Pediatrics (week 1)

[liveonearth]

Liz Collins speaking, she's funny

books: Schwartz---basic peds text, also Burkowitz, and 5 minute ped consult book (she loves this one), and Pediatric Telephone Advice (not currently available on amazon), also a good derm atlas, must have.

80% or more of office visits are made by women and children
seeing kids: you don't have to be very dignified, you can get down on the floor with them
prepare to see kids: it's unavoidable
the opportunistic physical exam: screaming? look in the throat
never ask a kid a yes or no question, say "do you want this first or that first?"
"have you ever listened to your own heart? do you want to listen to your heart?"
"does this hurt? that hurt? the other hurt? does your hair hurt?"
look in mom's ears first, or teddy bear's ears, keep moving until you get it done
parents who negotiate with 2 year olds aren't good at delivering tx
hx: collaborative process, get most info from parents
pts search internet-->"Doctor Google tells everyone they're dying"
pts think they know what it is, and mb biased by family members
"you can't imagine how much you're going to love this kid" = true
parents freaked about sick kid are worried about their most precious thing: so have compassion for parents

WELL CHILD VISITS
to monitor general growth, development and health of children
what's changed since last time
always talk about immunizations, document anything refused
document intentions regarding future births
always some counseling component, also reassurance "your child is in the normal range"
serving as primary care or as alternative? main care or one of team? different service
if 2nd or 3rd opinion, can spend more time on parent concerns
if primary care must be more general, screening
"when was last visit to pediatrician?"
start with talking, kids usu not comfortable until end of visit, sit far enough away, talk to parent
when child starts bringing you toys, you can talk to the child

she uses a form for developmental checklist, uses head to toe for physical
age appropriate questions cued by developmental checklist
daycare, sports, puberty
under 5: eating and sleeping cause most stress, you can't make anyone do these things

cue parents to get good vision test done before school starts, kids don't know that the world isn't blurry
vision and hearing screens done at school but usu not high quality
refer for hearing checks

be clear with parents about what you can and cannot do: realistic expectations help
are parents on same page? divorced?? "is this gonna work for (other parent)"
"Do you need a bottle for each house?" "do you need another photocopy of the instructions?"

do you want the prescription in case you need it over the weekend? call it in just in case.
we both know that we aren't going to use abx for this but
would you like a script to keep on the fridge just in case?

easiest to do immunizations at end of visit (then give prizes or send screaming kid away)
summarize findings at end of visit, normals and abnormals, how concerned you are,
expected tx response, followup plan

kids will tend to overexert on first day that they feel good, then feel bad again
warn parents this will happen

BIRTH TO 12MO
basic developmental Q's
getting around: rocking, rolling, crawling to get to interesting toy
walking at about 12 mo, talk about 24 mo
"spend the first 2 years trying to get kid to walk and talk
next 2 years trying to get them to sit down and shut up"
eating: breast, bottle, solids, where are they at, when introduce solids?
poop and pee
wt gain and growth are biggest cues, outputs are next biggest
teeth may come in at 3mo, usu 5-7mo, mb as late as 8-10mo
childproofing, car seats
siblings
supervision of child
immunizations
get birth and early post partum info, complications?
gestational age: for each month premature, takes a year to catch up
(1 month premature-->catch up at age 2 yrs)

potty training rare before age of 2
kids trained at 1.5 are kids who just did it, not exceptional parents

parents get excited about kids that do stuff early
insecure about kids that do stuff late
bottom line: it doesn't matter, no indication of future ability

PRESCHOOL
2-5 or 3-5
huge age of change
parents get insanely competitive
developmental q's
problem solving around sleep, kids get out of bed and come to parents
parents hit the wall from sleep deprivation, no sex life
eating: parents proud of kids that eat veggies
her theory: some kids eat veg and salad when start eating solid food, these kids eat veg forever
some kids eat some veg but won't touch salad, they will stop eating veg around age 3
"corn and peas are a grain and a legume, those are not vegetables"
teething: cavities not dt night nursing, change dentist if shame for nursing at night
potty training: accidents in bed, dry during day is supratentorial, kids do it when willing
dry at night has nothing to do with mind control, bribes don't work
coordination and physical skills: small motor starts to develop, holding a pencil not like a club
comparisons in preschool: are the teachers concerned?
"what are you planning on doing for starting elementary school?"
if you plan on having kid immunized by time school starts, start early to space out vaccines
start a schedule, have a plan
behavioral: biting, hitting, weeping, 3/4 of 3 year old speech is unintelligible to stranger

5-12 YEARS OLD: SCHOOL AGE
developmental
signs of puberty?
sleep: big issue, body clock shifts to nocturnal (medorrhinum for all teens)
eating: kids make bad choices given control
bedwetting: up to age 5-6 is common
dental, vision, hearing, physical, sports, injuries, prevention
safety in school age: bullying, sex and drugs, rock and roll (have a talk), seat belt wearing
birth control, STDs, all in there with bike helmet and seat belt
learning disabilities: vision screen first, don't offer dx: refer

ADOLESCENCE
no well child visits now, come in for sports physical but cover everything
puberty and development, growth, body image issues
sleep, eating disorders 20% male (wrestlers, body builders)
safety: driving, seatbelts, alcohol, sex, drugs, depression, conduct
family dynamics, friends, so's
ask about how things are going

ACUTE ILLNESS
what brought you in today, why did you feel you couldn't deal on your own?
start with hx: onset, duration, systems, concomitants, modalities
temperature: how did you take that? (ear ones are terrible) what was the number on the thermometer?
and did you do anything to number on thermometer?
she uses axillary temps, wants to know what thermom said.
always do ROS, basic vitals and weight in infants (sig wt loss when not eating is imp)(need wt for meds dose)
top 3: appetite, activity and sleep
note pertinent negatives then can note new sx as crud evolves
tx: must have buy in. explain what you're using, why, how.
write it down, hand it over, answer q's in ofc.
warn about possible ruptured eardrums, warn re: contagiousness, sibs may get it.
want to know if eardrum ruptures, escalation in screaming then kid wilts, wakes with goo coming from ear
call me the next day, don't put any ear drops in, don't flush, not serious, it's ok
tell when can return to school, do you need a note for your kid to go back to school, daycare
do you need a note for your work?
variety of ways to get meds into kids, explain perfect and acceptable
any is better than none: partial meds dose, brief sneaky hydro, etc
she dripped meds into her child's mouth while she slept
tell parents what's most important: if you can only do one thing, do this one
ice cube trick, or m&m, put pill on back of tongue, kid holds candy in front of mouth, give straw to drink
when kid is sick you'll remember to do this every 2 hours, when kid feels better you'll forget some doses
that's perfect
ibuprofen and tylenol at night mb helpful so everybody can sleep, sleep is medicine

CHRONIC AND ONGOING CONDITIONS
much more challenging
psych issues add up
first visit and followups much different
first: complete hx, txs tried, why stopped
PE: at least vitals and brief physical heart & lungs
targetted exam for condition of concern, skin exam w fingertips
track related items: if diaper rashes-->food sensit-->track growth
followup: doc drives visit, don't ask why they're here today
how are things working for you? course of illness, response to tx, use of things?
PE: continue tracking same and examine any new
charting helps you follow changes, parents can't always remember
tx: start minimal, I have 50 ideas and I want you to know that if I send you out with 3 things to do and 2 things to take, if this doesn't work then I want you to know there's 45 more. some will want all 50. keep track of ideas. some things kids outgrow (colic goes away at about 3mo)