The document outlines an upcoming clinical discussion session that will cover the basic flow of a clinical case including history taking, physical exam and assessment; basics of vital signs such as temperature, heart rate, respiratory rate, blood pressure, and head circumference; an overview of the well-child visit; and plans for future discussion sessions.

1. CCC Revere Pediatrics
Weekly Clinical Discussion Session
Introduction
Bao D. Truong

2. What we are discussing today …
 Basic flow of a clinical case
 Basics of Vital Signs
The Well-Child Visit
Q&A
 Future Sessions

3. What we are discussing today …
 Basic flow of a clinical case
 Basics of Vital Signs
The Well-Child Visit
Q&A
 Future Sessions

4. Basic flow of a clinical case
Pay attention to the order of these tasks
2 • Logic and efficiency
• Completeness (avoid missing information / details)
Vital Signs • Cost effectiveness
1 Assessment 3
Severity / Urgency
Review of Medical Differential Diagnoses History Taking
Records
(“Chart biopsy”)
Plan
Further investigations Physical Examinations
Management
Return to your Assessment frequently
4 after every step:
• Prioritize your differentials
Labs • Expand your differentials
• Assess the urgency of the condition
Imaging Studies
Other Studies

5. Basic flow of a clinical case
the “SOAP” model
Review of Medical
Records
(“Chart biopsy”)
Subjective Assessment
History Taking
Plan
Objective Assessment
Vital Signs Severity / Urgency
Differential Diagnoses
Physical Examinations Plan
Further investigations
Labs Management
Imaging Studies
Other Studies

6. What we are discussing today …
 Basic flow of a clinical case
 Basics of Vital Signs
The Well-Child Visit
Q&A
 Future Sessions

7. Basics of Vital Signs
VITAL SIGNS ARE VITAL
 “Red-flag” signs for emergencies
 Overall health status of patient
 Help guide diagnosis
 The only part of the physical exam that you are expected to master in the next
few months!
 Most main components should be taken at the beginning of every clinic visit,
with focus on components that are directly relevant to presenting complains
 Please report to your Senior Clinician ALL vital signs at the beginning of the
session, and please make sure your Senior Clinician have entered them before you
leave the clinic

8. What Are the Vital Signs?
Temperature
Heart Rate (aka Pulse)
Respiratory Rate
O2 saturation
Head Circumference Blood Pressure
(children < 3yo) (children ≥ 3yo)
Weight
Height
+ General Observation !!!

9.  Not always necessary
 Non-specific sign, can be influenced by many factors
Temperature
 Normal range: 97.0 – 100.4 ˚F
Heart Rate (aka Pulse)
 Fever in infants < 3 months might warrant a septic
Blood Pressure workup ! (send them to the ED)
Respiratory Rate
 Measurement:
O2 saturation  < 3-months
• Rectal
Head Circumference • If rectal is contraindicated (GI
bleeding, prematurity, oncology patients), use
Height/Length axillary
 > 6-months
Weight • Tympanic
• Oral (if child tolerates)
 Underestimate:
Rectal / tympanic (most accurate) > oral > axillary
(about 1 ˚F difference for each comparison)
http://www.pedsnurses.org/pdfs/downloads/gid,126/index.pdf

10. Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height /Length
Weight

11.  Look for
Temperature
 Bradycardia
• < 3yo: HR < 100 bpm
Heart Rate (aka Pulse) • 3-9 yo: HR < 60 bpm
• DDx: heart block, medications ...
Blood Pressure  Tachycardia (out of proportion with fever)
• DDx: dehydration, arrhythmia, congenital heart
Respiratory Rate disease, hyperthyroidism ...
O2 saturation  If checked manually, count for at least a full 60-second
interval
Head Circumference
Height /Length  “Normal” heart rate depending on age
Check for the median and range on UpToDate or in handbooks
Weight
 Where can I get the pulse?
• Radial
• Femoral
• Carotid (press one side only, please)

12. Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height /Length
Weight

13.  Routine check only recommended for children ≥3yo
Temperature
Heart Rate (aka Pulse)  Determine the right cuff size
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height /Length
The cuff bladder width should be approximately 40% of the circumference of the
arm measured at a point midway between the olecranon and acromion.
Weight
http://www.kidney.org/professionals/kdoqi/guidelines_bp/guide_13.htm
http://www.uptodate.com/contents/image?imageKey=PEDS%2F73414&topi
cKey=PEDS%2F6087&source=see_link&utdPopup=true

14.  Measuring blood pressure
Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference Blood pressure should be measured with cubital fossa at heart level. The arm should be
supported. The stethoscope bell is placed over the brachial artery pulse, proximal and
medial to the cubital fossa, below the bottom edge of the cuff.
Height /Length
http://www.kidney.org/professionals/kdoqi/guidelines_bp/guide_13.htm
Weight
 If blood pressure is elevated, recheck at later time
(when patient is calm – always recheck with manual
blood pressure cuff, not with machine)

15. Temperature
 Tachypnea = sign of respiratory distress (together with
Heart Rate (aka Pulse) increased work of breathing)
(DDx: ashthma, pneumonia, congestive heart failure)
Blood Pressure
 Only attempt when the child is at rest / asleep, not agitated
Respiratory Rate
 Count over at least 30 seconds (preferrably 1 minute)
O2 saturation
Head Circumference
 Methods:
 Observation: look at the chest wall rising
Height /Length  Direct auscultation / Palpation
(don’t wake them up or make him/her agitated !!!)
Weight

16. Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height/ /Length
Weight

17. Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
… to be discussed in a few weeks (hopefully during
O2 saturation
Respiratory physiology week)
Head Circumference
Height / Length
Weight

18.  For infants, do this toward the end of exam
 Make sure to get to the most prominent portion of
Temperature the occiput
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height / Length
Weight
http://www.scripps.org/articles/1907-growth-chart

19.  For young baby: make sure to check weight with
baby completely naked (not even with diaper on)
Temperature
Heart Rate (aka Pulse)
Blood Pressure  Measure length (patient in supine position) for
children < 2-year-old
Respiratory Rate
O2 saturation
Head Circumference
Height / Length
Weight

20. A case of failure to thrive ...
Temperature
Heart Rate (aka Pulse)
Blood Pressure
Respiratory Rate
O2 saturation
Head Circumference
Height / Length
Weight

21. Causes of Failure to Thrive
 Inadequate Nutrient Intake
Temperature (inappropriate feedings, GERD, disturbed caregiver/child
relationship, mechanical problems ...)
Heart Rate (aka Pulse)
 Inadequate Appetite / Inability to Feed
(GI obstruction, cerebral palsy, CNS tumor/hydrocephalus
Blood Pressure psychosocial problems,..)
Respiratory Rate
 Inadequate Nutrient Absorption / Increased
Nutrient Loss
O2 saturation (lactose intolerance, milk allergy, cystic fibrosis, cardiac
disease, malrotation, inflammatory bowel diseases, chronic
diarrhea/vomitting)
Head Circumference
Height / Length
 Increased Nutrient Requirement
(Malignancy, hyperthyroidism, chronic systemic inflammation, chronic
Weight infections)

22. What we are discussing today …
 Basic flow of a clinical case
 Basics of Vital Signs
The Well-Child Visit
Q&A
 Future Sessions

24. The Well-Child Visits
• Prenatal Visit
• Newborn Visit
• First week Visit
• 1, 2, 4, 6 months
• 9, 12, 15, 18 months
• 24, 30, 36 months
• 4 years
• Subsequent annual visits

25. The Well-Child Visits
The Principles
 Should be carried out in the context of the child’s age and development
(consider developmental milestones, environment etc.)
 First priority: address the patient’s and parents’ concern
Second priority: evidence-based screening, immunization, assess and address
patient’s safety
(5 priorities for each age group recommended by AAP-Bright Futures)
Everything else (personal belief of what is good for the child)
 It might be more helpful in certain situations to focus on a few important issues during
a visit, with appropriate close follow-up to address others, than trying to tackle all
problems at once
• Again, always address patient’s and parents’ concerns as well as urgent issues first

26. Contents of aWell-Child Visit
the “SOAP” model
Review of Medical Since last well-child visit ...
Records Phone call./ED / Clinic Visits?
(“Chart biopsy”) Hospitalization?
New lab/study results?
Assessment
New changes in social environment?
Subjective Concerns & Questions
Developmental surveillance
Plan
Basic activities (“eating & sleeping”)
History Taking Social activities & mental health
Safety / substances
Puberty Assessment
Severity / Urgency
Objective Differential Diagnoses
Plan
Vital Signs Vital Signs / Growth Further investigations
Complete physical exam Management
Physical Examinations Screening exams & tests
ASSESSMENT:
Overall, well-child?
Labs Assessment of each concerns/problems
Physical development
Imaging Studies Emotional development
PLAN:
Other Studies Address each concerns/problems
Anticipatory guidance
Immunizations

27. History Taking in a Well-Child Visit
The Basics (if you can’t remember the details)
Concerns / Questions ← anything wrong ?
Developmental ← ... err, those developmental milestones ...
Surveillance
← what a baby + everyone else does:
Basic Activities sleeping/eating/pooping/peeing
Social Activities / ← what an older child cares about ...
Environment / Mental home (parents, siblings...) ; school
Health (teachers, friends, homeworks, grades...)
←
Safety / Substance small children: second-hand smokes, fall-
risk, aspiration of objects ...
Puberty older child + adolescents: substances (include
alcohol), sexual history, bullying ...
Review PMH
Review Family History

28. History Taking in a Well-Child Visit
The Basics (if you can’t remember the details)
Concerns / Questions
 Ask open-ended questions first
Developmental
Surveillance
 Ask specific questions related to
Basic Activities information/concerns from prior visits
Social Activities /
Environment / Mental  Consider spending some time to address some
of these concerns before moving on
Health
Safety / Substance
Puberty
Review PMH
Review Family History

29. History Taking in a Well-Child Visit
The Basics (if you can’t remember the details)
Concerns / Questions
 We will cover in details next time...
Developmental
Surveillance
 Not necessarily have to ask ALL questions on
Basic Activities regarding developmental milestones – you might
have already got lots of answers just by
Social Activities / observing and interacting with the kids
Environment / Mental
Health
Do ask parents if they have any concern
Safety / Substance
Puberty
Review PMH
Review Family History

30. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
What everyone does ...
Concerns / Questions
Sleeping
Developmental
Surveillance Eating:
 Feeding
Basic Activities  Formula / milk?
 Solid food?
Social Activities /  Digestion
Environment / Mental  Refux / spitting
Health
 Pooping / peeing:
Safety / Substance  # diaper changes?
 Strange stools / urine? (blood? change in color?)
Puberty
What everyone should do...
Review PMH Exercise
Review Family History

31. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
At home
Concerns / Questions  Parents (stress? health?)
 Siblings (health? Interactions?)
Developmental  Lead exposure
Surveillance  Pets / animals
Basic Activities At school
 Friends (good number of friends? nice? being
Social Activities / teased or bullied? Weapons? Substance?)
Environment / Mental  Interest / Strength
Health  School reports & grades
Safety / Substance  Sick contacts:
 Infectious illness at home or at school?
Puberty  Travel history?
 Animal exposure?
Review PMH
Review Family History

32. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
Concerns / Questions
Developmental
Surveillance
Basic Activities
Social Activities /
Environment / Mental
Health
Safety / Substance
Puberty
Review PMH
Deer tick (Ixodes scapularis)
Review Family History - The main vector of Lyme disease

33. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
Mental Health
Concerns / Questions  Depression
 Anxiety
Developmental  Emotional problems
Surveillance  Eating habits (binge eating, purging, excessive
exercise ...)
Basic Activities
 Consider asking parents to step out during certain
Social Activities /
parts of the history, if they agree
Environment / Mental
Health
For patients 18-year-old or above:
Safety / Substance
• No parents / family members can be present
• You cannot communicate with parents/family members
Puberty
or anyone else about contents of history & patient’s
condition
Review PMH
(except if there is signficant safety issue, required by
Review Family History law, or of course if patient agrees)

34. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
Ask for ALL ages , not just older children / adolescent
Concerns / Questions
Infants / Younger children
Developmental  Fall risk
Surveillance  Sleeping location / position
 Swallowing objects
Basic Activities  Gun/weapon in home
 Second-hand smoke
Social Activities /
Environment / Mental Older children / Adolescents
Health  Gun/weapon
 Helmets
Safety / Substance  Sports
 Drugs & Alcohol
Puberty  Smoking
 Unsafe sexual practice
Review PMH
Review Family History

35. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
Concerns / Questions
Developmental
Surveillance
 Concerns over physical changes
Basic Activities
 Menstruation
Social Activities /
Environment / Mental  Sexual history
Health
Safety / Substance
Puberty
Review PMH
Review Family History

36. History Taking in a Well-Child Visit
The Basics (if you can’t remember/look up the details)
Concerns / Questions
 Review Past Medical History (you can get the
Developmental information from medial record before in the
Surveillance interview, but do review with the patients/parents)
Basic Activities Ask follow-up questions regarding:
• Recurrent / Chronic illness
Social Activities / • Recent surgical / procedural interventions
Environment / Mental • Any medications being taken (reason? adherence?
Health side effects)
Safety / Substance For infants/younger children: ask about mother’s
pregnancy and peri-natal history
Puberty
Review PMH
Review Family History

37. History Taking in a Well-Child Visit
The Details
Concerns / Questions
Developmental
Surveillance
Basic Activities
 Most important questions for each age group
Social Activities / can be found in Bright Future Guidelines /
Environment / Mental Handbooks
Health
(We will work to organize these materials so you
Safety / Substance can have ready access)
Puberty
Review PMH
Review Family History