the pressure in the external auditory canal by squeezing the rubber bulb. formal hearing testing is necessary for accurate detection of hearing deficits in young children you can grossly test for hearing standing behind the child, and have them repeat your whispered words while you cover one of the child's ear canals and rub the tragus using a circular motion. Inspect the nose, using a large speculum on your otoscope. Check for nasal deviation and polyps, and note the color and condition of the nasal mucous membranes. Pale, boggy nasal mucous membranes are found in children with chronic, perennial allergic rhinitis. Mouth and Pharynx wear gloves. Turn the examination into a game. Don't show the tongue blade unless absolutely necessary. The child who can say "ahhh" usually offers a sufficient, albeit brief, view of the posterior pharynx, rendering a tongue blade unnecessary. With the child's mouth open, examine the upper and lower lips. Examine the tongue, including the underside. Note the size, position, symmetry and appearance of the tonsils. The peak growth of tonsillar tissue is between 8 and 16 years. Then lift the upper lip to examine the upper teeth. Look for staining or signs of erosion, which often first appear here, and which may signify the need for a dental referral. note the quality of the child's voice. Certain abnormalities can change the pitch and quality of the voice. Examination of a child's neck, including the sternomastoid muscles, is the same as that for adults. The vast majority of enlarged lymph nodes in children are due to infections and not malignant disease. Lymphadenopathy is common in childhood. Check the neck for mobility. Ensure that the neck is supple and easily mobile in all directions. This is particularly important when the child is holding the head asymmetrically, and when central nervous system disease such as meningitis is suspected. Normally, children should be able to sit upright and touch their chins to their chests. In children, nuchal rigidity is a more reliable indicator of meningeal irritation than is Brudzinski's sign or Kernig's sign. Nearly all children with nuchal rigidity are extremely sick, irritable, and difficult to examine. Thorax and Lungs Carefully assess respirations and the pattern of breathing. first observe the child carefully. Assess the relative proportion of time spent on inspiration versus expiration. The normal ratio is one to one. Prolonged inspirations or expirations are a clue to disease location. prolonged expiration is a frequent sign of asthma or lower airway obstruction. Note any effort or "work of breathing," including nasal flaring and grunting. Palpation, percussion, and auscultation achieve greater importance in a careful examination of the thorax and lungs. Let children move the stethoscope themselves, going back to listen properly. Measure the blood pressure in the right arm. If the child is three to four years old, measure it in both arms and one leg at a time to check for possible coarctation of the aorta most school-aged children have a benign heart murmur at some point in their lives. The most common, Still's murmur, is a grade I-II/VI, musical, vibratory, early and midsystolic murmur with multiple overtones, located over the mid or lower sternal border but also frequently heard over the carotid arteries. Compression of the carotid artery usually causes the precordial murmur to disappear. The murmur will also diminish as the child goes from supine to sitting to standing. Also in preschool or school-aged children, you may detect a venous hum. This is a soft, hollow, continuous sound, louder in diastole, heard just below the right clavicle. It can be completely eliminated by maneuvers that affect venous return, such as lying supine, changing head position, or performing jugular venous compression. A venous hum has the same quality as breath sounds and therefore is frequently overlooked. The murmur heard in the carotid area or just above the clavicles, is known as the carotid bruit. It is early and midsystolic, with a slightly harsh quality. It is usually louder on the left and may be heard alone or in combination with Still's murmur. It may also be completely eradicated by carotid artery compression. Breasts and Abdomen breasts - inspection, because in both sexes there is little breast tissue. patient lie supine with knees flexed. placing your whole hand flush on the abdominal surface for a few moments without probing. For particularly sensitive children, try placing the child's hand under yours. Palpate lightly in all areas, then deeply, leaving the site of potential pathology to the end. Begin palpating low on the abdomen, moving your hand upward so that you do not miss the edge of the liver or spleen. to determine the lower border of the liver - the scratch test. Place the diaphragm of your stethoscope just above the right costal margin at the midclavicular line. With your fingernail, lightly scratch the skin of the abdomen along the midclavicular line, moving from below the umbilicus toward the costal margin. When your scratching finger reaches the liver's edge, you will hear a change in the scratching sound as it passes through the liver to your stethoscope. The spleen felt easily in most children. It too, is soft with a sharp edge and projects downward like a tongue from under the left costal margin. The spleen is moveable and rarely extends more than one-to-two centimeters below the costal margin. Palpate the other abdominal structures. You will commonly note pulsations in the epigastrium caused by the aorta. left of the midline, on deep palpation. Male Child Genitalia inspecting the penis. extremely active cremasteric reflex that may cause the testis to retract upwards into the inguinal canal, and thereby appear to be undescended. With warm hands, palpate the lower abdomen, working your way downward toward the scrotum along the inguinal canal. increase intra-abdominal pressure by asking the child to do a sit-up. If you can detect the testis in the scrotum, it is descended even if it spends much time in the inguinal canal. noting any swelling that may reflect an inguinal hernia. increase abdominal pressure and note whether a bulge in the inguinal canal increases. Female Child Genitalia A bright light source is essential. Most children can be examined in the supine, frog-leg position. If the child seems reluctant, it may be helpful to have the parent sit on the examination table with the child. Or, the examination may be performed while the child sits in the parent's lap Inspect the external genitalia for pubic hair, the size of the clitoris, the color and size of the labia majora, and any rashes, bruises, or other lesions. Next, visualize the structures by separating the labia with your fingers gentle traction by grasping the labia between your thumb and index finger of each hand and separating the labia majora laterally and posteriorly to examine the inner structures. Note the condition of the labia minora, urethra, hymen, and proximal vagina. If you are unable to visualize the edges of the hymen, ask the child to take a deep breath to relax the abdominal muscles. Another useful technique is to position the patient in a knee-chest position. Avoid touching the hymenal edges because the hymen is very tender without the protective effects of hormones. Examine for discharge, labial adhesions, estrogenization, hymenal variations, and hygiene. The physical examination may reveal signs of sexual abuse, and may require more complete evaluation by an expert in the field. The rectal examination is not routine, but should be done whenever intra-abdominal, pelvic or perirectal disease is suspected. Musculoskeletal System The normal young child has increased lumbar concavity, decreased thoracic convexity, and often a protuberant abdomen. watching carefully from both the front and behind as the child stands and walks barefoot, touches his toes and runs a short distance. To check for scoliosis, perform the Adam's Bend Test if the child is at least six years old. Have the child stand with his bare feet together and bend forward with the knees straight and the arms hanging straight down. Look for any asymmetry in positioning. If you detect scoliosis, use a scoliometer to test for the degree of scoliosis. Finally, check for leg length discrepancy by having the child stand straight as you observe from behind. Place your hands on his iliac crests. Your hands should be perfectly parallel to the floor. Test for severe hip disease by observing from behind as the child shifts weight from one leg to the other. A pelvis that remains level when weight is borne on the unaffected side is a negative Trendelenberg's sign. But with an abnormal positive sign in severe hip disease, the pelvis tilts toward the unaffected hip during weight bearing on the affected side. For children age eight or older, perform a sports pre-participation screening musculoskeletal examination. Organized sports often require this medical clearance in order for the child to participate. Nervous System The sensory examination can be performed by slightly tickling the child's skin using a cotton ball or soft object and asking the child to indicate when he feels it. Make sure the child's eyes are closed, and don't use a pin, because it will scare the child. Observe the child's gait and coordination while the child is walking and running. Note any asymmetries, weakness, undue tripping or clumsiness. To check for gross motor development and balance, ask the child to balance on one foot and to hop. You might try asking him to walk on his heels, if he is old enough to perform this maneuver. If you are concerned about the child's strength, have the child lie on the floor and then stand up and closely observe the stages. Most normal children will first sit up, then flex the knees and extend the arms to the side to push off from the floor and stand up. Hand preference is demonstrated by most children by age two. Check for weakness in the nonpreferred upper extremity. show the child the reflex hammer, treating it like a toy so he is not frightened. Distract the child or ask him to close his eyes so he does not see the impact of the hammer and provide a false reaction. fine motor development, ask the child to copy an "X" or a square, or draw a person (which should display several body parts). Then, discuss their pictures to test for cognition and language as well. The cerebellar examination can be performed by asking the child to touch your finger and then his nose, and by having him perform rapid hand movements. Children older than five years old should be able to tell right from left, so you can assign them right-left discrimination tasks as well. Cranial Nerve I, generally not tested at this age. Cranial Nerve II, visual acuity. Snellen chart or "E" chart for those children ages three years and older. Cranial Nerve II, along with Cranial Nerve III, child's eye assessment. Cranial Nerves III, IV, and VI, track light, or an object, Cranial Nerve V - having the child smile. Cranial Nerve VII - asking the child to make faces. Cranial Nerve VIII - formal hearing testing session. Cranial Nerves IX and X - asking the child to stick out his whole tongue and move it back and forth. Cranial Nerve XI - having the child push your hand away with his head. Cranial Nerve XII - observe the child's speaking ability.

Assessing Younger Children (Bates)

challenge - avoiding a physical struggle, a crying child, or a distraught parent. Gain the child's confidence and allay the child's fears from the start of the encounter. A health supervision visit allows greater rapport than a visit when the child is ill. Let the child remain dressed during the interview to minimize the child's apprehension. It also allows you to interact more naturally and observe the child playing, interacting with the parents, and undressing and dressing. Toddlers who are 9 to 15 months may have stranger anxiety, a fear of strangers that is developmentally normal. It signals the toddler's growing awareness that the stranger is new. You should not approach these toddlers quickly. Make sure they remain solidly in their parent's lap throughout much of the examination. Some Tips for Examining Young Children (1- to 4-Year-Olds) Useful Strategies for Examination Examine a child sitting on parent's lap. Try to be at the child's eye level. First examine the child's toy or teddy bear, then the child. Let the child do some of the exam (e.g., move the stethoscope). Then go back and "get the places we missed." Ask the toddler who keeps pushing you away to "hold your hand." Then have the toddler "help you" with the exam. Some toddlers believe that if they can't see you, then you aren't there. Perform the exam while the child stands on the parent's lap, facing the parent. If 2-year-olds are holding something in each hand (such as tongue depressors), they can't fight or resist. Hand the child an age-appropriate book and engage the child in reading Useful Toys and Aids "Blow out" the otoscope light. "Beep" the stethoscope on your nose. Make tongue-depressor puppets. Use the child's own toys for play. Jingle your keys to test for hearing. Shine the otoscope through the tip of your finger, "lighting it up," and then examine the child's ears with it. Use age-appropriate books. Engage children in age-appropriate conversation. Ask simple questions about their illness or toys. Compliment their appearance or behavior, tell a story, or play a simple game. If a child is shy, turn your attention to the parent to allow the child to warm up gradually. With certain exceptions, physical examination does not require use of the examining table; it can be done on the floor or with the child in a parent's lap. The key is to engage the child's cooperation. For young children who resist undressing, expose only the body part being examined. When examining siblings, begin with the oldest child, who is more likely to cooperate and set a good example. Approach the child pleasantly. Explain each step as you perform it. Continue conversing with the family to provide distraction. start with the least distressing procedures and end with the most distressing, usually involving the throat and ears. Begin with parts that can be done with the child sitting, such as examining the eyes or palpating the neck. Lying down may make a child feel vulnerable, so change positions with care. Once a child is supine, begin with the abdomen, saving throat and ears or genitalia for last. You may need a parent's help to restrain the child for examination of the ears or throat Patience, distraction, play, flexibility in the order of the examination, and a caring but firm and gentle approach are all key to successfully examining the young child. Use a reassuring voice throughout the examination. Let the child see and touch the examination tools you will be using. Avoid asking permission to examine a body part because you will do the examination anyway. Instead, ask the child which ear or which part of the body he or she would like you to examine first. Examine the child in the parent's lap. Let the parent undress the child. If unable to console the child, give the child a short break. Make a game out of the examination! For example, "Let's see how big your tongue is!" or "Is Elmo in your ear? Let's see!" Reassure parents that resistance to examination is developmentally appropriate. Some embarrassed parents scold the child, compounding the problem. Involve parents in the examination.

Why Is It Important to Assess Spine, Hip, and Knee During the Physical Examination? (bright futures)

key to appropriate referral. pathologic conditions - spine, hip, and knee during childhood. vary with age. require further evaluation and treatment by a specialist in general or pediatric orthopedic surgery.

Why Is It Important to Assess Orthopedic Issues During the Physical Examination? (bright futures)

prevalence of rotational findings of the lower extremities in early childhood, including intoeing, and outtoeing Many children who toe in or toe out are normal. Similarly, an appearance of knock knees and bow legs can be normal. It can be of great concern to parents. knowledge of the etiology and the natural history is reassuring to the parents. abnormal, appropriate studies and referrals can be made.

The Initial (Complete) Health History (book)

symptom analysis (i.e., onset, duration, characteristics or symptoms, exposure to illnesses or other causative factors, similar problems in other family members or neighbors, previous episodes of similar illnesses or symptoms, previous diagnostic measures, pertinent negative data, things that have been tried in attempts to manage the concern and their success, and the meaning of the concern for the family and child). Tests and treatment, including complementary therapies: what, when, where, who, and results, including complications and sequelae The meaning of the symptoms to patient and family and patient's reactions to symptoms always ask screening questions health promotion and disease prevention issues should be considered in addition to the problem at hand. An immunization history should be completed at every visit. PMH • Prenatal: Planned pregnancy? When did prenatal care begin? What was the mother's health during pregnancy? Drug, alcohol, and tobacco use? Illnesses and medications? Weight gain? Accidents? (With age and history of a healthy baby, these sections may become less significant.) • Perinatal: Where was the baby born and who delivered the infant? Duration and process of labor? Vaginal or cesarean delivery and process? Infant response to labor and delivery (breathing, crying)? Resuscitation needed? Apgar scores? Birthweight, length, and head circumference? Gestational age? Neonatal course: infections or other health problems, physiologic stabilization, feeding, responsiveness? Jaundice? Weight at discharge? Hospital duration? Neonatal follow-up over the first few weeks? (Again, with age and health, this section is given less attention.) • Growth: What has the child's growth pattern for height, weight, and head circumference been? Is the child similar in size to peers? Are clothing sizes changing? Has growth been a worry for the child or family? ROS • General: Is the child considered to be well, happy, and developing normally? • Skin: History of birthmarks, lesions, or skin conditions including hair and nails? • Head: Head trauma? Head growth—microcephaly, macrocephaly? Headaches? • Eyes, ears, nose, throat: Vision and eye problems? Hearing and ear problems? Nose—discharge or bleeding episodes, breathing interference? Throat problems or infections? • Respiratory: Breathing problems? Respiratory infections? Blue spells? Cough? Snoring at night or obstructive sleep apnea? • Cardiovascular: Heart murmur history? Cyanosis? Blood pressure problems? Activity intolerance? Syncope? • Gastrointestinal: Infections, diarrhea, constipation, vomiting, or reflux? Structural problems? Anal itching or fissures? Stomach aches? Weight loss? • Genitourinary: Infections, discharges? Structural problems? Stream appearance? Frequency or burning? • Gynecologic: Menarche and menstrual history including length of menses, frequency of cycle, cramps, and clots? Vaginal discharge or bleeding? Itching? • Musculoskeletal: Movement or structural problems? Broken bones or joint sprains? Joint inflammation? • Neurologic: Seizures? Movement disorders? Tremors? Tics? Loss-of- consciousness episodes? Headaches? • Endocrine: Problems with growth or pubescence? • Hematologic: Anemia history or symptoms? Blood transfusions? Bleeding disorders? • Dentition: Number of teeth and eruption pattern? Dental trauma? Dental care? Use of fluoride? Teeth brushing? Toothaches? Use of appliances? Family history of diseases: Classically the three-generation pedigree is used to map out risks for genetic diseases in families, but can be used more broadly to detect conditions with modifiable risk factors. In a broader form, the pedigree is also a genogram Families can use checklists to note conditions or construct a pedigree online • Mother's pregnancy history: Number of pregnancies, births, status of offspring. Familial and communicable diseases, such as diabetes, epilepsy, tuberculosis, hypertension or heart disease, cancer, sickle cell anemia, birth defects, known genetic disorders? • Genogram or pedigree: Draw out a genogram of the family members, including sex, age, and health status of each member. Environmental history: consider toxic exposures. What foods does the child eat and how are they prepared? What is the quality of the child's living environment(s) —water and air quality? Pesticides used? Are chemicals or heavy metals stored in or near the home? Has the child been exposed to tobacco smoke or lead? Exposure? What are the noise levels in the child's environment? Functional Health Domain Database Health maintenance and health perceptions: selection of health care providers, use of safety devices, learning how to take care of oneself, and daily care of the body. Problems identified might include health-seeking behavior, altered health maintenance, or noncompliance with a preventive or adaptive health care regimen. • Usual primary care provider: last visit? • Dentist: last visit? • Child's self-care or caregiver needs for more knowledge of caregiving? • Health care recommendations that the family chooses not to or is unable to follow? • Safety measures used: Car seats or seat belts? Smoke and carbon monoxide alarms? Window screens? Home safety measures? Pools? Firearms in the home? Helmet use? • Routine health promotion regimens? • Home and health management resource issues for the chronically ill or handicapped child? Home nursing? Equipment needs? Transportation needs? Nutrition: Quality and quantity of the daily diet and the processes of feeding and swallowing, in addition to data to support diagnoses, such as nutrition, less than or greater than body requirements; anorexia; bulimia; impaired swallowing; and breastfeeding issues • Daily diet: Breakfast, lunch, snacks, and dinner? Aversions and preferences? • Cultural patterns related to nutritional preferences and eating? • Supplements and vitamins? • Feeding patterns: Mealtimes and snack times? Feeding strategies? Self-feeding skills? • Breastfeeding and bottle-feeding issues? • Nutritional restrictions or special needs: calories, other? • Satisfaction with weight? • Difficulties chewing or swallowing? Reflux? Activities: Physical mobility and the diversional and occupational activities of daily life • Amount, timing, and types of physical activities? Other play opportunities and activities? • Television and computer or electronic games time? • Reading time? • Sports, organized activities, and hobbies of older children and adolescents? • Activity limitations caused by health problems? • Special equipment used or needed to support mobility? Sleep: Sleep and rest patterns Hours? Disturbances for the child or family? Sleep aids? Sleep position for infants? Signs of sleepiness? Elimination: genitourinary or gastrointestinal systems or in terms of daily living patterns. Enuresis and encopresis are daily living problems (bowel and bladder habits) • Urinary patterns: Bed-wetting? Toilet training? Voiding schedule? • Bowel patterns: Constipation or soiling? Stooling patterns? Toilet training? Role relationships: family relationships and relationships with peers and friends in the community. Family coping, family process alteration, parenting alteration, abuse, and social interaction or isolation. • Family interactions: Between parents? Parents and children? With other family members? • Parenting style and activities? • Peers and social supports for the child and family? Special adults in the child's life? • Communication with and by the child: Verbal? Nonverbal? • School performance for school-age children and teens. • Concerns that anyone has abused the child. Coping and temperament, mental health, and discipline issues: Discipline strategies used in families are important to identify. Anxiety, fear, hopelessness, grief, powerlessness, substance abuse, pain, and potential for violence • Stressors for the child and family? Losses? • Coping strategies of the child and caregivers? • Use of alcohol or drugs? • Temperament characteristics of the child and the "fit" with other family members? • Problem behavior, discipline strategies used and their outcomes? • Indications of depression, suicide, violent behavior, anxiety? Cognitive and perceptual: • Hearing or vision problems? • Learning disorders or attention problems? • Adaptations made at home and school to assist the child, especially for problems of comprehension? Selfperception or selfconcept: Personal role identity, body image, and self-esteem • Satisfaction with self? • Feelings of depression? Sexuality: Pregnancy • Sexual habits? • Sexual relationships? • Development of sexual identity? Values and beliefs: spiritual patterns and personal values and beliefs • Involvement with church? • Religious rituals? • Sense of alienation? • Sense of spiritual meaning in one's life? • Values the family wants to impart to their children? Development Domain Database past milestones and current functioning Developmental surveillance is expected at all visits, and screening tests should be administered periodically to infants and young children • Motor landmarks-gross and fine motor: sitting, standing, walking, use of hands and arms • Language landmarks—words, sentences, intelligibility, comprehension • Personal and social—play, attachment, self-care, peer and family relationships • Scholastic grade and progress

Bates Visual Guide to Examining Infant

A three‐month old infant will normally lift the head and clasp the hands. By six months, infants normally roll over, turn to voices and reach for objects—including those in your hands. A one‐year‐old may be standing and putting everything in their mouth—including any equipment you might set down within their reach. Temperaments vary; some infants respond positively to new stimuli—including you. Others may respond to you intensely, or negatively. You can increase the chances of obtaining cooperation by considering the following tips. Try to examine infants one to two hours after feeding, when they are most responsive and liable to be less cranky. Ask the parent about the infant's strengths in order to elicit useful developmental and parenting information. Begin by discussing with the parents any concerns or questions they may have. This is also a time to talk about strategies to optimize the health and well‐being of their infant. With the patient's health history in mind, and after good hand hygiene, you are ready for the physical examination. Examine the infant in the presence of the parents, as parents often can help to calm a restless or screaming baby. You can examine the infant in the parent's lap if needed but an examination table or crib is optimal. General Survey and Somatic Growth Perform a general survey, inspecting the patient closely—literally, from "head‐to‐toe"—in order to form impressions for your written assessment. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 2 During the general survey, observe the quality of parent‐child interactions. Also look for signs of stress or depression in parents, which may place the child at risk and sometimes can indicate an increased risk for child abuse or neglect. Approach the infant gradually, using a toy or object for distraction. Speak softly to the infant or mimic the infant's sounds to attract attention. Don't expect to do a head‐to‐toe exam in a specific order. Take what the infant gives you and save the mouth and ear exam for last. In general, you will perform non‐disturbing maneuvers early in the examination, and potentially distressing maneuvers near the end. Follow the general survey with an assessment of somatic growth. Growth is one of the most important indicators of a child's health, and deviations from normal may be an early sign of an underlying problem. When assessing growth, compare your findings with normal values according to the child's age and sex. The most important tools for assessing somatic growth are growth charts. Growth charts display a series of lines that enable you to establish percentile rankings for your patients, indicating their growth relative to other children of the same chronologic age. For safety reasons, it is recommended that pediatric examination tables be placed flush against the examination room wall. For the infant, height is measured as body length. Direct measurement using a tape measure is inaccurate. For a more accurate measurement, place the baby supine on a measuring board or tray, holding the patient still with hips and knees fully extended. Weigh infants directly with an infant scale. Infants should be naked, or clothed only in a diaper—in which case the diaper should be weighed separately, and that weight subtracted from the overall measurement. Head circumference always should be measured during the first two years of life. This measurement reflects the rate of growth of the cranium and the brain. Place the measuring tape over the occipital, parietal, and frontal prominences to obtain the maximum circumference. Vital Signs While blood pressure is routinely measured in children older than two years, it can also be obtained from infants, but only if indicated. You will need skills in distraction or play to help obtain this measurement. The most easily used measure of systolic blood pressure in infants is the Doppler method, which detects arterial blood flow vibrations, converts them to systolic blood pressure levels and transmits them to a digital read‐out device. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 3 You may have trouble obtaining an accurate pulse rate in squirming infants. The best strategy is to palpate either the femoral arteries in the inguinal area... or the brachial arteries in the antecubital fossa... or to auscultate the heart. This measurement is important because the heart rate of infants is more sensitive to the effects of illness, exercise, and emotion than that of adults. The respiratory rate in infants has a greater range compared to adults and, in fact, may vary considerably from moment to moment, with alternating periods of rapid and slow breathing. In infants, the normal rate ranges between 30 and 60 breaths per minute. Ideally, the respiratory pattern should be observed for at least 60 seconds to assess both the rate and pattern. Because fever is so common in children, obtain an accurate body temperature when you suspect infection. Auditory canal temperatures are considered accurate. The technique for obtaining rectal temperature is relatively simple. Place the infant or child prone on the examining table, on the parent's lap, or on your own lap. Separate the buttocks with the thumb and forefinger on one hand and with the other hand gently insert a well‐lubricated rectal thermometer to a depth of 2 to 3 centimeters. Keep the thermometer in place for at least 2 minutes. The average rectal temperature is higher in infancy and early childhood, usually 99.0 degrees Fahrenheit until after three years, and may fluctuate as much as 3 degrees during a single day. The Skin As you proceed through the examination, and as opportunity arises, examine the skin of the infant carefully to identify both normal markings and potentially abnormal ones. In infants, the skin texture is soft and smooth because it is thinner than the skin of older children. A response to cooling and chronic exposure to radiant heat can occasionally produce cutis marmorata, a lattice‐like, bluish mottled appearance on the trunk, arms, and legs. Other common skin conditions and rashes include acrocyanosis, milia, miliaria rubra, erythema toxicum, and pustular melanosis. Note any birthmarks in the infant ... ... and palpate to assess the degree of hydration, or turgor. Roll a fold of loosely adherent skin between your thumb and forefinger to determine its consistency. In well‐hydrated infants, the skin returns to its normal position immediately upon release. Normal "physiologic" jaundice occurs in half of all infants, appearing on the 2nd or 3rd day of life, peaking at about the 5th day, and usually disappearing within one week. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 4 Pressing the red color from the skin allows better recognition of the yellow of jaundice. This infant displays no sign of jaundice. Head and Neck When examining the head of the infant, you'll find that the bones of the skull are separated from one another by membranous tissue spaces called sutures. The areas where the major sutures intersect in the anterior and posterior portions of the skull are known as fontanelles. Palpate the sutures and fontanelles carefully with the baby sitting quietly or being held upright. The fullness of the fontanelles reflects intracranial pressure. In normal infants, the anterior fontanelle is soft and flat. A full anterior fontanelle with increased intracranial pressure can be seen when a normal baby cries or vomits. Pulsations of the fontanelle reflects the peripheral pulse. Assess the symmetry of the skull. Several conditions can cause asymmetry of the skull in newborns and infants. Some are normal or benign, while others reflect underlying pathology. Examine the skull shape from behind. Asymmetry of the cranial vault, or positional plagiocephaly, occurs when an infant lies mostly on one side, resulting in a flattening of the parieto‐occipital region on the dependent side. It normally disappears as the baby becomes more active. But plagiocephaly may also reflect injury to the sternocleidomastoid muscle or premature closure of the sutures (craniosynostosis). Next, check the face of the infant for symmetry ... then concentrate on forming an overall impression of the facies. It is often helpful to compare the face of the baby with the face of the parent. A systematic assessment of a child with abnormal‐appearing facies can identify specific syndromes. Percuss the cheek to check for Chvostek's sign, which is present in some metabolic disturbances and occasionally in normal infants. Percuss at the top of the cheek just below the zygomatic bone in front of the ear, using the tip of your index or middle finger. The Eyes When assessing the infant's eyes, use subdued room lighting, because bright light causes infants to blink. Newborns keep their eyes closed except during brief awake periods. If you attempt to separate their eyelids, they will tighten them even more. By one month of age, an infant should be able to fix on objects such as your face, and follow a bright light, provided you catch the baby during an alert period. Examine the infant for eye movements. Hold the baby upright, supporting the head. Rotate yourself with the baby slowly in one direction. This usually causes the baby's eyes to open, allowing you to examine the sclerae, pupils, irises, and extraocular movements. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 5 During the first few months of life, some infants have intermittent crossed eyes or intermittent laterally deviated eyes. This can be normal. Look for abnormalities or congenital problems in the sclerae and pupils. Subconjunctival hemorrhages are common in newborns. The eyes of many newborns are edematous from the birth process. Pupillary reactions can be observed either by response to light or by covering each of the infant's eyes with your hand and then uncovering them. Inspect the irises carefully for abnormalities and examine the conjunctiva for swelling or redness. Then, try to use your ophthalmoscope to examine the red retinal fundus reflex. Failure to see a red or orange reflex may indicate an abnormality. Set the ophthalmoscope to 0 diopters and view the pupil from 10‐12 inches away. Normally a red or orange color is reflected from the fundus through the pupil. The cornea can normally be seen at +20 diopters, the lens at +15 diopters, and the fundus at 0 diopters. Also look carefully for retinal hemorrhages. Ears and Nose Examination of the infant's ears is important because many abnormalities can be detected, including structural problems, otitis media, and hearing loss. Note the position of the ears in relation to the eyes. An imaginary line drawn across the inner and outer canthi of the eyes should cross the pinna or auricle. If the pinna is below this line then the infant has low‐set ears. While this may be normal, it may also be a sign of a congenital syndrome. The infant's ear canal is directed downward from the outside, so you must pull the auricle downward, not upward, to get the best view of the eardrum. Test for hearing using the acoustic blink reflex—a blinking of the infant's eyes in response to a sudden sharp sound. You should be able to produce this reflex by snapping your fingers or using a bell, beeper or other noisemaking device approximately one foot from the infant's ears. Be sure that you are not producing an airstream that may cause the infant to blink. This reflex may disappear after the first two or three times within a brief period because of a phenomenon known as habituation. The most important component of the examination of the infant nose is to test patency of the nasal passages. You do this by gently occluding each nostril alternately. Because infants are nasal breathers, they should easily tolerate this gentle maneuver. Do not occlude both nostrils at once, however, which would cause considerable stress. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 6 To inspect the nose, use a wide speculum and ensure that the nasal septum is midline. Palpation of the sinuses of newborns is not helpful. Mouth and Pharynx To inspect the mouth and pharynx of infants, use a tongue blade and a light, as well as palpation. One method of examination utilizes the parent to hold the infant's head and arms. Palpate the upper hard palate to make sure it is intact. You may notice small pearl‐like cysts called Epstein's pearls along the alveolar ridges, or centrally on the hard palate. Epstein's pearls disappear within one or two months. You may see a whitish covering on the tongue. If this coating has been caused by milk, it can easily be removed by scraping or wiping it away. Try to distinguish milk from thrush, which is also commonly seen on the buccal and gingival surfaces. The pharynx of the infant is best seen while the infant is crying. Listen to the quality of the infant's cry. It should be lusty and strong. You will likely have difficulty using a tongue blade, because it produces a strong gag reflex. Do not expect to be able to visualize the tonsils. Begin examination of the infant's neck by palpating. Because the necks of infants are short, it is best to palpate them in the supine position. Palpate the lymph nodes of the neck and assess for any additional masses, such as congenital cysts, including branchial cleft cysts, thyroglossal duct cysts, or cystic hygromas. Next, check the position of the thyroid cartilage and trachea. In newborns, palpate the clavicles and look for evidence of fracture. Thorax and Lungs Carefully assess respirations and pattern of breathing. An important tip is not to rush to the stethoscope, but rather to observe the infant carefully and note... ...respiratory rate, color, nasal component of breathing, and audible breath sounds, including nasal flaring, grunting, audible wheezing, or retractions (known as chest indrawing). Chest indrawing is the inward movement of the ribs during inspiration. Any of these signs of work when breathing indicate respiratory pathology. Percussion is not helpful in the examination of the chest of infants, as the infant's chest is hyperresonant throughout. So assess tactile fremitus by palpation. Place your hand on the infant's chest when the Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 7 infant cries or makes noise. Place your hand or fingertips over each side of the chest and feel for symmetry in the transmitted vibrations. Next, begin auscultation. Breath sounds are louder and harsher in infants than in adults because the stethoscope is closer to the origin of the sounds. Also, it is often difficult to distinguish transmitted upper airway sounds from sounds originating in the chest. Upper airway sounds tend to be loud, transmitted symmetrically throughout the chest, and loudest as you move your stethoscope toward the neck. They are usually inspiratory, coarse sounds. Lower airway sounds are loudest over the site of pathology, are often asymmetric, and may occur during expiration. Expiratory sounds are generally from an intrathoracic source, while inspiratory sounds can arise from an extrathoracic airway such as the trachea or an intrathoracic source. The characteristics of the breath sounds, such as vesicular and bronchovesicular, and of the adventitious lung sounds, such as crackles, wheezes, and rhonchi, are the same as those for adults, except that they may be more difficult to distinguish in infants and often occur together. The Heart Before examining the heart itself, carefully observe the skin for cyanosis. The best place to ensure that the infant is pink is to look in the mouth. A true pink, the color of a strawberry, is normal, while cyanosis appears more like the deeper red of a raspberry. Acrocyanosis is important to detect. While it may be a normal response to exposure to cold air, it may also reflect congenital cardiac abnormalities as well as respiratory diseases. Observe the infant for general signs of health. The infant's nutritional status, responsiveness, happiness, and irritability are all clues that may be useful in evaluating cardiac disease. Observe the respiratory rate and pattern to help distinguish the degree of illness and cardiac versus pulmonary disease. While respiratory disease tends to cause "work of breathing," cardiac disease in infants tends to cause peaceful tachypnea. Palpate the peripheral pulses. The brachial artery pulse in the antecubital fossa is easier to feel than the radial pulse at the wrist. Feel the femoral pulses, which lie in the midline just below the inguinal crease, between the iliac crest and the symphysis pubis. This is particularly challenging in squirmy, chubby infants, but it is important to assess because coarctation of the aorta can cause absent femoral pulses on the affected side. One trick is to flex the infant's thighs. The infant will likely stretch them out a bit and allow you to palpate in the inguinal canal. You should also try to palpate the dorsalis pedis and posterior tibial pulses, although these may be difficult to feel. Note that the point of maximal impulse is often not palpable in infants. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 8 Next, place your hand on the chest to feel for thrills. The rough, vibrating turbulence of thrills within the heart or great vessels is quite rare in infants. You can evaluate the heart rhythm more easily by listening to the heart rather than by feeling the peripheral pulses. Auscultate using the diaphragm and the bell of your stethoscope to evaluate the S1 and S2 heart sounds carefully. They are normally crisp. You can usually hear the second sounds, or S2, at the base separately, but they should fuse into a single sound in deep expiration. A split S2 may be detected in neonates who are quiet or asleep. Hearing a split S2 reduces the likelihood of serious congenital cardiac defects. If S2 is detected, listen for the intensity of the aortic or first component, which is normally louder than the second component, the pulmonic sound. Third heart sounds that are low pitched and early diastolic may be detected best at the lower sternal border (or right ventricular area). They reflect rapid ventricular filling and not disease. Fourth heart sounds are not often heard in children, and are low frequency, late diastolic sounds occurring just before the first heart sound. You might even hear an apparent gallop in the presence of a normal rate and rhythm—this is normal in infants. Remember that infants breathe rapidly, so you will need to mentally subtract the sounds of respiration from the heart sounds. One of the most challenging aspects of the cardiac examination of infants is the evaluation of heart murmurs. Characterize heart murmurs by noting their specific location—for instance, locating a murmur in the left sternal border is less helpful than describing the location as the left upper sternal border. Listen for systolic or diastolic murmurs, as well as third heart sounds. Fourth heart sounds are rare in newborns. Most children will have one or more functional or benign heart murmurs at some point in their childhood. With time and practice you will improve your ability to differentiate between these murmurs and the unusual or pathologic ones. Breasts and Abdomen While examining the breasts of both the male and female newborn, you'll find they are often enlarged as a result of the effects of maternal estrogen. Such enlargement may last several months. The breasts also may be engorged with a white liquid, sometimes colloquially called "witch's milk." This finding may last for the first week or two of life. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 9 Inspect the abdomen of the infant with the baby lying supine. The normal infant's abdomen is protuberant as a result of poorly developed abdominal musculature. In a very young infant, inspect the umbilical cord to detect abnormalities. Normally there are two thick‐ walled umbilical arteries and one larger thin‐walled umbilical vein, which is usually located at 12 o'clock. Look for any redness of the skin around the umbilicus, which would be abnormal and could signify infection. Swelling around the umbilicus is probably due to umbilical hernias, which are detectable at a few weeks of age and tend to disappear by 1 year. You may notice a diastasis recti in many normal infants. This is a separation of the two rectus abdominis muscles, causing a midline ridge especially on contraction of the abdominal muscles. This is a benign condition in most cases. As in adults, auscultate the abdomen prior to palpation. You may note active tympanic sounds because of the infant's propensity to swallow air. It is easy to palpate an infant's abdomen because infants like being touched. A useful technique to relax the infant is to hold the legs flexed at the knees and hips with one hand while palpating the abdomen with the other. You may also want to request assistance from a parent, or use a pacifier or bottle to quiet the infant in this position. Start gently palpating the liver in infants low in the abdomen, moving upwards with your fingers. This technique helps you avoid missing an extremely enlarged liver that extends down into the pelvis. With a careful examination, you can feel the liver edge in most infants 1-2 centimeters below the right costal margin. It is more difficult to feel the spleen than the liver. The spleen is soft with a sharp edge and projects downward like a tongue, normally 1-2 centimeters under the left costal margin. You may be able to palpate the kidneys of infants by carefully placing the fingers of one hand in front of, and those of the other hand behind each kidney. Genitalia and Rectum In the newborn female, the genitalia will be prominent as a result of the effects of maternal estrogen. The labia majora and minora have a dull pink color in light‐skinned infants and may be hyperpigmented in dark‐skinned infants. Examine the different structures systematically including the size of the clitoris, the color and size of the labia majora, and any rashes, bruises, or external lesions. Separate the labia majora at their midpoint with the thumb of each hand and inspect the urethral orifice and the labia minora. Assess the hymen, which is a thickened avascular structure with a central orifice covering the vaginal opening. Begin examination of the infant male genitalia with inspection. With the infant supine, note the appearance of the penis, testes, and scrotum. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 10 Then, unless the infant's penis has been circumcised, examine the foreskin, which completely covers the glans penis. You may be able to retract the foreskin of the infant just enough to visualize the external urethral meatus. Do not retract the foreskin forcefully. Examine the shaft of the penis, noting abnormalities. Make sure the penis is straight. Inspect the scrotum and testes, making sure you can feel both testes. Note any swelling within the scrotal sac and try to differentiate it from the testes. Familiarizing yourself with the appearance of the genitalia at different ages will help you recognize normal variations from subtle abnormalities. For infants, the rectal examination consists of visual inspection of the anus. Digital examination is not routinely performed unless pathology is suspected. Musculoskeletal System Much of the musculoskeletal examination focuses on detection of congenital abnormalities, particularly in the hands, spine, hips, legs, and feet. Combine the musculoskeletal examination with the developmental and nervous system examinations. The infant's hands are clenched because of the palmar grip reflex. Extend the fingers carefully and inspect, noting any defects. Palpate along the clavicle, noting any lumps, tenderness, or crepitus that may indicate a fracture. Carefully inspect the spine. Major defects such as meningomyelocele will be obvious, but look also for subtle abnormalities including pigmented spots, hairy patches or deep pits, particularly along the midline. Palpate the spine in the lumbosacral region. Examine the infant's hips carefully for signs of dislocation. Two techniques are especially helpful. For the Barlow test, hold the legs as shown and rotate your hands outward, seeing if the femoral head feels stable or moves laterally. Movement of the femoral head signifies laxity and a dislocatable hip. For the Ortolani test, again hold the legs as shown and rotate your hands the other way —inward until each knee touches the table. A palpable movement of the femoral head back into place is abnormal. It is important to examine the legs and feet to detect developmental abnormalities. Assess symmetry, bowing, and torsion of the legs. There should be no discrepancy in leg length. Some normal infants exhibit twisting, or torsion of the tibia, inwardly or outwardly on the longitudinal axis. Parents may be concerned about a toeing in or toeing out of the foot and an awkward gait in toddlers, all of which are usually normal. Tibial torsion corrects itself during the second year of life after months of weight bearing. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 11 Finally, examine the feet of the infant. At birth, the feet may appear deformed from retaining intrauterine positioning, often being turned inward. Manipulate the affected foot. A normal foot should be easy to correct to neutral and even to an over‐corrected position. Scratch or stroke along the outer edge of the foot to see if it assumes a normal position. The normal infant's foot has several features that, while they may initially concern you, are benign. The foot appears flat because of a plantar fat pad. There is often inversion of the foot, elevating the medial margin. The infant may exhibit adduction of the forefoot without inversion, or even adduction of the entire foot. Each of these normal variants tends to resolve within one or two years. Nervous System The examination of the nervous system in infants includes techniques specific to their particular age. Because neurologic abnormalities in infants often present as developmental abnormalities, these two examinations need to proceed together. First, assess the mental status during alert periods. If the baby is transiently too drowsy, return at a later time. Assess motor function and tone by carefully watching the infant's position at rest and then testing resistance to passive movement. Assess tone as you move each major joint through its range of motion, noting any spasticity or flaccidity. Hold the baby in your hands to determine if the tone is normal, increased, or decreased for age. You can test for the infant's sensory function only in a limited way. Test for pain sensation by flicking the infant's palm or sole with your finger. Observe for withdrawal, arousal, or change in facial expression. Do not use a pin to test for pain. Testing an infant's cranial nerves requires special methods that differ from those used for older patients. Cranial Nerve I, which mediates sense of smell, is difficult to test in infants. Cranial Nerve II mediates vision, while Cranial Nerves III, IV, and VI mediate extraocular movement. These nerves can be tested by having the baby regard your face or a moving toy that has no sound. Look for facial response and tracking. Cranial Nerves II and III control response to light. To test, raise the baby to a sitting position to open the eyes. Use a light and test for optic blink reflex. You may also use the otoscope (without a speculum) to assess pupillary response. Cranial Nerve V can be assessed by testing the rooting reflex and the sucking reflex. Cranial Nerve VII innervates all muscles of facial movement and expression. Observe the baby crying and smiling while you assess symmetry of the face and forehead. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 12 Cranial Nerve VIII mediates hearing and vestibular function. Test acoustic blink reflex and tracking in response to sound. Cranial Nerves IX and X mediate the sensory and motor functions of the palate, pharynx, and larynx. These nerves are assessed by observing the infant's coordination during swallowing and by testing for a gag reflex. Cranial Nerve XI innervates the sternomastoid muscles and upper trapezius muscles and is assessed by observing the symmetry of the infant's shoulders. Cranial Nerve XII mediates motor functions of the tongue, affecting articulation of words. Observe coordination of swallowing, sucking, and tongue thrusting. The deep tendon reflexes are variable in newborns and infants because the corticospinal pathways are not fully developed. Their exaggerated presence or their absence has little diagnostic significance, unless this response is different from results of previous testing, or unless extreme responses are observed. To elicit deep tendon reflexes of the biceps and quadriceps, use the same techniques as you would for an adult, substituting your index or middle fingers for the neurologic hammer. However, the triceps, brachioradialis, and abdominal reflexes are difficult to elicit before six months of age. Although a normal flexion plantar response is obtained in 90% of infants, a positive Babinski response to plantar stimulation (that is, dorsiflexion of the big toe and fanning of the other toes) can be elicited in some normal infants until two years of age. Try to elicit the ankle reflex by grasping the infant's malleolus with one hand and abruptly dorsiflex the ankle. You may note rapid, rhythmic plantar flexion of the foot in response to this maneuver. Up to ten beats can be normal but 1-2 beats are most common. The infant's developing central nervous system can be evaluated by assessing infantile automatisms, called "primitive reflexes." These develop during gestation, are generally demonstrable at birth, and disappear at defined ages. A few of the more important primitive reflexes include: The palmar grasp reflex. Place your fingers into the baby's hands and press against the palmar surfaces. In infants up to three‐to‐four months old, the baby should flex all fingers to grasp your fingers. The rooting reflex. Stroke the perioral skin at the corners of the mouth. In infants up to four‐to‐six months old, the mouth should open and the baby should turn the head toward the stimulated side and suck. The moro (or startle) reflex. Hold the infant supine, supporting the head, back, and legs. Abruptly lower the entire body about 2 feet. In infants up to four‐to‐six months old, the arms should abduct and extend, hands open, while the legs flex. The infant may cry. Abnormalities in these primitive reflexes, merit more intensive investigation. Downloaded From: http://batesvisualguide.com/pdfaccess.ashx?url=/data/multimedia/ by a New York University/Medical Center--New York User on 01/30/2018 Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 13 There are standardized developmental screening instruments, which illustrate the key developmental milestones that an infant normally reaches. These charts can aid you in determining which age‐specific developmental tasks to evaluate. By observation and play with the infant, you can do both a developmental screening examination and an assessment for gross and fine motor achievements. Recording Your Findings Remember that a clear, well‐organized clinical record—employing language that is neutral, professional, and succinct—is one of the most important adjuncts to patient care. [TYPING] Anterior fontanelle 1 centimeter and soft. Posterior fontanelle is closed. The right occiput shows mild plagiocephaly. Ears were normal with normal TM's.... After practice and further review of this video, make sure you have mastered the important learning objectives for examining infants.

How Should You Perform an Early Childhood Caries Examination ("Knee to Knee Oral Examination")? (bright futures)

Early signs are subtle heavy soft plaque accumulation on the maxillary incisors, particularly along the gum line, and "white spot" lesions that indicate early enamel decalcification. Have Your Supplies and Equipment Ready • 2 x 2 gauze • A source of good direct overhead light • Gloves • Tongue depressor • Dental mirror (optional) • Fluoride varnish (optional) Position Yourself Correctly Visualize the infant or toddler's mouth from above by positioning yourself behind the child's head with the child lying on the examining table, in a carrying seat, or in your lap as you sit knee-to-knee with the parent. Conduct the Examination • Pull down on the lower lip and examine the mucosa. • Lift the upper lip to examine mucosa and the maxillary anterior teeth. The first signs of ECC occur on the front surfaces of these teeth. Note that the front surface of the lower front teeth are almost never affected by caries in young children. Any visible difference between the integrity, color, or sheen of the lower and upper teeth may indicate early signs of ECC Look for soft whitish plaque accumulation. Gently scrape with a tongue blade along the gum line to see if this plaque is present on these upper teeth before wiping them dry. • Look closely at the dry teeth along the gum line for crescent shaped or linear white opacities (white spots). • Check for color and translucency (shininess). Primary teeth should be uniform in these aspects. Any discoloration is cause for concern. • Press gently on the teeth to assess that all are firmly in place and that the child does not react to upward pressure, particularly on obviously decayed teeth. • With gentle pressure, press down on—or in front of (in the mucolabial fold)—the lower teeth to open the child's mouth. Alternatively place the tongue blade between the child's molars and turn 90 degrees. Examine the posterior teeth for color, form, and integrity. Any dark fissure in young children is of concern. • Examine the buccal mucosa, palate, tongue, and oropharynx. • Examine the dentition for numbers, color, form, an disturbances that may relate to development, trauma, or caries. • Lean forward while tipping the child's head back to look closely at the back surface of the maxillary incisors as this is another common place for first cavities to appear. A disposable or sterilized dental mirror is recommended for use. • Grasp the child's chin gently and guide the mouth closed along the midline until the teeth touch. Examine for bite. Look for normal occlusion. All of the upper teeth should drape closely over all of the lower teeth. Any disturbance from this pattern is cause for concern. • Apply fluoride varnish: After drying the teeth with the gauze, use the brush supplied with the fluoride varnish to apply a thin layer of the material to all surfaces of the teeth, with particular attention to the front and back surfaces of the maxillary incisors. Counsel and prescribe appropriate topical and systemic fluoride. ` Assess systemic fluoride: For children whose water supply is not fluoridated and at caries risk, assess the child's primary water supply for fluoride content by submitting a water sample to a state or private laboratory. For children with a primary water supply that contains suboptimal fluoride, prescribe a fluoride supplement Recommend appropriate topical fluoride toothpaste use: AAPD recommends that parents use an age-appropriate toothbrush twice daily to apply a "smear" of fluoridated toothpaste for children younger than 2 years who are at caries risk and a non-fluoride toothpaste for children not at risk. For children ages 2 through 5, a "pea sized" amount of toothpaste is appropriate Summary: Causes of Concern • Plaque accumulation • White opacities • Discoloration of primary teeth • Differences in tooth surface appearance • Any disturbance from normal occlusion

Focused Assessment** (Bates)

Is appropriate for established patients, especially during routine or urgent care visits Addresses focused concerns or symptoms Assesses symptoms restricted to a specific body system Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible patient with sore throat - decide who may have infectious mononucleosis and warrants careful palpation of the liver and spleen and who has a common cold and does not need this examination

Child Health Assessment Foundations (book)

I. Patient-identifying information: name, birth date, sex, address, record number, and name of historian, along with relationship to the patient stated II. Chief complaint (CC) III. History of present illness (HPI) IV. Past medical history (PMH) A. Prenatal, natal, postnatal B. Past illnesses C. Allergies D. Accidents E. Hospitalizations F. Immunization history G. Nutrition history H. Growth I. Development V. Review of systems (ROS): A. Psychological—colic, breath-holding, thumb sucking, head banging, fears, tics, behavior disorders, temper tantrums, nail biting, hair pulling, masturbation. Adjustment to home, school, neighborhood. Temperament—activity level, predictability, moods, intensity of reactions, adaptability, initial responses, distractibility. Sleep— amount, habits, problems. VI. Family history (FH) VII. Socioeconomic (SE) A. Occupations of father and mother B. Time spent with child by parents, activities together C. Finances—adequacy D. Persons in the home E. House or apartment living arrangements F. General relationship of family members G. Community support systems—friends, church, agencies involved with family H. Safety precautions Issues such as nutrition, development, and activities of daily living are included, primarily as they relate to various diseases. The system fails to provide a framework for integrating the daily living (also called functional health patterns) and developmental issues of children into the problem lists and management plans. may fail to clearly identify and document many of the unique contributions they make to child health care. patient problems can be grouped into three distinct domains: developmental problems, functional health problems, and diseases Domain I: Development Diagnoses Cognitive Development • Cognitive delay • Learning disorder Language Development • Language delay • Speech delay Motor Development • Gross motor delay • Fine motor delay Social Development • Social developmental delay • Attachment failure Domain II: Functional Health Diagnoses Health Perception and Health Management Pattern • Adjustment impaired • Decisional conflict • Health maintenance alteration • Health-seeking behavior • Home-care resources inadequate • Home-maintenance management impaired • Knowledge deficits • Noncompliance • Risk of injury—suffocation, poisoning, trauma, aspiration • Self-care deficits—dressing, toileting, hygiene • Skill deficit • Therapeutic regimen management ineffective—individual or family Nutritional—Metabolic Pattern • Anorexia • Anorexia nervosa • Breastfeeding ineffective, interrupted, or effective • Bulimia • Colic • Infant-feeding pattern ineffective • Nausea • Nutrition alterations less than or more than body requirements • Swallowing impaired Elimination Pattern • Constipation • Encopresis • Enuresis • Incontinence, bowel or urinary Activity and Exercise Pattern • Activity intolerance • Diversional activities deficit • Fatigue • Physical mobility impaired Sleep Pattern • Sleep pattern disturbance Cognitive and Perceptual Pattern • Attention-deficit disorder • Disorganized infant behavior • Memory impaired • Potential for enhanced organized infant behavior • Sensory-perceptual alteration -Blind -Deaf SelfPerception and SelfConcept Pattern • Body image disturbance • Personal identity disturbance • Self-esteem disturbance, chronic or situational Role Relationships Pattern • Abuse • Caregiver role strain • Communication impaired—verbal • Family coping ineffective, disabling, compromised, potential for growth • Family process alteration • Family process alteration: alcoholism • Loneliness, risk for • Parenting alteration • Parental role conflict • Risk of alteration in parent-infant-child attachment • Role performance alteration • Social interaction impaired • Social isolation Sexuality Pattern • Pregnancy • Sexual dysfunction • Sexual pattern alteration Coping and Stress Tolerance Pattern • Anxiety • Comfort alteration • Coping—individual, ineffective, defensive • Depression • Fear • Grieving—anticipatory, dysfunctional • Hopelessness • Ineffective denial • Pain, chronic • Posttrauma response • Powerlessness • Rape-trauma response • Self-mutilation risk • Substance misuse • Violence potential, self or others Values and Beliefs Pattern • Potential for enhanced spiritual well-being • Spiritual distress Domain III: Pediatric Disease Diagnoses Infectious Diseases • Candidiasis • Chickenpox • Chlamydia • Diarrheal infection • Giardiasis • Gonorrhea (or other sexually transmitted disease [STD]) Endocrine, Nutritional, Metabolic, and Immune Diseases • Diabetes mellitus • Fluid volume excess or deficit • Food allergy • Immunodeficiency disease • Thyroid disorders Diseases of Blood and Blood Forming Organs • Anemias and red blood cell disorders • Jaundice • Leukemia and white blood cell disorders • Platelet disorders Neurologic and Sense Organ Diseases • Central nervous system—epilepsy or seizures, cerebral palsy • Ear—otitis externa, otitis media, serous otitis • Eye—amblyopia, conjunctivitis, dacryocystitis, myopia, strabismus • Macrocephaly, hydrocephaly, microcephaly Circulatory System Diseases • Cardiac output decreased • Congenital heart disease • Hypertension Respiratory System Diseases • Acute nasopharyngitis • Allergic rhinitis • Asthma • Bronchiolitis • Pharyngitis • Pneumonia Digestive System Diseases • Acute abdomen • Constipation (not encopresis) • Diarrhea • Gastroesophageal reflux disease • Hernia • Vomiting Dental Disorders • Caries • Malocclusion • Oral mucous membrane alteration Genitourinary System Disorders • Adhesions • Cryptorchidism • Hydrocele • Hypospadias • Incontinence • Urinary tract infection Gynecologic Disorders • Menstrual disorder • Vaginitis Skin Diseases • Acne • Atopic dermatitis • Cellulitis • Congenital lesion • Contact dermatitis • Folliculitis • Impetigo • Nevus • Seborrhea • Urticaria Musculoskeletal Diseases • Developmental dislocated hip • Genu varum or valgum • Internal tibial torsion • Lordosis • Metatarsus adductus • Osgood-Schlatter disease • Scoliosis • Strain or sprain Symptoms, Signs, IllDefined Conditions • Hypotonia • Jaundice • Temperature alteration—hypothermia, hyperthermia Injury and Poisoning • Abrasion • Bee sting • Burn • Contusion • Corneal abrasion • Fracture • Insect bite • Sprain or strain • Injury, high risk for Environmental • Exposure to toxin (specify) • At risk for environmental exposure

Infant Assessment - Notes from Lecture

Listen first, even if crying. Always let them stay in parents arms if possible. Leave them in chair with parent or have parent sit on table and hold them. Go right for heart and lungs. Speak to parent, find out why they are here. Get parents comfortable with me. Approach slowly. Distribgush between heart sounds and breath sounds - baby 170-180 if crying. Count heart rate. Block out crying and screaming. Infant - do it same time, listen for 1 minute count apically. Breathing is irregular so hard to count. Watch its chest goes up and down. Watch and listen Undress but keep them warm - esp Latino babies - keep warm Retractions - suprasternal, intercostal, sub costal (very compliant chest, if sucking in and out difficulty) Feel the fontanelle - anterior and posterior (closes 4-6 weeks). Anterior closes 12-18 months. Make sure it's not bulging - pressure, make sure it's flat and soft. Sunken - dehydration. Sit them up if really concerned about dehydration and meningitis. Gently touch don't push Look at eyes. Gently open eyes. Otoscope - go across and check babies eye - make sure there's a red reflex. Outside in. PERRLA. No red reflex - congentital cataract, retinoblastoma (cancer behind eye). Always doc PERRLA and Bil red reflex. Sometimes will cross eye, takes time and will go away don't worry about in first few months, Make sure baby looks around - take a toy and move it around. Head circumference - up until age 2 Nose - look up both sides. Close one side and make sure air goes up other side. Cholanal atresia - one side isn't open Mouth - glove, pinky finger - look around. Can have thrush - not eating, crying and irritable. Take a gauze pad, wipe the tongue with it and if it doesn't come off its thrush. Check genatalia for thrush. If breast feeding treat baby and mother. - nystatin. Put finger in and make sure no tissue missing in hard palate. If you see a bifib uvula - need to document. Have a higher chance of having a cleft palate. Look for tongue tie Newborn baby - make sure ears are patent. Older child or child with earache - pull up on top of ear and see if it hurts - otitis external, pull down on lobe. Press on Tragus. See if it hurts. Neck - sides of neck, could be torticollis - if neck is over to the side and kid doesn't want to turn. PT exercises. Feed the baby the opposite way so the baby turns the head to feed, or put the baby in crib facing a way so it turns to look at you. No lymph nodes. Feel clavicle to make sure no fracture. Arm hanging down and not moving it - can be nerve injury from birth Nipples - can be swollen. Can leak white fluid. Mom's hormone. Pimple - warm soaks. Bowel sounds - normal 4 sounds, diarrhea or vomiting - hyper. Bowel obstructions. Not hear anything. Umbilical hernia - can push it in. Most close by age 3 years. Palpate abdomen - palate edge of liver on right side. Don't feel spleen or kidneys. Make sure it's soft. Might be able to feel stool in thin kids - on left. Groin - boy - circumcised or not. Urinary meatus - opening, middle. Hypospadius - underneath. Testicles are both there. Gently feel. Might run away from you - make sure they come down. Inguinal hernia - in the crease. Size of a golf ball. girls - ovary can get stuck in there. Baby - go to OR in a day or two for hernia. Older kids can finish sports season Girl - white discharge, what kind of soap do you use if still has white discharge for a while after breast feeding. Genital might be swollen. If really swollen congential hyperplastic. Labial adhesions - labia fused at top, wait until potty trained. Use Premarin cream and sit on toilet backwards sometimes surgical corrected. Hips - bring feet up and open hips and see if you hear a click. Hip dysplasia. YouTube - ortolani hip movements. Feet up - see anus. No anus - imperforat anus. In girls impartial - anus is really close to vaginal opening - have surgeon check it out Turn baby over - feel neck and back, see if spine is straight. Leg length is the same, back of knee creases uneven - hip dysplasia. No tuffs hair. If see opening there, need ultra sound. Reflexes - clap in front of the baby - Moro reflex. Tap the table or giggle. Babinski - heel up and over across ball - see if curls toes Stepping reflex - hold up above the table. One foot on the table - start stepping Primitive reflexes - 5-6 months (not babinski) First walk in room - awake and alert, lethargic, blue, resp distress - call 911 How is mom doing with the baby? Crying baby - hair tourniquet - wrapped around finger, penis, often hungry and mom has had it, missing cues. If you can't figure it out - Start squeezing baby. Could there be an injury Who has been taking care of the baby? Tiny whole by ear - prearicular pit

The Family's Role in Health Care of Children (book)

a mother's level of education, her beliefs and attitudes about health, and her own health practices have significant influences on the health status of her children. Parental stress and mental health problems such as depression affect health care for children. Nationally, nearly 13% of children live in households with at least one parent experiencing high stress. Children in those families are more likely to seek emergency care for their children rather than using a medical home for care and experience more injuries Maternal depression in the first year of her infant's life has been associated with poorer caregiving and resulting poorer language development at 3 years of age and maternal depressive symptoms were predictive of asthma symptoms in inner-city African-American families. parents who believe that they can improve their health status by practicing health promotion behaviors tend to raise children who share similar beliefs. inadequate or poor parenting is linked to factors such as poverty, substance abuse, and minimal education, research suggests that a poor "fit" between a child and a significant adult can occur in any family, including those in which the adults are well educated, socially competent, and economically successful.

What is Early Childhood Caries? (bright futures)

all children establish a dental home by 12 months. teeth have erupted, the "Knee-to-Knee Oral Exam" represents the basic physical examination required to assess for dental caries. Some children need early referral to a dentist before tooth eruption, screening tool for assessing caries risk The American Academy of Pediatric Dentistry (AAPD): one or more decayed, missing, or filled teeth in children younger than 6 years.

Why Is It Important to Assess for ECC During the Physical Examination? (bright futures)

highly prevalent 28% of US children ages 2 to 5 have visible cavities, and 73% of these children are in need of treatment. Caries prevalence in children is 5 times that of asthma. increased 15% over the past decade. strong social, cultural, biological, dietary, and environmental determinants. interact at multiple levels and result in inequitable distribution of ECC by income and race. By income • Poor children younger than 5 years are 5 times more likely to have cavities than are children from families living at 3 times the poverty level. • Poor and low-income children have 3.5 times more decayed teeth than higher-income children.3 Poor and low-income children ages 3 to 5 years, those targeted by Head Start, experience the highest rates of tooth decay, the most unmet dental care needs, the highest rates of dental pain, and the fewest dental visits despite enjoying the highest rates of dental coverage because of Medicaid and SCHIP. By race • Hispanic children experience higher rates of ECC (36%) than do black (30%) or white (23%) children.3 • Native American and Asian-Pacific Islander children experience the highest rates of ECC. Children at high risk of ECC include • Children with special health care needs for whom diet and oral hygiene are problematic • Children of mothers/caregivers with a high caries experience • Children who do not yet have cavities but have earlier signs of caries activity including heavy plaque accumulation along the gum line or "white spot" demineralizations • Children with high-frequency sugar consumption, including those who sleep with a bottle or continuously breastfeed throughout the night • Children in families of low socioeconomic status children at high risk - the referral should be made as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first). The caries process is typically established before age 2 - before most children obtain their first dental visit. Once established, the intensity of an individual's caries process tends to be stable over the lifetime. Children with ECC are more susceptible to long-term dental problems. Pain andminfection resulting from the rapid progression of ECC into the dental pulp distracts from play and learning; often results in disturbances of eating, sleeping, and behavior; and may disturb growth. preventable through a combination of • Delay in acquisition of Streptococcus mutans and other cariogenic bacteria, which are typically acquired by infants from their mothers by direct salivary transmission • Reduced frequency and duration of sugar consumption, including in bottle and sippy cup use • Exclusion of sugar-laden liquids, including juice, in the bottle or sippy cup when used ad libitum as pacifiers • Age- and risk-appropriate use of fluorides and exposure to fluoridated water Unmet needs for dental care among all US children are 3 times greater than unmet needs for medical care. Young children are more likely to have a first dental visit for pain relief than for preventive care or anticipatory guidance. American Academy of Pediatrics and AAPD recommend that children have a dental home at the time of the first tooth or first birthday, particularly for children at risk of ECC or with signs or symptoms of other oral problems. Infant oral health care provides an opportunity to examine children and counsel families on ECC. oral and dental development, digit sucking and occlusion, oral soft tissues, home care, use of fluorides, oro-facial injury prevention, feeding behaviors, and age-appropriate engagement of children in their own oral hygiene.

Problem Interactions (book)

iron deficiency anemia - disease - effects of lack of iron on heme production, red blood cells, oxygen transport, and cellular metabolism - diagnose and prescribe an iron supplement related to a lack of iron in the diet, intervene at the functional health-nutrition level, call the problem "Nutrition: Less Than Body Requirements for Iron," and teach the family how to increase the selection of iron-rich foods for the table. Iron deficiency -> developmental delays provide additional support in the school setting, a developmental problem would be diagnosed. Down syndrome, a chromosomal disorder, -> cognitive development problem. If the intervention is for cognition, a developmental problem of cognitive delay is listed. Content issues for which the clinician is planning interventions are the diagnoses. The contextual issues are not the diagnoses. interventions must be based on or derived from diagnoses. The preventive work also needs to be identified.

Health History - Younger Children (bates)

parents are usually watching and taking part in the interaction, observe the parent-child interaction Note - child displays age-appropriate behaviors. observe child's interactions with parents and unstructured play - reveal abnormalities in physical, cognitive, and social development. Normal toddlers are occasionally terrified or angry at the examiner. they are completely uncooperative. Most eventually warm up to you. If this behavior continues or is not developmentally appropriate, there may be an underlying behavioral or developmental abnormality. Older, school-aged children have more self-control and prior experience with clinicians and are generally cooperative with the examination. Abnormalities Detected While Observing Play Behavioral* Poor parent-child interactions Sibling rivalry Inappropriate parental discipline "Difficult temperament" Developmental Gross motor delay Fine motor delay Language delay (expressive, receptive) Delay in social or emotional tasks Social or Environmental Parental stress, depression Risk for abuse or neglect Neurologic Weakness Abnormal posture Spasticity Clumsiness Attentional problems, hyperactivity Autistic features Musculoskeletal abnormalities *Note: The child's behavior during the visit may not represent typical behavior, but your observations may serve as a springboard for discussion with parents.

Setting Up the Assessment Environment (book)

privacy must be ensured. places to sit down, room well lighted patient to lie down comfortably. examiner work comfortably health care provider sit down during the history to make data collection a conversation, to equalize the status of clients and examiner, and to help clients feel that they have time to talk. Sitting - conserve energy for a busy day. environment safe present an atmosphere of warmth and welcome.

Genograms and Ecomaps (book)

two approaches to developing a family database, assist clinicians in assessing family structure and roles, life cycle transitions, family functioning, and social networks assist the provider to organize family data for analysis and identification of problems repetitive symptoms and relationships or patterns of functioning seen across the family or over generations. more effective when constructed during initial visit with children and their families and then revised as new information becomes available. useful to identify members of the current household in which children live. drawing a circle around the members of the genogram who currently live together include at least three generations of the family. Health history information, including serious medical, behavioral, and emotional problems, (e.g., drug or alcohol problems, serious problems with the law, and causes of death). ethnic background, language spoken in the home, education of parents, occupations, religious affiliation, major family moves, and current location of family members. Significant others who live with or are important to the family should be included, for example family friends, foster children, and babysitters. family pet. provide child patients with their own paper and pencils or crayons to use while conducting the interview; they might even draw a picture of their family for you. genogram interview can begin with an open question, such as, "Tell me about your family." • Who is in your family? • Who currently lives with you and your child? • If the relationships are not clear: How are you related to the members of your household? • If divorce or separation is involved: Where does the child's other parent live? What are the custody and visitation agreements? How often does the child see or hear from the other parent? • Who in your family was involved in the decision to come here today? • If a health-related problem is involved: How do other members of your family see this problem? With whom will you discuss today's visit when you go home? Current family situation • Have there been any changes in your family since your last visit? • What, if any, changes do you anticipate in the near future? Extended family situation • When was your mother born? Where? Who were her parents? • Who was in her family while she was growing up? • Is she living? If yes: Where does she live now? How often do you have contact with her? If no: When did she die? What was the cause of death? • How did she meet your father? When were they married (if applicable)? Family composition and structure • How would you describe your parenting style? How does it compare with your partner's? Who in your family is responsible for monitoring your children's health? • What does your family enjoy most about this child? • What are some of the things you do together as a family? How often? • How do you generally make important decisions in your family? • To whom does your child tend to tell problems and concerns? • How do family members show their support for one another? • How well do you think your family adapts to change? • How does your family nurture the interests and talents of each individual family member? • To whom do you go for advice about being a good parent? Why do you go to that person? • How do you deal with unwanted advice from family members about raising your child(ren)? Two-parent families • How do you decide who does what at home? • Who has primary responsibility for daily childcare? How is that working? • Who has primary responsibility for health care and appointments? How is that working? Working parents and childcare • How many hours do you work outside the home in a typical week? How does that affect your family life? • What tensions do you anticipate (or are you experiencing) to be associated with balancing work and home? • What child care arrangements have you made? How satisfactory are they? What would you change if you could? • How do you manage care for a child who is ill on a workday? Multiple Births • Have things gone as you expected with the babies? • When you have questions about their care, whom do you ask? Have you had help from your partner? Family members? Friends? • How are your babies similar? How do they differ from one another? • How have you managed those times that happen to all new parents when you feel overwhelmed? • How have the babies' sibling(s) responded to them? Families with a child with a chronic illness • How are things going on a day-to-day basis with your child's care? • How is the child's illness affecting your child's relationships with other children? • How is school going? • How is the child's illness affecting family life? • What are your hopes for the future? Your concerns? • What do you need most right now to better care for your whole family? Blended Families Have things gone as you expected they would in your new family? • How is each child coping with the new family? • How are the children responding to the situation? • How has their childcare or school situation changed, and how have they responded? • What do the parents identify as the most significant loss for each child in the blended family? The most significant benefit? • How are the relationships between parents (including stepparent) and children? • How are the relationships among the stepsiblings? • How are the parents handling discipline issues? Single-Parent Families • What is the best thing about being your child's only parent? What is most challenging for you about being a single parent? • How do you get the support you need as a parent? • What would most help you raise your child at this point in time? Foster parents • What is the best thing about being a foster parent for this child? • What challenges do you have in taking care of this child? • What other information do you need to understand and care for this child? • How do you manage the loss when you must relinquish a child? • What support systems do you have to help you provide care to this foster child and still maintain your own mental health and sense of happiness? Gay/lesbian families • What support systems do you use as a gay family with a child/children? • Have your children had any difficulties at school or elsewhere when they explain that they have two dads or moms instead of a mom and dad at their house? How have you helped them cope? • Is one of you a biological parent and the other has adopted the child or is there some other arrangement that we should know about? Are there any legal issues that we should be aware of so that if the child needs emergency care or hospitalization that care can be authorized and both of you will have visitation rights as you want? Ecomaps - depict the systems and relationships essential to the functioning of the family. Mapping of family relationships within and outside family boundaries highlights the nature of those relationships, their potential for support, conflicts in the relationships, and areas of current or potential strain and stress. uses a genogram as a foundation, so the genogram should be constructed first A large circle representing the family boundary is drawn in the center of the paper; smaller circles representing different parts of the environment (individuals, organizations and institutions, hobbies, work) are drawn around the large circle. Inside the large circle, a genogram depiction of the family members in the household is drawn. Family members are then asked to label the smaller circles with those people, places, and activities, whether enjoyable, stressful, or both, that make up their world - extended family members, friends, work, school, band practice, church or synagogue, camping, exercise, and health care. Connections between individual family members or the family as a whole and the smaller circles are then drawn. Coded lines and brief descriptions are used to indicate the strength and quality of the relationships. Direction of the flow of energy, resources, or interest can be indicated by drawing arrows along the connecting lines. a scarcity of connections outside the household suggests isolation and may be a problem if the family needs significant support during a crisis. A sheet full of circles may indicate a family overcommitted and overwhelmed by activities and responsibilities. ecomaps provide both additional data about a family's social network and potential for social support. a way of validating information from the genogram interview, especially around family relationships and roles. Selected Family Assessment Tools results in a fairly complete picture of the family's composition, social network, and family functioning.

How Should You Perform These In-Toe and Out-Toe Examinations? (bright futures)

• What do parents see that they are concerned about? • When did they first notice the problem? • Has it changed over time? Is it better? Is it worse? Is it just different? • What is the family history? Did anyone else have the problem as a child or persisting into adulthood? • What is the child's birth history? • Have they reached the appropriate developmental milestones? • What is the child's diet? observe the undressed child playing in the examination room. long hallway is used to observe the child run or walk and observe their gait. Intoeing and Outtoeing Toeing in or out may come from the hip, tibia or foot. observing the child walking or running. Estimate the foot progression angle, which is the degrees that the foot points in (a negative foot progression angle) or points out (a positive foot progression angle) relative to a straight line. assess the hip range of motion, assess the tibial torsion, and examine the feet. Hip Rotation Evaluation examine on parent's lap. With the child's hips flexed to a right angle, internally and externally rotate the hips. Lie the child down on the lap and do the same examination with the hips extended. Estimate the degree of internal and external rotation. turn the child prone to assess the rotation with the hips extended. place one hand on the pelvis and rotate the hip internally and externally until you feel the pelvis move. Examine each hip individually. Estimate the degree of rotation and record it Do one hip at a time and record the degree of internal and external rotation as you do the exam. Tibial Torsion patient prone on the examination table. It can be done at the same time as the hip rotation evaluation. reserve this examination for older children, or children who are not fearful. With the child prone, flex the knee 90 degrees and imagine a line down the thigh and a line down the axis of the foot. This is the "thigh-foot-angle" and represents the amount of tibial torsion. For feet that turn inward as a result of twisting between the knee and the ankle (internal tibial torsion) this would be a negative thigh-foot-angle and is measured in degrees. for feet that turn outward as a result of twisting of the tibia outward, the thigh-foot-angle would be a positive number. younger children, examination on the parent's lap. the degree of twisting of the tibia and the amount of twisting is assessed with the patient in a sitting or supine position. less fearful in this position, and easier to demonstrate to the parents why the child toes in. Show the parents the position of the leg between the knee and the ankle. Point the knee toward you and gently dorsiflex the foot to neutral. Show the parents that while the knee is facing you, the ankle joint is facing inward (internal tibial torsion) or outward (external tibial torsion). For a strong demonstration to the parents about the etiology, place the child in their in-utero position. Usually this will be with the hips externally rotated so the knees are facing outward, and the feet tucked in toward the midline. The tibia has to be twisted for the child to fit in the uterus; there is no in-utero position with the knees and feet straight ahead. Remember that the child can also be packed in utero with the feet turned outward in the same direction as the knee and will be born with external tibial torsion. Most noticeable is when one leg has external tibial torsion and one has internal tibial torsion, giving a "windswept" appearance. The child can still be placed in this in-utero position to demonstrate to the parents. Feet Observe the feet separately from the tibia. From the bottom of the foot you will be able to see clearly if there is a "hooking" inward of the forefoot, giving it a bean shape. This is metatarsus adductus, or metatarsus varus. Assess how flexible it is by tickling the child or observing their spontaneous movements. If the child does not straighten it out spontaneously, stretch it and see if it is passively correctable. Putting It All Together Natural history: Many children when they start to walk have physiologic bow legs (genu varum). This is not a true varus. Confirm this by putting the patellae facing anteriorly and the bowing should be much less evident. They have soft tissue external rotation contractures of their hips from the in-utero positioning combined with internal tibial torsion. As a result, they walk with their knees turned outward and their feet straight ahead, giving an appearance of bow legs. every time they take a step, their knee flexes and looks like it is jutting out laterally. As the hips loosen up, usually by the age of 2 years, they walk with their knees forward, and now the internal tibial torsion is "uncovered" and they intoe. If you explain the natural history to the parents, they will be reassured, especially as time goes on and they see that the bowing is disappearing and the intoeing in is appearing as predicted. Over time, although it is slow, the tibial torsion and the femoral anteversion also correct. all children do not fully correct these rotational "deformities." Family history and examining the parents can be useful in predicting how much the child will correct the intoeing by the time they reach adulthood. By the time the children are age 3, they will typically have a true knock knee (genu valgum). If they have a combination of internal rotation of the hip (the typical child will sit in the "W" position easily) combined with external tibial torsion the knock knee appearance will be more pronounced. The typical physiologic genu valgum corrects spontaneously and the knees should be straight by about age 6 years. Young babies who have external tibial torsion from their in-utero position, as typically seen with calcaneovalgus feet, will predictably outtoe when they start to walk. These children have external rotation contractures of their hips, but now combined with external tibial torsion. As the hips loosen up and they walk with their knees straight ahead, their feet will also be straight ahead. The children who have metatarsus adductus may spontaneously correct without treatment. It is usually detected at birth or shortly after birth. Often simple stretching is sufficient to fully correct the foot deformity. If it is rigid or severe, specific treatment may be needed. Most intoeing and outtoeing, knock knees, and bowlegs are of concern in toddlers. older children may continue to intoe due to excessive internal rotation of their hips. If this is combined with internal tibial torsion that has persisted, then the intoeing may be very noticeable. What Do You Do With an Abnormal Result? history is consistent with a normal condition examination is also consistent with normal intoeing and outtoeing, reassure the family. Keep a close eye on the child to be sure the condition is correcting and changing the way you expect. Most intoeing and outtoeing is normal. early adolescence - unable to get their feet straight ahead due to femoral anteversion, or residual internal tibial torsion. Surgery may be indicated referred to a pediatric orthopedist. adolescent who outoes needs to be evaluated for a slipped capital femoral epiphysis. presenting complaints may be outtoeing and a limp. Adolescent children with genu varum should be referred to a pediatric orthopedist for diagnosis and treatment for possible adolescent Blounts.

How Is Hypertension Defined in Children and Adolescents? (bright futures)

BP falls into several categories. • Prehypertension: systolic BP and/or diastolic BP ≥90th percentile but <95th percentile for age, sex, and height. Adolescents with BP ≥120/80 should be considered prehypertensive, even if 120/80 is less than the 90th percentile. • White-coat hypertension is BP at ≥95th percentile in the office, normal outside of the office setting. Ambulatory BP monitoring is often needed to make this diagnosis. • Hypertension is defined as systolic BP and/or diastolic BP ≥95th percentile for age, sex, and height on 3 or more occasions. Hypertensive children are further categorized into 2 stages. ` Stage 1: BP ≥95th percentile but <5 mm Hg above the 99th percentile (<99th percentile + 5 mm Hg) ` Stage 2: BP is >5 mm Hg above the 99th percentile (>99th percentile + 5 mm Hg)

Comprehensive Assessment** (Bates)

Is appropriate for new patients in the office or hospital Provides fundamental and personalized knowledge about the patient Strengthens the clinician-patient relationship Helps identify or rule out physical causes related to patient concerns Provides baselines for future assessments Creates platform for health promotion through education and counseling Develops proficiency in the essential skills of physical examination

What Sexual Maturity Results Should You Document? (bright futures)

Record Tanner staging in the chart at all routine health supervision visits. For patients showing signs of early or delayed pubertal maturation, see the child every 6 months rather than yearly, before deciding if a referral to an endocrinologist is needed. Document lab tests and x-rays ordered, results, follow-up plan. If referred to a specialist give a copy of the results of any hormone testing or x-rays done as well as the growth chart to the parents to take to the appointment. Be certain to send full evaluation testing on growth chart to referral source

What Results Should You Document - EEC? (bright futures)

• intraoral examination was performed and report findings that may indicate hard and soft tissue pathologies, abnormal development, and occlusion. • Document fluoride varnish application as applicable. • Use the AAPD Caries Risk Assessment Form to document risk. Document referral to the dentist, including any specific recommendations to parents facilitating the referral.

Child and Family Health Assessment (book)

Family-centered, community-based primary care for children - best practice model for providing health care services to children and their families. The family is the most influential factor in a child's life family- centered care is perceived as time consuming. families are still too often viewed from a pathology-based model borrowed from psychiatry and psychology, and primary care providers often report feeling inadequate to the task of working with the complex and often stressed families they meet in their practices. shift focus from child-as-the-unit-of-analysis to family-as-the-unit-of- analysis. unless the family is healthy, the child cannot achieve true physical, developmental, and psychological health.

How Should You Take These Measurements? (bright futures)

Measure Stature (Length or Height) Infancy and Early Childhood (0-2 years) • Until they can stand securely (age 2 years), measure infants lying down in a supine position on a measuring frame or an examining table. • Align the infant's head snugly against the top bar of the frame and ask an assistant to secure it there. Parents can help restrain infants for length measurements • Straighten the infant's body, hips, and knees. • Hold the infant's feet in a vertical position (long axis of foot perpendicular to long axis of leg). Bring the foot board snugly against the bottom of the foot. Some authorities suggest measuring twice and taking an average. •If an examining table is used, mark the spots at the top of the child's head and bottom of feet and then measure between the marks. (Note that this is not ideal as it is difficult to get an accurate length using this technique.) • Plot length measurements on a standard growth chart for age and gender, or one appropriate for the child (eg, low birth weight infant, infant with trisomy 21, infant with Turner syndrome). Child (2 years and older) • Have the child remove his or her shoes. • Have the child stand up with the bottom of the heels on floor and back of foot touching the wall, knees straight, scapula and occiput also on the wall, looking straight ahead with head held level. Align the measuring bar perpendicular to the wall and parallel to the floor (on a stadiometer or other measuring rod) with the top of the head. •If a scale with a measuring bar is not available, place a flat object such as a clipboard on the child's head in a horizontal position and read the height at the point at which the object touches a measuring tape on the back of the scale or a flat wall surface. • Plot height measurements on a standardized growth chart for age and gender, or one appropriate for the child. Measure Weight Infancy and Early Childhood • Weigh younger infants nude or in a clean diaper on a calibrated beam or electronic scale. Weigh older infants in a clean, disposable diaper. • Position the infant in the center of the scale tray. •It is desirable for 2 people to be involved when weighing an infant. One measurer weighs the infant and protects him or her from harm (such as falling) and reads the weight as it is obtained. The other measurer immediately notes the measurement in the infant's chart. • Weigh the infant to the nearest 0.01 kg or 1/2 oz. • Record the weight as soon as it is completed. • Then reposition the infant and repeat the weight measurement. Note the second measurement in writing. Compare the weights. They should agree within 0.1 kg or 1/4 lb. If the difference exceeds this, reweigh the infant a third time. Record the average of the 2 closest weights. If an infant is too active or too distressed for an accurate weight measurement, try the following options: • Postpone the measurement until later in the visit when the infant may be more comfortable with the setting. •If you have an electronic scale, use this alternative measurement technique: Have the parent stand on the scale and reset the scale to zero. Then have the parent hold the infant and read the infant's weight. Child • A child older than 36 months who can stand without assistance should be weighed standing on a scale using a calibrated beam balance or electronic scale. • Have the child or adolescent wear only lightweight undergarments or gown. • Have the child or adolescent stand on the center of the platform of scale. • Record the weight of the individual to the nearest 0.01 kg or 1/2 oz. (If the scale is not digital, record to the nearest half-kilo or pound). Record the weight on the chart. • Reposition the individual and repeat the weight measure. • Compare the measures. They should agree within 0.1 kg or 1/4 lb. (If the scale is not digital, compare to the nearest half-kilo or pound.) If the difference between the measures exceeds the tolerance limit, reposition the child and measure a third time. Record the average of the 2 measures in closest agreement. In the standardized scale for children, all weights between the 5th and 85th percentiles are considered normal. important - over time the weight follows one of the percentile curves. A child is defined as having a failure to thrive syndrome (a medical diagnosis) if height or weight drops below the third percentile on a standardized growth chart. Calculate BMI ` English: (Weight (lb) / [Stature (in) x Stature (in)]) x 703 ` Metric: Weight (kg) / [Stature (m) x Stature (m)] BMI growth charts are available for ages 2 to 20. Measure Head Circumference Obtain accurate head circumference, or occipital frontal circumference, using flexible non-stretchable measuring tape. generally measured on infants and children until the age of 3 years. Measure over the largest circumference of the head, namely the most prominent part on the back of the head (occiput) and just above the eyebrows (supraorbital ridges). • Pull tape snugly to compress hair and underlying soft tissues. Read measurement to nearest 0.1 cm or 1/8 inch and record on the chart. • Reposition tape and remeasure head circumference. The measures should agree within 0.2 cm or 1/4 inch. If the difference between the measures exceeds the tolerance limit, the infant should be repositioned and remeasured a third time. The average of the 2 measures in closest agreement is recorded. • Plot measurements on a standardized growth chart for age and gender. • Head circumference should correlate with the child's length (eg, if length is in the 40th percentile, head circumference should also be 40th percentile).

Family Social Network (book)

emotional support, tangible help, and informed includes those individuals, activities, agencies, and institutions that have the potential to support, harm, or drain energy from the family. Assessing the family's relationships with extended family, friends, and the community provides information on which to base recommendations and further assessment.

What Should You Do With an Abnormal BP Result? (bright futures)

persistent prehypertension (>6 months in duration) overweight, have diabetes, kidney disease, or Stage 1 hypertension - evaluation for secondary hypertension and target-organ damage persistent Stage 1 hypertension, despite trial of lifestyle modification, may need antihypertensive medications. referral to practitioner with expertise in pediatric hypertension. Consider early referral to a practitioner with expertise in pediatric hypertension for all children and adolescents with Stage 2 hypertension.

Past Medical History - Adolescents (Book)

1. In the past year have you had any injury or illness that made you miss school or cut down on activities, or that required medical care? 2. Have you been hospitalized or used Emergency Department Services in the past year? 3. Do you have any illnesses or medical conditions? 4. Are you taking any medications? 5. Have you been exposed to tuberculosis in the past year? 6. Have you stayed overnight in a homeless shelter, jail, or detention center in the past year? 7. Girls only: Have you had a period? Date of last one. Do you do breast self-examinations? 8. Boys only: Have you had wet dreams? Do you do testicular self-examinations?

Creating the Management Plan (book)

A plan must be developed for every identified problem. consider diagnostic, therapeutic, and educational interventions for every problem listed. The plan should always include a recommendation for the next visit and what is to be done at that visit in an attempt to move the patient into a health maintenance pattern rather than being seen only episodically. plans for care should be communicated to the family with a discussion of alternatives for management of issues with risks and benefits for each option. Active parent-child involvement with creation of the plan of care is the most desirable. Deliberation time with families averaged about 3 minutes per visit with a mean of four plans proposed. Passive involvement with parents occurred in 68% of visits

How Should You Perform Sexual Maturity Staging? (bright futures)

Pubic Hair Staging • Ensure adequate lighting, and examine the genital area with the pants and underwear completely removed or lowered to the knees. This is especially true in girls, where the first pubic hair may initially be only along the labia. •In assessing pubic hair do not confuse fine, light colored hair in the genital area with pubic hair if it is similar to the hair found on other parts of the trunk or thighs. Breast Staging • inspection alone and comparing it with standard pictures, palpation for overweight girls. ` If further assessment is needed • Examine breast with patient in supine position. If the consistency under the areola is similar to peripheral tissue, it is likely adipose tissue. Breast tissue is firmer and discoid in shape. • In girls, the areola becomes thicker and darker with progressive exposure to estrogens. Male Genital Measurements • The examiner should verify that the testes are descended and that the urethral opening is at the tip of the glans (that the boy does not have hypospadius). •In boys, the earliest and most reliable sign of pubertal development is enlargement of the testes, as it reflects increased secretion of the pituitary gonadotropins. • Where further assessment is needed ` Testicular size can be assessed by comparing testes with beads of varying size developed by Prader, known as an orchidometer. The beads correspond to testicular volumes of 1 mL through 25 mL. Other methods of measurement include rulers, calipers, and ultrasound. Ultrasound is the most accurate measurement method. ` Another widely used method is to measure the greatest diameter by positioning the testis between the thumb, index, and middle finger and lining up a small ruler along the long axis of the testis. ` Prepubertal boys nearly always have a testicular length of 2.5 cm or less or volume of 4 mL or less. As puberty progresses, the increase in testicular size usually precedes the increase in penis size, and eventually reaches the adult size of 5.0 cm or 25 mL. ` Increasing penile length occurs later than initial growth of the testes. ` To measure penile length accurately, use either a ruler or a marked tongue blade pressed at the base of the penis while applying firm stretch to the penis itself. ` In normal prepubertal boys, the penile length is usually between 5 to 7 cm. A stretched length of 8 cm or greater indicates increased testosterone effect. ` The physical examination record should note for undescended testicles; penile abnormalities, such as chordee; hypospadias; or anomalous genital development. • Adrenal androgens, which cause pubic hair development, do not increase penile length.

The Interval History (book)

The complete history usually needs to be completed only once for new patients. After that for routine scheduled health maintenance visits, the history is updated only from the last contact to the present. The format remains the same as for the complete history; however, questions are modified to verify that the situations are as they were in the past or to add new information. All areas of the history should be assessed.

How Should You Perform A Sports Physical Exam? (bright futures)

American Academy of Pediatrics suggests that adolescents in need of a yearly physical examination to participate in sports receive a complete health supervision checkup. history is the most important aspect 3 key systems being the cardiac, musculoskeletal, and neurologic systems. fourth edition of the preparticipation physical evaluation form - excellent tool for documenting evaluation for athletes Perform a Cardiac History and Examination 12 to 36 sudden cardiac deaths occur annually in youth younger than 18 years. The most common causes : hypertrophic cardiomyopathy (HCM), Marfan syndrome, total anomalous pulmonary venous return, and long QT syndrome. If an athlete answers yes to any of the following questions, withhold participation clearance until you complete further diagnostic workup. -Have you fainted/passed out (or nearly fainted) during or after exercise? • Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? • Does your heart ever race or skip beats during exercise? • Do you get lightheaded, feel more short of breath, or feel more fatigued than expected during exercise? • Has a doctor ever told you that you have any heart problems? • Has a doctor ever ordered a test for your heart? • Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50? • Does anyone in your family have a heart condition, such as hypertrophic cardiomyopathy or dilated cardiomyopathy, Marfan syndrome, arrhythmias, or long QT syndrome? • Has anyone in your family had unexplained fainting or drowning? Syncope. a sudden, transient loss of postural tone and consciousness with spontaneous recovery, not due to head injury or seizure. occurring during exercise is concerning for a cardiac disorder (both anatomical abnormalities [HCM] and conduction [WolfeParkinson-White syndrome, prolonged QT] abnormalities). occurring while standing or sitting with no other pertinent historical events is not a contraindication to sports participation. Nutrition counseling, salt and hydration status, is needed. Perform a Musculoskeletal History and Examination these types of conditions and injuries are identified more than any other conditions and injuries. Acute (ankle sprain, shoulder dislocation, patella dislocation) and chronic (Osgood-Schlatter disease, Sever's disease, shin splints) conditions may present themselves during the history or the physical examination. Ankle sprains. most commonly lateral and are graded for function as mild, moderate, or severe. •mild sprain, the athlete can typically run and jump but may have difficulty with lateral movement. Noncontact sports may be permitted at the time of the examination. •In a moderate sprain, the athlete can usually walk but not run and jump. •In a severe sprain, walking may be difficult. The return to play may be anywhere from 2 to 12 weeks. Shoulder and patella dislocations. An athlete should not return to play until full range of motion and 90% of baseline strength are achieved. Range of motion is easy to test but strength may be difficult. In the case of a patella dislocation, functional testing, such as sprinting and jumping on one foot, may be performed. Once the athlete can demonstrate function, he or she may begin to practice. Osgood-Schlatter disease (tibial tuberosity inflammation at patella tendon insertion). The athlete may participate if he or she is not limping at the end of a game or practice. Nonsteroidal anti-inflammatory drugs may be used for analgesia and anti-inflammatory effects, but limited duration is advised. Stretching and strengthening is suggested. Sever's disease (calcaneal apophysitis). The patient will have pain at the distal Achilles tendon insertion into the calcaneous. athletes may participate as long as they are not limping at the end of a game or practice and have full range of motion and 90% strength. Shin splints (medial tibia stress syndrome). This injury is defined as diffuse pain over the anteromedial tibia. not be confused with a tibial stress fracture, which may be differentiated from medial tibial stress syndrome by well-localized, pinpoint pain and tenderness. Running and jumping may not be permitted for 4 to 6 weeks following tibial stress fractures. Scoliosis and kyphosis. typically diagnosed at the time of the physical examination. Neither is a contradiction to full participation; assessment for underlying genetic or neuromuscular disorder. Perform a Neurologic History and Examination many athletes who have experienced concussions return to play but still experience symptoms, such as inability to concentrate and learning difficulties. Perform Eye and Kidney Histories and Examinations funduscopic examination for cataracts and screening for visual acuity. Athletes with poor vision and best-corrected visual acuity of 20/40 in one eye are considered functionally one-eyed. protective eyewear is recommended. Noncontact sports are permitted in all cases of decreased visual acuity. Participation in high-contact sports, such as wrestling or full-contact martial arts, is not recommended. For patients who have a single kidney or a single functioning kidney, the athlete needs individual assessment for contact, collision, and limited-contact sports and a clear discussion about the risks of participation in sports and recreational activities that may have incidental or deliberate contact. Protective equipment may reduce risk of injury to the remaining kidney sufficiently to allow participation in most sports, providing such equipment remains in place during activity. For athletes who have one paired organ, every effort should be made for some type of sports participation, with protective gear if necessary.

Diseases (book)

Diseases are conditions assessed and managed at the tissue or organ level of analysis. Otitis media, streptococcal pharyngitis, and appendicitis are examples of disease diagnoses. The International Classification of Diseases represents physiologic problems of patients extremely well but includes few labels, or rubrics, for the behavioral, social, and developmental problems that NPs also manage. The ICD10CM listings are recognized by many insurance carriers for billing purposes and, as such, have become the "currency" for much health care delivery in the U.S., whereas the NANDA nursing diagnoses have not yet achieved that recognition. a variety of diagnoses similar to those in the NANDA classification can be found among the medical listings, thus facilitating reimbursement for management of functional health patterns.

Why Is It Important to Assess Blood Pressure During the Physical Examination? (bright futures)

High blood pressure is a growing health concern for children and adolescents. prevalence of high blood pressure children and adolescents is increasing. Primary hypertension is detectable in children and adolescents. common problem. Target-organ damage is commonly associated with hypertension in children and adolescents. Left ventricular hypertrophy, the most prominent finding, is present in up to 36% of hypertensive children. elevated BP in childhood correlates with the presence of hypertension in adulthood. Obesity and hypertension are linked. Children and adolescents with hypertension are frequently overweight, with hypertension present in approximately 30% of overweight children.

How Should You Perform Spine, Hip and Knee Examination? (bright futures)

When evaluating any presenting complaint anywhere in the lower extremities or back, it is critical to evaluate the spine, hip, and knee, at a minimum. pathologic hip conditions will present with knee symptoms. Perform an Overview Examination of the Musculoskeletal System • Take a careful history of developmental milestones. • Observe gait and other movements. symmetry and difficulty in basic movements. ` Asymmetry should raise suspicion for underlying pathology. ` Unilateral refusal to bear weight in the very young child or significant exacerbation of pain with weight bearing in the verbal child can be worrisome and requires further evaluation. • Examine the extremities. • Assess neurologic function, light touch sensation in the major dermatomes and peripheral nerve distributions. • Test muscle strength in the major flexion and extension groups for each joint, deep tendon reflexes, abdominal reflexes, and gag reflex. Perform a Spine Examination -Observe. inspection of the skin overlying the spine. Dimples, hair tufts, or disruption of the skin in the midline raises concern for underlying spina bifida. -Assess. note the symmetry in the height of the shoulders, the scapula, and the iliac crests with the patient in a 2-leg stance. Although more sensitive radiographic measures of lower limb length discrepancy and truncal imbalance for screening exist, careful observation should reveal any severe asymmetries. -Palpate. A single spinous process should be palpable in the midline at all levels from the lower cervical through the lumbar spine. In the coronal plane, these should be vertically well-aligned. Conduct a provocative test. • The AAP and the USPSTF no longer recommend screening for scoliosis; when a concern is present regarding spinal curvature, the forward bend test is as follows. ` The patient stands with feet shoulder width apart, facing you. ` With hands together and arms dangling down, the patient slowly bends forward at the hips and lower spine until the hands are near or have touched the floor. The patient then straightens up again, slowly. ` The patient repeats the bending a second time with back facing you. • Watch for the truncal rotations that consistently result from scoliosis and other spine deformities. • The scapulae and posterior rib contours should be symmetric. If the scapula or ribs on one side appear rotated upward when the patient is bent forward, the difference in height relative to the lower side or the angle subtended between the horizontal and a line tangential to the rotated section of the trunk should be measured and recorded. A scoliometer can also be used and the angle of rotation measured and recorded. Perform a Hip Examination -Observe. Swelling or erythema around a hip is highly unusual. signs of an intra-articular pain and effusion are that the patient resists or refuses to bear weight. The hip is slightly flexed and externally rotated. -Palpate. hip joint capsule palpated just lateral to the palpable femoral pulses, best clinical information about the hip joint is gleaned from observing gait and supine resting preferred position as well as examining range of motion (flexion, extension, abduction, adduction, and internal and external rotation) and strength. Both the maximal arc of motion and the presence of pain at the extremes of that arc should be noted. -Assess • Flexion/extension: With the child lying supine on table, bring both hips up to maximal flexion and then release one at a time to extend back to the table. This permits measurement of degree of flexion in the flexed hip and the potential presence of a lack of full extension in the extended hip. Lack of full extension, flexion contracture, common with long-standing intraarticular hip pathology. not noticeable unless the contralateral hip is fully flexed, which usually prevents it from laying flat against the bed. •Internal/external rotation: Assess with the hip flexed to 90 degrees, or perpendicular to the body. Hip internal rotation levers the foot away from body midline and hip external rotation levers the foot toward body midline. Assess rotation with the hip extended with the child lying prone on the examination table and the knees flexed to 90 degrees. Rotate at hip. When feet are brought toward and past each other, the hips are in external rotation. When the feet are brought away from midline, the hips are in internal rotation. -Abduction/adduction: important in toddlers. Developmental dysplasia of the hip (DDH) may have no obvious sign other than limited hip abduction unilaterally and/or bilateral waddling gait. child supine on the table, the knees are brought maximally away from midline both at full hip extension and at 90 degrees' hip flexion. Measure abduction by recording the angle subtended between the midline axis and the femur at the extremes of abduction. Adduction is measured similarly in hip extension but with the knees brought toward and past midline. Conduct a provocative test • Trendelenburg sign: Intra-articular hip pathology induces weakness in hip abduction. Hip abduction raises the joint reactive forces across the painful hip, and is avoided. Weakness -when the patient stands on the ipsilateral lower limb. positive Trendelenburg sign - contralateral pelvis dropping below level, or the patient leaning over the painful hip for balance. Compare side to side. Single-leg stance on the normal hip with normal abductor strength will maintain a level pelvis. • Barlow provocative test: screen an infant (0-3 months of age) for DDH. infant supine on a firm surface and calm, flex the both hips to 90 degrees (thighs will be perpendicular to the trunk if the knees are also at 90-degree flexion). Hold the infant's thighs with thumbs medially and fingers laterally. The infant's knees are nested in the examiners first web space. Apply posterior (downward) pressure. A positive Barlow test will yield a clunk sensation as the femoral head subluxes or dislocates from the acetabulum. negative test should yield firm, smooth resistance without yield or clunk. • Ortolani test: DDH screening, infants 0 to 3 months of age. Hold hips as in Barlow, grasping knee between thumb and fingers, place the tip of (second or third digit) finger(s) over the infant's greater trochanters. Abduct hips with the thumbs and simultaneously apply medial and anterior pressure with the long fingers. A positive test will reduce the femoral heads into the acetabulum during abduction. Perform a Knee Examination Observe. overall alignment of the lower limbs. ankles centered under the anterior-superior iliac spines, the patella should be vertically aligned between them. The normal degree of coronal plane angulation across the knee will vary with age. Infants are born with physiologic varus or bow-legged alignment of their lower extremities. This corrects to neutral alignment by 18 to 24 months of age. Maximal valgus, or knock-kneed alignment, is characteristic of 3- to 5-year-olds. Normal adult alignment of 7 degrees of valgus between the tibia and the femur is reached by early school age. Watch the child walk and look for a lateral thrust of the knee, or an opening up of the knee into a more varus position. - bowing is not physiologic. Palpate. Differentiate effusion from generalized swelling by the presence of a fluid wave or by shifting of the area of maximal swelling with variously applied manual pressure over bulging areas of the joint capsule. Tenderness of the knee just proximal to the tibial plateau, at the joint line (laterally or medially), is suggestive of (lateral or medial) meniscal pathology. Prominence or tenderness of the tibial tubercle suggests a diagnosis of Osgood-Schlatter disease Assess. Knee motion ranges from full extension, where the tibia and femur are parallel, to full flexion, where the heel touches the ipsilateral buttocks. To evaluate genu varum (bow legs) or genu valgum (knock knees), the child should be supine on table with the knees and hips extended and adducted until the limbs touch. If the knees touch first, measure the distance between the medial malleoli of the ankles (intermalleolar distance). quantitative measure of clinical valgus. If the ankles approximate first, the distance between the medial femoral condyles (intercondylar distance) is the quantification of genu varum. child can be examined in the parent's lap: Child and parent will be facing examiner with child seated in lap. Hips and knees are flexed 90 degrees with knees facing examiner. If there is internal tibial torsion, feet will cross. If bowing (or valgus) is no longer present, the condition is likely physiologic. To evaluate Q-angle: With the child lying supine, but with the knee flexed 30 degrees, the angle between a line connecting the anterior superior iliac spine and the center of the patella and a line from the center of the patella to the tibial tubercle (the insertion of the patella tendon). This angle is normally 12 degrees with the apex toward the midline. Increases in this angle may be associated with patellofemoral instability.

Family Structure and Roles (book)

composition of the family or household, demographic data, intergenerational data, and information about family roles. the way the family defines itself and how the family gets its work done.

Developmental Problems (book)

long-term issues of development and maturation over the life span. The National Survey of Children's Health estimates that 15.8% of children are at moderate risk for developmental, behavioral, or social delays and another 10.6% are at high risk for similar delays developmental problems can affect a child's entire future if not remedied or managed to minimize their effects. Clinicians assess for developmental problems in the areas of gross motor, fine motor, speech and language, cognitive, social/emotional, and adaptive behaviors. Developmental surveillance is considered integral to every pediatrics visit developmental assessments were completed for only 57% of children ages 10 to 35 months. does not change the length of visits and increases parental reports so that they discussed more developmental concerns and had their questions answered. Significant increases in developmental screening and parent reports of quality of care occurred in practices in which extra education related to development was given to providers and additional systems to promote childhood development were instituted Zero to Three has developed a taxonomy of developmental diagnoses

The Episodic History (book)

specific problems. chief complaint with symptom analysis and history of present illness The other areas of the history should be updated since data were last collected. Always listen for emerging problems and developmental progress.

Communication with Children and Families (book)

three elements essential to excellent communication are as follows: • Communication needs to provide information. • Communication should be sensitive interpersonally, with affective behaviors indicating the provider's attention to and interest in the parents' and child's feelings and concerns. • Communication should help to build a partnership among the three parties, allowing discussion of concerns, perspectives, and suggestions from all. drug use, alcohol consumption, and smoking addressed with mothers, parent- provider relationships were positively affected discussion of maternal stress also results in greater maternal satisfaction with care addressed by last names, shake hands with the provider, and have the provider introduce himself or herself When the script is to be varied (no immunizations this visit), alert them to the change with cues and explanations for the new experiences of this visit and the likelihood that the new script will be repeated at future visits. It might not be practical for data to be fully collected on the first visit; the collection can be staged according to the visit priorities. When time with patients is limited, it is common to ask new families to come early for their first appointment to complete a written history before meeting the clinician. Notation of any missing data should be made so that further baseline data can be collected at the next visit. interpreter services must be available if the clinician and family are not fluent in each other's languages. These services are mandated by law. Use of family members as interpreters is not recommended. Family members may try to protect the patient by hiding important information. Legally, the provider may be at risk if information was not transmitted correctly or completely either to or from the clinician

When and How Should You Measure Blood Pressure? (bright futures)

When to Measure younger than 3 years: ` History of prematurity, low birth weight, care in the neonatal intensive care unit ` Congenital heart disease ` Renal or urologic disease ` Family history of congenital renal disease ` Solid-organ or bone marrow transplant ` History of malignancy ` Treatment with drugs known to raise BP ` Any systemic illness associated with hypertension ` Elevated intracranial pressure • older than 3 years: BP routinely measured. How to Measure • Position the child. ` sitting quietly for 5 minutes prior to taking BP ` Back supported with feet on floor ` Right arm supported with cubital fossa at heart level • Use the appropriate cuff size. ` Inflatable bladder width should be at least 40% of the arm circumference at the midpoint between the olecranon and acromion. ` Cuff bladder length should cover 80% to 100% of the arm circumference. ` If a cuff is too small, use the next largest cuff, even if it appears too large. Take the measurement. ` If possible, use the right arm - measurement consistent with national norms and prevent confusion with the effects of potential coarctation. ` Place stethoscope over brachial artery pulse, proximal and medial to the cubital fossa, below the bottom edge of the cuff. ` Consider using the bell of the stethoscope; it may allow softer Korotkoff sounds to be heard. ` Determine the systolic BP by the onset of Korotkoff sounds (K1). ` Determine the diastolic BP by the disappearance of Korotkoff sounds (K5). ` In some children, Korotkoff sounds can be heard all the way to 0. In this situation, repeat the BP with less pressure on the stethoscope head. ` If Korotkoff sounds still go to 0, then record muffling of the Korotkoff sounds (K4) as the diastolic BP.

Avoiding Diagnostic Errors (book)

To assist with reliability, consider the following techniques: test-retest, interrater reliability, and internal consistency. • Testretest: Ask the question again later. Take a blood pressure reading twice. Look for the physical finding a second time a bit later. • Interrater reliability: Ask someone else to listen, palpate, and so on for the same finding. Does someone else get the same answer to the same question you asked? • Internal consistency: Look for a logical consistency to the findings obtained. If something is "out of sync," question it. If there is significant variation, consider a measuring error before looking for a health problem that has altered growth. Does the history support the physical findings? Does the story keep changing? Algorithms, computer algorithms, protocols, and flowsheets can improve the consistency and reliability of the data collected, especially when several staff members are involved with the data for a given patient. To assess the validity, or meaning, of data collected, the provider should consider sources of error: • Do the cumulative data fit and support a given diagnosis? If not, perhaps the diagnosis was inadequate or an error in data collection, sequencing, or interpretation occurred. Providers constantly need to attend to age, sex, race, culture, and other issues when they consider data. • Was the diagnosis made on the basis of one isolated finding or a cluster? • Sometimes two problems occur with overlapping findings. One problem might be missed, whereas the other is pursued. • The patient might change the data provided because of stress or worry about the outcomes of the assessment visit. Both findings and their meaning to patients need to be explored with the patient and family. • Provider expectations can also threaten accurate diagnosing. • Were cues missed or questions unasked? • Data are often compared with specific criteria (e.g., heights and weights for age are known, developmental milestones are established, laboratory norms are set for children of different ages). Which test has been used? What is its specificity and sensitivity? Is the right criterion being used? • Were all data such as laboratory studies reviewed promptly?

Comprehensive vs Focused Exam** (Bates)

patients you are seeing for the first time in the office - comprehensive assessment - includes all elements of health history and complete physical examination. flexible focused or problem-oriented assessment for patients you know well who are returning for routine office care or for patients with specific "urgent care" concerns like sore throat or knee pain. adjust the scope of history and physical to the situation at hand, keeping in mind: the magnitude and severity of the patient's problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available

What Should You Do With the EEC Results? (bright futures)

refer children for further evaluation by a dentist comfortable with young children. • Make an urgent dental referral for: -any young child with oral or dental symptoms, including stimulated or unstimulated pain, particularly if the child awakens at night with apparent dental pain. • any intraoral or extraoral swelling that you suspect is of dental origin. • any young child with dental discoloration, developmental irregularity, soft tissue lesion, malocclusion, or evidence of oral trauma. For other children, counsel parents to establish a dental home at the time of the first tooth or first birthday. Ensure referral of all children older than age 1 for routine dental care. Prioritize those children whose parents report a history of problems with tooth decay in themselves or their other children.

How to Apply Fluoride Varnish (bright futures)

not a substitute for fluoridated water, toothpaste, or sealants, but it can decrease tooth decay rates by as much as 38%. Varnish applications are most effective if done 4 times per year, after the first primary tooth erupts for high-risk children. Pediatricians should consider applying fluoride varnish for patients at risk for caries during well-child visits between 6 months and until the patient is able to access a dental home. Supplies needed Gloves Wipes Light source Varnish packets Technique • Position the patient on the lap of the parent/guardian (facing the parent/guardian) with legs wrapped around parent/guardian's waist, or on an examination table, or sitting on caregiver's lap • Sit with your knees touching knees of parent/guardian. •If possible, have a medical assistant, older sibling, or other parent/guardian hold the light source (your otoscope light will work fine) directed toward the mouth; other options include a well-positioned goose neck lamp or head light lamp. • Have supplies ready to go and gloves on. • Have the parent/guardian drop the patient's head back onto your lap and have them hold the child's hands. • Open the varnish packet; consider brushing most of the material on the non-dominant glove to retrieve quickly. • Wipe the teeth with 2 x 2 gauze; do 1 quadrant at a time if applying to more than 12 teeth. • Quickly brush the varnish on all tooth surfaces. Varnish dries almost instantly on contact with saliva, so there is very low risk of toxicity from swallowing. Have the parent/guardian pull the child back up into a sitting position. • Give the child something cold to drink; it will help set up the varnish. Instructions after No brushing until the following morning. Depending on the brand of fluoride varnish, there may be a slight temporary discoloration of the teeth; it will go away in 2 to 3 days due to brushing and eating. The teeth will return to their natural color.

Parenting Issues for Different Family Structures (book)

composition and structure of the family, socioeconomic status, and health status, have the potential to influence the health and well-being of children and adolescents in significant ways. Some of these family structures and family issues include: • Two-parent families • Working parents and child care • Poverty and families • Single-parent families • Displaced and homeless families • Blended families • Adolescent parents • Gay and lesbian parent families • Adoptive parent families • Grandparents raising grandchildren • Foster parent families • Families raising children with special needs Multiple births Premature infants Children with special needs

Periodicity Schedule (AAP)

https://www.aap.org/en-us/Documents/periodicity_schedule.pdf Hearing: "Screen with audiometry including 6,000 and 8,000 Hz high frequencies once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. Psychosocial/Behavioral: "This assessment should be family centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health Depression Screen: Adolescent depression screening begins routinely at 12 years of age Maternal Depression Screen: Screening for maternal depression at 1-, 2-, 4-, and 6-month visits Newborn bilirubin: Screening for bilirubin concentration at the newborn visit has been added Dyslipidemia: Screening for dyslipidemia has been updated to occur once between 9 and 11 years of age, and once between 17 and 21 years of age HIV: Screening for HIV has been updated to occur once between 15 and 18 years of age. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually. Oral Health: Assessing for a dental home has been updated to occur at the 12-month and 18-month through 6-year visits. A subheading has been added for fluoride supplementation, with a recommendation from the 6-month through 12-month and 18-month through 16-year visits. "Assess whether the child has a dental home. If no dental home is identified, perform a risk assessment and refer to dental home. Recommend brushing with fluoride toothpaste in the proper dosage for age If primary water source is deficient in fluoride, consider oral fluoride supplementation Head Circum: newborn - 24 months Weight for Length: newborn - 18 months BP: >3 years - unless illness BMI: starts at 24 months Developmental: 9, 18, 30 months Autism Screen: 18 & 24 mo Tobacco, Alcohol, drugs: >11 years

Comprehensive Family Assessment Models

These models provide ways to organize family assessment material. They can provide a database characterized by both breadth and depth. • Calgary Family Assessment Model (CFAM) Family Health Assessment Form Family Assessment Screening Tool This screening tool is quick to administer (5 minutes) and provides an overview assessment of family functioning. • Family Apgar Family Functioning Tools These tools vary in length and complexity, but all are easy to score and provide in-depth data about family functioning. • Family Adaptability and Cohesion Evaluation Scale (FACES IV) • Family Environment Scale (FES) • Feetham Family Functioning Survey (FFFS) Family Stress and Coping Tools These tools provide clinicians with information about how families define and manage stress. They can be used to help families self- diagnose their strengths and identify areas needing modification. • Assessing adolescent stress: Adolescent-Family Inventory of Life Events and Changes (A-FILE) • Family Inventory of Life Events (FILE) • Family Coping Strategies (F-COPES)

The Psychosocial Problem History (book)

collected in the functional health pattern domain database and Family Database section t 1. Use good communication skills—listen. Nonjudgmental approach. Seek a balanced give and take of information. 2. Interview the child or adolescent alone and with parents. Time alone with the preschooler may be used for play or drawing. 3. Have questionnaires or checklists from parents, teachers, and childcare workers available. Use the information in the interview. 4. Be alert to emotional tone and interactions among family members. 5. Review the context for the concern: • Information about parents and family members: illnesses, mental health problems, poverty, employment, violence, social isolation • Information about the child: school, peer relationships, temperament, neglect or abuse history, foster home placements, losses • Information about child-parent relationships: attachment disorder, unrealistic expectations, poor family communication, lack of knowledge of child development and appropriate parenting 6. The history of present illness becomes an amalgam of information from the multiple sources—child, parents, others. Do not assume that both parents have the same views of the issues. 7. Remember that the interview itself may be therapeutic. For adolescents, the HEEADSSS (home, education and employment, eating, activities, drugs, depression, sexuality, suicide, and safety) method

Family Life Cycle (book)

data on the present family life cycle stage (such as a family with young children), family life cycle transitions or developmental crises (such as serious illness of a frail, elderly grandparent), and family life cycle events that are untimely or "out of sync" (such as the terminal illness of a young wife and mother).

Functional Health Problems (book)

derived from Gordon's functional health patterns and are incorporated into the international taxonomy of nursing diagnoses These patterns represent the universal health behavior patterns of all humans, regardless of culture, sex, age, or economic status. Gordon's 11 patterns include health beliefs and behavior, nutrition, elimination, activity, sleep, role relationships, coping, self-perception, cognition and perception, sexuality, and values and beliefs. NPs and other providers become involved when the family's knowledge and experience are insufficient to meet the needs of the child or when the family directly contributes to the child's problems as with the role-relationship problem of child abuse.

Health History: Adolescents (bates)

interview focuses on them rather than on their problems. start with specific questions to build trust and rapport and get the conversation going. Chat informally about friends, school, hobbies, and family. Using silence in an attempt to get adolescents to talk or asking about feelings directly is usually not a good idea. It is particularly important to use summarization and transitional statements and to explain what you are going to do during the physical examination. Once you have established rapport, return to more open-ended questions. ask what concerns or questions the adolescent may have. often reluctant to ask their most important questions (which are sometimes about sensitive topics), ask if the adolescent has anything else to discuss. Adolescents' behavior is related to their developmental stage, and not to chronologic age or physical maturation. Explain to both parents and adolescents that the best health care allows adolescents some degree of independence and confidentiality. It helps if the clinician starts asking the parent to leave the room for part of the interview when the child is age 10 or 11 years. This prepares both parents and teens for future visits when the patient spends time alone with the clinician. Before the parent leaves, obtain relevant medical history from him or her, such as certain elements of past history, and clarify the parent's agenda for the visit. Adolescents need to know that you will hold in confidence what they discuss with you. never make confidentiality unlimited. Always state explicitly that you may need to act on information that makes you concerned about safety An important goal is to help adolescents bring their concerns or questions to their parents. discuss sensitive issues with their parents and offer to be present or help. modesty is important. The patient should remain dressed until the examination begins. Leave the room while the patient puts on a gown. Most adolescents older than 13 years prefer to be examined without a parent in the room, but this depends on the patient's developmental level, familiarity with the examiner, relationship with the parent, and culture. Ask younger adolescents and their parent their preferences. The sequence and content of the physical examination of the adolescent are similar to those in the adult. Keep in mind, however, issues unique to adolescents, such as puberty, growth, development, family and peer relationships, sexuality, decision making, and high-risk behaviors.

Family Assessment Basic Elements (book)

requires attention to family structure, family life cycle stage, family functioning, and social network. addresses characteristics of the family, transitions that the family is experiencing, how family members interact and get things done, what they believe and value, and how they interact with the community. providers' own definitions of family and healthy family functioning are culturally and temporally bound, determine who is and who is not family, and can profoundly affect assessment, treatment, and outcomes. "a self-identified group of two or more individuals whose association is characterized by special terms, who may or may not be related by bloodlines or law, but who function in such a way that they consider themselves to be a family."

What Should You Do With an Abnormal Sports Physical Result? (bright futures)

results will lead to 1 of 3 categories for sports participation: cleared, not cleared, and in need of further evaluation. result from an injury (eg, a fracture or recent surgery) or medical condition (infectious mononucleosis or concussion). a coordinated approach with the team coach, family, and athlete. document: The patient's health record and school forms need to indicate the student's participation or restrictions.

General guidelines for infant visit

distraction and play to examine infant - infants pay attention to one thing at a time, easy to distract infant from examination. use a moving object, a flashing light, a game of peek-a-boo, tickling, or any sort of noise Approach the infant gradually, using a toy or object for distraction. Perform much of the examination with the infant in the parent's lap. - tired, hungry, or ill, ask the parent to hold the baby against the parent's chest. Speak softly to the infant or mimic the infant's sounds to attract attention. If the infant is cranky, make sure he or she is well fed before proceeding. Ask a parent about the infant's strengths to elicit useful developmental and parenting information. Don't expect to do a head-to-toe exam in a specific order. Take what the infant gives you and save the mouth and ear exam for last. Make sure appropriate toys, a blanket, or other familiar objects are nearby. Many neurologic conditions can be diagnosed during this general part of the exam. hypotonia, conditions associated with irritability or signs of cerebral palsy Close observation of an awake infant sitting on the parent's lap can reveal hypotonia or hypertonia, conditions with abnormal skin color, jaundice or cyanosis, jitteriness, or respiratory problems. Observe parent-infant interactions. Watch the parent's affect when talking about the infant. Note the parent's manner of holding, moving, dressing, comforting infant. Observation of the infant's communication with the parent can reveal developmental delay, language delay, hearing deficits, or inadequate parental attachment. may identify maladaptive nurturing patterns - maternal depression or inadequate social support. Infants do not object to removing their clothing. To keep yourself and your surroundings dry, leave the diaper in place; remove it only to examine the genitals, rectum, and hips

What Should You Do With an Abnormal Spine, Knee or Hip Result? (bright futures)

hip abnormalities in an infant - Refer the infant for plain films (generally after 4 months of age) of the hips or for ultrasonography (usually done in the first 2-4 months referral to the pediatric orthopedic surgeon Consider skeletal dysplasia in any child with genu varum or valgus deformities who has poor linear growth. If the child is bow legged, and it is getting worse over time, consider rickets (obtain a dietary history; examine wrists for metaphyseal flaring; examine ribs for beading; and obtain radiographs, calcium, phosphorus, alkaline phosphatase, and 25 OH vitamin D). Infantile Blount's disease, or tibia vara, - children who walk early and have an increasing or persistent varus deformity at 2 1/2 years, especially with lateral thrust on weight bearing. This is a radiographic diagnosis and requires consultation from a pediatric orthopedist. Adolescent children may develop Blount's disease. It is often a unilateral disorder in obese children with complaints of knee pain; referral to an orthopedic or pediatric orthopedic surgeon is recommended. Genu valgum - Use laboratory studies to rule out renal osteodystrophy and rickets. Use radiographs to rule out tumors, fractures, and skeletal dysplasias, especially poor linear growth. Refer severe, progressive, or asymmetric genu valgum to an orthopedic surgeon or pediatric orthopedist for evaluation.

Development Database - Adolescents (book)

A Motor Development 1. All teens should be active and skilled in a variety of physical activities and sports. 2. Fine motor development should also be mature. Special arts or crafts or occupational activities may be learned. B Cognitive Development 1. Early adolescents are still concrete and generally present rather than future oriented. Questions can be answered quite literally. 2. Middle adolescents can use and understand if-then statements. They are able to understand long-term consequences and think of the future. They might challenge many ideas and rules with their newfound skills in logic and reasoning. 3. Late adolescents are able to consider options before making decisions, engage in sophisticated moral reasoning, and use principles to guide their decisions. C Social Development 1. Early adolescents are egocentric in thinking. They can vacillate between childish and mature behavior, especially around their parents. Their peers are usually of the same sex. Group activities are the norm. 2. Middle adolescents are concerned with their identity within society and less concerned with their sexual identity unless they are struggling with recognizing their homosexuality. They tend to distance themselves from parents, spend less time at home, and increasingly challenge parental control. Cliques or friends prevail, with only a few close friends. Physical intimacy can occur during this stage, and romantic partners are common. 3. Late adolescents have distanced themselves from parents and then reestablished relationships with family on a new basis of independence. Romantic and emotional intimacy appears. D School and Vocational Development 1. Early adolescents are usually adjusting to the expectations of middle school. Setting priorities and completing homework independently can be a challenge. Future goals are often unrealistic and change frequently. 2. Middle adolescents are entering high school and beginning to develop an awareness that their performance in school will affect their future options for work or college. They do not usually have specific ideas about future vocations in mind. 3. Late adolescents are making decisions about vocations, college, working, or entering the military.

Older Kids Assessment Lecture

Always listen under shirt - or "I'm going to lift up your shirt" Sore throat - look in throat first. Strep 20% chance, 80% viral. Look at tonsils - tend to have big tonsils bigger than adults - can't tell if it's strep or not by looking. Infant may or may not need tongue blade - try not Eyes and ears - pull it till you can see. Don't go in too far bc once you hurt not going back in Check lymph nodes - esp adolescents - Hodgkin lymphoma. Mono - lymph nodes in the back of neck. Feel scalp for lymph nodes if you want. Describe - bilateral anterior cervical lymph node 1cm mobile, soft, not erythematous, nontender. (If red could be lymphadenitis). Strep - LN 6 months to go back to normal. Eczema - lymph node that doesn't go away. Feel below clavicle. Feels ominous LN - firm, non mobile. Matted 3-5 together. Hard fixed greater 1cm nontender. Arm pit Trochlea LN - inner elbow area Groin LN - inguinal area Generalized lymphadenopathy - eczema, chronic condition that's causing Feel PMI and heave is a problem. Abdomen pain - leave mcburneys point at last. Show me where it hurts the most. Genitalia - circumcised or not. Make sure no cysts. Joints are not warm, painful or edematous. Juvenile idiopathic arthritis. - elbow, knees and ankles Lyme dz - knees and elbows hurt Reflexes - same as adult, 2-3 start Neuro - same as adult If don't want to take their pants down - write refused. Don't fight them on it. UTI - costal margins. Might touch chest - not percuss or whispered pectriloquy Scolosis - 20% start to worry, as kids get older tend to outgrow. Fix tongue tie as infant. Wait till a year - if 3-4 months old. NPs can snip it. Harriet Lane? Can download for free? Chest when sunken in - excavata. Protrude - caranodim. Pectus - look for heart, no need for surgery except cosmetic - rods in for years. Sternum can be close to spine and they will be okay.

Why Is It Important to Assess Sexual Maturity Stages During the Physical Examination? (bright futures)

Sexual maturity staging is a standard assessment for normal growth and development. Identification of sexual maturity also is important in order to offer appropriate anticipatory guidance and to recognize problems related to pubertal abnormalities that need referral. early puberty - problems coping with the physical and hormonal changes of puberty. Girls - early menses and boys - excessive libido. Early and rapidly progressive precocious puberty can sometimes result in adult short stature. Most cases of precocious puberty are idiopathic, but occasionally boys or girls with precocious puberty have intracranial abnormalities or adrenal or gonadal conditions that require intervention. delayed puberty - may require intervention. These constitutional delayed puberty, often a positive family history. acquired gonadal failure, gonadal dysgenesis due to Turner syndrome, isolated gonadotropin deficiency, or decreased body fat due to exercise (particularly swimming, gymnastics, and ballet dancing), or anorexia nervosa. studies suggest that the age of onset of puberty is close to 1 year earlier in US girls than 30 years ago. Early puberty may be a marker for environmental exposure to estrogen-like chemicals, known as endocrine disrupters, that may affect the reproductive axis. Several studies suggest that earlier onset of puberty may be associated with being overweight in girls, and late onset may be associated with abnormal thinness or a very high sustained level of physical activity. early-maturing children need close monitoring of their physical and mental health.

What Are the Stages of Sexual Maturity? (bright futures)

based on the work of Marshall and Tanner. Tanner stages. There is no conventionally accepted scale for axillary hair development. Pubic Hair: Male and Female Pubic Hair Stage 1: Prepubertal. The vellus over the pubis is similar to that on the abdomen. This hair has not yet developed the characteristics of pubic hair. Pubic Hair Stage 2: There is sparse growth of long, slightly pigmented downy hair, straight or only slightly curled, mainly at the base of the penis. Pubic Hair Stage 3: The hair is considerably darker, coarser, and more curled. It is spread sparsely over the pubis. Pubic Hair Stage 4: The hair is adult in type, but the area over which it is present is smaller than in most adults. It has not yet spread to the medial thighs or along the linea alba (in males). Pubic Hair Stage 5: The hair is adult in quality and quantity and has the classical triangular distribution in females. It may spread to the medial surface of the thighs. Breasts: Females Breast Stage 1: There is no development. Only the nipple is elevated. Breast Stage 2: The "breast bud" stage, the areola widens, slightly darkens, and elevates from the rest of the breast. A bud of glandular tissue is palpable below the nipple. Breast Stage 3: The breast and areola further enlarge, presenting a rounded contour. There is no change of contour between the nipple and areola and the rest of the breast. The diameter of breast tissue is still smaller than in a mature breast. Breast Stage 4: The breast continues to grow. The papilla and areola project to form a secondary mound above the rest of the breast. Breast Stage 5: The mature adult stage. The secondary mound disappears. Some females never progress to Stage 5. Genitals: Males Genital Stage 1: Prepubertal. Penis, testes, and scrotum are about the same size and proportions as in early childhood. take into account whether the penis is uncircumsized when assessing penile growth, as the uncircumsized penis may appear larger than it really is. Genital Stage 2: Only the testes and scrotum have begun to enlarge from the early childhood size. The penis is still prepubertal in appearance. The texture of the scrotal skin is beginning to become thinner and the skin appears redder due to increased vascularization. Genital Stage 3: There is further growth of the testes and scrotum. The penis is also beginning to grow, mainly in length with some increase in breadth. It can be difficult to distinguish between Stages 2 and 3. Genital Stage 4: The penis enlarges further in length and breadth and the glans becomes more prominent. The testes and scrotum are larger. There is further darkening of the scrotal skin. Genital Stage 5: The penis, testes, and scrotum are adult in size and shape.

Assessing Older Children (Bates)

few difficulties. Many children at this age are modest. Providing gowns and leaving underwear in place as long as possible are wise approaches. Suggest that children disrobe behind a curtain. Consider leaving the room while they change with parents' help. Some children may prefer opposite-sex siblings to leave, but most prefer a parent of either sex to remain in the room. Parents of children younger than 11 years should stay with them. Refer to the child by name rather than by "him" or "her." Clarify the role or relationship of all of the adults and children. Ask children about their clothes, one of their toys, what book or TV show they like, or their adult companion in an enthusiastic but gentle style. Spending time at the beginning of the interview to calm and connect with an anxious child A child may be able to sit still or may get restless and start fidgeting. Watch how the parents set, or fail to set, limits when needed. Family members who are not present (e.g., the absent parent or grandparent) may also have concerns. Ask about those concerns, too. "If Suzie's father were here today, what questions or concerns would he have?" A good strategy is to view the parents as experts in the care of their child and yourself as their consultant. Statements acknowledging the hard work of parenting and praising successes are always appreciated.

Comprehensive, Episodic and Emergency Histories (Blackboard)

history - important component of assessment of child. guides your physical assessment, management, and education of child and family. Comprehensive history - used when a child and family are evaluated during a initial visit. You should include in visit: - Identifying data - name, age, date of birth - Chief complaint - History of present illness - Past medical history- this includes illnesses, hospitalizations, surgeries - Family history -Genetic History -Social history - Developmental Data - Nutritional assessment - Review of systems Episodic history - used when a child returns for a follow up or return visit. need to consider the amount of time since the last visit. need to update health history, family history, and social history. note growth and developmental progression of the child. guide you in developing your focus of the assessment, management, and education of child and family. Emergency History - used when child presents with a specific problem. focus of history should be directed towards the chief complaint. Questions should be problem specific. Once this history is elicited, consider other areas to expand parts of a comprehensive history. not to rush when obtaining the history. Never assume that all of the pertinent information from the child/family has been elicited. During the visit, try to maintain a relaxed and open manner to encourage the child/parent to provide me with the necessary information for assessment, management, and education. follow up the visit with a phone call the next day, although this might be time consuming it is an excellent opportunity for the parent to ask you questions and for you to re-enforce your plan of care.

Family Database (book)

identify basic family, daycare, school, work, or community agency factors that form the context of the child's life and need to be considered in planning care. impaired communication among family members, social isolation, family violence, impaired parents, alterations in parenting, caregiver role strain obtained using a genogram and/or ecomap format mothers preferred to answer domestic violence questions away from the children Family Composition and Structure who makes up the family as the family defines it. Who lives in the home—family and others? How are they related? What is the meaning of the family structure to the child? does the child feel like a member of the family—cared for and supported? Does the family feel whole or is it missing members from the child's or another's point of view? Current Family Situation Understanding changes that the family is facing and where they are in the family life cycle Are there family problems that put the family at risk—"out of sync" issues, such as a seriously ill parent, young teen parent, or grandparenting by an ill elder? Extended Family Context used when the clinical picture includes conflicting information or when the effectiveness of a prevention activity is a concern. Demographic Data dates of birth, death, adoption, marriage, separation, divorce, significant illness, and major family events; culture and ethnicity; religion; education; and occupations. Historical Perspective timing and repetition of significant family events or behavior in a family's intergenerational history. years of conflict in Iraq and Afghanistan, Immigration, voluntary or forced, Natural disasters such as floods, hurricanes, and droughts Family Relationships and Roles understanding how parents make decisions and solve problems can be useful in helping parents improve health promotion practices or to recognize the positive actions they take with their families. • Primary caregiver? Who helps? Stresses of caregiver: is the caregiver well both physically and emotionally? • Does anyone require more attention from the primary caregiver than the patient? • How much time do parents and child spend in the home together? • How are family decisions made? How are arguments worked out? • What is the relationship between caregiver and partner? • Do the family members consider household relationships to provide a safe environment for all? Family Social and Community Network What community resources and family support systems are used? What agencies work with this child and family? Where does the child go for daycare, school, work (teens), and what is the quality of each setting? Family Environment and Resources What is the home environment: apartment, home, or farm? Fenced yard or perceived unsafe neighborhood? Family financial resources: health insurance, money for necessities? What are the sources of money for the family—jobs or government assistance? Family stresses over resources and home environment?

Family Functioning (book)

Terkelsen called the "good-enough family" the majority of families are able to meet most of their members' needs most of the time. a hopeful stance, one that allows for the less than perfect family to feel successful and empowered. Family resilience is a helpful concept referring to healthy family functioning Characteristics of healthy family functioning: Open communication, mutual respect and support, differentiation, shared problem-solving, shared decision-making, flexibility, enhancement of members' personal growth, sense of play and humor, and a shared value of service to others are some of these assets AAP states that a child will thrive best when cared for by two mutually committed parents who respect and support each other, who have adequate social and financial resources, and who both are actively engaged in the child's upbringing. Characteristics of the successful family: cohesive, enduring, and mutually appreciative. communicate effectively and often, adapt to changing circumstances, spend time together, are committed to the family, and embrace a common religious or spiritual orientation Protective factors for family resilience include individual factors: internal locus of control, emotional regulation, effective coping skills family factors: structure, stable partner relations, cohesion, social support, and adequate income, supportive community factors: community involvement, peer acceptance, supportive mentors, a safe neighborhood; and access to quality school, daycare, and health care

Why Is It Important to Assess Growth and Nutrition During the Physical Examination? (bright futures)

Accurate and reliable physical measures are used to monitor the growth of an individual, detect growth abnormalities, monitor nutritional status, and track the effects of medical or nutritional intervention. Growth measurements correlate directly to nutritional status, indicate whether a child's health and well-being are at risk. may be familial patterns but may indicate medical problems abnormal linear growth or poor weight gain - malnutrition, chronic illness, psychosocial deprivation, hormonal disorders, or syndromes with dwarfism. Calculating and tracking BMI provides vital information about weight status and risk of overweight and obesity. Obesity -> immediate and long-term adverse health and psychosocial outcomes, health problems in as many as 50% of US children. assoc with increased blood pressure, total cholesterol, low-density lipoprotein cholesterol, and triglycerides and low levels of high-density lipoprotein cholesterol. Measuring head circumference, especially within the first 3 years, may identify neurologic abnormalities as well as malnutrition. hydrocephalous, slowed head growth - Rett syndrome.

What Should You Do With an Abnormal Result? (bright futures)

Stature • Children who fall off their height curves (decline in stature/length percentiles or present with extreme short stature) - evaluations for underlying medical problems. • measurements - accurate, make sense, and appropriately plotted. Calculate mean parental height and plot. ` Mean parental height calculation: Add parental heights and subtract 5 inches for a girl (from Dad's height) or add 5 inches (to Mom's height) for a boy, and then divide that entire number by 2. ` If the child is short, but mean parental height falls in the same percentile, the child may have familial short stature. ` If the parents entered puberty late and the child is short and prepubertal at a time when most children are in puberty, he or she may have constitutional delay. followed closely and evaluated or referred to an appropriate specialist. • assess for endocrinopathies, pubertal delay, boney dysplasias, or syndromes. Pubertal delays - genetic/familial or due to an underlying medical condition Weight/BMI • Drop in weight percentiles by more than one large percentile or presentation with extreme underweight may warrant further investigation. • medical conditions with weight loss or fall off weight growth curves - malabsorption, renal disease, cardiac disorders, neurologic and pulmonary disorders, food or feeding abnormalities, family or environmental difficulties, and chronic infections. -Workup, potential referral Head Circumference abnormal head size: • assess pattern of head growth. assess onset of abnormal head size. •Inspect and palpate skull. • Compare head circumference with other growth parameters. • Observe for the presence or absence of dysmorphic features. • Note the presence or absence of congenital abnormalities involving other organ systems. • Measure the head sizes of first-degree relatives. • Conduct neurologic and developmental assessments that may: ` Reveal asymmetries ` Abnormalities in muscle tone, posture, strength, and reflexes ` Generalized psychomotor retardation ` Motor delays ` Speech or language and cognitive impairments ` Autistic features • Assess for signs and symptoms of increased intracranial pressure.