As you follow your patients in CCC, you will learn important differences between primary ambulatory patient care and the secondary and tertiary inpatient care of your in-hospital rotations.
Data collected on patients in this Clinic (an outpatient setting) is done in a stepwise fashion, over time ("longitudinally"), as opposed to the more in depth ("vertical") collection of information in a short time, which characterizes inpatient care.
Additionally, ambulatory patient care concerns itself with prevention
of disease, as well as screening for disease in asymptomatic people. This
area of health maintenance is a large and essential one in the practice
of any form of primary care; and it is carried out in the context of ongoing
medical care. This means, then, that you will be following and treating
patients with established illnesses as well as acute and episodic problems
and, simultaneously, will become involved in screening, prevention, and
health maintenance. Preventive medicine can be divided into three levels:
before it begins.
early stage (screening).
disability and promoting rehabilitation.
There are no absolute guidelines that physicians uniformly follow in providing these services. Instead, the methods are tailored to fit the type of practice and patient popula-tion the physician has. These variations will become apparent to you as you work in the Clinic with preceptors from a number of different practice settings.
If you look at how all these areas are attended and follow the Recommendations
for Preventive Pediatric Health Care (Table 1), you will see a recommended schedule
for following healthy children from infancy through adolescence.
First of all, a history and physical examination should be done at each suggested visit, as well as a developmental behavioral assessment and anticipatory guidance. Careful attention to these important areas will provide clues to unsuspected disease and, frequently, direct you to specific needs for patient or parent education and counsel. The Well Baby Cook-book and the Denver Developmental Screening Test, which are available to you in the Clinic, are good reference sources.
Certain measurements are a necessary part of the physical examination in infants and children in order to evaluate their growth and development. Specifically, height and weight should be measured at each visit from infancy through adolescence, and head circumference at each visit for the first year. Recording of blood pressure at least every 1 to 2 years, beginning at age 3, is important and often overlooked (Table 2).
Heredity/metabolic screening for PKU and hypothyroidism is required
as a one-time screen with all infants at about 2 weeks. We also screen
for sickle disease in all black children at about 9 to 12 months of age.
A minimum of laboratory testing (i.e., hemoglobin or hematocrit and urinalysis)
is desirable at least once in the first year (at 9 to 12 months), and again
at ages 2, 8, and 14 to 18 years. Obviously, if circumstances suggest a
variation from normal, additional checks are necessary.
The Committee on Infectious Diseases recommends tuberculin testing annually for high risk child-ren (blacks, Hispanics, Asians, American Indians, Alaskan natives, and contacts). Low risk groups should be tested at 12 to 15 months of age (either before or at the time of MMR administration), at 4 to 6 years of age, and at 14 to 16 years of age.
The success of protective immunization against certain infectious diseases in children has changed the face of practice to some extent, and continues to be an important part of preventive medicine in children and adults. A schedule of immunization is provided in the Clinic examining rooms, and you can offer your patients the option of obtaining these immunizations free, either in the Clinic or at the Health Unit.
The need for visual and auditory screening is being recognized now, as well as dental referral. These areas are usually assessed subjectively by careful history plus specific attention to abnormalities sugges-ted on physical examination on each visit until pre-school age (3 to 5 years), and are then evaluated objectively by specific screening tests or referral for these. Repeat objective evaluations are suggested in pre-adolescent and adolescent patients.
When you break down these different areas as we have done here, it begins to sound like a lot of information and also time consuming. I think, however, that by referring to schedules like these and others and making appropriate use of the Clinic personnel, you will find these areas of your practice very gratifying.
Pediatric Outpatient Encounter
Major objectives of the clinical encounter:
Clinical skills in examining children are a blend of:
child during the encounter.
Specific techniques and procedures for examining children are widely described in texts and physical diagnosis courses (type of stethoscope, palpation techniques, lap exam, etc.).
Behavioral approaches to children often generalize a need for gentle-ness, kindness, warmth, and a friendly, unhurried attitude, without much specific information on how these are translated into action.
We all have been amazed, at times, at a clinician's "magical ability"
to approach and examine an uncooperative or screaming child. Part of this
art comes as you incorporate your own personal style and ability into the
process. In order to de-mystify this seemingly magical ability, it is useful
to organize the process around three general principles or concepts:
Table 3. Cognitive and Developmental Characteristics
of the Child.
months of age
(ages 18 months
to 3 years)
Child (ages 3 to 6 years)
(ages 6 to
(puberty to late teens/early 20s)
|Responds to touch
(auditory), visual stimuli.
paper on table;treating as passive;
|Detaching from patient; rushing
expression that frighten; rushing through exam.
expressions that frighten.
talking down to.
|Place on blanket on lap for exam;
allow to grasp
|Reassure a lot; let them touch/hold
instrument first on Mom or bear;
flatter; give hero
show respect; be
** Communicate according to age and development
Not systematic --> gradually more systematic --> more "head, chest, abdomen, etc."
Much of our training in interviewing and pediatric history-taking takes place around well-defined or acute situations in which the "complaint" is easily stated and readily viewed (Johnny has a cold, sore throat, earache, fever, etc.).
Such is not the case with the normal newborn, who comes to your office for a two-week checkup. We are programmed to ask for a "chief complaint," which the mother doesn't have (she's there only because you asked her to come), a "present illness," which she can't elaborate on because the baby hasn't appeared ill, or a "past history," which seems essentially uneventful in that there has been no significant illness, surgery, injury, or allergy. So what do we do?
- pregnancy history: inquire specifically about infections, bleeding, high blood pressure, etc.
- delivery: Inquire about place of birth, birth weight, problems in labor or delivery, use of forceps, whether particularly painful, etc.
- nursery-- length of stay, oxygen ±, jaundice ±, antibiotics ±
- feedings-- breast or formula (type), quantity and frequency of feedings
- sleeping-- through the night?
- stools-- character and frequency
- family history-- relative to specific diseases.
- social and environmental-- who lives in household, ages of sibs, baby-sitters?
- occupations of mother, mate, and other members of the household.
- head circumference (until age 3 years).
- 0-36 months
- 2-18 years