PHYSICAL EXAM TECHNIQUE - try to examine kids in the parents laps for infants and small

children. Tricks to examine: Progress from least to most invasive and then head to toe. To examine the
ears, have the parent hold the child facing to the side and hold their hands against them and u hold the
kid's head in your palm and straighten out the ear canal with your thumb and look thru the otoscope b4
inserting the otoscope speculum and advance the speculum only as far as u need to see the TM. To
examine the oropharynx have the parents hold the kid's hands down and the head with the other hand
(and hold their legs with the parent's legs if needed) and look at the labial and bucal mucosa and the
tongue and palate and then finally the oropharynx. If the child is clenching teeth, then slide the tongue
depressor past the last molar and move it to the midline and this will make the pt gag. The abdominal
exam is done supine on the bed starting at the anterior superior iliac spine and push with the top hand
and feel with the bottom hand feeling for HSM, masses, tenderness.
IMMUNIZATIONS / CHECKUP AGES - always check growth and ask do you have any questions or
concerns about your child
Pediarix = DTap/IPV/HBV
Pentacel = DTap//IPV/Hib
Proquad = MMRV
Kinrix= DTaP/IPV (4yr vaccine)
Menveo, Menactra= MCV (Meningococcal conjugate vaccine)
Rotateq- Rotavirus vaccine (<8mo old)
Prevnar13=PCV (Pneumococcal conjugate vaccine) (<5y)
Hib <5yrs old
HPV >9yrs old for males and females
ASQ = Autism Screening Questionairre
Birth HBV
1-2d old NBST#1
2-3days after discharge from the nursery
2wks Newborn Screen #2
6-8wks DTaP, IPV, HIB, HBV, PCV, ROTA
4m
DTaP, IPV, HIB,
PCV, ROTA
6m
DTaP, IPV, HIB, HBV, PCV, ROTA
Hgb
9m
1y
HIB
PCV, MMRV, Hep A Hgb, Pb Dentist ASQ
15m
DTaP
18m
Hep A
ASQ
2y
Hgb and Pb
ASQ
30m
ASQ
3y
ASQ
4y
Kinrix
MMRV
ASQ
5y
6y
Hgb
7y
8y
9y HPV----2m---->HPV#2----4m---->HPV#3
10y
11y TdaP MCV
12y
Hgb

13y
14y
15y
16y
17y
18y

MCV

Hgb

Annual Flu shot for all kids for kids with Asthma, chronic diseases, premies in October:
6m-8y: 2 doses required (1mo apart)
>8y full dose or if they already had 2 doses in the prior year
Flumist can be given >2yrs
Synagis: monoclonal Ab directed against RSV for premies, kids with diseases like chronic lung disease,
cyanotic heart disease, significant neuromuscular weakness from October thru March

CARSEATS
Rear facing till 2y
Forward facing toddler carseat 2-4y (40lbs)
Booster seat 4y, 40lbs - 8y (80lbs)
Regular seat belt when seat belt strikes clavicle and not the neck

GROWTH AND DEVELOPMENT

Birth Weight 3kg---->Regain BW by 10days of life---->Gain 1oz/d x 3mos OR 2lbs/mo x 3mos OR 1kg/mo
x 3mos
Double BW by 3-6mos
Triple BW by 1yr
Age (y)
1
3
5
7
9
11
13
15
17

Weight (kg)
10
15
20
25
30
35
45
55
65

Birth Length is 20in

1st yr of life grows 10in
2nd yr of life grows 5 in
3rd yr of life grow 3in
4th yr 2.5in/yr until pubertal growth spurt

2wks baby can see well and start smiling

4mo good head control
7-8mo sitting up without support
9mo crawling
1yr walking and talking
17mo 17words
2yr 2 word sentences
4yr speech should be understood by strangers

URI/PHARYNGITIS/NASOPHARYNGITIS/BRONCHITIS
Ibuprofen 50mg/1.25ml, 100mg/5ml
10mg/kg/dose qid
Acetaminophen 160mg/5ml
15mg/kg/dose qid
If pt has OM and >2y: Ibuprofen or Acetainophen, Lortuss LQ
If pt does not have OM and >2y: Bromfed DM
2-6y: 0.5tsp po qid
6-12y: 1tsp po qid
>12y: 2tsp po qid
Pills >12y: Deconex DMX 1tab po qid
If on treatment for URI and they come in for followup and not better then start antibiotics (sometimes I will
write script for abx and at bottom of script I will write: void after 5 days)
If pt has a viral prodrome and then begins to run fever later into the course of the illness then I generally
start antibiotics...........kids usually start with a viral infection and then get a superimposed bacterial
component on top of that. If pt has exudate tonsillitis then I give either Amoxil or Zithromax depending on
results of rapid strep and if pt's medication allergies

ALLERGIES
>6mos: Claritin, Zyrtec, Singulair
>2yrs: Nasonex, Astelin
If med or combo of meds don't work then do allergy testing with South TX Allergy Panel (RAST test) and
if cannot finds things to avoid then refer to Allergist

OTITIS MEDIA
Organisms: H. flu, Strep pneumonia, M.Cat
Complications: Mastoiditis, Meningitis
Tx: Amoxil 45mg/kg/d
Augmentin (daycare, recurrent OM, 80mg/kg/d), Omnicef (great taste,once a day), Zithromax 12mg/kg
qD x5d(great compliance), Rocephin 50mg/kg IM q2-3D x1-3 doses (use if vomiting or looks toxic)
CiproDex (use if has otorrhea with or without PE tubes), Bactrim (covers H.flu)
PE (pressure equalization) Tubes:
>6 OM/yr, hearing loss, speech delay, OM>3mos (ear infections should resolve in 2wks-3mos)

CROUP
Organisms: PARAINFLUENZA, (influenza, RSV, adenovirus)
Mild: barky cough, +/-stridor: prednisolone 1mg/kg/dose bid x 3-5days or Dexamethasone 0.3mg/kg IM
Moderate: barky cough, stridor, retractions: Dexamethasone 0.6mg/kg IM and Racemic Epi neb and
observe 2-4hrs in ER or office
Severe: barky cough, stridor, retractions, altered LOC (fussy or lethargic): Solumedrol IV and Racemic
Epi nebs and admit

BRONCHIOLITIS
Organisms: RSV, Influenza, Parainfluenza, Adenovirus, Metapneumovirus,
By 2y old everybody has had RSV
By 5y old you reach high Ab levels and maintain thru life
RSV+Rhinovirus+genetics=asthma in 1st decade of life
TX: supportive BUT if +FH: asthma then tx like asthma

ASTHMA
S/Sx's: nocturnal cough, post-exercise cough, FH: Asthma, h/o eczema
Tx: Infant/Toddler: Pulmicort BID & Albuterol or Xopenex Nebs PRN
Child >4y: Qvar, Flovent----->Advair, Symbicort, Dulera & Albuterol or Xopenex PRN

ACUTE ASTHMA EXACERBATION: bronchoconstriction, inflamation, increased mucus production, Most

Common Trigger: URI
Mild: wheezing (sometimes pt wheezes only at nighttime and sounds normal at time of exam)
Tx: prednisolone 1mg/kg/dose BID x 7days, Albuterol/Xopenex PRN
Moderate: wheezing, retracting, prolonged expiration, decreased air exchange, hypoxia
Tx: Celestone (0.5 or 1ml IM) or Solumedrol 2mg/kg IM vs. oral steroids
O2 PRN
Albuterol/Xopenex Neb-->Albuterol/Xopenex + Atrovent 1 unit dose-->Admit for IV steroids and
Albuterol/XopenexNebs
Severe: wheezing, retracting, prolonged expiration, decreased air exchange, altered LOC (fussy or
lethargic), SOB, difficulty talking
Tx: IV Solumedrol, continuous Xopenex Neb, ADMIT

NEW WHEEZER
No prior h/o asthma and now sounds like an asthmatic pt
Dx: Mycoplasma pneumonia
Tx: Zithromax 12mg/kg/dose qd x 5d, prednisolone 1mg/kg/dose bid x1wk, Albuterol or Xopenex

COLIC - outgrows problem by 3mos old

Mylicon Infant Drops: 0.3ml po QID PRN
Playtex Drop Ins
Levsin Drops: 4-6drops po qid prn
Nutramigen/Alimentum or Enfamil Gentleease, Similac Total Comfort (if not breastfed), Gerber Goodstart
Soothe (lowe lactose, only whey protein)
UGI to rule out GERD

BREASTFEEDING
Allergy-free
Bonding
Colic-free
Digestibility
Economics: It's free!
Immunity: fewer OM and AGE cases per yr
IQ: Higher IQ

FORMULAS
Intake per day: 24-30oz/day
Optigrow/Lipil: Added DHA, ARA, Vitamin E and lutein for visual and neurologic development
Early Shield/Premium: Prebiotics (softens stools)
Similac Products will be changing to 19cal/oz b/c closer to breastmilk

For Breasfeeding Moms: Similac for Supplementation (has more prebiotics) and Enfamil for
Supplementation (partial hydrolysate with Vitamin D)
Healthy babies (19-20cal/oz): Similac Optigrow Early Shield, Enfamil Premium Lipil, Gerber Good Start
Gentle (prebiotics), Gerber Good Start Protect (probiotics)
Neonatal (<1mo) v/d: Similac Sensitive
GERD: Sim Sens f/Spit Up, Enfamil AR
Colic: Enfamil Gentleease, Gerber Good Start Soothe (lower lactose, only whey protein), Similac Total
Comfort
Premies (22cal/oz): Neosure Advance, Enfacare Lipil, Gerber Goodstart Nourish
Constipation, Milk allergy, Lactose Intolerance: Similac Soy Isomil, Prosobee Lipil, Gerber Goodstart Soy
Constipation: Enfamil Reguline (partial hydrolysate, decreased lactose by 50%, 2 prebiotics, low iron)
AGE: Pedialyte
9-18mo: Enfamil Transitions
Milk allergy with bloody diarrhea, Colic: Alimentum, Nutramigen LGG
PurAmino, Elecare
Toddlers: Pediasure, Next Step, Next Step Soy, Next Step Gentleease, Nutramigen for Toddlers

Food Introduction: give child a couple of days to see if they will react to a new food with v/d/rash
4mos: cereal
5mos: veges and fruits
6mos: meats
1yr: 2% or WHOLE MILK 16-24oz/day
2yr: Any kind of milk 16-24oz/day

DENTAL
Go see a dentist at 1yr of age

AGE
S/Sx's: f/v/d, bloody or mucusy diarrhea (bacterial), protracted diarrhea for 2wks or longer (parasitic)
Organisms: Viral: Rotavirus, Norwalk virus, Enterovirus, adenovirus
Bacterial: Shigella, Salmonella, E. Coli 0157, Yersinia hemolytica (requires special media in
lab), Campylobacter (requires special growth media in lab)
Parasitic: Giardia, Cryptosporidium
Tx: Infants: Pedialye or breastmilk, fruits and veges are ok,
Toddlers and Kids<6yrs: Pedialyte and bland diet, no dairy and no greasy/spicy foods
Kids>6yrs old: Gatorade and bland diet, no dairy and no greasy/spicy foods
Diarrhea >2wks: Flagyl or Alinia

CONSTIPATION
S/Sx's: hard stools >5days between BM's
Tx: Infant: <4mos: Bottle with 1oz clear Karo syrup and 1oz water qd-bid
>4mos: Pear juice (>4m)
Lactulose liquid if above doesn't work
Older kids: Kristalose (powdered Lactulose), diet (low dairy, high fiber)

GERD
S/Sx's: vomiting half the feeds half the time, chronic congestion, Sandifer syndrome
W/U: UGI
Tx: Similac Sensitive for Spit Up, Axid, Zantac, Prevacid, Prilosec, Nexium

ADHD
S/Sx's: inattention, hyperactivity that are interfering with school performance
Start low dose and then increase the dose weekly to desired effect up
Vyvanse (lasts 13hr)
Focalin XR (lasts 8-12hrs)
Concerta (swallow pill only) (lasts 12hrs) (fewer side effects)

Adderall XR (lasts 8-12hrs)

Daytrana patches (last 4hrs after patch taken off)
Quillivant XR (only liquid 12hr med, >6y old: 20-60mg per day)
Insomnia: Clonidine qHS, Trazodone or Remeron qHS
ADHD only partially helped with stimulants: Intuniv,Tenex, test for learning d/o like dyslexia, psych testing
CBC,AST,ALT q6mo

ACNE
First visit: Benzaclin Gel Pump
Second visit: Benzaclin Gel Pump qam and Epiduo Gel qhs and Minocycline 100mg qd
Third visit: Accutane

ECZEMA/NUMMULAR ECZEMA
Cetaphil Cream
Triamcinolone 0.1% cream BID PRN

TINEA CORPORIS
Nystatin cream bid x 2 weeks

TINEA VERSICOLOR
Nystatin cream bid x 2 weeks or Lamisil

TINEA CAPITUS
Gris-PEG x 6 weeks or Lamisil x 6 weeks

PITYRIASIS ALBA
Mytrex Cream BID x 2 weeks (Triamcinolone 0.1% cream AND Nystatin cream bid x 2 weeks)

KERATOSIS PILARIS
Scrub with Loofa sponge at bathtime followed by moisturizer after bath

SCABIES
Elimite Cream and environmental modification

SEBORRHEA
Triamcinolone 0.1% cream bid prn rash

MILIARIA RUBRA
Reassurance

Scabies
Elimite cream and environmental modification

Molluscum Contagiosum
reassurance

ENURESIS
Positive feedback
Enuresis Alarm

DACROSTENOSIS / NASOLACRIMAL DUCT STENOSIS

S/Sx's: infant with eye d/c without conjunctivitis
Tx: Wipe eye with clean warm wash cloth and nasolacrimal duct massage, can last for mos., refer to pedi
ophthomology if not resolved by 1yr old

CONJUNCTIVITIS
Vigamox

DIAPER RASH
Irritant diaper dermatitis if oustide inguinal folds: Dr. Smith's diaper cream, Calmoseptine, Silvadene
Candidal diaper dermatitis if involving inguinal folds: Mytrex or Nystatin or Triple Paste AF
Staph Diaper Dermatitis: Keflex + Bactroban

VISION/HEARING/SPEECH CONCERNS

Always refer (with few exceptions)

HERPETIC GINGIVOSTOMATITIS/HERPANGINA
Herpes: anterior mouth ulcerations
Herpangina: blisters in the posterior/anterior mouth ulcerations

NEONATAL HERPES INFECTION

Start Acyclovir if meningitis, high LFT's, pneumonitis, or DIC

INFECTIOUS RASHES
Roseola: <2y old: high fever, fever breaks, maculopapular rash erupts on the trunk
Scarlet Fever: fever, strep pharyngitis or strep skin infection, sunburn appearing, fine-sandpaper feeling
rash on the trunk accentuated in the arm pits and the inguinal folds
Fifth Dz: slapped cheek appearance and lacy, reticular rash on the extensor surfaces of the arms and
thighs
Hand Foot Mouth Disease: fever, herpangina, vesicles on the palms and/or soles
Viral Exanthem: viral prodrome and maculopapular rash on the trunk
Varicella: viral prodrome +/-fever, vesicular rash in various stages of healing
HSP: viral prodrome, palpable purpura below the waist
Meningococcemia: fever and palpable purpura