Well Child Visits

components of the well child visit
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components of the well child visit
-history
-developmental screening
-physical exam
-anticipatory guidance
-screening tests
-immunizations
Denver Developmental Scale
the _____ _____ _____ is the most used scalethat tracks infancy progression; includes 4 total categoriessocial, fine motor, language, gross motor
2 weeks old
-most important item assessment ofadequate nutrition andgood weight gain
-newborn should be back to birth weight or above
-breast fed babies should be seen at 1 week ld
anticipatory guidance
_____ _____ given at 2 weeks
-avoid prone sleeping position
-safety: car seat (rear facing), water temperature
-cannot spoil baby at this age!
-no passive smoking
give 1st HBV vaccine
at the 2 week check up, which immunization should be administered if not given in the nursery?
2 months
physical exam:
-supine position with same exam as newborn

Denver Developmental:
GM: baby prone lifts head to 45 degrees some to 90 degrees

FM: grasp at objects and lets go

Lan: beginning to vocalize responsively and spontaneously (35%)

PS: smiles responsively (100%)
rolling over
pets immunized
anticipatory guidance at 2 months includes what 2 things?
2 months
immunizations for _____ _____ include:

DTaP
IPV
HBV
HIB
Prevnar 13
Rotavirus
4 months
physical exam:
-supine position as in newborn but parent may need to hold hands (down) during parts of the exam
2 weeks, 2 months, 4 months
which well checks do we see the infant in the supine position during the physical examination?
4 monthsDenver Developmental: GM: *rolls* from *stomach to back* (80%) FM: brings *hands together* (100%) Lan: *laughs* aloud (100%) PS: *smiles spontaneously* (100%)stool may become more formed as solid foods added teething Sx--drooling, biting, crankiness, decreased appetite, low grade temperature?*4 months anticipatory guidance* for parents? (2)4 months -same as the 2 month old vaccines*immunizations* for _____ _____ include: DTaP IPV HBV (if given in a combination vaccine) HIB Prevnar 13 Rotavirus6 monthsphysical exam: -may to do better on *parents lap*earsto examine _____- sit pt across pts lap lying *head on parents chest*; parent holds top of head with one hand and around arms/thorax with the other -6 month visiteyes, mouth, noseto examine _____, _____, _____- pt sits on parents lab with *back to parents chest/abdomen*; parent holds forehead with one hand and around arms/thorax with the otherabdomento examine the _____- infant lays on parents lap parallel to parents legs6 monthsDenver Developmental: GM: *rolls back to stomach*, no head lag, *starts to sit alone* FM: *passes toys* hand to hand (55%) Lan: initiates *speech sounds* (30%) PS: *turns* head from *strangers* (30%)rolling over poison control number outlets burns stairwells walkers*6 months anticipatory guidance* for parents? (6)6 months*immunizations* for _____ _____ include: DTaP IPV (If in a combined vaccine) HBV HIB (depending on the brand used) Prevnar 13 Rotavirus (depending upon the brand used) *Influenza* (may depend upon the time of year)9 monthsDenver Developmental: GM: *sits alone* (100%), *cruises* (holds onto table and cruises along side) (45%) FM: *thumb/finger graps* (70%) Lan: *mama, dada, nonspecific* (75%) PS: plays *repetitive games* (85%)increase cup use safety (stairwells, table cloths, screens on windows, aspiration of sell objects/poisoning)*9 months anticipatory guidance* for parents? (2)Hgb- need to test now to see if *iron stores* from mom have been depleted between 4 and 6 months old; can also wait until 12 month visit*labs* for *9 month olds*?9 months*immunization* for _____ _____ include: -catch up vaccines -influenza if timely12 monthsDenver Developmental: GM: *stands lone BRIEFLY* (70%), walks (50%) FM: bangs 2 cubes together Lan: mama and dada *specifically* (80%) PS: *drinks from a cup* (50%), plays *pat a cake* (85%)crawling_____ implies the *belly* is still on the *floor*creeping_____ refers to *mobility* with the child on *hands and knees* (quadruped)causing_____ refers to *standing with 2 handed support* on stationary objects before moving with stepsfree walking_____ _____ means the child has no need for any assistance and can move freelyweaning off the bottle educate on early childhood caries normal decrease in appetite*12 months anticipatory guidance* for parents? (3)lead TB screening if indicated (high risk groups or areas)*labs* for *12 month olds*?lead_____- numerous *neuropsychological deficits* are associated with increased _____ levels levels >70 can cause *seizures and coma*lead assessmentneed to do a _____ _____ to screen for those at high risknormal levle*<5* mg/DL of *lead*should have evaluation of environment to find and eliminate sources of lead*levels >5* mg/dL of *lead*?candidates for chelation therapy*levels >45* of *lead*?12 months*immunization* for _____ _____ include: *MMR* (MMRV is available but may have an increased risk of febrile seizures) Varivax HAV Influenza if timely15 monthsDenver Developmental GM: *walks well* (100%), *stoops and recovers* (100%) FM: *scribbles* (70%) Lan: *3 words* besides mama and dada PS: attempts to use *spoon*dental hygiene D/C bottle*15 months anticipatory guidance* for parents? (2)15 months*immunization* for _____ _____ include: Prevnar 13 if not given at 12 months HIB Influenza if timely18 monthsDenver Developmental: GM: *walks backwards* (70%) FM: *stacks 2 cubes* (80%) Lan: *2 words together* (60%), *points* to *one named body part* (55%) PS: helps to *remove clothing* (65%)18 months*immunization* for _____ _____ include: HAV DTaP Influenza if timely catch up on other immunizations as indicated2 yearsphysical exam: -*no more head circumference* -brain has stopped physically growing2 yearsDenver Developmental: GM: *up steps without help* (100%), *throws ball overhanded* (80%) FM: *stacks 4 cubes* Lan: *many single words*, *names pictures* (75%) PS: *puts on some clothing alone* (60%)2 yearsgeneral speech evaluation: stranger (you) should be able to *understand 50%* of what the _____ pt saystoilet training temper tantrums*2 year anticipatory guidance* for parents? (2)U/A- when toilet trained lead- risk screening and or testing*labs* for *2 year olds*?2 years*immunization* for _____ _____ include: catch up Influenza if timely3 yearsphysical exam: -begin *BP screening*: compare to age related percentage curves -*height* may be done upright -may attempt objective *hearing and vision screening* anticipated VA for different ages 3 y/o 20/50 4 y/o 20/40 5 y/o 20/30 6 y/o 20/202 line 20/40 (3-5 y/o) 20/30 (6 y/o+)refer if: -_____ _____ *difference* in acuity between eyes may indicate *amblyopia* -visual acuity is worse than _____ in *3-5 year olds* or rose than _____ in *6 year olds or older*amblyopia_____ is difference in acuity not correctable by refractive means3 yearsDenver Developmental: GM: *broad jump* (75%) FM: *copies circle* (80%) Lan: knowns *first and last name* (65%) PS: *separates from mom* (50%)3 yearsgeneral speech evaluation: *stranger* should be able to *understand* approximately *75%* of what pt saysbegin dental visits if not previously done*3 year anticipatory guidance* for parents? (1)U/A if toilet trained*labs* for *3 year olds*?3 years*immunization* for _____ _____ include: Influenza4 yearsDenver Developmental: GM: *hops on one foot* (75%) FM: *picks longer line* (80%) Lan: 3 out of 4 *colors* (85%) PS: *dresses* without supervision5 yearsDenver Developmental: GM: *walks heel to toe* (60%) FM: *copies square* (60%)4 yearsgeneral speech evaluation for _____- stronger should be able to understand almost *100% of what is said*safety- strangers, crossing the street, "good touch, bad touch" booster seat in car; back seat, especially if air bags*4/5 year anticipatory guidance* for parents?Hgb? U/A? Hearing Vision TB testing if indicated*labs* for *4/5 year olds*?4/5 year old; Kindergarten Boosters*immunization* for _____ _____ include: DTap #5 Polio #4 MMR #2 Virivax #2elementary years6-12 are what age group?1-2 yearsin *elementary years (6-12)* pts are see ever _____-_____ _____scoliosis exam*elementary years (6-12)* what is check on the physical exam?scoliosis_____ is a curvature and a twisting of the spinehow to check for scoliosisphysical examination: -from visual overview: shoulder blades will off and pelvis will also be off balance -tell pt to remain are square as possible; have them place 2 hands together and touch their toes -3 fingers and track right down the spine -do not try to estimate degree of curvaturestage 1preadolescents: *NO HAIR*stage 2a *few wispy strands* of hairstage 3little more hair, starts to *curl*stage 4adult pattern of pubic hair but does *NOT extend to the abdomen or inner thighs*stage 5hair *does* extend to the *abdomen and inner thighs*stage 1nothing, *no development*stage 2a breast *nodule* under the nipplestage 3*areola is in the same plane* as the rest of the breaststage 4considered *mound on mound*; separate planestage 5the *areola should be in the same plane of the mound*femalepubic hair in an *upside down triangle*malepubic hair in a *right ride up triangle; more abdomen coverage*stages 3 and 4during which tanner stage do girl get their period?school performance / peer interaction tobacco / drug / alcohol prevention television / video games (no more than 2hrs) seat belt use sport (mouth guards)*elementary years (6-12) year anticipatory guidance* for parents?U/A Hearing / Vision*testing* for *elementary years (6-12) year olds*?elementary years (6-12)*immunization* for _____ _____ include: Tdap at 11-12 years Menactra or Menveo (meningococcal conjugate quadrivalent) Gardasil 9 (HPV)adolescenceages 13- 21risk assessment counselingAdolescence (13-21) -most recent recommendation to see this age group *yearly* for _____ _____ -_____ more important than exam; *must have parents leave the room*tobacco use (including oral tobacco or vapes) drug / alcohol use, drinking and driving, in care with someone impaired sexual activity, proper condom use, other contraceptions, STDs and HIV seat belt use guns at home feeling safe at home and school (abuse, gangs etc) self breast or self testicualr exam*Adolescence (13-21) assessment of Risk Factors*?home / friends education / employment alcohol drugs diet sex suicide / depressionAdolescence (13-21): HEADDSS?adolescence (13-21)physical exam: -scoliosis -tanner staging -testicular exam: tech self testicular exam -pelvic exam inf indicatedHgb once in males; some recommend annually in menstruating femaleslabs for adolescence (13-21)?adolescence (13-21)*immunization* for _____ _____ include: Td every 10 years (as in adults) Tdap if not previously given MenB (2 dose series) catch up with previously missed vaccines