Case #29

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There are two parts to this case.  Make sure you complete each of them.

Introduction to the Well Child Visit

It is the first day of your Family and Community Medicine Clerkship. You are armed with a Harriet Lane Handbook, calculator, pharmacopoeia, and an antibiotic guide. Determined to become a well-rounded family physician, you reviewed immunization schedules and developmental milestones last evening. Your clerkship begins at a busy outpatient clinic where lots of children are seen. As you glance at the preceptor’s schedule, you see the first two appointments are well child checks. You breathe a sigh of relief, knowing your first patients are healthy ones. Knowing that you have just completed your pediatric rotation, your preceptor tells you to see the first patient then present the case to her.

Patient One: SJ, 2 month old female, here with her mother for a Well Child Exam

As you enter the room, SJ is sleeping soundly in her mother’s arms. She is a 2 month-old white female. Her mother is a 25 year-old G1P1 woman, whose past medical history is negative. Her mother, Jill, appears relaxed and tells you that SJ has been doing well. She is eating and seems to be growing, but mom is concerned SJ may not be getting enough breast milk. She will be returning to work next week and wants to know if she should change to formula feeding. Also she wants to know when she should introduce other foods.
 
  1. What is appropriate infant weight gain over the first year of life?  When should a baby double and triple his/her weight?
  2. What is the importance of measuring head circumference?

History

SJ is at the 50th percentile for both weight and length; head circumference is at the 60th percentile. You show the growth curves to mom and explain to her that half of babies SJ’s age are weigh more than she does right now; the other half weigh less. She has been following these growth parameters since birth without dropping off “the curve.” Jill is concerned with how much her baby should be eating and when it is ok to advance her diet.


 
  1. What is the recommended infant caloric consumption (based on kg weight)?
  2. Discuss advantages of breast milk over infant formula?

Exam

Jill tells you that she thinks SJ is feeding well, however, she is not sure SJ is feeding frequently enough and getting enough breast milk with each feed.
  1. How would a mom know if her baby is receiving enough breast milk?
  2. How often should Jill feed SJ and should she wake her up for feeding?
  3. When should an infant begin to eat solid food? Juice?

Exam (con't)

SJ’s mom now wants to know what developmental milestones are expected for a two-month-old infant and what to expect over the next 10 months?

 
  1. Discuss key developmental milestones (gross motor, language, fine motor, social) in a 2-3 month old infant. What would cause concern in the physician?

You reassure SJ’s mom that rolling over is achieved between 3-6 months. She should expect to begin to bear weight on her legs and grasp a rattle in the next two months. You then proceed to SJ’s physical exam. She is smiling at you, playing with her hands, following objects past midline, laughing and cooing. She holds her head up when placed her on her belly. Her exam is normal including primitive reflexes.

 
  1. Discuss the primitive reflexes of the newborn and when each reflex appears and disappears in the normal newborn?
Your conversation next turns to immunizations. SJ’s mom would like her to receive vaccines on schedule and would like more information on vaccine safety and necessity. SJ received Hep B #1 in the nursery. You pull out the latest copy of the CDC’s childhood immunization schedule and review it with SJ’s mother. You also provide handouts on each of the vaccines given today.

 
  1. What immunizations should SJ receive today? What is the normal vaccination schedule for children?
After SJ receives her immunizations. Before she leaves, however, you ask Jill about her car seat. You discuss general safety, car safety, and provide information for future safety issues as SJ approaches 1 year of age.

 
  1. What are the appropriate safety methods for securing an infant-toddler in a vehicle?
  2. What are some other safety issues for children ages birth to 6 months? 6 months to 1 year of age?

Patient Two: MB, a 2-year-old male, here with his mother and father for a Well Child Exam

MB is an active 2 year old, who was adopted by his parents 2 weeks ago from Thailand. His parents do not have any of his medical records and are not sure if he has had any immunizations. They do know that his mother had some limited prenatal care and had a normal delivery at 38 weeks gestation. MB has been healthy to date, has been living in a shelter in Thailand. You begin by taking a brief social history to accompany the past medical history, birth history, and growth/developmental history the family already gave you.

The parents and MB live in Hershey, PA, and use the township water supply which does not contain fluoride. There is no smoking, alcohol, or drug use in the home. MB’s adoptive mother, Angie, will care for him during the day for the next year before returning to her job as a nurse. His father, Ryan, is a local high school teacher. You also learn that while at the shelter, MB was consuming a diet of soymilk and table foods (predominately rice, meats, and beans). Since coming to the US, his parents have expanded his diet and given him whole milk and fruit juice to drink. They tell you he has a voracious appetite and particularly enjoys cheese, chicken, apples, and carrots. They do note he only eats when he wants, not necessarily at standard family meal times. They tell you he seems to have adjusted well over the past 2 weeks.

His parents are concerned about his immunization status, developmental status, and how best to childproof their home. They would also like to be sure his physical exam is normal and that he does not have any underlying medical conditions of which they are not aware.
 
  1. What is the proper procedure for vaccinating MB? Can his parents and physician assume he has received the proper vaccinations thus far?
  2. What is the catch-up schedule for children who have not received immunizations?

History

 MB’s parents are concerned about him receiving three shots in one day. They are also worried about side effects and wonder if there is any reason he should not receive a vaccine. Angie notes that she had a sore arm and fever after receiving a flu shot at work—she wonders if this will happen to MB.

 
  1. What are some common side effects to vaccinations? Rare side effects?
  2. What are some contraindications to vaccines? (i.e., Who should not be vaccinated?)
  3. What are some general contraindication myths? How effective are vaccines?

 

You see MB sitting nervously on his mother’s lap. Though he appears thin, you do not believe he is malnourished. As you approach him, you ask him his name. He tells you his name is “Mikey.”

  1. Discuss the developmental milestones of a 12-18 month old? 2 year old? A 3 year old? Because MB has not had well childcare to date, you would want to be sure he has met prior milestones in each category.
  2. What missing milestones would be cause for concern at MB’s age/or end of 2 years of age?
Ryan and Angie are concerned with MB’s diet. They want to be sure they are providing proper nutrition so he will grow appropriately. They also want to be sure he does not become overweight.
  1. Discuss appropriate diet in a 2 year old?
  2. Obesity and overeating are huge problems in the United States. Discuss some means of preventing or combating obesity.

Physical Examination

 

Satisfied with the information and direction you have given them, Angie and Ryan are anxious to know if MB has a normal physical exam. They are concerned because they are not sure if he ever went to a doctor while in Thailand.

On physical exam, your attending notices a 3/6 systolic murmur over MB’s left lower sternal border (LLSB). Because you have not had a chance to take Pediatric or Adult Cardiology yet, you did not initially notice the murmur and aren’t sure how to proceed at this point. Your attending calmly reassures MB’s parents that he believes it is a benign murmur, but would like them to see a Pediatric Cardiologist to obtain a proper work-up. Also, he does not know if this murmur has been present since birth or changed at all as MB has been growing.

The remainder of MB’s physical exam is within normal limits. Although he is thin, MB does not appear emaciated or malnourished. He is interactive with you during the exam and developmentally appears on target, meeting the proper 2 year old milestones.
 
  1. Heart murmurs are common findings on Pediatric exam. Discuss the appropriate heart murmur work-up in a child. Describe some innocent murmurs and murmurs associated with cardiac pathology.
Finally, Ryan and Angie want to know best how to childproof their home for their very active 2 year old. They would also like some anticipation of safety measures to take in the future, telling you he gets into everything now.

 
  1. Discuss key safety issues (for each age) for children 1-2 years of age.

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This page was last updated on March 31, 2006
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