Case 3: Well Child Visit

Front 1

3 year old health maintenance visit

Back 1

• Social
  
• Nutrition
  
• Exercise
  
• Toilet training
  
• Dental
  
• Safety
  

Front 2

Why evaluate social history?

Back 2

• factor of development
  
• family context
  
• changes and family stressors
  

Front 3

What to evaluate for nutrition?

Back 3

• often preschoolers suffer poor nutrition
  
• calc and vit D deficiencies common
  
• vit D supplementation for all children
  

Front 4

What to evaluate for exercise?

Back 4

supervised outdoor physical activity

quality play environments

positive effect on prevention of obesity

Front 5

What to do for toilet training?

Back 5

not too worrisome if child not toilet trained by 3, but may preclude attendance at childcare or preschool

Front 6

Dental screens?

Back 6

seen by dentist within 6 months of first tooth eruption or by one year of age

Front 7

Safety?

Back 7

• toddlers older than 24 or who have outgrown weight and height limits on car seats should be in forward facing car seat in car's rear seat
  
• stay in booster until 142 cm
  
• injuries major morbidity
  

Front 8

3 year old

Back 8

brushes teeth, feeds self, 2-3 word sentences, knows name and use of cup, ball, spoon and crayon, tower of 6-8 cubes, rides tricycle

Front 9

4 year old

Back 9

knows gender and age, friendly, fantasy play, names colours, draws person with three parts, hops on one foot, balances for 2 seconds, pours, cuts mashes own food, brushes teeth

Front 10

5 year old

Back 10

listens, tell difference between real and make believe, sympathy

articulates well, simple story, counts to 10, person with more than 6 body parts, balances on one foot, hops and skips, ties knot, undresses/dresses

Front 11

Excema

Back 11

itch that rashes

irritation leads to scratch to rash

Front 12

eczema differential diagnosis

Back 12

psoriasis

seborrhea

Front 13

psoriasis, guttate precipitated by infection

Back 13

j

Front 14

seborrhea

Back 14

early infancy, cradle cap

Front 15

treating eczema

Back 15

protect skin with lubrication

use anti infalammatories in short bursts

treat associated skin infections aggressively

Front 16

pharm treatment

Back 16

hydrocortisone, topical, high conc for severe flares, low for minor bouts

antihistamines can help with itch, non-sedating (e.g. loratidine and cetirizine

Front 17

Risk of high amount of milk or juice

Back 17

dental caries

Front 18

Risk of food rewards

Back 18

promote obesity

Front 19

important causes of injury in childhood?

Back 19

• car accidents
  
• swimming pools
  
• falls
  
• firearms
  
• poisoning
  
• fires
  

Front 20

How many parents who own guns give specific instruction to their children?

Back 20

40%

only 12% of parents who owned guns actually locked them

Front 21

Risk factors for lead poisoning?

Back 21

• young age, exploring environment by mouthing objects
  
• at risk house
  
• not born in US
  

Front 22

How common is iron deficiency anemia?

Back 22

low iron stores in 35% of low income children (7%) of other preschoolers

up to 10% have iron deficiency anemia

Front 23

association between iron deficiency anemia and low cognitive scores?

Back 23

unclear why, but iron is a co-catalyst in CNS processes

Front 24

Causes of iron deficiency anemia

Back 24

lack of iron intake

chronic GI blood loss

Front 25

Therapy to treat iron deficiency anemia?

Back 25

trial or iron (vs. further workup)

Front 26

Other causes of anemia?

Back 26

• Alpha thal
  
• G6PD
  
• Sickle cell disease
  

Front 27

Rare causes of anemia in children (with severe anemia)

Back 27

• aplastic anemia
  
• hemolytic anemia
  
• vitamin deficiencies
  

Front 28

unusual acquired causes of anemia?

Back 28

chronic or severe illnesses including

• collagen vascular disease
  
• malig
  
• other
  

Front 29

How to interact with toddler?

Back 29

talk

reassuring calm voice

pleasant

Front 30

How to examin for strabismus

Back 30

hirschberg light reflex

cover/uncover test

Front 31

If physical exam needs to be truncated due to child's behaviour, what to focus on?

Back 31

• neurodevelopment
  
• monitor previously recognized findings
  
• new findings identified by parents
  
• physical problems in preschoolers
  

Front 32

What to look for on HEENT?

Back 32

Mouth: Caries

Ears: Middle ear effusions that may persist after earlier URI and affect hearing

Front 33

What to look for on eye exam?

Back 33

strabismus

Front 34

What to look for on neck exam?

Back 34

An enlarged thyroid is rare in children.Many children have "shotty" nodes

Front 35

What to look for on cardiac exam?

Back 35

Most murmurs will be functional.New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect sometimes areappreciated better in older children

Front 36

What to look for on exam of lungs?

Back 36

Yield likely to be low in a healthy child.May hear subtle wheezing in a child with a history of allergies

Front 37

What to look for on abdo exam?

Back 37

Palpation for organomegaly and masses is appropriate.While the most common mass will be stool, children this age occasionally have an enlarged kidneyor, very rarely, an abdominal tumor such as Wilms' or neuroblastoma.

Front 38

MSK

Back 38

in toeing

Front 39

Genitals

Back 39

hernias are sometimes seen

Front 40

Neurological

Back 40

overall muscle tone, strength, coordination

Front 41

Anemia screening

Back 41

in states, 12 months

Front 42

how to improve toddler eating habits

Back 42

• stop bottle now
  
• limit childs eating to 3 meals and 2 snacks, stop food and drink grazing
  
• no bargaining or cajoling
  
• gradually change diet content