Well Child Visit

Presented by: Leila Boubshait MD MPH

Assistant Professor at Department of Family & Community Medicine, IAU
 Goals of the Well Child Visit:
• Making sure child meets milestones in growth, behavior, and skills.
• Providing children with a physical exam and regular health screens.
• Child vaccinations.
• Providing information to parents on child's health, safety, nutrition,
and fitness needs.
• Answering questions about growth and development.
 Goals of the well child visit:
• Diagnosing and treating illnesses, infections, injuries, and other health
problems.
• Referring to specialists if specialized care is needed.
Case: Well Child Exam for a 6-Month-Old
Chief Complaint: Routine well child examination
• History :
• Emma is a 6-month-old infant brought in by her parents for a routine check-up. She was born full-term via vaginal delivery
and had no complications during birth. Her parents report that she has been growing well and meeting developmental
milestones per history. She is exclusively breastfed and has been tolerating feeds without any issues. Dirty diapers range
between 5-6. They have no immediate concerns except for occasional fussiness during teething. And seems to be growing
normally as her siblings.

• Developmental History:
 Developmental screening tools
Developmental Red Flags
Preschool age School age

School failure
Inability to perform self-care tasks, hand
washing simple dressing, daytime toileting
Lack of friends

Lack of socialization
Social isolation
Unable to play with other children

Aggressive behavior: fights, fire setting,

unable to follow directions during exam animal abuse
Developmental History done:
Breast Vs Formula
Breast Vs Formula
Breast Vs Formula
Case: Well Child Exam for a 6-Month-Old
Chief Complaint: Routine well child examination
• History cont.
• Past Medical History:
• Emma has had no significant illnesses or hospitalizations since birth.
• She has received all of her immunizations up to the recommended schedule.
• Family History:
• There is no significant family history of genetic disorders, developmental delays, or chronic illnesses.

• Social History:
• Emma lives with her parents and has a safe and healthy living environment. Both parents are non-smokers, and there is no
exposure to secondhand smoke. There are no pets at home. Emma's parents demonstrate warmth and engagement in her
care.
Case: Well Child Exam for a 6-Month-Old

• 8. Neurological Examination:
• - Cranial nerves II-XII intact.
• - Infant exhibits symmetric movements of all extremities.
• - Steady head control in supported sitting position.
Vaccination
Schedule:
Vaccination Card/Schedule:
Physical Examination:
Physical Examination:
• VS, General Exam and Growth Parameters
• Head and Neck
• ENT
• Chest
• CVS
• Limbs
• Abdomen
• Genitalia
• Back
Case: Well Child Exam for a 6-Month-Old

• Physical Examination:
• 1. Vital Signs:
• - Temperature: 98.9°F (37.2°C)
• - Heart Rate: 120 bpm
• - Respiratory Rate: 30 breaths per minute
• - Blood Pressure: Not applicable for routine well-child exam.(begin at age 3)

• 2. General Appearance:
• - Alert and active infant, making eye contact and responsive to stimuli.
• - Hydrated, with good skin turgor and no signs of dehydration.
Case: Well Child Exam
for a 6-Month-Old

• 3. Growth Parameters:
• - Length: 65 cm (Between 50th and
75th percentile for age)
• - Weight: 7 kg (Between 75th and 90th
percentile for age)
• - Head circumference: 43 cm (Between
50th and 75th percentile for age)
• - Plot the growth measurements on
the appropriate growth chart.
Growth parameters:
Case: Well Child Exam for a 6-Month-Old

• 4. Head and Neck Examination:

• - Normocephalic head, with a smooth and symmetric skull shape.
• - No fontanelle abnormalities observed. (post@2mo, Ant@18mo)
• - Neck supple, without any masses or lymphadenopathy.

• 5. Eyes and Ears Examination:

• - Pupils are equal, round, and reactive to light.
• - Bilateral red reflex present.
• - Bilateral tympanic membranes are pearly grey, without any bulging or
effusion.
 Case: Well Child Exam for a 6-Month-Old

• 6. Cardiorespiratory Examination:
• - Regular rate and rhythm of heart sounds, with no murmurs or abnormal
sounds.
• - Normal vesicular breath sounds bilaterally, without any added sounds.

• 7. Abdominal Examination:
• - Soft and non-tender abdomen, with normal bowel sounds.
• - Absence of organomegaly or masses.
Case: Well Child Exam for a 6-Month-Old

• Assessment and Plan:

• Based on the physical examination and history obtained, the child appears to be a
healthy 6-month-old infant meeting expected growth and developmental milestones.
The parents should be commended for providing good care and following the
recommended immunization schedule.

• 1. Growth and Development:

• - Continue exclusive breastfeeding until 6 months and encourage introduction to
complementary foods.
• - Discuss age-appropriate developmental milestones and provide anticipatory guidance.

• 2. Immunizations:
• - Administer recommended immunizations as per the national vaccination schedule.
Case: Well Child Exam for a 6-Month-Old

• 3. Teething:
• - Educate parents regarding teething signs and symptoms.
• - Provide guidance for managing teething discomfort, including the
use of teething rings and appropriate pain relief measures.
• 4. Schedule Follow-Up:
• - Schedule the next well child examination at 9 months of age.
• Education and Counseling:
• - Discuss the importance of child safety (e.g., car
Follow up Visit Schedule:
• Three to four days after birth
• Two weeks old
• Two months
• Four months
• Six months
12 Visits from birth to age 5
• Nine months
• 12 months (one year)
• 15 months
• 18 months
• 24 months (two years)
• 30 months
• At three years of age and older, you can bring them in once a year.
Screening:
Screening Does and Don’t
Vision
• The USPSTF recommends at least one vision screening to
detect amblyopia between three and five years of age.
Anticipatory guidence
Parental Guide:
Anticipatory Guidance

SAFETY
• Infants need a rear-facing car
safety seat until two years of age
or until they reach the height or
weight limit for the specific car
seat.
• Children should then switch to a
forward-facing car seat for as long
as the seat allows, usually 65 to 80
lb (30 to 36 kg).
 Case: Well Child Exam for a 6-Month-Old
Assessment & Plan
Diet, Activity and Sleep:
Breast feeding, supplements, free play, Sleep hygiene

Referrals:
Dental health, Ophthalmology, Social Services

Labs:
Hb level
Sickling and G6PD tests

Treatments:
Vitamin D
Liquid iron
paracetamol
Adolescent Health
Approach:
• History/ Screening
• Physical examination
History:
• III. Approach: Mnemonic -HEEADSSS
1. Home environment
2. Education
3. Employment
4. Eating
5. Activities
1. Electronic Media Use in Children (Screen Time and Social Media use)
2. Physical Activity
3. Best friend
6. Drugs
7. Sexuality (Contraception, Sexually Transmitted Infection)
8. Suicide (and Major Depression)
9. Safety (and Social Media Use in Adolescents)
History:
• IV. History: Home Life
1. Who do you live with?
2. Where do you live?
3. How many of you share the same bedroom?
4. Who can you talk to about things?
5. Do you get along with your family?
6. What would you change about your family?
7. Are there new people in your home?
8. Are you allowed to come and go as you want?
9. Have you ever been kicked out of your home?
10.Have you ever been in Foster Care?
11.Have you ever been arrested or been in jail or prison?
12.Have you ever runaway?
13.Have you moved recently?
• V. History: Education
1. What grade are you in?
2. What are your favorite subjects?
3. What are your grades like?
4. How many different schools have you attended in the last 4 years?
5. Do you ever skip school?
6. Have you ever dropped out of school?
7. Have you had to repeat classes or repeat a year of school due to failing grades?
8. Have you ever been suspended or expelled from school?
9. What do you want to do when you are done with school?
10.Do you have a job?
11.How do you make money?
• VI. History: Activities
1.Tell me about a day in your life
2.What type of activities do you do each day?
3.What do you do for fun or for hobbies?
4.What do you do on weekends?
5.Do you have many friends?
6.Do you play sports?
7.How much television or online entertainment do you watch each day?
8.Do you wear Seat Belts?
• VII. History: Drugs
1. Do you smoke Cigarettes, including Electronic Cigarettes?
2. Do you smoke Marijuana or weed?
3. Do you drink Alcohol?
1. How much?
2. Where do you get it?
4. Have you ever tried other drugs?
1. What type of drugs?
2. How did you pay for them?
5. Do you ever get sick, pass out or have a hangover from drugs or Alcohol?
6. Do you ever use drugs or Alcohol to escape from reality?
7. Have you ever done anything you did not want to do when you were high, drunk or passed
out?
• VIII. History: Suicide and Safety
1.Do you ever feel lonely or sad
2.Have you ever had thoughts of Suicide?
3.Do you ever get in fights with friends or with a boyfriend or
girlfriend?
4.What is it like when you fight?
5.Have you ever been abused physically or experienced Violence?
• IX. History: Sex
1. Do you have a boyfriend or girlfriend?
1. How old are they?
2. How did you meet?
2. How many people have you had sex with in your lifetime?
3. When was the last time you had sex?
4. Have you ever been pregnant?
5. Have you ever had a Sexually Transmitted Infection (e.g. Chlamydia, Trichomonas, Gonorrhea)?
6. Do you use protection (e.g. Condoms)?
7. Have you ever been pressured into doing things sexually you did not want to do?
8. Some people trade sex for money, clothes, drugs or housing. Do you know anyone who does this?
9. Has anyone ever asked you to do sexual things for money?
• X. History: Social Media
1.See Social Media Use in Adolescents
2.How many hours do you spend per day in front of a screen (e.g. computer, television,
smartphone)?
1. Do you wish you spent less time on Screen Time?
3.Some of my patients spend most of the free time online. What types of things do you do
online?
4.When was the last time you sent a text message while driving?
5.Have you messaged photos or texts that you later regretted?
6.Have any of your friends been harmed by their time spent online?
7.How often do you view pornography online (nude photos or videos)?
8.Have you ever sent unclothed pictures of yourself to anyone online?
History:

Puberty Definitions:
• is a time of rapid and complex changes involving overlapping
components: hormonal, physical, and cognitive.
• A process of sexual maturity and secondary sexual characteristic
development
History: Puberty:
• Strong genetic component is noted.
• A trend toward earlier start of puberty in recent genetations has been
noted.

• For boys: average age is 11.4 years

• For girls: ranges between 6 years to 11.6 years (ethnic influence)
History: Puberty:
• Signs and symotoms:
• Boys: first sign is testicular enlargement and thining of scrotum,
redding of scrotum. Followed by growth of penis and pubic hair. Facial
and axillary hair occur next. Hight acceleration occurs at the end of
puberty. 2 years after girls.

• Girls: first sign is breast bud growth, followed by pubic hair, menarche
occurs 2-2.5 years after breast buds.
History: Puberty:
Physical Examination:
• General Apperance
• Vital Signs
Physical examination:

Tanner Staging: also known as Sexual Maturity Rating (SMR):

• is an objective classification system that providers use to document
and track the development and sequence of secondary sex
characteristics of children during puberty.
Physical Exam Tanner Staging:
• The physical changes of puberty require a concerted effort from many
organs; these changes are initiated by the activation of the
hypothalamic-pituitary-gonadal (HPG) axis (gonads refer to ovaries in
females and testes in males).

• The first hormonal change in puberty is the pulsatile release of GnRH

triggered by disinhibition of the hypothalamic-pituitary-gonadal (HPG)
axis.
Pubic Hair Scale (both males and females)
• tage 1: No hair
• Stage 2: Downy hair
• Stage 3: Scant terminal hair
• Stage 4: Terminal hair that fills the entire triangle overlying the pubic
region
• Stage 5: Terminal hair that extends beyond the inguinal crease onto
the thigh
Female Breast Development Scale

• Stage 1: No glandular breast tissue palpable

• Stage 2: Breast bud palpable under the areola (1st pubertal sign in
females)
• Stage 3: Breast tissue palpable outside areola; no areolar development
• Stage 4: Areola elevated above the contour of the breast, forming a
“double scoop” appearance
• Stage 5: Areolar mound recedes into single breast contour with areolar
hyperpigmentation, papillae development, and nipple protrusion
Male External Genitalia Scale
• Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm
• Stage 2: 4 ml-8 ml (or 2.5 to 3.3 cm long), 1st pubertal sign in males
• Stage 3: 9 ml-12 ml (or 3.4 to 4.0 cm long)
• Stage 4: 15-20 ml (or 4.1 to 4.5 cm long)
• Stage 5: > 20 ml (or > 4.5 cm long)
Testicular Volume in mL

Testicular legth in cm
Use of Sexual Matiraty Rating Scale:
• delivering timely anticipatory guidance on menstrual hygiene needed.
• Precocious puberty is defined as the onset of Tanner 2 secondary
sexual characteristics before age 8 years in females or age 9 years in
males if the continued progression of pubertal development occurs
soon after.
• Delayed Puberty:
Girls: no pubertal signs before age 13, or no menarche before age 16.
Boys: no pubertal signs by 14, or more then 5 years passed from initial
signs.
Purpose of SMR:
• Delayed Puberty should be considered if females have not reached
Tanner 2 by age 13 years old or if males have not reached Tanner 2
by age 14 years.
• Primary Amenorrhea is defined as a failure to start menses within 3
years of Tanner Stage 2 or by age 15 years.
• It is important to note that some males will temporarily develop
glandular breast tissue (pubertal gynecomastia) between genital
tanner stage 3 and 4, which may be emotionally troubling but not
physically harmful.
Screeinig:
Substance Abuse:
• Alcohol and cigerets are the most prevelent drugs
• Marijuana is the most comonly reported ilicit drug.

• Know the signs and symtoms of intoxication…

• Use the CRAFT interview screening tool.
Universal Screening recommended between
ages 9 and 11. again between 17 and 21
Ask At age 15 -18
Risk factors: previous STDs, IV drug abuse…
Begin at age 12
Use PHQ2/PHQ9 tools
At 11-12 years of ge
2
Immunization:
• Flu vaccine
Thank you
References:
1.AAFP
2.Getting into Adolescent Heads
1. http://www.contemporarypediatrics.com/pediatrics/getting-adolescent-heads
3.Updated HEADSS Interview
1. https://www.contemporarypediatrics.com/modern-medicine-feature-articles/h
eeadsss-30-psychosocial-interview-adolescents-updated-new-century-fueled-
media/page/0/1
 Key History & Physical Examination points:
Visit Pertentant Points

First Vist Birth history, urine output, stooling, Vitamin D. Weight, red reflex & Jaundice Asessment

1 month Weight, legth, Head cercumfrenx, Hip addessment, depression screening

2 months Growth, sleep assessment/back to sleep, tummy time

4 months Solid food “discussion”, injury discussion

6 months Assess for teath (floride varnish), able to sit (tone), start water and solid foods

9 months More active

1 year First word, first tooth, first step