Well child visit preschool age

Julie M Hurtado, MD9/10/09

I. IntroductionII. Growth and Development

1. Physical development• Ht/Wt• Vision/ Hearing• Muscle/ Neuro• Cardio/ Respiratory• GI

2. Psychosocial and CognitiveIII. History and Physical ExamIV. ScreeningV. Anticipatory GuidanceVI. Common QuestionsVII. Common Concerns

• Nutrition• Sleep • TV and Internet

VIII. Common Conditions• Febrile Illness• AGE• Constipation• URI

IX. PREP questions

I. Introduction

• 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• 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• 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

• General physical appearance– Ht/Wt

• Skin (images)• Head

– Size/Shape– Fontanelles closed

• Eyes– Size/Shape/Equal– Visual acuity– Red Reflex

• Ears– Hearing– External Canal

• Nose/Throat– Teeth hygiene– Nasal polyps

• Neck– Lymph nodes

• Respiratory– Inspection– Auscultation

• Cardiology– Auscultation

• Gastrointestinal– Hernias/Organ size– Rectum

• Genitourinary– Females: Vagina– Males: Foreskin/Testicles– Check for Sexual abuse

• Neurologic– Motor– Sensory

• Musculoskeletal– 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:

• 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

– Healthy food choices– Family shares meals– Nighttime rituals– Regularly brushes teeth

• Cognitive Growth

– 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

• Self-care

– 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 yearsDid 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.

• 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.

• PoisoningsYour 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.

• 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.

• 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

• 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.

Of the following, the MOST appropriate statement about acetaminophen toxicity is that

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

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.

Of the following, the MOST appropriate statement about acetaminophen toxicity is that

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

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, blood-tinged 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, blood-tinged 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. Azithromycinb. Cefdinirc. Cephalexind. Penicilline. 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. Azithromycinb. Cefdinirc. Cephalexind. Penicilline. 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. cystic fibrosisb. Human immunodeficiency virus

infectionc. primary ciliary dyskinesia

(Kartagener syndrome)d. severe combined

immunodeficiencye. 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. cystic fibrosisb. Human immunodeficiency virus

infectionc. primary ciliary dyskinesia

(Kartagener syndrome)d. severe combined

immunodeficiencye. 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. even mild conductive hearing loss could affect his later school performance without frank speech delay

b. OME does not cause conductive hearing loss severe enough to cause speech delay

c. performing hearing screening solely in response to parental concern is not recommended

d. testing air and bone conduction thresholds in the office will help you rule out hearing loss

e. 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. even mild conductive hearing loss could affect his later school performance without frank speech delay

b. OME does not cause conductive hearing loss severe enough to cause speech delay

c. performing hearing screening solely in response to parental concern is not recommended

d. testing air and bone conduction thresholds in the office will help you rule out hearing loss

e. 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!!!!!