Transcript Well child visit pre

Well child visit
preschool age
Julie M Hurtado, MD
9/10/09
I. Introduction
II. Growth and Development
1. Physical development
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Ht/Wt
Vision/ Hearing
Muscle/ Neuro
Cardio/ Respiratory
GI
2. Psychosocial and Cognitive
III. History and Physical Exam
IV. Screening
V. Anticipatory Guidance
VI. Common Questions
VII. Common Concerns
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Nutrition
Sleep
TV and Internet
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Febrile Illness
AGE
Constipation
URI
VIII. Common Conditions
IX. PREP questions
I. Introduction
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3-5 y/o
Magical period of curiosity and activity
Enormous amount of attention
Period of physical, psychological,
cognitive and emotional changes
II. Growth and Development
• Series of tasks to be master within
certain stages
• Biological changes reflects
developmental changes influenced by
the environment
• Individual variations may be transient
• Early clinical intervention is crucial for
children with dev. delay
1. Physical development
– Gains in Ht and Wt are constant during this
age
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Ht ~7cm (2inch)/year
Wt ~2kg (1lb)/year
HC ~ 2cm (1inch)/year
Boys > Girls
– Adb flattens and body appears slimmer & face
becomes elongated
– Legs grow faster than the trunk/head and
arms
*As the child grows, parents might mistake this for weight loss. Keeping clear
records and growth charts can be reassuring
– Vision
• 3 years ~ 20/40
• 4-5 years ~20/30
• 6-7 years ~20/20
– Teeth:
• By 3 all 20 primary teeth have erupted
– Muscle:
• 3y/o:
– Increase strength and refinement
– Walk with steady gait
– Ride tricycle, walk tiptoe and balance in 1 foot
• 4y/o
– Skip and hop in one foot
– Can catch a ball
• 5y/o
– Skip on alternate feet
– Fine motor: drawing and dressing
– Neurologic Development
• By age 2, complete brain myelinization finalized
• Cognitive, emotional and physical abilities of the
preschooler are related to brain maturation
• Sensory function becomes more developed, and
the awareness of full rectum or bladder
accompanies the ability of control the rectal
sphincter
• As neural growth slowly continues, the child
performs more complex tasks
– Cardiovascular Development
• By the 5th year, the size of the heart has
quadrupled since birth
• The HR decreases to 70-100/min as the myocardium
growths and the energy demand decreases
• Adult levels of pulmonary vascular resistance and
pulmonary arterial pressure are attained before
reaching age 2 years
• Innocent murmur  possible, as the heart gains size
throughout this phase
– Respiratory Development
• The number of alveoli and its associated
structures increases
• Conversely, the RR slows from infancy to approx
20-30 beats/min
• As the diaphragm matures, abdominal
respiratory movements decreases
• By the end of the 5th year, respiratory
movement becomes more diaphragmatic
– Gastrointestinal Development
• By age 5, the GI tract is enzymatically mature,
enabling the child to eat and digest a wide range
of foods
• Anatomically, the stomach is relatively small
• Healthy snacks should be encouraged between
meals to support nutritional requirements
2. Psychosocial and Cognitive
development
– Preschool children deal with the word around
them
– Vocabulary increases from 50-100 words, to
>2000
– The use of language as and expressive tool
increases
– Children understand the inhibitions that
surround them and are able to express
feelings, anger and frustration without acting
out
*Language-delay children exhibit higher rates of tantrums and other
externalizing behavior
– Preschool age corresponds with Piaget’s
preoperational stage of thinking and
egocentrism
– Uses magical thinking to explain the
surrounding word (“the sun goes down because is tired and
needs to sleep”)
– Play activities are increasingly complex and
imaginative
– Increased cooperative play and play that is
governed by rules
III. HYSTORY AND PHYSICAL
EXAMINATION
• Examination room should be
comfortable and safe for children of all
ages
• Wearing a white lab coat might evoke a
fearful response from the pediatric
patient
*Friendly interaction with the parents decreases the child’s anxiety. Use a calm tone
1. History Taking
– A thorough history is essential
– History elements reviewed during annual preschool
visit
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Family psychosocial status
Milestones: Language, Cognitive, Emotional and Spiritual
Elimination habits
Nutritional habits
Medication intake
Sleep habits
Television habits
Dental hygiene
Immunization status
Tuberculosis risk factors
– Preschool child’s need to know continually
what is happening explain each step of
the examination (“I’m going to talk to your mom about how’re
you doing at home. If you have any questions or want to add anything, let us
know”)
– Child as an active participant
– The use of drawing to explain medical
problems
– Vague complains can be use to provide AG
and assure that the child is developing
normally
– Initial visit  prenatal history, pregnancy
illness, medication or drug use, birth history,
neonatal and familial genetic history
– Child’s environment is very important and
should be explained to the caregiver (home
environment, people at home, financial
structure, occupation of caregivers and marital
status)
– Each intake of information should be tailored
to the individual’s needs and parental concerns
– Educational material and resources for
reference should be available as well
2. Physical Examination
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General physical appearance
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Respiratory
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Skin (images)
Head
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Cardiology
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Gastrointestinal
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Genitourinary
– Hearing
– External Canal
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Neurologic
– Teeth hygiene
– Nasal polyps
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Musculoskeletal
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– Ht/Wt
– Size/Shape
– Fontanelles closed
Eyes
– Size/Shape/Equal
– Visual acuity
– Red Reflex
Ears
Nose/Throat
Neck
– Lymph nodes
– Inspection
– Auscultation
– Auscultation
– Hernias/Organ size
– Rectum
– Females: Vagina
– Males: Foreskin/Testicles
– Check for Sexual abuse
– Motor
– Sensory
– Exposure
– Inspection
• General physical appearance
– The child should be examined after the
interview and most development screen is
completed
– Ht and wt should be measured appropriately
and plotted in the growth chart at each visit
– Normal Vs Abnormal variations
*Crossing percentile lines on standardized growth charts between the ages of
3-12 for boys and 3-10 in girls is abnormal and requires further evaluation
– Inaccurate data may lead to wrong
diagnosis of growth abnormality
• Weight with no clothes or shoes
• >3 years, Ht should be done standing without
shoes
• HC not done after age 2 years unless there is a
medical reason to do it
• Staff should be educated about importance of
accurate measures, and if possible, the same
staff members should do the measurements
– Guidelines create impression that child growth is a
continuous process. Growth is discontinuous and
repeated observations of growth parameters are
important
– A single value measurement of growth does not
reflect a pattern of development
– Time is a tool in assessment as both the age of the
child and the presence or absence of significant
clinical findings can be observed and evaluated
over time
*Abnormal growth patterns accompanied by abnormal findings necessitate immediate
evaluation
*Standard Growth curved were developed in 1960’s and 1970’s and deviations does occur
depending on the child’s ethnicity
• Eyes
– Size and shape
– Pupils for symmetry and light reflex
– Conjunctivae and color of sclera
– EOM for any muscle weakness
– Visual acuity with appropriate vision screen
• ENT
– Ears:
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Size, shape and asymmetry
Internally for abnormalities, discharge or inflammation
Posterior for skin infection or mastoid tenderness
Hearing using gross and objective measurements
– If language development is delayed, further eval should be
done
– Nose:
• Size, shape and patency
• Mucosa for dryness and polyps
• FB if chronic nasal discharge
– Mouth:
• Mouth and tongue symmetry
• Teeth for caries, color and gum inflammation
• Chest and Lungs
– Inspection can uncover Pectum excavatum
• Might be visually prominent but lung capacity
not reduced
– Percussion and auscultation
• Rales, ronchi, wheezes and rubs should be
investigated
• Cardiovascular system
– Palpation
• Point of maximum impact
• Thrills or heaves
– Auscultation
• Murmurs or extra-sounds
*Because most congenital heart diseases are discovered before the
preschool period, acquired heart diseases account for the greatest
morbidity and mortality of conditions related to this system during this
period
• Gastrointestinal
– Abdomen should be check for size, shape
and distention
– Inguinal, umbilical and femoral hernias
– Auscultation for BS
– Palpation of organs for size and
abnormalities
• Liver edge may be palpated which is normal
• Palpable spleen is abnormal and should be
investigated
• Genitalia and Rectum
– Female:
• Redness, swelling lesions and discharge
*Persistent foul smelling vaginal needs gynecologic referral to r/o FB or chronic
sexual abuse
– Males:
• Foreskin should be fully retractile by age 3-4 years
• Position of urethral meatus x hypospadias
• Scrotal sac x both testicles and hernias
– Rectal exam Both sexes:
• Fissures, tears, redness and irritation
*Perineal irritation and lichenification may indicate the presence of worms
• Musculoskeletal and Neurologic Systems
– Done throughout the examination, watching
child
– Neurologic examination includes language,
motor and cognitive tasks which are done
during the developmental exam. Vision and
hearing are also assessed
*Socks should be removed to check for feet malformation and hygiene.
Problems could be preventing normal gain and posture
IV. SCREENING
(Health Promotion/Disease Prevention)
• Rhythmicity and daily patterns
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Healthy food choices
Family shares meals
Nighttime rituals
Regularly brushes teeth
• Cognitive Growth
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Limit television to 1-2 hrs/day
Parents talk to child to develop vocabulary
Parents read to child to support language
Parents provide toys that child can use creatively
Parents listen with care and respond actively
Parents allow the child to explore
• Emotional growth
Family manages anger and resolves conflicts
Family shows affection
Child makes choices as appropriate
Parents praise good behavior and accomplishments
Family avoids power struggles
Parents set clear and consistent limits
Child has opportunity to play with other children of the same
age
– Child is provided with transitional objects
– Family uses night-light (Unless shadows increase child's
fears)
– Parents provide reassurance if nightmares occurs
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• Self-care
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Family encourages self-feeding
Parents anticipate child’s interest in genital differences
Parents promote toilet training and hygienic habits
Parents promote physical activities in safe places
Family insists on use of car seat
• Strength and coordination
– Child can exercise big muscles
– Child sings and dances to music
– Parents promote outdoor play opportunities in safe areas
V. ANTICIPATORY GUIDANCE
• Is interactive and occurs throughout
the provider-patient interaction
• Safety is always a priority
• AAP has the TIPP (The Injury
Prevention Program) age-related safety
sheets, that can be given to the parents
TIPP 2-4 years
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Did you know that injuries are the leading cause
of death of children younger than 4 years in
the United States? Most of these injuries
can be prevented.
Often, injuries happen because parents are not
aware of what their children can do.
Children learn fast, and before you know it
your child will be jumping, running, riding a
tricycle, and using tools. Your child is at
special risk for injuries from falls, drowning,
poisons, burns, and car crashes. Your child
doesn't understand dangers or remember
"no" while playing and exploring.
Falls
Because your child's abilities are so great now, he
or she will find an endless variety of
dangerous situations at home and in the
neighborhood.
Your child can fall off play equipment, out of
windows, down stairs, off a bike or tricycle,
and off anything that can be climbed on. Be
sure the surface under play equipment is
soft enough to absorb a fall. Use safety
tested mats or loose-fill materials (shredded
rubber, sand, woodchips, or bark) maintained
to a depth of at least 9 inches underneath
play equipment. Install the protective surface
at least 6 feet (more for swings and slides) in
all directions from the equipment.
Lock the doors to any dangerous areas. Use gates
on stairways and install operable window
guards above the first floor. Fence in the play
yard. If your child has a serious fall or
does not act normally after a fall, call your
doctor.
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Firearm Hazards
Children in homes where guns are present are in more
danger of being shot by themselves, their friends,
or family members than of being injured by an
intruder. It is best to keep all guns out of the
home. If you choose to keep a gun, keep it unloaded
and in a locked place, with ammunition locked
separately. Handguns are especially dangerous.
Ask if the homes where your child visits or is
cared for have guns and how they are stored.
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Poisonings
Your child will be able to open any drawer and climb
anywhere curiosity leads. Your child may swallow
anything he or she finds. Use only household
products and medicines that are absolutely
necessary and keep them safely capped and out of
sight and reach. Keep all products in their original
containers.
If your child does put something poisonous in his or
her mouth, call the Poison Help Line
immediately. Attach the Poison Help Line
number (1-800-222-1222) to your phone. Do
not make your child vomit.
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Burns
The kitchen can be a dangerous place for your child,
especially when you are cooking. If your child is
underfoot, hot liquids, grease, and hot foods can
spill on him or her and cause serious burns. Find
something safe for your child to do while you are
cooking.
Remember that kitchen appliances and other hot
surfaces such as irons, ovens, wall heaters, and
outdoor grills can burn your child long after you
have finished using them. If your child does get
burned, immediately put cold water on the burned
area. Keep the burned area in cold water for a
few minutes to cool it off. Then cover the burn
loosely with a dry bandage or clean cloth. Call
your doctor for all burns. To protect your child
from tap water scalds, the hottest temperature
a the faucet should be no more than 120°F. In
many cases you can adjust your hot water
heater.
Make sure you have a working smoke alarm on every level
of your home, especially in furnace and sleeping
areas. Test the alarms every month. It is best to
use smoke alarms with long-life batteries, but if you
do not, change the batteries at least once a year.
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And Remember Car Safety
Car crashes are the greatest danger
to your child's life and health. The
crushing forces to your child's brain
and body in a collision or sudden stop,
even at low speeds, can cause injuries
or death. To prevent these injuries,
correctly USE a car safety seat
EVERY TIME your child is in the car.
If your child weighs more than the
highest weight allowed by the seat or
if his or her ears come to the top of
the car safety seat, use a belt
positioning booster seat.
The safest place for all children to ride is
in the back seat. In an emergency, if a
child must ride in the front seat, move
the vehicle seat back as far as it can
go, away from the air bag.
Do not allow your child to play or ride a
tricycle in the street. Your child
should play in a fenced yard or
playground. Driveways are also
dangerous. Walk behind your car
before you back out of your driveway
to be sure your child is not behind your
car. You may not see your child through
the rear view mirror.
Remember, the biggest threat to your
child's life and health is an injury.
VI. COMMON QUESTIONS
• 1. My child is inventing imaginary friends
and talking to them. Is this normal?
VI. COMMON QUESTIONS
• 1. My child is inventing imaginary friends
and talking to them. Is this normal?
– Yes, magical thinking accelerates during
preschool years, which allows the child to
role play, develop sexual identity, and
growth emotionally.
– Nightmares and fears of monsters are
common. Calm reassurance that monsters
and dreams are not real usually is adequate
to treat these sleep disturbances
• 2. My child is “showing off” his or her
genitalia and is curious about sex. Is
this normal?
• 2. My child is “showing off” his or her
genitalia and is curious about sex. Is
this normal?
– Yes, The preschool’s mind is ablaze with
fantasy and this is a normal manifestation
– Children should be told that others are not
to touch them in their private areas
• 3. My child doesn’t understand limits to
activities. Does he overstep these limits just to
anger me?
– Caregivers must agree and be united in decision
making concerning their child. The rules must be
consistently enforced. If expectations are made
clear, the child will strive to achieve them
– When reprimanding the child, it’s most important
that parents criticize the deed, but never the
child
– The child is not trying to anger the parents, he’s
testing the parent’s limits
– Preschoolers are learning the boundaries of their
new and challenging word
• 4. When my child misbehaves, should I punish
him?
– When dealing with preschoolers it is especially
important not to delay the consequences of
inappropriate behavior.
– Punishment should be weighed carefully and with
reason. A child should never be spanked or hit.
– Instead, restrictions of privileges often create
positive effects
– Encouraging and rewarding positive behavior can
provide a mechanism to communicate with love.
*The action should be punished, not the child
• 5. My child occasionally wets the bed after he
witnesses a fight between my husband and me.
Is this normal? Should I punish him for these
accidents?
– Family counseling should be part of all plans for
anticipatory guidance
– Children should be never punished for accidents.
Rather, children should learn to understand the
consequences of bed wetting by assisting parents
with the removal of soiled bedding
– Children should be rewarded for dry nights
VII. COMMON CONCERNS
• Nutrition
– The nutritional goal is the child’s satisfactory growth
– From age 2 throughout adolescent only 2% of energy
expenditure is directed toward growth (from ~40% during
infancy)
– Calorie requirements are 70-90 cal/kg/day, including
1.5 gr/kg/day of protein
– Fluid requirements are 100 ml/kg/day for average
activity
– Children are more likely to eat foods they have helped
to prepare
– Important to encourage healthy foods
*Common concern is that the children are not eating enough. If they are
following a steady growth pattern and are eating a healthy diet, they’re
doing OK
– Serving size ~ ½ of adult’s portion
– Child should never be forced to eat
– Mealtime should be in relaxant and pleasant
atmosphere
*Children will eat when they’re hungry.
– 12 million Americans are vegetarians
• Lacto-ova vegetarians consume eggs and dairy
products
• Vegans exclude all animal products
• With proper AG, children can achieve good protein
intake (soybeans, fortified soy milk, tofu, legumes, nuts, seeds and peanut
butter)
• Vit B12 supplementation
• Calcium: dark leafy greens, tofu, and beans
• Sleep
– Essential for child’s healthy growth and development
– Amount of overall sleep and REM sleep decreases while
quiet sleep increases
– By age 4, daytime sleep is not longer needed, and the
child should have a sleep routine
– Nightmares and night terrors can be addressed by
reassuring the child
– New disturbances (frequent night awaking or bedtime difficulties) 
Look for cause (pinworms, hypothyroidism, colic, infections)
– Discourage co-sleeping (X 2-3 more times of night awakening)
*Explore cultural practices and economic situation before
• Television and internet
– Often takes place of imaginative playing
– The amount of TV time peaks during
preschool years (21-30 hrs/week)
– Prosocial TV and Moderate amount of TV
viewing appropriate for age level can be
positive impact (~ 80% of TV is developmentally
inappropriate with ~ 5 acts of violence/hr)
– Violent TV increase aggression in children
– > 5hrs TV/day is associated with obesity
and hypercholesterolemia
– Electronic media may serve as educational
tools, but need to be supervised
– Parents should set limits on television and
electronic media
– In general 2 hrs or less of responsible TV
viewing is acceptable
VIII. COMMON CONDITIONS
• Febrile illness
– Acute viral infections cause most febrile illness.
– Unless extremely high (>41.1 or 106) fever doesn’t
specifically harm the child
– Hydration and antipyretics
• Vomiting and diarrhea (together)
– Usually self-limited AGE
– Assure hydration
*Increase ICP, intestinal obstruction and toxic ingestion should be suspected if sudden
vomiting with no diarrhea
• Constipation
– Cause most of the times is inadequate
water intake, not enough high-residue
foods, disruption of daily habits or painful
anal fissures
• URI’s
– Usually viral
– Symptomatic relief
IX. PREP QUESTIONS
• You are evaluating a 3-year-old
boy because he bangs his head
on his bed before he goes to
sleep. His mother has no other
concerns about his behavior.
There have been no recent
changes in the family or stresses
that she can identify. Physical
examination findings are normal
except for excoriated skin on the
boy's forehead and minimal
ecchymosis.
Of the following, the MOST likely
diagnosis is
a.
Autism
b.
brain injury
c.
childhood depression
d.
global developmental delay
e.
normal variant behavior
• You are evaluating a 3-year-old
boy because he bangs his head
on his bed before he goes to
sleep. His mother has no other
concerns about his behavior.
There have been no recent
changes in the family or stresses
that she can identify. Physical
examination findings are normal
except for excoriated skin on the
boy's forehead and minimal
ecchymosis.
Of the following, the MOST likely
diagnosis is
a.
Autism
b.
brain injury
c.
childhood depression
d.
global developmental delay
e.
normal variant behavior
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You are evaluating a 5-year-old boy
who has cerebral palsy and mental
retardation, is fed through a
gastrostomy tube, and is dependent
for all his care. He will be attending a
full-day program at the school in
which he previously was enrolled. His
parents are divorced, and his mother
is his primary caretaker. She will
begin working while he is in school.
He has a 10-year-old brother with
whom he shares a room and who
alerts his mother when his brother
needs help at night.
Of the following, the concern you are
MOST likely to address is
a.
family stress
b.
need for nursing services during the
night
c.
need for the mother to be available
during school hours
d.
potential for child abuse in school
e.
vulnerability to communicable
diseases
•
You are evaluating a 5-year-old boy
who has cerebral palsy and mental
retardation, is fed through a
gastrostomy tube, and is dependent
for all his care. He will be attending a
full-day program at the school in
which he previously was enrolled. His
parents are divorced, and his mother
is his primary caretaker. She will
begin working while he is in school.
He has a 10-year-old brother with
whom he shares a room and who
alerts his mother when his brother
needs help at night.
Of the following, the concern you are
MOST likely to address is
a.
family stress
b.
need for nursing services during the
night
c.
need for the mother to be available
during school hours
d.
potential for child abuse in school
e.
vulnerability to communicable
diseases
•
A 3-year-old child is rushed to the emergency
department after the mother found her with
an open and empty bottle of acetaminophen.
The mother has no idea how many tablets
were in the bottle. She estimates that no
more than 1 hour has passed since the child
ingested the tablets. The child began to
vomit during the trip to the emergency
department, and has vomited three times
more since her arrival. The child is awake and
alert but clearly unhappy, crying even in her
mother's arms. She appears pale and
diaphoretic. Her heart rate is 110 beats/min,
respiratory rate is 26 breaths/min,
temperature is 98.6°F (37°C), and blood
pressure is 90/60 mm Hg.
a.
an antidote is available, but its use can be
deferred until further information is
gathered
b.
given the short duration since the
ingestion, it will be helpful to administer
syrup of ipecac
c.
multiple episodes of vomiting indicate that
irreversible liver damage already has
occurred
d.
the administration of activated charcoal is
contraindicated in acetaminophen toxicity
Of the following, the MOST appropriate
statement about acetaminophen toxicity is
that
e.
the contents of one bottle of
acetaminophen are not sufficient to cause
life-threatening toxicity in a child
•
A 3-year-old child is rushed to the emergency
department after the mother found her with
an open and empty bottle of acetaminophen.
The mother has no idea how many tablets
were in the bottle. She estimates that no
more than 1 hour has passed since the child
ingested the tablets. The child began to
vomit during the trip to the emergency
department, and has vomited three times
more since her arrival. The child is awake and
alert but clearly unhappy, crying even in her
mother's arms. She appears pale and
diaphoretic. Her heart rate is 110 beats/min,
respiratory rate is 26 breaths/min,
temperature is 98.6°F (37°C), and blood
pressure is 90/60 mm Hg.
a.
an antidote is available, but its use can be
deferred until further information is
gathered
b.
given the short duration since the
ingestion, it will be helpful to administer
syrup of ipecac
c.
multiple episodes of vomiting indicate that
irreversible liver damage already has
occurred
d.
the administration of activated charcoal is
contraindicated in acetaminophen toxicity
Of the following, the MOST appropriate
statement about acetaminophen toxicity is
that
e.
the contents of one bottle of
acetaminophen are not sufficient to cause
life-threatening toxicity in a child
• A 4-year-old-boy presents to your
clinic with anal itching of 2 weeks'
duration. His mother denies
itching in other family members.
Tape applied to his perianal skin
shows oval structures.
Of the following, the most
appropriate management of this
patient is
a.
albendazole administered three
times daily for 7 days
b.
ivermectin administered in a
single dose and repeated in 2
weeks
c.
ketoconazole administered daily
for 7 days
d.
mebendazole administered in a
single dose and repeated in 2
weeks
e.
praziquantel administered three
times in 1 day
• A 4-year-old-boy presents to your
clinic with anal itching of 2 weeks'
duration. His mother denies
itching in other family members.
Tape applied to his perianal skin
shows oval structures.
Of the following, the most
appropriate management of this
patient is
a.
albendazole administered three
times daily for 7 days
b.
ivermectin administered in a
single dose and repeated in 2
weeks
c.
ketoconazole administered daily
for 7 days
d.
mebendazole administered in a
single dose and repeated in 2
weeks
e.
praziquantel administered three
times in 1 day
• The mother of a 4-year-old
otherwise healthy-appearing
boy brings him in for
evaluation because he had
profound generalized body
odor (bromhidrosis) for the
past several days. Upon careful
questioning, the mother
recalls an episode of sneezing
followed by a 3-to 4-day
history of a purulent, bloodtinged nasal discharge.
Of the following, the most
likely cause of the body odor is
a.
allergic rhinitis
b.
epidermolytic hyperkeratosis
c.
nasal foreign body
d.
pachyonychia congenita
e.
premature adrenarche
• The mother of a 4-year-old
otherwise healthy-appearing
boy brings him in for
evaluation because he had
profound generalized body
odor (bromhidrosis) for the
past several days. Upon careful
questioning, the mother
recalls an episode of sneezing
followed by a 3-to 4-day
history of a purulent, bloodtinged nasal discharge.
Of the following, the most
likely cause of the body odor is
a.
allergic rhinitis
b.
epidermolytic hyperkeratosis
c.
nasal foreign body
d.
pachyonychia congenita
e.
premature adrenarche
• A 4-year-old boy presents to your
clinic with a 4-day history of fever.
Over the past 24 hours, he
developed swelling over the left
side of his face, and his left eye is
starting to close. On physical
examination, his temperature is
102°F (38.9°C), and his left cheek
and lower eyelid are swollen
(Item Q140A) but not red or
warm. On oral examination, you
note a severe decay of the second
maxillary molar and elicit pain
when you tap on this tooth.
Of the following, the MOST
appropriate therapy is
a.
b.
c.
d.
e.
Azithromycin
Cefdinir
Cephalexin
Penicillin
trimethoprim-sulfamethoxazole
• A 4-year-old boy presents to your
clinic with a 4-day history of fever.
Over the past 24 hours, he
developed swelling over the left
side of his face, and his left eye is
starting to close. On physical
examination, his temperature is
102°F (38.9°C), and his left cheek
and lower eyelid are swollen
(Item Q140A) but not red or
warm. On oral examination, you
note a severe decay of the second
maxillary molar and elicit pain
when you tap on this tooth.
Of the following, the MOST
appropriate therapy is
a.
b.
c.
d.
e.
Azithromycin
Cefdinir
Cephalexin
Penicillin
trimethoprim-sulfamethoxazole
•
A 4-year-old boy presents with a
history of chronic upper and lower
respiratory tract infections. His
weight is 15 kg (25th percentile),
height is 97 cm (10th percentile),
temperature is 98.1°F (36.8°C), and
pulse oximetry is 96% on room air. On
physical examination, he coughs
intermittently and has mild clubbing.
On nasal examination, you note
purulent rhinorrhea and nasal polyps.
Auscultation of the heart reveals a
regular rate and rhythm, with the
point of maximal impulse displaced
to the right.
Of the following, the MOST likely
diagnosis is
a.
b.
c.
d.
e.
cystic fibrosis
Human immunodeficiency virus
infection
primary ciliary dyskinesia
(Kartagener syndrome)
severe combined
immunodeficiency
X-linked (Bruton)
agammaglobulinemia
•
A 4-year-old boy presents with a
history of chronic upper and lower
respiratory tract infections. His
weight is 15 kg (25th percentile),
height is 97 cm (10th percentile),
temperature is 98.1°F (36.8°C), and
pulse oximetry is 96% on room air. On
physical examination, he coughs
intermittently and has mild clubbing.
On nasal examination, you note
purulent rhinorrhea and nasal polyps.
Auscultation of the heart reveals a
regular rate and rhythm, with the
point of maximal impulse displaced
to the right.
Of the following, the MOST likely
diagnosis is
a.
b.
c.
d.
e.
cystic fibrosis
Human immunodeficiency virus
infection
primary ciliary dyskinesia
(Kartagener syndrome)
severe combined
immunodeficiency
X-linked (Bruton)
agammaglobulinemia
• A 3-year-old girl is brought to
your clinic because her mother
noticed blood in her
underwear that morning. She
has otherwise been doing
well, and she recently has
been toilet trained. Findings
on the physical examination,
including the hymen and
external genitalia, are normal.
There is a small amount of
purulent, bloody discharge at
the vaginal introitus.
Of the following, the MOST
likely cause of her bleeding is
a.
penetrating trauma
b.
precocious puberty
c.
sarcoma botryoides
d.
urethral prolapse
e.
vaginal foreign body
• A 3-year-old girl is brought to
your clinic because her mother
noticed blood in her
underwear that morning. She
has otherwise been doing
well, and she recently has
been toilet trained. Findings
on the physical examination,
including the hymen and
external genitalia, are normal.
There is a small amount of
purulent, bloody discharge at
the vaginal introitus.
Of the following, the MOST
likely cause of her bleeding is
a.
penetrating trauma
b.
precocious puberty
c.
sarcoma botryoides
d.
urethral prolapse
e.
vaginal foreign body
• A 3-year-old child who has a
history of recurrent otitis media
with effusion (OME) in infancy is
brought to the clinic. His mother
is afraid that he has a hearing loss
because he does not talk as much
as his brother did at the same
age. He speaks in three-word
sentences, and you can
understand fewer than 50% of his
words. Results of his physical
examination, including the ears,
are normal.
Of the following, the MOST
appropriate statement regarding
this child's condition is that
a.
b.
c.
d.
e.
even mild conductive hearing
loss could affect his later school
performance without frank
speech delay
OME does not cause conductive
hearing loss severe enough to
cause speech delay
performing hearing screening
solely in response to parental
concern is not recommended
testing air and bone conduction
thresholds in the office will help
you rule out hearing loss
the absence of middle ear fluid
rules out conductive hearing
loss
• A 3-year-old child who has a
history of recurrent otitis media
with effusion (OME) in infancy is
brought to the clinic. His mother
is afraid that he has a hearing loss
because he does not talk as much
as his brother did at the same
age. He speaks in three-word
sentences, and you can
understand fewer than 50% of his
words. Results of his physical
examination, including the ears,
are normal.
Of the following, the MOST
appropriate statement regarding
this child's condition is that
a.
b.
c.
d.
e.
even mild conductive hearing
loss could affect his later school
performance without frank
speech delay
OME does not cause conductive
hearing loss severe enough to
cause speech delay
performing hearing screening
solely in response to parental
concern is not recommended
testing air and bone conduction
thresholds in the office will help
you rule out hearing loss
the absence of middle ear fluid
rules out conductive hearing
loss
Community Resources
• http://www.aap.org
• http://www.healthfinder.org
• http://www.rxlist.com for medication
info
• http://www.wellweb.com for alternative
medicine
• http://www.pbs.com
Thanks!!!!!